Every finding on record at Mountain Manor of Paintsville

Based on observation, interview, record review, and facility policy review, the facility failed to provide a dignified dining experience for 2 (Resident #81 and Resident #91) of 2 sampled residents.Findings included: A facility policy titled, Assistance with Meals, revised 09/2013, indicated, 3. Residents Requiring Full Assistance: a. Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. b. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. A facility policy titled, Dignity, revised 02/2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. The policy continued, 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience. An admission Record revealed the facility admitted Resident #81 on 03/18/2022. According to the admission Record, the resident had a medical history that included diagnoses of dementia and dysphagia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2025, revealed Resident #81 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a staff assessment for mental status (SAMS). Per the MDS, the resident was dependent on staff assistance for eating during the seven-day look back period. Resident #81's Care Plan Report, included a focus area, revised 02/14/2024, that indicated the resident had a self-care deficit related to impaired range of motion, weakness, and cognitive deficits. Interventions directed staff to provide assistance with eating (initiated 03/23/2022). An admission Record revealed the facility admitted Resident #91 on 10/05/2022. According to the admission Record, the resident had a medical history that included diagnoses of dementia, dysphagia, blindness in one eye and low vision in the other. A significant change MDS, with an ARD of 06/14/2025, revealed Resident #91 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Per the MDS, the resident was dependent on staff for eating during the seven-day look back period. Resident #91's Care Plan Report, revised on 10/06/2022, revealed a focus area the indicated the resident had a self-care deficit related to disease process. Interventions directed staff to provide assistance with eating (initiated 03/31/2025). During an observation on 07/28/2025 at 12:18 PM, State Registered Nursing Assistant (SRNA) #6 and SRNA #13 were observed providing eating assistance to Resident #81 and Resident #91 in their room. SRNA #6 was providing eating assistance to Resident #81 and SRNA #13 was providing eating assistance to Resident #91. SRNA #6 and SRNA #13 conversed with each other on topics unrelated to work. SRNA #13 and SRNA #6 discussed Resident #91 aloud in the third person and did not include the resident in the conversation, stating I'm surprised [the resident] ate this much. This is the most [the resident's] had. If it's like pasta or something [the resident] will kick it. If you get [the resident] calm enough right now [he/she] will pass out after this. In an interview on 07/31/2025 at 11:34 AM, SRNA #6 stated he received training on how to provide feeding assistance to residents who required assistance. He stated if the resident was included in the conversation, then they (SRNA #6) could converse with other people during the meal. He stated if the resident was not included in the conversation, then it would not be appropriate to talk to the resident about someone else. He stated that he recalled talking to SRNA #23 on 07/28/2025 at lunch time while providing feeding assistance to Resident #81, and felt it was inappropriate. In an interview on 07/31/2025 at 4:52 PM, SRNA #13 stated that Resident #91 was verbal, though the resident did not always understand when staff would speak to them. SRNA #23 stated that she recalled speaking to SRNA #6 on 07/28/2025 during lunch, but neither resident was cognitively intact. She stated that typically staff would never talk about one resident in front of another due to privacy reasons, and it was not appropriate. In an interview on 07/31/2025 at 11:15 AM, SRNA #14 stated that when providing feeding assistance to a resident, he conversed with the resident. He stated that even if the resident was not cognitively intact or verbal, it was inappropriate and rude to have side conversations with other staff. He stated the facility provided training on that aspect of resident dignity. In an interview on 07/31/2025 at 2:22 PM, the Staffing Development Coordinator (SDC),stated nurse assistants received training regarding feeding assistance. The SDC stated that when doing a competency check for feeding assistance, she looked to see if staff positioned themselves in front of the resident and in a seated position. She stated that when staff were assisting a resident with a meal, the staff were to focus on the resident, converse with the resident if the resident wished to talk and were not to converse with other staff members. In an interview on 07/31/2025 at 4:13 PM, the Director of Nursing (DON) stated that her expectation regarding dignity and the feeding assistance experience was that staff's sole focus be on the resident and not anyone else. The DON stated sometimes the resident conversed with their roommate, and that was fine, but staff should not converse with other staff. Per the DON, while it was acceptable to have momentary interruptions, it would not be okay to have conversations about a resident with another staff member. The DON stated it would be a dignity concern if that occurred. She stated when providing feeding assistance, the focus should be only on assisting the resident to eat. In an interview on 07/31/2025 at 6:30 PM, the Administrator stated that he would expect a dignified dining experience that met the resident's expectations. The Administrator stated the staff and residents had good rapport, and staff had conversations amongst each other all the time. The Administrator stated if staff were not talking about something inappropriate, he did not have an issue with them talking to each other while providing feeding assistanc

Based on record review, interview, facility document review, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of property, which affected 1 (Resident #4) of 3 residents reviewed for personal property. Specifically, a staff member stole Resident #4's credit cards and made multiple unauthorized charges.Findings included: A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. A facility policy titled, Resident Rights, revised 12/2016, indicated, Employees shall treat residents with kindness, respect, and dignity. The policy revealed, 1. Federal and state laws guarantee certain basic rights to residents of this facility. These rights include the resident's right to, including, c. be free from abuse, neglect, misappropriation of property, and exploitation. An admission Record indicated the facility admitted Resident #4 on 11/26/2024. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #4's Care Plan Report included a focus statement dated 01/27/2025, that indicated the resident had impaired cognitive ability related to dementia. An Initial Report document, dated 07/07/2025 and completed by the Social Services Director (SSD), indicated that the Kentucky State Police (KSP) notified the Administrator that Licensed Practical Nurse (LPN) #1 was seen on video at a retail drug store and a retail supermarket using Resident #4's credit card. A Final Report/5 Day Follow-Up document, dated 07/11/2025 at 1:45 PM and completed by the SSD, revealed LPN #1 was observed on video provided by the KSP using Resident #4's credit card, which she did not have permission to use. The document indicated that LPN #1 was arrested at the facility on 07/07/2025 by the KSP. During an interview on 07/29/2025 at 11:10 AM, Resident #4 stated that their family member, Family Member (FM) #15, told them credit cards that were in their (Resident #4's) wallet were stolen. Resident #4 stated FM #15 would know all the details. During a telephone interview on 07/29/2025 at 11:38 AM, FM #15 stated the stolen credit cards had been in a wallet in a dresser next to Resident #4's bed. FM #15 stated they received notification from a credit card company on 07/03/2025 that there was fraud detected. FM #15 stated that someone attempted to use a credit card at a retail drug store and a retail supermarket. FM #15 stated that some of the charges were denied but some were not, and the charges totaled $1,700. FM #15 stated that on 07/04/2025 at approximately 12:00 PM, they reported to LPN #2 and another staff member, who LPN #2 asked to be present, that Resident #4's credit cards had been stolen. FM #15 stated that LPN #2 stated she would report it immediately to the Administrator and the Director of Nursing (DON). FM #15 stated that the police came to the facility on Monday (07/07/2025) with pictures, and staff were able to identify the person using the stolen credit cards. FM #15 stated they thought the alleged perpetrator was arrested on 07/07/2025. During a telephone interview on 07/29/2025 at 4:40 PM, LPN #2 stated that on 07/04/2025 at approximately 3:30 PM, FM #15 came into the facility and reported to her and Registered Nurse (RN) #3 that Resident #4's credit cards had been stolen, and the alleged perpetrator had attempted to use them. LPN #2 stated FM #15 showed her and RN #3 the resident's handbag/wallet and showed them where the credit cards had been stored prior to being stolen. LPN #2 stated she immediately told the Assistant Director of Nursing (ADON), who advised her to call the SSD. LPN #2 stated she notified the SSD, who told her that she would take care of it on Monday morning since it was a weekend. LPN #2 stated she thought the alleged perpetrator, who was a staff member, was identified, suspended, and arrested on Monday (07/07/2025) at the facility. During a telephone interview on 07/29/2025 at 5:06 PM, RN #3 stated LPN #2 asked her to be present as a witness when FM #15 came to the facility on [DATE] to report that Resident #4's credit cards had been stolen. RN #3 stated FM #15 told her and LPN #2 that Resident #4 had a handbag with a wallet that contained some credit cards, inside of a dresser in the resident's room; but the resident's credit cards had been stolen, and someone had attempted to use them that day (07/04/2025). RN #3 stated FM #15 showed her and LPN #2 the handbag and there were no credit cards in it. RN #3 stated FM #15 told them the alleged perpetrator attempted to use the credit cards at a retail drug store, a retail supermarket, and gas stations. During an interview on 07/30/2025 at 12:12 PM, the ADON stated she remembered LPN #2 called her on 07/04/2025, and she told LPN #2 to call SSD and report to her. The ADON stated she also called the SSD and reported it to her. The ADON stated the KSP came to the facility on Monday, 07/07/2025, with photos, but they were not clear, so they were not able to identify the alleged perpetrator at that time. She stated that the KSP brought in better pictures later that day and staff were able to identify the person in the photos as a staff member who was attempting to use Resident #4's credit card. She stated that the KSP requested the facility to allow the alleged perpetrator to report for work on 07/07/2025 so they could make the arrest at the facility. The ADON stated the alleged perpetrator was asked to come to her office and was informed of her suspension pending the investigation, and that was when KSP arrested the alleged perpetrator. During an interview on 07/30/2025 at 1:50 PM, the SSD stated she was notified on 07/04/2025 that FM #15 had come into the facility and had reported to LPN #2 that someone tried to use Resident #4's credit cards that had been in Resident #4's handbag inside a dresser next to the resident's bed. The SSD stated that she told the ADON she would handle it on Monday (07/07/2025). The SSD stated the KSP came to the facility on [DATE] with videos and photos, but they were not good quality, but the KSP came back later that day with other videos and photos, and the ADON or the Administrator were able to identify the staff member as the alleged perpetrator. The SSD stated the staff member was scheduled to work the evening of 07/07/2025 and the KSP asked the facility to allow the nurse to come into work, call her to the office prior to her shift starting, then she would be arrested. During an interview on 07/31/2025 at 8:30 AM, the Administrator stated that on 07/07/2025, the KSP came to the facility with photos from a retail drug store, but they were poor quality. He stated that the KSP came back the same day with clearer photos from a retail supermarket, and two different staff members, the Admissions Director and the Business Office Manager (BOM), were able to positively identify the alleged perpetrator as LPN #1. During an interview on 07/31/2025 at 8:56 AM, the Admissions Director stated the KSP brought in pictures on 07/07/2025 from a retail drug store, and she was not able to identify the person, but the KSP came back to the facility the same day with photos from a retail supermarket, and she was able to positively identify the person in the photos as LPN #1. During an interview on 07/31/2025 at 9:18 AM, the BOM stated that on 07/07/2025, KSP brought some pictures, but she was not able to identify the person. She stated that the KSP brought in more photos from a retail supervisor later that same day and she was able to positively identify the person in the photos as LPN #1.

Based on record review, interview, facility document review, and facility policy review, the facility failed to report an allegation of misappropriation of resident's property to the state survey agency timely, which affected 1 (Resident #4) of 3 residents reviewed for personal property. Specifically, an allegation was made on 07/04/2025 that Resident #4's credit cards that were kept in the resident's room were stolen and unauthorized charges had been made, and the facility did not report the allegation to the state survey agency until 07/07/2025.Findings included: A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating, revised 04/2021, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy revealed, 1. If resident abuse, neglect, exploitation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies, which included a. The state licensing/certification agency responsible for surveying/licensing the facility. The policy revealed, 3. ‘Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. An admission Record indicated the facility admitted Resident #4 on 11/26/2024. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #4's Care Plan Report included a focus statement dated 01/27/2025, that indicated the resident had impaired cognitive ability related to dementia. During an interview on 07/29/2025 at 11:10 AM, Resident #4 stated that their family member, Family Member (FM) #15, told them credit cards that were in their (Resident #4's) wallet were stolen. Resident #4 stated FM #15 would know all the details. During a telephone interview on 07/29/2025 at 11:38 AM, FM #15, stated the stolen credit cards had been in a wallet in a dresser next to Resident #4's bed. FM #15 stated they received notification from a credit card company on 07/03/2025 that there was fraud detected. FM #15 stated that someone attempted to use a credit card at a retail drug store and a retail supermarket. FM #15 stated that some of the charges were denied but some were not, and the charges totaled $1,700. FM #15 stated that on 07/04/2025 at approximately 12:00 PM, they reported to Licensed Practical Nurse (LPN) #2 and another staff member, who LPN #2 asked to be present, that Resident #4's credit cards had been stolen. FM #15 stated that LPN #2 stated that she would report it immediately to the Administrator and the Director of Nursing (DON). An Initial Report document, dated 07/07/2025 and completed by the Social Services Director (SSD), indicated that the Kentucky State Police (KSP) notified the Administrator that LPN #1 was seen on video at a retail drug store and a retail supermarket using Resident #4's credit card. An email from the SSD to the state survey agency, dated 07/07/2025 at 4:29 PM indicated the Initial Report was submitted to the state survey agency at that time. During a telephone interview on 07/29/2025 at 4:40 PM, LPN #2 stated that on 07/04/2025 at approximately 3:30 PM, FM #15 came into the facility and reported to her and Registered Nurse (RN) #3 that Resident #4's credit cards had been stolen, and the alleged perpetrator had attempted to use them. LPN #2 stated FM #15 showed her and RN #3 the resident's handbag/wallet and showed them where the credit cards had been stored prior to being stolen. LPN #2 stated she immediately told the Assistant Director of Nursing (ADON), who advised her to call the SSD. LPN #2 stated she notified the SSD, who told her that she would take care of it on Monday (07/07/2025) morning since it was a weekend. During a telephone interview on 07/29/2025 at 5:06 PM, RN #3 stated LPN #2 asked her to be present as a witness when FM #15 came to the facility on [DATE] to report that Resident #4's credit cards had been stolen. RN #3 stated FM #15 told her and LPN #2 that Resident #4 had a handbag with a wallet that contained some credit cards, inside of a dresser in the resident's room; but the resident's credit cards had been stolen, and someone had attempted to use them that day (07/04/2025). RN #3 stated FM #15 showed her and LPN #2 the handbag and there were no credit cards in it. RN #3 stated FM #15 told them the alleged perpetrator attempted to use the credit cards at a retail drug store, a retail supermarket, and gas stations. During an interview on 07/30/2025 at 12:12 PM, the ADON stated she remembered LPN #2 called her on 07/04/2025, and she told LPN #2 to call SSD and report to her. The ADON stated she also called the SSD and reported it to her. During an interview on 07/30/2025 at 1:50 PM, the SSD stated she was notified on 07/04/2025 that FM #15 had come into the facility and had reported to LPN #2 that someone tried to use Resident #4's credit cards that had been in Resident #4's handbag inside a dresser next to the resident's bed. The SSD stated that she told the ADON she would handle it on Monday (07/07/2025). The SSD stated she should have come in on 07/04/2025 and reported the allegation to the state survey agency and started the investigation process. During an interview on 07/31/2025 at 3:55 PM, the DON stated the facility had two hours to report an allegation of abuse to the state survey agency, and 24 hours for other allegations. She stated that the Abuse Coordinator should report within the timeframe. During an interview on 07/31/2025 at 4:13 PM, the Administrator stated he expected the staff to notify the Abuse Coordinator immediately upon an allegation of misappropriation of resident property. He stated that there was no reason to report the allegation unless it was a true allegation. He stated that it was his understanding that FM #15 did not accuse anyone at the facility, just that they had a conversation about a missing credit card.

Based on record review, interview, and review of the Centers for Medicare & Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to complete a discharge Minimum Data Set (MDS) upon discharge and transmit the data for 1 (Resident #101) of 1 resident reviewed for resident assessment.Findings included: The Centers for Medicare & Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed, OBRA [Omnibus Reconciliation Act] Discharge assessments consist of discharge return anticipated and discharge return not anticipated. The manual revealed, 09. Discharge Assessment-Return Not Anticipated (A0310F=10), which included Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days, Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days), and Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). An admission Record revealed the facility admitted Resident #101 on 03/05/2025. According to the admission Record, the resident had a medical history that included a diagnosis of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. The admission Record indicated the facility discharged the resident on 03/20/2025. An admission MDS, with an Assessment Reference Date (ARD) of 03/11/2025, revealed Resident #101 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #101's Care Conference Summary, dated 03/20/2025, indicated the facility care plan team met for an admission review. The record indicated Resident #101 chose not to attend, had no questions or concerns, and planned to discharge home that day. Resident #101's Progress Notes revealed a note, dated 03/20/2025 at 1:35 PM, that revealed Resident #101 was discharged home. Resident #101's record revealed no evidence that the facility completed a discharge MDS or transmitted data for the resident's discharge. During an interview on 07/31/2025 at 6:25 PM, the MDS Nurse stated a discharge MDS should have been completed with an ARD of 03/20/2025. She stated that it should have been completed within 14 days after the resident discharged , and she was not sure why it was missed. During an interview on 07/31/2025 at 3:01 PM, the Director of Nursing (DON) stated she had limited knowledge of the MDS process and was unable to provide a time frame of when or how assessments were to be completed; however, the DON stated she expected them to be completed accurately and timely. During an interview on 07/31/2025 at 3:28 PM, the Administrator stated he did not know much about the MDS process but expected the assessments to be completed accurately and timely.

Based on observation, interview, record review, facility document and policy review, the facility failed to provide nail care for 1 (Resident #126) of 3 sampled residents for activities of daily living (ADL).Findings included: A facility policy titled, Activities of Daily Living (ADL), Supporting, dated 03/2018, revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy continued, 1. Residents will be provided with care, treatment and services to assist them maintaining their highest functional status. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). An admission Record revealed the facility admitted Resident #126 on 02/04/2025. According to the admission Record, the resident had a medical history that included diagnoses of age-related physical debility, lack of coordination, and muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/13/2025, revealed Resident #126 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident required substantial/maximal assistance from staff with personal hygiene. Resident #126's Care Plan Report, included a focus area initiated 02/05/2025 that indicated the resident had a self-care ADL deficit related to their disease process, obesity, and weakness. Interventions directed staff to assist with bathing and personal hygiene. Resident #126's Point of Care Audit Report, for the timeframe from 05/01/2025 through 07/29/2025, revealed the resident received a bed bath daily. During a concurrent observation and interview on 07/28/2025 at 10:54 AM, Resident #126's nails were observed to be long with a brown-colored substance visible underneath the nail. Resident #126 stated staff did not provide nail care when assisting with the resident's bath. During an interview on 07/30/2025 at 9:27 AM, Resident #126 stated they had gotten a bed bath, but their nails were not trimmed. Resident #126 stated their nails had dirt under them and needed to be trimmed. During a concurrent observation and interview on 07/31/2025 at 8:34 AM, Resident #126 held out their hands and stated their nails had not been cut or cleaned. The residents' nails remained long and with a brown-colored substance visible underneath the nails. During an interview on 07/31/2025 at 8:38 AM, State Registered Nursing Assistant (SRNA) #9 stated they tried to do nail care during a bed bath if they had time. If they did not have time during the bath, they returned later to provide nail care. SRNA #9 stated if the resident was not a diabetic, they were allowed to trim the nails, and if the resident was diabetic, the nurses trimmed the nails. SRNA #9 stated she would provide nail care for Resident #126 on that day. During an interview on 07/31/2025 at 4:28 PM, the Director of Nursing (DON) stated her expectation was that nail care be provided when residents were given a bed bath. During an interview on 07/31/2025 at 4:31 PM, the Administrator stated he deferred clinical concerns to the DON.

Based on interview, record review, and facility policy review, the facility failed to follow up on a urologist's orders and did not ensure that the physician's orders were transcribed and administered for 1 (Resident #11) of 2 residents sampled for catheter care.Findings included: A facility policy titled, Administering Medications, revised 04/2019, indicated, Medications are administered and as prescribed. The policy continued, 2. Medications are administered in accordance with prescriber orders, including any required time frame. An admission Record revealed the facility admitted Resident #11 on 03/17/2023. According to the admission Record, the resident had a medical history that included diagnoses of obstructive and reflux uropathy, retention of urine, and benign prostatic hyperplasia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2025, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The MDS indicated Resident #11 had an indwelling catheter during the seven-day look back period. Resident #11's Care Plan Report, indicated a focus area, initiated on 11/20/2024, that indicated the resident had an alteration in urinary elimination and required an indwelling urinary catheter. Interventions directed staff to provide catheter care each shift and as ordered/as needed, to observe for signs and symptoms of urinary tract infection (UTI), and change the catheter and drainage bag as ordered. A document titled, Office Visit Report dated 07/16/2025 from Resident #11's urology provider, under the heading Assessment & Plan, indicated, Instruct nursing home to replace the catheter monthly. Further, Prescribe Hiprex [a urinary anti-infective drug] to be taken twice daily to maintain clean urine and prevent UTIs. The document revealed a fax date and time of 07/18/2025 at 1:27 PM. Resident #11's Order Summary Report, dated 07/31/2025, revealed no evidence of an order for the Hiprex. Resident #11's Medication Administration Record and Treatment Administration Record, dated 07/01/2025 - 07/31/2025, revealed no evidence of an order entry for the Hiprex. A review of Resident #11's Progress Notes, from 07/01/2025 through 07/31/2025, revealed no evidence the Hiprex was ordered and administered as recommended by the resident's urologist, or that the recommendation or order for the Hiprex by the urologist was followed up on by the facility staff. A review of the Progress Notes revealed a health status note, dated 07/28/2025 at 6:36 PM, that indicated Resident #11 had a new diagnosis of a UTI, had started on an antibiotic, and nursing staff was monitoring. During an interview on 07/31/2025 at 2:54 PM, the Infection Preventionist (IP) stated that Resident #11 had gone to the urologist on 07/16/2025. The IP reviewed the urology paperwork from the 07/16/2025 visit and confirmed that there was an order for Hiprex. She stated it was the responsibility of the nurse on duty to transcribe new orders when a resident returned from an appointment. During an interview on 07/31/2025 at 3:53 PM, the urology Medical Assistant (MA) stated that Resident #11 was seen in their office on 07/16/2025. She stated when a resident left their office, they provided a verbal report over the phone to the nursing home, gave the patient a verbal explanation of the visit and orders, and then sent a note with whoever accompanied the resident to the appointment. The MA stated they would also faxed a letter with the prescriptions to the facility. Per the MA, they sent a fax to the facility on [DATE] for Resident #11. During an interview on 07/31/2025 at 4:00 PM, the urology Nurse Practitioner stated Resident #11 was at elevated risk for a UTI due to their age and having an indwelling catheter. Per the NP, the Hiprex order was to keep the bladder cleaner, and that could help prevent a UTI. As far as not starting Hiprex, it could be linked to Resident #11 getting a UTI on 07/29/2025, but she would not say it was the direct cause. Hiprex could have reduced the risk, but it depended on the hygiene practices and how much perineal care Resident #11 received. With an indwelling catheter, the risk was always there. If someone did get a UTI with Hiprex, that meant it would not be as bad. The NP stated when a resident visited the urologist, the office sent paperwork with the resident and then faxed any orders over to the nursing home. In an interview with Licensed Practical Nurse (LPN) #4 on 07/31/2025 at 4:45 PM, she stated that if a resident went to an appointment, they were accompanied by a staff member. Either the staff member who accompanied them would bring the nurse the paperwork, or the doctor's office would fax the orders to the facility. Any new orders were entered into the resident's chart after review with the provider. If there was no paperwork from the visit, then medical records would reach out to the outside provider's office for follow-up. In an interview with Medical Records on 07/31/2025 at 4:48 PM, she stated that nursing staff would drop off a resident's paperwork from outside appointments in the medical records box. If they were in her box, that meant they had already been reviewed and had orders inputted into the resident's chart. She would then scan them in. If a resident did not get paperwork from the doctor's office she would send out for it. Once received, she would then take it to the nurse to get the order put in. For Resident #11, she stated the uploaded time stamp in the electronic health record was the same day she received their urology visit report. She stated it said 07/21/2025 so that was when she received the urology visit paperwork. In an interview on 07/31/2025 at 4:13 PM with the Director of Nursing, she stated it was her expectation that orders were transcribed from an offsite doctor's visit. She stated that she expected that upon return from an appointment, nursing staff would talk to the resident and the staff who transported the resident and review the visit paperwork. They would then be expected to call the doctor to implement orders from the visit. She expected that the nurse on duty when the resident came back would input the orders and coordinate with the doctor.During an interview 07/31/2025 at 6:32 PM, the Administrator stated that he expected orders to be entered and followed as ordered if a resident returned from an appointment with new orders.

Based on interview, record review, and facility document and policy review, the facility failed to prevent a fall for 1 (Resident #95) of 3 sampled residents reviewed for accidents. Specifically, on 06/01/2025, State Registered Nursing Aide (SRNA) #6 was providing bathing assistance to Resident #95, who was dependent upon one staff member for bed mobility, when the SRNA rolled the resident onto their left side and then stepped to the resident's doorway to notify a nurse of a soiled bandage needing changed on the resident's coccyx, leaving the resident unattended. The resident fell from their bed and sustained a bruise to their right neck, a 2-centimeter (cm) skin-tear to their left inner wrist, and two skin tears (4 cm and 13 cm) to their right forearm.Findings included: A facility policy titled, Falls and Fall Risk, Managing, revised 03/2018, revealed, According to the MDS [Minimum Data Set], a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. An admission Record revealed the facility admitted Resident #95 on 05/02/2025. According to the admission Record, the resident had a medical history that included diagnoses of peripheral vascular disease (PVD), type II diabetes mellitus, hypertension secondary to other renal disorders, muscle weakness, difficulty walking, and lack of coordination. A quarterly MDS, with an Assessment Reference Date (ARD) of 07/22/2025, revealed Resident #95 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident required partial/moderate assistance from staff to roll from lying on their back to their left and right side and to return to their back, substantial/maximal assistance from staff for showering/bathing themself and personal hygiene, and was dependent on staff for sit to lying, lying to sitting on the side of the bed. The MDS indicated Resident #95 had sustained one fall with injury since their prior assessment. Resident #95's Care Plan Report, included a focus area initiated05/02/2025 that indicated the resident had a self-care ADL (activity of daily living) deficit related to deconditioning, weakness, and PVD (peripheral vascular disease). Interventions directed staff to perform bathing (including bed bath) and bed mobility with the assistance of one staff member. The Care Plan Report also indicated a revision was made on 06/01/2025 that directed staff to perform bathing (including bed bath) and bed mobility with the assistance of two staff members. The Care Plan Report also included a focus area revised 05/02/2025 that indicated the resident was at risk for injury, falls related to ambulation/elimination status, history of falls, medications, PVD, with vascular wounds bilateral, and history of amputation of toes. Interventions indicated ADL and bed mobility assistance was reassessed and updated to two-person staff assistance on 06/01/2025. A document titled, #3252 Un-witnessed Fall, completed by Registered Nurse (RN) #8, dated 06/01/2025 at 11:00 AM, revealed a nurse aide called from Resident #95's room for assistance. The document indicated that when staff entered the resident's room, the resident was on the floor lying on their right side. Per the document, the resident stated they were not in pain, but they were unable to state whether they had hit their head. The resident was assisted back to bed, vital signs measurements were obtained, and neurological checks were initiated. The document further revealed the resident was found to have the following injuries:- a bruise to their right neck,- a 2 cm skin tear to left inner wrist with steri-strips (wound closure adhesive strips) and bandage applied,- a 4 cm right, forearm skin tear with 10 steri-strips, a liquid band-aid, non-adhesive bandage applied, and the area wrapped with gauze,- a second skin tear to the right forearm 13 cm in length with 30 steri-strips, a liquid band-aid, non-adhesive bandage applied, and the area wrapped with gauze.The document indicated that the resident's family member and physician were notified, treatments were initiated for all areas, and orders were received for x-rays. The document further revealed, Resident Description: When I was getting my bath, I was rolled on my side and my legs began to come off the bed. Before I knew it, I just slid into the floor. I am not sure if I hit my head or not. Nothing hurts and I am not going to the hospital because I am just fine. During an interview on 07/28/2025 at 10:43 AM, Resident #95 stated they experienced a fall while a male staff member was providing bathing assistance. During an interview on 07/31/2025 at 10:44 AM, SRNA #6 indicated he provided bathing assistance to Resident #95 during his shift on 06/01/2025. He stated that at the time of the fall, the resident required one staff physical assistance for bed mobility and bathing. He stated that while providing Resident #95 a bed bath, he had disrobed the resident's upper and lower body and had cleaned the resident's front portion of their body. SRNA #6 stated that when he turned the resident to the left side, he noticed a bandage on the resident's coccyx area was soiled and needed to be replaced. SRNA #6 stated that while the resident was on their left side, he ran to the resident's door to alert the nurse of the bandage. He stated that while at Resident #95's door, he heard a [thud] and heard the resident begin to scream. SRNA #6 said he then alerted the nurse that the resident had fallen and then immediately returned to the resident. SRNA #6 indicated the resident was positioned on the floor on the window side of the bed, lying on their right side with their head somewhat underneath the bed. SRNA #6 stated he glanced over the resident to see if there were any immediate injuries while waiting for the nurse and stated he noticed a large cut on the resident's right arm that was bleeding a good amount. He stated Resident #95 informed him that they did not think they had hit their head during the fall. Once the nurse arrived and assessed the resident, SRNA #6 stated he, SRNA #7, and RN #8 placed a sheet under the resident and transferred the resident back to their bed. He stated the resident did not have any pain at the time but recalled later the resident began to report some pain in the lower extremities and the arm, stating they were sore. SRNA #6 stated that following the resident's fall, the resident's bed mobility and bathing assistance was increased to require the assistance of two staff. He stated he thought the reason the fall occurred was due to the linens being wet from the bath and the resident throwing their leg too far over to the edge of the bed. During an interview on 07/31/2025 at 10:38 AM, SRNA #7 stated she was on duty on 06/01/2025 but was not in the room when the incident occurred. She stated she heard SRNA #6 call for assistance saying Resident #95 was on the floor. SRNA #7 stated when she entered the room, the resident was completely disrobed and lying on the floor on their right side. SRNA #7 stated she assisted SRNA #6 and RN #8 place a sheet under the resident and transferred the resident back to their bed. Per SRNA #7, when Resident #95 rolled onto their side, they sometimes threw themself close to the edge of the bed. During an interview on 07/31/2025 at 10:10 AM, RN #8 stated she was on duty on 06/01/2025 when Resident #95 sustained a fall from their bed while being bathed by SRNA #6. RN #8 stated she recalled that at the time, Resident #95 required one-person physical assistance for bathing, and SRNA #6 was providing the resident with a bed bath and had approached the door to alert her that the resident's sacral dressing was soiled when the fall occurred. She stated that while SRNA #6 was at the door, the resident began to scream out and fell to the floor. RN #8 stated that when she arrived to the room, Resident #95's bilateral side rails were both up, and the resident was lying on the floor on the left side of their bed, on their right side. RN #8 indicated that at the time, Resident #95 did not complain of any pain, but had sustained multiple skin tears, and one large skin tear on the right upper extremity was bleeding. RN #8 said she assessed each area, treated the areas, and assessed the resident's pain. RN #8 stated the resident denied pain and refused to be transferred to the hospital for evaluation. RN #8 stated she notified the resident's family and the medical provider and received orders for x-rays. RN #8 stated the x-ray results were all negative. During an interview on 07/31/2025 at 3:01 PM, the Director of Nursing (DON) stated Resident #95 sustained a fall from their bed on 06/01/2025 while SRNA #6 was providing bathing assistance. She stated she was aware SRNA #6 thoroughly cleaned the resident, which caused the bed to be more saturated potentially than others; however, she stated SRNA #6 should not have left the resident unattended to alert the nurse of the need for the bandage change but instead should have used the resident's call light. During an interview on 07/31/2025 at 3:28 PM, the Administrator stated he deferred his expectation of falls to the DON.

Based on interview, record review, facility document and policy review, the facility failed to ensure medications were stored safely when a medication was found at the bedside for 1 (Resident #38) of 3 residents sampled for medication administration.Findings included: A facility policy titled, Administering Medications, revised 04/2019, revealed, 2. Medications are administered in accordance with prescriber orders, including any required time frame. An admission Record revealed the facility admitted Resident #38 on 02/24/2025. According to the admission Record, the resident had a medical history that included diagnoses of Huntington's disease, bipolar disorder, anxiety disorder, and insomnia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/2025, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. Resident #38's Order Summary Report, dated 07/31/2025 contained an order for mirtazapine 30 milligrams (mg) one tablet by mouth at bedtime. An observation on 07/31/2025 at 9:00 AM revealed a single, pink, oval-shaped pill in a medicine cup on Resident #38's overbed table, which was located near the resident's bed. On 07/31/2025 at 9:02 AM, during the medication administration task, Registered Nurse (RN) #10 observed the single pill in the medication cup on Resident #38's overbed table. RN #10 identified the single pill as a mirtazapine 30 mg tablet by comparing it against other medication supply cards in their medication cart. RN #10 said Resident #38 was scheduled to receive the mirtazapine at bedtime. RN #10 stated she had not entered Resident #38's room prior to the observation and therefore had not noticed the medication at the resident's bedside prior. Resident #38's July 2025 Medication Administration Record (MAR), revealed an order entry for mirtazapine 30 mg one tablet at bedtime. The MAR revealed Licensed Practical Nurse (LPN) #12 documented that they administered the mirtazapine on 07/30/2025 at 9:00 PM. During an interview on 07/31/2025 at 9:30 AM, LPN #11 stated medications were not allowed to be left at bedside. LPN #11 verified that LPN #12 was the nurse who worked from 7:00 PM on 07/30/2025 until 7:00 AM on 07/31/2025 and who would have administered the medication to Resident #38. During a telephone interview on 07/31/2025 at 6:48 PM, LPN #12 verified she worked from 7:00 PM on 07/30/2025 until 7:00 AM on 07/31/2025. LPN #12 said she recalled taking Resident #38 their medication and stated the resident took the cup of pills and threw them back into their mouth. LPN #12 said she thought the resident had swallowed their pills. LPN #12 indicated Resident #38 often discarded the medication cup themselves; therefore, she did not check the cup afterwards to verify that all the medications were taken prior to leaving the resident's room. LPN #12 indicated she should have checked the cup to verify all pills were swallowed by Resident #38 before leaving the room. An interview was held on 07/31/2025 at 3:01 PM, with both the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON stated she was made aware a single mirtazapine pill had been left at the bedside of Resident #38. She stated LPN #12 had worked in the facility for a very long time and had knowledge not to leave any medications at the resident's bedside. The DON said she expected the nurse administering the medication to stand at the resident's bedside until all medications were administered. The ADON stated that when she became aware that the medication was left at bedside, she had attempted to contact LPN #12 and had completed a medication error report for the resident who did not receive the mirtazapine. During an interview on 07/31/2025 at 3:28 PM, the Administrator stated he deferred his expectation for medication administration to the DON.

Based on observation, interview, facility policy review, and review of a Centers for Disease Control publication, the facility failed to maintain infection control practices during catheter care for 1 (Resident #11) of 2 residents sampled for urinary catheter. Specifically, a nursing assistant failed to don a gown as recommended for enhanced barrier precaution (EBP) while providing catheter care and placed a soiled washcloth into the same water basin as the clean washcloths, then continued to provide catheter care with the contaminated washcloths. Findings included: A facility policy, titled, Infection Prevention and Control Program, revised 12/2023, indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A facility policy titled, Catheter Care, Urinary, revised 09/2014, under the heading, Steps in the Procedure: included, 13. With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure. The policy continued, 15. For a male resident male [sic]: Use a washcloth with warm water and soap to clean around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. 16. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion side to approximately four inches outward.A review of a Centers for Disease Control (CDC) publication, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 07/12/2022, indicated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Further, Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. An admission Record revealed the facility admitted Resident #11 on 03/17/2023. According to the admission Record, the resident had a medical history that included diagnoses of obstructive and reflux uropathy, retention of urine, and benign prostatic hyperplasia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2025, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The MDS indicated Resident #11 had an indwelling catheter during the seven-day look back period. Resident #11's Care Plan Report, indicated a focus area, initiated on 11/20/2024, that indicated the resident had an indwelling urinary catheter. Interventions directed staff to provide catheter care each shift and as ordered/as needed, to observe for signs and symptoms of urinary tract infection (UTI) and change the catheter and drainage bag as ordered. During an observation of catheter care performed on 07/31/2025 at 12:58 PM, State Registered Nursing Assistant (SRNA) #14 entered Resident #11's room, donned clean gloves, retrieved a wash basin from the closet, and emptied the supplies from inside the basin. SRNA #14 filled the basin with warm water, placed the basin on the resident's overbed table, and pulled the privacy curtain. SRNA #14 placed clean washcloths in the basin of water, added perineal wash to the water, then retrieved a washcloth from the basin to wipe the end of the penis tip and the scrotum. SRNA #14 did not clean the penis shaft. SNRA #14 then placed the soiled washcloth in the basin of water on top of the clean washcloths. SRNA #14 then retrieved another washcloth from the same basin of water, rinsed the area, and then placed the washcloth back into the basin of water. SRNA #14 retrieved a towel from on top of the comforter on the bed and dried the area. SRNA #14 did not don a gown at any time during the care. During an interview on 07/31/2025 at 1:04 PM, SRNA #14 stated Resident #11 had a urinary catheter for about a year. SRNA #14 stated he was familiar with how to provide catheter care. SRNA #14 verified the resident was on EBP by the signage on the door and stated he should have donned a gown and gloves for the task but forgot to don a gown before providing care. SRNA #14 stated he knew to pull back the foreskin of the penis to clean the area but stated the resident's penis shaft was difficult to get to so he did not do it. SRNA #14 acknowledged he placed the soiled washcloth in the basin on top of the clean washcloths, contaminating the water and remaining clean washcloths prior to using a clean washcloth to rinse the area. He stated the soiled washcloths should have been placed in a bag rather than the basin to prevent contaminating the water. A concurrent interview was held on 07/31/2025 at 3:01 PM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The ADON stated when providing catheter care for a male resident, the foreskin should be pulled back and cleaned in a circular motion from the tip to the base of the penis, and then the scrotum area should be cleaned. The ADON stated the washcloths should be discarded into a plastic bag to be taken to the dirty linen barrels. The DON stated SRNA #14 should not have placed the soiled washcloth back into the clean basin for any reason. The DON stated Resident #11 was on EBP requiring a gown and gloves for incontinence care. She stated the aide should have donned a gown before providing the care. The DON stated catheter care should be performed properly each time, including pulling back the foreskin, to help prevent catheter-associated UTIs.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of one (1) of twenty-six (26) sampled residents (Resident #80). Resident #80 had experienced a greater than ten (10) percent weight loss in less than six (6) months (between 05/06/2021 and 10/12/2021); however the resident's weight loss was not reflected on the resident's annual MDS dated [DATE]. The findings include: Review of the facility policy titled, Resident Assessment Instrument, undated, revealed the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Review of the RAI 3.0 User's Manual revealed staff should code 02 for section K0300, if a resident has a weight loss of ten (10) percent or more in the last six (6) months and is not on a physician-prescribed weight-loss regimen. Review of the medical record for Resident #80 revealed the facility admitted the resident on 11/20/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS for Resident #80 completed by the facility on 10/12/2021 revealed staff documented that the resident had not had a weight loss in the last six (6) months; however, a review of Resident #80's medical record revealed the resident weighed one hundred thirteen and six tenths (113.6) pounds on 10/12/2021 and one hundred forty-three and one tenth (143.1) pounds on 05/06/2021 revealing the resident had a weight loss of twenty-one and eight tenths (21.8) percent. Interview with the MDS Coordinator/Interim Director of Nursing (DON) on 11/04/2021 at 5:11 PM, revealed she completed the MDS assessment for Resident #80 on 10/12/2021. The MDS Coordinator/Interim DON stated the Dietary Manager has the responsibility for coding the Swallowing/Nutritional Status on the MDS; however the MDS Coordinator/Interim DON revealed she was responsible for signing the MDS as completed. The MDS Coordinator/Interim DON further revealed each department was responsible for accurately coding the MDS. Interview with the Dietary Manager on 11/04/2021 at 5:52 PM revealed the MDS section K0300 for Resident #80 should have been marked 02 revealing the resident had a weight loss of 10 percent or more in the last six (6) months. The Dietary Manager further revealed her computer usually flags weight losses and the computer had failed to do so; the Dietary Manager also revealed she had overlooked the weight loss to code on the MDS.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of four (4) sampled residents (Resident #1 and Resident #2) was protected from abuse. On 04/19/2021 at approximately 9:30-10:00 PM, State Registered Nurse Aide (SRNA) #3 told Resident #1 to shut the h**l up at the nursing station. Licensed Practical Nurse (LPN) #1 and SRNA #1 witnessed the verbal abuse. Later during the shift on 04/20/2021 at approximately 2:00 AM, while SRNA #1 and SRNA #3 was providing care for Resident #2, SRNA #3 placed her hand over the resident's mouth to keep him/her from yelling out. The allegations of abuse were not reported to administrative staff until 04/22/2021. The facility investigated the abuse allegations and substantiated both the verbal and physical abuse. The findings include: Review of the facility policy titled Abuse Prohibition Prevention, undated, revealed the facility provides information for the prevention of allegations of abuse and neglect to residents. The procedures for the prevention of abuse are to include staff training to assure staff can identify others who have inappropriate behaviors, such as derogatory language, rough handling, ignoring residents while giving care, etc. Review of the facility policy titled Abuse Identification, undated, revealed the facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident's property may occur. All staff are required to report any observation, suspicion, or information otherwise obtained related possible abuse to their supervisor, social services, Director of Nursing and Administrator immediately. Review of the initial facility investigation dated 04/22/2021 completed by the Administrator revealed it was alleged on 04/19/2021 and 04/20/2021, SRNA #3 told Resident #1 to shut the h-l up and placed her hand over Resident #2 mouth when he/she was talking. Review of Resident #1 medical record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Dementia, Pain, Hypertension, Restlessness and Agitation. Review of resident Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. Review of Resident #2 medical record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Dementia, [CONDITION(S)] and Chronic Obstructive Pulmonary Disorder ([CONDITION(S)]). Review of resident Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a BIMS score of five (5) indicating severely impaired cognition. Attempts to interview Resident #1 or Resident #2 were unsuccessful due to the residents' cognitively impaired mental status. Interview with SRNA #1, on 06/08/2021 at 3:23 PM, revealed on 04/19/2021 at approximately 9:30 PM to 10:00 PM, Resident #1 was at the nursing station with LPN #1, SRNA #3 and herself. She revealed Resident #1 was yelling when SRNA #3 looked at him/her and told the resident to shut the h-l up. She further revealed LPN #1 witnessed the abuse and told SRNA #3 to walk out and take a breather; however, SRNA #3 did not exit the facility. SRNA #1 revealed SRNA #3 remained in the facility and provided resident care. During the shift, on 04/20/2021 at approximately 2:00 AM, SRNA #1 and SRNA #3 entered Resident #2's room to provide care. The SRNA stated Resident #2 would make noises like [NAME]. While providing care, SRNA #3 placed her hand on the resident's mouth and the resident stopped making noise. SRNA #1 stated she told SRNA #3 to remove her hand. She stated she finished providing care for Resident #2 and went immediately and notified LPN #1 at which time she thought the LPN reported it to the appropriate staff. SRNA #1 finished the shift with SRNA #3 until approximately 7:00 AM on 04/20/2021. SRNA #1 revealed she returned to work on 04/22/2021 and she identified SRNA #3 was working. The SRNA stated at that time, she notified LPN #3 of the events which occurred on 04/19/2021 and 04/20/2021. LPN #3 removed SRNA #3 from resident care and an investigation was initiated. SRNA #1 revealed she was aware abuse was to be reported immediately and she should have followed the chain of command when LPN #1 failed to remove SRNA #3 from resident care. Interview with SRNA #3, on 06/09/2021 at 9:23 AM, revealed she denied the allegations of verbal and physical abuse toward Resident #1 and Resident #2. Interview with LPN #1, on 06/08/2021 at 9:13 PM, revealed Resident #1 was at the nurse's station with SRNA #1, SRNA #3 and herself. She revealed the resident was hollering like he/she does. She stated SRNA #3 was having one of her meltdowns and turned around and told Resident #1 to shut the f-k up. She revealed she immediately told SRNA #3, You do not ever say that to or in front of a resident next time I'll send you home; you cannot do that. She revealed SRNA #3 apologized to Resident #1. LPN #1 revealed she did not remove SRNA #3 from resident care and did not report the verbal abuse to appropriate staff. She revealed she should have. LPN #1 further revealed later in the night at some time before midnight SRNA #1 whispered to her at the nurse's station SRNA #3 put her hand over Resident #2's mouth so he/she could not holler. She stated she responded to SRNA #1 you're just now telling me. She stated SRNA #1 and SRNA #3 had been out of that room for like an hour. LPN #1 revealed she did not take it as a report of abuse; however, she should have and it should have been reported. She revealed SRNA #3 was not removed from resident care and she did not report the abuse to anyone. Interview with LPN #3, on 06/09/2021 at 4:05 PM, revealed on the night of 04/22/2021, SRNA #1 came in for her shift and voiced concerns when she learned SRNA #3 was working. The LPN stated SRNA #1 reported the allegations of abuse involving Resident #1 and Resident #2. The LPN stated after receiving the allegations, she notified the Director of Nursing, SRNA #3 was removed from resident care and escorted to the time clock. Per the LPN, she assessed both Resident #1 and Resident #2 and did not identify any new concerns. Interview with Social Service Director (SSD,) on 06/09/2021 at 2:20 PM, revealed she was not notified of the abuse until 04/22/2021 by LPN #3. The SSD stated on 04/22/2021 around shift change (7:00 PM), she received a call from LPN #3 stating SRNA #1 came in for her shift and questioned why SRNA #3 was not suspended. She revealed LPN #3 then notified her of the allegations at which point the investigation was initiated. The SSD stated staff are educated to report all abuse immediately and remove the accused person from resident care. She revealed she was unaware why LPN #1 failed to report the abuse immediately; however, both the verbal abuse toward Resident #1 and physical abuse toward Resident #2 should have been reported. Interview with Assistant Director of Nursing (ADON), on 06/09/2021 at 3:10 PM, revealed she was not notified of the abuse on 04/19/2021 or on 04/20/2021. The ADON stated the expectation is for staff to stop the abuse and report it immediately. She revealed SRNA #3 should have been removed from the floor when she verbally abused Resident #1. Interview with the Director of Nursing (DON), on 06/09/2021 at 3:23 PM, revealed the facility had identified the allegation of both verbal and physical abuse was substantiated. The DON stated she was unaware of the abuse until 04/22/2021 at around 7:00 PM when LPN #3 notified her of SRNA #1 statement. She revealed LPN #1 should have removed SRNA #3 from resident care and suspended her pending investigation when the abuse occurred. The DON stated LPN #1 had been educated on proper abuse reporting; however, was unable to determine why LPN #1 failed to report abuse and follow abuse protocol. Interview with the Assistant Administrator, on 06/09/2021 at 4:22 PM, revealed SRNA #1 reported to LPN #3 that approximately two (2) days prior on 04/19/2021-04/20/2021, SRNA #3 had verbally abused Resident #1 and later in the shift physically abused Resident #2. The Assistant Administrator stated SRNA #1 reported the abuse to LPN #1, in addition LPN #1 witnessed the verbal abuse. She further revealed staff are educated to report all allegations of abuse immediately to the nurse. The nurse is then expected to follow protocol and remove the accused from resident care and escort the accused to time clock for suspension pending an investigation. The Administrator stated LPN #1 failed to report the verbal abuse and failed to remove SRNA #3 from resident care. Per the Administrator, if LPN #1 would have followed the facility policy and procedure, Resident #2 would have not suffered the physical abuse later in the shift. She revealed the facility had substantiated the abuse and SRNA #3 was terminated from employment. Furthermore, LPN #1 received disciplinary action and re-education. **The facility alleges the following action was taken to correct the deficient practice and alleges substantial compliance as of 04/30/2021: 1). On 04/22/2021, an allegation of potential abuse by State Registered Nursing Assistant (SRNA) #2 was reported to Licensed (LPN) #3 by SRNA #1. LPN #3 immediately removed SRNA #2 from resident care and sent the SRNA home pending results of the investigation. LPN #3 notified the DON on 04/22/2021 of potential allegations involving SRNA #2. The Director of Nursing (DON) and the Social Services Director (SSD) on 04/22/2021 and initiated an investigation immediately. The Administrator and Assistant Administrator were notified on 04/22/2021. The facility reported the incident to the appropriate agencies on 04/22/2021. 2). Resident #1 and Resident #2 both had severe cognitive impairment and were not be interviewed. Staff conducted skin assessments on both residents, with no concerns noted. 3). The DON notified the Attending Physician of the allegations on 04/22/2021. 4). The SSD notified Resident #1 and Resident #2's responsible parties of the incident on 04/23/2021. 5). On 04/22/2021 a Quality Assurance Performance Improvement (QAPI) meeting was conducted. The following QAPI members were in attendance: Administrator, Assistant Administrator, DON, SSD and Medical Director. 6). A root cause analysis (RCA) was initiated on 04/22/2021 by the Administrator to help identify possible cause(s) for the alleged abuse and why LPN #1 failed to report the allegations to Administrator, Assistant Administrator, DON, ADON or SSD. 7). On 04/28/2021, a final/investigation involving Resident #1 and potential allegation of abuse was sent to appropriate agencies. The facility substantiated that abuse allegation. The facility terminated SRNA #2 on 04/27/2021. LPN #1 received education and disciplinary action for failure to report allegations of abuse. LPN #1 was required to complete a post-test following education. 8). Questionnaires for residents with a BIMS score of eight (8) to fifteen (15) were conducted on 04/22/2021 and 04/23/2021 by the Assistant Administrator and SSD regarding any concerns with staff. 9). Skin assessments were completed for all residents with a BIMS of seven (7) or below to identify any signs and/or symptoms of abuse. LPN #3 and the DON completed skin assessments on 04/22/2021 and 04/23/2021. No issues were identified. 10). All staff were in-serviced on 04/22/2021, 04/23/2021, 04/24/2021, 04/25/2021, and 04/26/2021 by the Administrator, Assistant Administrator, SSD, Staff Development Coordinator and Unit Manager regarding Abuse Prevention and Reporting. All staff completed post-test to ensure their understanding and comprehension of the education. All newly hired staff will receive education regarding Abuse Prevention, Reporting and will be required to complete a post-test during the orientation period. All newly hired staff will receive education regarding Abuse Prevention, Reporting and will be required to complete post-test during the orientation period. The education included: A). Facility Abuse Prevention Policy and appropriate actions to take when abuse is observed or suspected, including stop it, ensure safety, remove perpetrator immediately, immediately report allegations and if report of allegation is not immediately acted upon by supervision, staff are to further report to another supervisor immediately. B). The definitions and types of abuse-(i.e. physical, mental, verbal, neglect, misappropriation of resident property, sexual, exploitation). 11). The facility Abuse Prevention Policy is located in each department for all staff to review, including nursing stations. The Administrator, Assistant Administrator and DON reviewed the facility's abuse policy on 04/23/2021 and made no changes to the policy. The facility consulted the Medical Director on 04/23/2021 who was in agreement. 12). any reported allegations of abuse or neglect will be discussed in the daily stand-up meeting and at least quarterly through QAPI. The areas reviewed included but were not limited to a thorough review of incidents to include immediate interventions to ensure resident safety, investigation of the incident, notification of responsible party, physician, facility leadership and state and local agencies as required, root-cause analysis, completion of any identified areas of education and training, equipment or environmental repairs, etc. The QAPI Committee included, the Administrator, Assistant Administrator, DON, ADON, Medical Director, Pharmacist, Dietary Manager, MDS Nurse, Admission Coordinator, Maintenance Director, Housekeeping/Laundry Supervisor, Activities Director and SSD. The QAPI Committee will review, discuss, and implement any necessary changes as indicated. 13). The SSD or assigned designee will observe Resident #1 and Resident #2 for any signs or symptoms of mental anguish or distress and will document findings. This will occur daily three (3) times per week for two (2) weeks and will then be re-evaluated. This will be reported quarterly through QAPI and will be re-evaluated as needed. 14). Beginning the week of 04/22/2021, the Administrator, Assistant Administrator, SSD, SSD Designee, Activity Director or an assigned designee will round and observe staff interactions with residents. Any interaction that could be defined as abuse or neglect per guidelines will be immediately acted upon to ensure resident safety, removing the staff member from the environment and reporting the incident per regulation. The monitoring will be conducted across all shifts as follows, five (5) times per week for two (2) weeks, then three (3) times per week for two (2) weeks, then one (1) time per week for four (4) weeks. The monitoring will be reported quarterly through QAPI and will be re-evaluated at that time. 15). Beginning the week of 04/22/2021, random interview of twelve (12) residents and employees will be conducted regarding care and treatment and Abuse Prevention and Reporting by the SSD, Activities Assistant, Administrator or an assigned designee for a total of three (3) months. The interviews will be reported quarterly through QAPI and will be re-evaluated at that time. All allegations of abuse or neglect will be reported to the appropriate agencies in accordance with regulations. 16) The Medical Director will be informed of any allegations of abuse or neglect by the Administrator, Assistant Administrator, DON, ADON and/or an assigned designee. The Medical Director will continue to provide oversight during the compliance process. The QAPI committee reviewed and approved the immediate action on 04/22/2021 and reviewed and approved the plan of correction on 04/28/2021. ** The State agency verified the facility's corrective action as follows, and determined the facility was back in compliance as alleged on 04/03/2021. 1). Interview with LPN #3 on 06/09/2021 at 4:05 PM revealed she was notified of the potential allegation by SRNA #2 on 04/22/2021 at approximately 7:00 PM. She immediately removed SRNA #2 from resident care and notified the DON. She revealed that she received instruction by the DON to escort SRNA #2 to the time clock and suspend her until further investigation. Interview with the DON on 06/09/2021 at 2:55 PM revealed that LPN #3 notified her of the allegation on 04/22/2021. She revealed that she was notified that the allegation occurred on 04/19/2021 to 04/20/2021, however, LPN #1 failed to notify the appropriate staff when she witnessed verbal abuse by SRNA #2 and was notified of physical abuse by SRNA #1. She further stated staff immediately removed SRNA #2 from the floor and escorted her to the time clock. The SRNA was suspended pending further investigation. She revealed that she notified the SSD on 04/22/2021. Interview with SSD on 06/09/2021 at 2:20 PM revealed she was notified on 04/22/2021, she revealed that she immediately initiated an investigation of the allegation. She stated she reported to the building where she ensured the allegation was reported to the appropriate agencies. Review of record revealed all appropriate agencies were notified on 04/22/2021. 2). Interview with the DON on 06/21/2021 at 2:45 PM, revealed she assisted with skin assessments completed on 04/22/2021. She stated no new areas were identified for Resident #1 or Resident #2. Review of Resident #1 and Resident #2 skin assessments completed on 04/22/2021, revealed no new areas of concern. 3). Interview with Physician #1 on 06/09/2021 at 9:47 AM revealed he does expect staff to notify him of allegations of abuse. He stated he could not recall one way or another if he was notified. However, he stated that he was aware of the situation and did not have any new orders related to the incident. He further revealed that he trusted the facility to follow the abuse protocol and had no concerns with abuse in the facility at this time. Interview with the Medical Director on 06/21/2021 at 2:15 PM revealed he was notified of the allegation and had no new orders. Review of medical record revealed Physician #1 was notified on 04/23/2021 and the Medical Director was notified on 04/22/2021. 4). Review of medical records revealed both Resident #1 and Resident #2's responsible parties were notified on 04/23/2021. Interview with SSD on 06/21/2021 at 2:34 PM revealed she notified both Resident #1 and Resident #2's responsible parties of the allegations. 5). Review of minutes revealed a QAPI meeting was conducted with the attendees including the Administrator, Assistant Administrator, DON, SSD and Medical Director. Interview with the SSD on 06/09/2021 at 2:20 PM, DON on 06/09/2021 at 2:55 PM, Assistant Administrator on 06/09/2021 at 4:22 PM and Administrator on 06/21/2021 at 3:20 PM revealed they attended the meeting and implemented the Quality Assurance process. Interview with the Medical Director on 06/21/2021 at 2:15 PM revealed that he attended the QAPI meetings and followed the facility plan for correction. 6). Review of the Root Cause Analysis (RCA) initiated on 04/22/2021 revealed LPN #1 failed to report the allegation. Interview with the Administrator on 06/21/2021 at 3:20 PM revealed she initiated the root-cause analysis, she stated LPN #1 failed to follow the protocol and report the allegation of abuse. 7). Review of the Final Report/Investigation revealed the facility substantiated the abuse allegation. Interview with the Administrator on 06/21/2021 at 3:20 PM revealed the facility substantiated the allegation based on LPN #1 and SRNA #1 witnessing the abuse. She further revealed that SRNA #2 was terminated from employment and LPN #1 received education and disciplinary action. Review of employee termination record, revealed SRNA #2 was terminated from the facility on 04/27/2021. Review of education and post-test for LPN #1 revealed no concerns. Interview with LPN #1 on 06/08/2021 at 9:13 PM, revealed that she was educated by the DON related to reporting potential allegations. She revealed that she was required to complete a post-test for education and received disciplinary actions for failure to report. She further revealed that she was aware she should have reported the allegation. 8). Review of questionnaires completed by all residents with a Brief Interview for Mental Status (BIMS) of eight (8) to fifteen (15) completed on 04/22/2021 and 04/23/2021, revealed no concerns. Interview with the SSD on 06/09/2021 at 2:20 PM and the Assistant Administrator on 06/09/2021 at 4:22 PM revealed no concerns were identified during completion of the questionnaires. 9). Review of the skin assessments completed for all residents with BIMS of seven (7) or below, revealed no concerns. Interview with the DON on 06/21/2021 at 2:45 PM revealed no concerns were identified. 10). Review of in-service education revealed no concerns. Interview with SRNA #1 on 06/08/2021 at 323, SRNA #2 on 06/09/2021 at 9:02 AM, SRNA #4 on 06/09/2021 at 10:06 AM, SRNA #5 on 06/09/2021 at 9:30 AM, SRNA #6 on 06/21/2021 at 1:56 PM, SRNA #7 on 06/21/2021 at 2:08 PM, LPN #1 on 06/08/2021 at 9:13 PM, LPN #2 on 06/09/2021 at 4:00 PM, LPN #3 on 06/09/2021 at 4:05 PM, LPN #4 on 06/09/2021 at 4:14 PM, LPN #5 on 06/21/2021 at 2:30 PM and RN #2 on 06/09/2021 at 11:30 AM revealed they had all received the education related to abuse. Further, interview, revealed they were educated on proper reporting of abuse and utilizing the chain of command. The staff were required to complete a post-test following the education. Review of new hire on 06/08/2021, revealed education and posttest with no identified concerns. 11). Interview with SRNA #6 on 06/21/2021 at 1:56 PM, SRNA #7 on 06/21/2021 at 2:08 PM and LPN #5 on 06/21/2021 at 2:30 PM, revealed the staff could verbalize and reference the facility policy. Further interview revealed the policy was easily accessible at each nursing station. Interview with the DON on 06/21/2021 at 2:45 PM, Administrator on 06/21/2021 at 3:20 PM and Medical Director on 06/21/2021 at 2:15 PM revealed no concerns regarding the facility abuse policy. 12). Review of the facility QAPI process and tracking of facility allegations revealed no identified concerns. Interview with the DON on 06/21/2021 at 2:45 PM, SSD on 06/21/2021 at 2:34 PM and Administrator on 06/21/2021 at 3:20 PM revealed the facility discussed any allegation of abuse and/or incident/accident in daily morning meeting (Monday-Friday). Further interview revealed that all allegations were reviewed in QAPI at least quarterly. 13). Review of monitoring for Resident #1 and Resident #2 revealed no identified concerns. Interview with SSD on 06/21/2021 at 2:34 PM revealed she was responsible for the monitoring for Resident #1 and Resident #2 and had not identified any concerns regarding any signs or symptoms of mental anguish or distress. Interview with Physician #1 on 06/09/2021 at 9:47 AM revealed no any signs or symptoms of mental anguish or distress had been identified for Resident #1 and/or Resident #2. 14). Review of monitoring for staff/resident interactions revealed no identified concerns. Interview with the DON on 06/21/2021 at 2:45 PM, SSD on 06/21/2021 at 2:34 PM and Administrator on 06/21/2021 at 3:20 PM revealed no identified concerns regarding abuse. 15). Interview with residents and staff conducted on 06/08/2021, 06/09/2021 and 06/21/2021 revealed no identified concerns regarding abuse and/or care and treatment. Review of interviews for residents and employees revealed no identified concerns. Interview with SSD on 06/21/2021 at 2:34 PM and Administrator on 06/21/2021 at 3:20 PM revealed no identified concerns. 16). Interview with the Medical Director on 06/21/2021 at 2:15 PM revealed that he was involved in the ongoing QAPI process and was in agreement with the allegation of compliance on 04/28/2021.

Based on interview, record review and facility policy review, it was determined the facility failed to report an allegation of verbal and physical abuse timely for two (2) of four (4) sampled residents (Resident #1 and Resident #2). On 04/19/2021 at approximately 9:30-10:00 PM, State Registered Nurse Aide (SRNA) #3 told Resident #1 to shut the h**l up at the nursing station. Licensed Practical Nurse (LPN) #1 and SRNA #1 witnessed the verbal abuse. LPN #1 failed to report the allegation of abuse and failed to ensure residents were protected from further potential abuse. Later during the shift on 04/20/2021 at approximately 2:00 AM, while SRNA #1 and SRNA #3 were providing care for Resident #2, SRNA #3 placed her hand over the resident's mouth to keep him/her from yelling out. SRNA #1 reported to LPN #1; however, again the LPN failed to report the allegation and remove SRNA #3 from resident care. The allegation was not reported/investigated until 04/22/2021. The findings include: Review of the facility policy titled, Abuse Response and Reporting, undated, revealed employees are required to report allegations of abuse, neglect, exploitation or mistreatment and misappropriation of resident property are reported immediately to the Social Services Director, the Administrator and the Director of Nursing. Review of the initial facility investigation dated 04/22/2021 completed by the Administrator revealed it was alleged on 04/19/2021 or 04/20/2021 that SRNA #3 told Resident #1 to shut the h-l up and placed her hand over Resident #2's mouth when he/she was talking. Review of Resident #1 medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. Review of Resident #2 medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a BIMS score of five (5)indicating severely impaired cognition. Attempts to interview Resident #1 or Resident #2 were unsuccessful due to the residents' cognitively impaired mental status. Interview with SRNA #1, on 06/08/2021 at 3:23 PM, revealed on 04/19/2021 at approximately 9:30 PM to 10:00 PM, Resident #1 was at the nursing station with LPN #1, SRNA #3 and herself. She revealed Resident #1 was yelling when SRNA #3 looked at him/her and told the resident to shut the h-l up. She further revealed LPN #1 witnessed the abuse the incident and told SRNA #3 to walk out and take a breather; however, SRNA #3 did not exit the facility. SRNA #1 revealed SRNA #3 remained in the facility and provided resident care. During the shift, on 04/20/2021 at approximately 2:00 AM, SRNA #1 and SRNA #3 entered Resident #2's room to provide care. The SRNA stated Resident #2 would make noises like [NAME]. While providing care, SRNA #3 placed her hand on the resident's mouth and the resident stopped making noise. SRNA #1 stated she told SRNA #3 to remove her hand. She stated she finished providing care for Resident #2 and went immediately and notified LPN #1 at which time she thought the LPN reported it to the appropriate staff. SRNA #1 finished the shift with SRNA #3 until approximately 7:00 AM on 04/20/2021. SRNA #1 revealed she returned to work on 04/22/2021 where she identified SRNA #3 was working. The SRNA stated at this time, she notified LPN #3 of the events which occurred on 04/19/2021 and 04/20/2021. LPN #3 removed SRNA #3 from resident care and investigation was initiated. SRNA #1 revealed she was aware abuse was to be reported immediately and she should have followed the chain of command when LPN #1 failed to remove SRNA #3 from resident care. Interview with SRNA #3, on 06/09/2021 at 9:23 AM, revealed she denied the allegations of verbal and physical abuse toward Resident #1 and Resident #2. Interview with LPN #1, on 06/08/2021 at 9:13 PM, revealed Resident #1 was at the nurse's station with SRNA #1, SRNA #3 and herself. She revealed the resident was hollering like he/she does. She stated SRNA #3 was having one of her meltdowns and turned around and told Resident #1 to shut the f-k up. She revealed she immediately told SRNA #3, You do not ever say that to or in front of a resident. Next time I'll send you home; you cannot do that. She revealed SRNA #3 apologized to Resident #1. LPN #1 revealed she did not remove SRNA #3 from resident care and did not report the verbal abuse to appropriate staff. She revealed she should have. LPN #1 further revealed later in the night at some time before midnight SRNA #1 whispered to her at the nurse's station SRNA #3 put her hand over Resident #2's mouth so he/she could not holler. She stated she responded to SRNA #1 you're just now telling me. She stated SRNA #1 and SRNA #3 had been out of that room for like an hour. LPN #1 revealed she did not take it as a report of abuse; however, she should have and it should have been reported. She revealed SRNA #3 was not removed from resident care and she did not report the abuse to anyone. Interview with LPN #3, on 06/09/2021 at 4:05 PM, revealed on the night of 04/22/2021, SRNA #1 came in for her shift and voiced concerns when she learned SRNA #3 was working. The LPN stated SRNA #1 reported the allegations of abuse involving Resident #1 and Resident #2. The LPN stated after receiving the allegations, she notified the Director of Nursing and SRNA #3 was removed from resident care and escorted to the time clock. Per the LPN, she assessed both Resident #1 and Resident #2 and did not identify any new concerns. Interview with Social Service Director (SSD), on 06/09/2021 at 2:20 PM, revealed she was not notified of the abuse until 04/22/2021. The SSD stated on 04/22/2021 around shift change (7:00 PM), she received a call from LPN #3 stating SRNA #1 came in for her shift and questioned why SRNA #3 was not suspended. She revealed LPN #3 then notified her of the allegations at which point the investigation was initiated. The SSD stated staff are educated to report all abuse immediately and remove the accused person from resident care. She revealed she was unaware why LPN #1 failed to report the abuse immediately; however, both the verbal abuse toward Resident #1 and physical abuse toward Resident #2 should have been reported. Interview with Assistant Director of Nursing (ADON), on 06/09/2021 at 3:10 PM, revealed she was not notified of the abuse on 04/19/2021 or on 04/20/2021. The ADON stated the expectation is for staff to stop the abuse and report it immediately. She revealed SRNA #3 should have been removed from the floor when she verbally abused Resident #1. Interview with the Director of Nursing (DON), on 06/09/2021 at 3:23 PM, revealed the facility had identified the allegation of both verbal and physical abuse was substantiated. The DON stated she was unaware of the abuse until 04/22/2021 at around 7:00 PM when LPN #3 notified her of SRNA #1's statement. She revealed LPN #1 should have removed SRNA #3 from resident care and suspended her pending investigation when the abuse occurred. The DON stated LPN #1 had been educated on proper abuse reporting; however, she stated was unable to determine why LPN #1 failed to report abuse and follow the abuse protocol. Interview with the Assistant Administrator, on 06/09/2021 at 4:22 PM, revealed SRNA #1 reported to LPN #3 that approximately two (2) days prior on 04/19/2021-04/20/2021, SRNA #3 had verbally abused Resident #1 and later in the shift physically abused Resident #2. Per the Assistant Administrator, SRNA #1 had reported the abuse to LPN #1, in addition LPN #1 witnessed the verbal abuse. She further revealed staff are educated to report all allegations of abuse immediately to the nurse. The nurse is then expected to follow protocol and remove the accused from resident care and escort the accused to time clock for suspension pending an investigation. The Assistant Administrator stated LPN #1 failed to report the verbal abuse and failed to remove SRNA #3 from resident care. Per the Assistant Administrator, if LPN #1 followed the facility policy and procedure, Resident #2 would have not suffered the physical abuse later in the shift. She revealed the facility had substantiated the abuse and SRNA #3 was terminated from employment. Furthermore, LPN #1 received disciplinary action and re-education. **The facility alleges the following action was taken to correct the deficient practice and alleges substantial compliance as of 04/30/2021: 1). On 04/22/2021, an allegation of potential abuse by State Registered Nursing Assistant (SRNA) #2 was reported to Licensed (LPN) #3 by SRNA #1. LPN #3 immediately removed SRNA #2 from resident care and sent the SRNA home pending results of the investigation. LPN #3 notified the DON on 04/22/2021 of potential allegations involving SRNA #2. The Director of Nursing (DON) and the Social Services Director (SSD) on 04/22/2021 and initiated an investigation immediately. The Administrator and Assistant Administrator were notified on 04/22/2021. The facility reported the incident to the appropriate agencies on 04/22/2021. 2). Resident #1 and Resident #2 both had severe cognitive impairment and were not be interviewed. Staff conducted skin assessments on both residents, with no concerns noted. 3). The DON notified the Attending Physician of the allegations on 04/22/2021. 4). The SSD notified Resident #1 and Resident #2's responsible parties of the incident on 04/23/2021. 5). On 04/22/2021 a Quality Assurance Performance Improvement (QAPI) meeting was conducted. The following QAPI members were in attendance: Administrator, Assistant Administrator, DON, SSD and Medical Director. 6). A root cause analysis (RCA) was initiated on 04/22/2021 by the Administrator to help identify possible cause(s) for the alleged abuse and why LPN #1 failed to report the allegations to Administrator, Assistant Administrator, DON, ADON or SSD. 7). On 04/28/2021, a final/investigation involving Resident #1 and potential allegation of abuse was sent to appropriate agencies. The facility substantiated that abuse allegation. The facility terminated SRNA #2 on 04/27/2021. LPN #1 received education and disciplinary action for failure to report allegations of abuse. LPN #1 was required to complete a post-test following education. 8). Questionnaires for residents with a BIMS score of eight (8) to fifteen (15) were conducted on 04/22/2021 and 04/23/2021 by the Assistant Administrator and SSD regarding any concerns with staff. 9). Skin assessments were completed for all residents with a BIMS of seven (7) or below to identify any signs and/or symptoms of abuse. LPN #3 and the DON completed skin assessments on 04/22/2021 and 04/23/2021. No issues were identified. 10). All staff were in-serviced on 04/22/2021, 04/23/2021, 04/24/2021, 04/25/2021, and 04/26/2021 by the Administrator, Assistant Administrator, SSD, Staff Development Coordinator and Unit Manager regarding Abuse Prevention and Reporting. All staff completed post-test to ensure their understanding and comprehension of the education. All newly hired staff will receive education regarding Abuse Prevention, Reporting and will be required to complete a post-test during the orientation period. All newly hired staff will receive education regarding Abuse Prevention, Reporting and will be required to complete post-test during the orientation period. The education included: A). Facility Abuse Prevention Policy and appropriate actions to take when abuse is observed or suspected, including stop it, ensure safety, remove perpetrator immediately, immediately report allegations and if report of allegation is not immediately acted upon by supervision, staff are to further report to another supervisor immediately. B). The definitions and types of abuse-(i.e. physical, mental, verbal, neglect, misappropriation of resident property, sexual, exploitation). 11). The facility Abuse Prevention Policy is located in each department for all staff to review, including nursing stations. The Administrator, Assistant Administrator and DON reviewed the facility's abuse policy on 04/23/2021 and made no changes to the policy. The facility consulted the Medical Director on 04/23/2021 who was in agreement. 12). any reported allegations of abuse or neglect will be discussed in the daily stand-up meeting and at least quarterly through QAPI. The areas reviewed included but were not limited to a thorough review of incidents to include immediate interventions to ensure resident safety, investigation of the incident, notification of responsible party, physician, facility leadership and state and local agencies as required, root-cause analysis, completion of any identified areas of education and training, equipment or environmental repairs, etc. The QAPI Committee included, the Administrator, Assistant Administrator, DON, ADON, Medical Director, Pharmacist, Dietary Manager, MDS Nurse, Admission Coordinator, Maintenance Director, Housekeeping/Laundry Supervisor, Activities Director and SSD. The QAPI Committee will review, discuss, and implement any necessary changes as indicated. 13). The SSD or assigned designee will observe Resident #1 and Resident #2 for any signs or symptoms of mental anguish or distress and will document findings. This will occur daily three (3) times per week for two (2) weeks and will then be re-evaluated. This will be reported quarterly through QAPI and will be re-evaluated as needed. 14). Beginning the week of 04/22/2021, the Administrator, Assistant Administrator, SSD, SSD Designee, Activity Director or an assigned designee will round and observe staff interactions with residents. Any interaction that could be defined as abuse or neglect per guidelines will be immediately acted upon to ensure resident safety, removing the staff member from the environment and reporting the incident per regulation. The monitoring will be conducted across all shifts as follows, five (5) times per week for two (2) weeks, then three (3) times per week for two (2) weeks, then one (1) time per week for four (4) weeks. The monitoring will be reported quarterly through QAPI and will be re-evaluated at that time. 15). Beginning the week of 04/22/2021, random interview of twelve (12) residents and employees will be conducted regarding care and treatment and Abuse Prevention and Reporting by the SSD, Activities Assistant, Administrator or an assigned designee for a total of three (3) months. The interviews will be reported quarterly through QAPI and will be re-evaluated at that time. All allegations of abuse or neglect will be reported to the appropriate agencies in accordance with regulations. 16) The Medical Director will be informed of any allegations of abuse or neglect by the Administrator, Assistant Administrator, DON, ADON and/or an assigned designee. The Medical Director will continue to provide oversight during the compliance process. The QAPI committee reviewed and approved the immediate action on 04/22/2021 and reviewed and approved the plan of correction on 04/28/2021. ** The State agency verified the facility's corrective action as follows, and determined the facility was back in compliance as alleged on 04/03/2021. 1). Interview with LPN #3 on 06/09/2021 at 4:05 PM revealed she was notified of the potential allegation by SRNA #2 on 04/22/2021 at approximately 7:00 PM. She immediately removed SRNA #2 from resident care and notified the DON. She revealed that she received instruction by the DON to escort SRNA #2 to the time clock and suspend her until further investigation. Interview with the DON on 06/09/2021 at 2:55 PM revealed that LPN #3 notified her of the allegation on 04/22/2021. She revealed that she was notified that the allegation occurred on 04/19/2021 to 04/20/2021, however, LPN #1 failed to notify the appropriate staff when she witnessed verbal abuse by SRNA #2 and was notified of physical abuse by SRNA #1. She further stated staff immediately removed SRNA #2 from the floor and escorted her to the time clock. The SRNA was suspended pending further investigation. She revealed that she notified the SSD on 04/22/2021. Interview with SSD on 06/09/2021 at 2:20 PM revealed she was notified on 04/22/2021, she revealed that she immediately initiated an investigation of the allegation. She stated she reported to the building where she ensured the allegation was reported to the appropriate agencies. Review of record revealed all appropriate agencies were notified on 04/22/2021. 2). Interview with the DON on 06/21/2021 at 2:45 PM, revealed she assisted with skin assessments completed on 04/22/2021. She stated no new areas were identified for Resident #1 or Resident #2. Review of Resident #1 and Resident #2 skin assessments completed on 04/22/2021, revealed no new areas of concern. 3). Interview with Physician #1 on 06/09/2021 at 9:47 AM revealed he does expect staff to notify him of allegations of abuse. He stated he could not recall one way or another if he was notified. However, he stated that he was aware of the situation and did not have any new orders related to the incident. He further revealed that he trusted the facility to follow the abuse protocol and had no concerns with abuse in the facility at this time. Interview with the Medical Director on 06/21/2021 at 2:15 PM revealed he was notified of the allegation and had no new orders. Review of medical record revealed Physician #1 was notified on 04/23/2021 and the Medical Director was notified on 04/22/2021. 4). Review of medical records revealed both Resident #1 and Resident #2's responsible parties were notified on 04/23/2021. Interview with SSD on 06/21/2021 at 2:34 PM revealed she notified both Resident #1 and Resident #2's responsible parties of the allegations. 5). Review of minutes revealed a QAPI meeting was conducted with the attendees including the Administrator, Assistant Administrator, DON, SSD and Medical Director. Interview with the SSD on 06/09/2021 at 2:20 PM, DON on 06/09/2021 at 2:55 PM, Assistant Administrator on 06/09/2021 at 4:22 PM and Administrator on 06/21/2021 at 3:20 PM revealed they attended the meeting and implemented the Quality Assurance process. Interview with the Medical Director on 06/21/2021 at 2:15 PM revealed that he attended the QAPI meetings and followed the facility plan for correction. 6). Review of the Root Cause Analysis (RCA) initiated on 04/22/2021 revealed LPN #1 failed to report the allegation. Interview with the Administrator on 06/21/2021 at 3:20 PM revealed she initiated the root-cause analysis, she stated LPN #1 failed to follow the protocol and report the allegation of abuse. 7). Review of the Final Report/Investigation revealed the facility substantiated the abuse allegation. Interview with the Administrator on 06/21/2021 at 3:20 PM revealed the facility substantiated the allegation based on LPN #1 and SRNA #1 witnessing the abuse. She further revealed that SRNA #2 was terminated from employment and LPN #1 received education and disciplinary action. Review of employee termination record, revealed SRNA #2 was terminated from the facility on 04/27/2021. Review of education and post-test for LPN #1 revealed no concerns. Interview with LPN #1 on 06/08/2021 at 9:13 PM, revealed that she was educated by the DON related to reporting potential allegations. She revealed that she was required to complete a post-test for education and received disciplinary actions for failure to report. She further revealed that she was aware she should have reported the allegation. 8). Review of questionnaires completed by all residents with a Brief Interview for Mental Status (BIMS) of eight (8) to fifteen (15) completed on 04/22/2021 and 04/23/2021, revealed no concerns. Interview with the SSD on 06/09/2021 at 2:20 PM and the Assistant Administrator on 06/09/2021 at 4:22 PM revealed no concerns were identified during completion of the questionnaires. 9). Review of the skin assessments completed for all residents with BIMS of seven (7) or below, revealed no concerns. Interview with the DON on 06/21/2021 at 2:45 PM revealed no concerns were identified. 10). Review of in-service education revealed no concerns. Interview with SRNA #1 on 06/08/2021 at 323, SRNA #2 on 06/09/2021 at 9:02 AM, SRNA #4 on 06/09/2021 at 10:06 AM, SRNA #5 on 06/09/2021 at 9:30 AM, SRNA #6 on 06/21/2021 at 1:56 PM, SRNA #7 on 06/21/2021 at 2:08 PM, LPN #1 on 06/08/2021 at 9:13 PM, LPN #2 on 06/09/2021 at 4:00 PM, LPN #3 on 06/09/2021 at 4:05 PM, LPN #4 on 06/09/2021 at 4:14 PM, LPN #5 on 06/21/2021 at 2:30 PM and RN #2 on 06/09/2021 at 11:30 AM revealed they had all received the education related to abuse. Further, interview, revealed they were educated on proper reporting of abuse and utilizing the chain of command. The staff were required to complete a post-test following the education. Review of new hire on 06/08/2021, revealed education and posttest with no identified concerns. 11). Interview with SRNA #6 on 06/21/2021 at 1:56 PM, SRNA #7 on 06/21/2021 at 2:08 PM and LPN #5 on 06/21/2021 at 2:30 PM, revealed the staff could verbalize and reference the facility policy. Further interview revealed the policy was easily accessible at each nursing station. Interview with the DON on 06/21/2021 at 2:45 PM, Administrator on 06/21/2021 at 3:20 PM and Medical Director on 06/21/2021 at 2:15 PM revealed no concerns regarding the facility abuse policy. 12). Review of the facility QAPI process and tracking of facility allegations revealed no identified concerns. Interview with the DON on 06/21/2021 at 2:45 PM, SSD on 06/21/2021 at 2:34 PM and Administrator on 06/21/2021 at 3:20 PM revealed the facility discussed any allegation of abuse and/or incident/accident in daily morning meeting (Monday-Friday). Further interview revealed that all allegations were reviewed in QAPI at least quarterly. 13). Review of monitoring for Resident #1 and Resident #2 revealed no identified concerns. Interview with SSD on 06/21/2021 at 2:34 PM revealed she was responsible for the monitoring for Resident #1 and Resident #2 and had not identified any concerns regarding any signs or symptoms of mental anguish or distress. Interview with Physician #1 on 06/09/2021 at 9:47 AM revealed no any signs or symptoms of mental anguish or distress had been identified for Resident #1 and/or Resident #2. 14). Review of monitoring for staff/resident interactions revealed no identified concerns. Interview with the DON on 06/21/2021 at 2:45 PM, SSD on 06/21/2021 at 2:34 PM and Administrator on 06/21/2021 at 3:20 PM revealed no identified concerns regarding abuse. 15). Interview with residents and staff conducted on 06/08/2021, 06/09/2021 and 06/21/2021 revealed no identified concerns regarding abuse and/or care and treatment. Review of interviews for residents and employees revealed no identified concerns. Interview with SSD on 06/21/2021 at 2:34 PM and Administrator on 06/21/2021 at 3:20 PM revealed no identified concerns. 16). Interview with the Medical Director on 06/21/2021 at 2:15 PM revealed that he was involved in the ongoing QAPI process and was in agreement with the allegation of compliance on 04/28/2021.

Based on interview and record review it was determined the facility failed to notify the resident's representative of a change in condition and the need to alter treatment for one (1) of three (3) sampled residents (Resident #1). Review of a skin assessment completed for Resident #1 on 01/06/21, revealed the resident had developed skin breakdown; On 01/08/21, the resident was diagnosed with [REDACTED]. However, the facility failed to notify Resident #1's Responsible Party (RP) of the resident's changes in condition and altered treatment. The findings include: A review of the facility's policy Change in a Resident's Condition or Status, revised August 2011, revealed unless otherwise instructed by the resident, the nurse should notify the resident's family or representative when there was a significant change in the resident's status. Review of Resident #1's medical record revealed the facility admitted the resident on 05/06/15 with [DIAGNOSES REDACTED]. Review of Resident #1's most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Continued review of Resident #1's medical record revealed Family Member #1 was the resident's RP and made all medical, financial and personal decisions on behalf of Resident #1. However, review of the resident's Face Sheet, the document used by staff to determine a resident's contact information, revealed the facility had listed Family Member #2 first, instead of Family Member #1 who was the Resident's RP. Review of a skin assessment completed for Resident #1 on 01/06/21, revealed Resident #1 had developed blisters to the both hands, the right hip, right foot, redness to both heels, and excoriation to the sacrum area. Review of physician revealed on 01/08/21, the resident's physician ordered Resident #1 to receive intravenous antibiotics every eight hours to treat a newly diagnosed UTI. On 01/11/21, the physician ordered the resident to receive intravenous fluids due to poor food intake. However, further review of Resident #1's medical record revealed there was no documented evidence that the facility notified the Resident's RP of the resident's skin breakdown, the initiation of antibiotics, or that the resident was having poor food intake requiring the administration of fluids. Further review of Physician orders [REDACTED].#1 to the hospital. Interview with the resident's RP on 01/27/21 at 2:48 PM, revealed she had not been aware that the resident had developed wounds, been diagnosed with [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2 on 01/28/21 at 1:49 PM revealed she conducted a skin assessment for Resident #1 on 01/06/21 and had contacted a family member and notified them of the skin breakdown, but could not recall whom she had contacted. However, the LPN stated it was most likely the first contact listed on the resident's face sheet. Interview with Registered Nurse (RN) #3 on 01/28/21 at 4:47 PM revealed she was the nurse who had initiated the intravenous antibiotics for Resident #1 on 01/08/21. According to RN #3, she contacted the resident's family member, but did not contact the RP, because that was not the family member listed first on the resident's face sheet. Interview with RN #2 on 01/28/21 at 3:15 PM revealed she had administered IV fluids to Resident #1 per physician orders [REDACTED]. The RN stated she contacted a family member and notified them of the new orders, but was unable to recall the name of the family member. However, the RN stated it was normal procedure to call the first family member listed on the face sheet. Interview with the Social Worker on 01/27/21 at 4:02 PM revealed she was responsible for reviewing and updating the contact information for residents. The Social Worker stated she was aware that Resident #1 had a RP, but was not aware that the RP was not the first contact listed on the resident's face sheet or that staff had not been notifying the RP when a change in condition occurred. Interview with the Administrator on 01/28/21 at 5:25 PM revealed all resident change in conditions were reviewed in the clinical morning meeting to ensure appropriate notifications were being made. However, the Administrator stated she was not aware that Resident #1's RP was not listed first on the resident's face sheet and that staff were not notifying the RP as required.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to immediately inform the physician when a significant change in condition occurred for one (1) of three (3) sampled residents (Resident #1). On 04/18/2020, at approximately 9:30 AM, Resident #1 informed staff that his/her arm was hurting, screamed out in pain and stated someone broke it. Licensed Practical Nurse (LPN) #1 assessed Resident #1's right shoulder to be swollen/red and stated the resident complained of pain when staff attempted to care for him/her (approximately breakfast time, unable to recall exact time); however, the LPN stated she was unable to reach the resident's physician to inform him of the significant change in the resident's condition. LPN #1 stated she was finally able to reach Resident #1's physician in the afternoon on 04/18/2020, (unable to recall what time) and orders for an x-ray were obtained. LPN #1 acknowledged it took too many hours to reach the physician to inform him of the significant change in Resident #1's condition. Review of the x-ray results dated 04/18/2020 at 5:23 PM revealed Resident #1 was diagnosed with [REDACTED]. The findings include: Review of the facility's policy, Change in a Resident's Condition or Status, dated, August 2011, revealed staff would promptly notify the resident's attending physician and representative of changes in the resident's medical or mental condition. Review of Resident #1's medical record revealed the facility admitted the resident on 12/31/2014 with [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated he/she was interviewable. The resident was assessed to be totally dependent on two (2) staff members for bed mobility, transfers, and bathing. During the investigation on 10/07/2020 at 11:20 AM an interview was attempted with Resident #1; however, he/she had experienced a significant change in condition since the incident occurred and was no longer interviewable. Review of the resident's most recent MDS dated [DATE] revealed he/she was assessed to be cognitively impaired with a BIMS score of four (4). Interview with State Registered Nurse Aide (SRNA) #1 on 10/07/2020 at 4:00 PM, revealed she cared for Resident #1 on 04/18/2020, during the early morning of the shift (was unable to recall exact time) and the resident stated, They broke my arm. SRNA #1 stated the resident complained of pain in his/her right arm and LPN #1 was immediately notified. The SRNA stated she provided care to the resident throughout the day shift on 04/18/2020, and he/she complained of pain every time care was provided. SRNA #1 stated the nurse was notified of the resident's ongoing complaints of pain during the shift. Interview with SRNA #2 on 10/08/2020 at 10:05 AM, revealed she had cared for Resident #1, on 04/17/2020, and the resident had no complaints of pain. However, the SRNA stated early in the shift, on 04/18/2020 at approximately 9:30 AM, (unable to recall exact time) Resident #1 screamed out in pain and told the SRNA somebody broke it, in reference to his/her right arm. SRNA #2 stated she immediately informed LPN #1 of the resident's complaints of pain. SRNA #2 also stated the resident continued to complain of pain each time care was provided during the remainder of the shift on 04/18/2020, and LPN #1 was notified. However, according to SRNA #2, They didn't show up to get an x-ray until after supper, to evaluate the etiology of the resident's ongoing complaints of pain. Interview with LPN #1 on 10/07/2020 at 4:30 PM, revealed staff informed her at breakfast time (unable to recall exact time) on 04/18/2020, that Resident #1 hollered out when they turned him/her. The LPN stated the resident's right shoulder was swollen and red and complained of right arm pain. The resident also told the LPN that someone hurt me. LPN #1 stated she attempted to reach Resident #1's physician; however, was unable to reach him in a timely manner. LPN #1 stated she was unable to recall what time she was able to reach the physician; however, stated it was too many hours, before the physician was contacted and informed of the significant change in the resident's condition. She stated she informed the Director of Nursing (DON) of her inability to reach Resident #1's physician on 04/18/2020. Review of Resident #1's medical record revealed an order, on 04/18/2020 at 1:14 PM, to Obtain x-ray from right shoulder to wrist due to complaints of pain when moved on 04/18/2020. Review of the nurse's notes, dated 04/18/2020 at 5:35 PM, for Resident #1, revealed LPN #1 documented resident c/o (complained of) pain in right shoulder when moved informed the physician who stated to get x-ray. Further review of the nurse's notes revealed LPN #1 also documented, on 04/18/2020 at 7:28 PM, that when this nurse was informed of resident having pain in shoulder this nurse checked resident and found that resident cried out in pain when right shoulder and arm. Review of Resident #1's record indicated the X-ray results were received, on 04/18/2020 at 5:23 PM, and revealed he/she was diagnosed with [REDACTED]. Further review of Resident #1's record revealed he/she was transferred to the hospital for further care and treatment, on 04/18/2020 at 8:02 PM, and admitted to the hospital with [REDACTED]. Interview with Physician #1 on 10/08/2020 at 11:25 AM, revealed he expected staff to immediately inform him when changes in a resident's condition occurred. The physician stated he was on-call that weekend for a local hospital and there should have been no reason for staff not to contact him when the change in Resident #1's condition occurred on 04/18/2020. Interview with the Director of Nursing (DON) on 10/08/2020 at 1:25 PM, revealed staff were required to immediately notify the resident's physician when a significant change in a resident's condition was identified. She also stated if staff was unable to reach a physician within fifteen (15) minutes after the change occurred, staff should inform her, and she would also make attempts. The DON further stated if her attempts were unsuccessful, she would inform the facility's medical director. The DON acknowledged she was notified of the inability to reach Resident #1's physician timely on 04/18/2020; however, was not aware of the extended time that had lapsed between the resident's complaints of pain and the physician notification. The DON also stated she was not notified of the resident's ongoing complaints of pain when care was provided during the shift, on 04/18/2020, but stated she should have been notified. Interview with the Administrator on 10/08/2020 at 1:15 PM, revealed she expected staff to inform a resident's physician immediately as required, when a change in their condition occurred.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide services to meet professional standards of practice for one (1) of three (3) sampled residents (Resident #1). On 04/18/2020 at approximately 9:30 AM, Resident #1 screamed out in pain and informed staff that someone broke his/her right arm. Interview with Licensed Practical Nurse (LPN) #1, revealed she assessed Resident #1's right shoulder on the morning of 04/18/2020 and observed the resident's shoulder was swollen/red and the resident complained of pain during care. However, there was no evidence of that assessment in the medical record. Interviews with State Registered Nurse Aide (SRNA) #1 and #2, revealed Resident #1 complained of pain when care was provided, throughout the shift, on 04/18/2020, and they notified LPN #1 of the resident's ongoing complaints of pain. Again, review of Resident #1's medical record revealed no evidence LPN #1 provided ongoing assessment and/or monitoring for Resident #1 related to his/her continued complaints of pain to the right shoulder on 04/18/2020. Review of an X-ray report, dated 04/18/2020 at 5:23 PM, revealed Resident #1 was diagnosed with [REDACTED]. Resident #1 was transferred to the hospital, on 04/18/2020 at 8:02 PM, and admitted with diagnoses, which included a Right Humeral Neck Fracture. The findings include: A policy related to Resident Assessment was requested on 10/08/2020; however, no policy was provided for review. Interview with the Director of Nursing (DON) on 10/08/2020 at 1:25 PM, revealed when residents voiced complaints of pain, staff were expected to assess the resident and document the findings in the medical record. Review of Resident #1's medical record revealed the facility admitted the resident on 12/31/2014, with diagnoses, which included [MEDICAL CONDITION] and Anxiety Disorder. Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated he/she was interviewable. Resident #1 was assessed to be totally dependent on two (2) staff members for bed mobility and bathing. Observation of Resident #1, on 10/07/2020 at 11:20 AM, revealed the resident did not appear to be in pain. An interview was attempted with Resident #1; however, the resident did not respond to questions. Review of the Resident's most recent MDS, dated [DATE], revealed he/she was cognitively impaired with a BIMS score of four (4). Review of a physician's orders [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #1, on 10/07/2020 at 4:00 PM, revealed she cared for Resident #1, on 04/18/2020. She stated early morning (unable to recall the exact time), the resident complained of pain in his/her right arm. SRNA #1 stated she immediately notified LPN #1 of the resident's complaints of pain. According to SRNA #1, the resident continued to complain of pain, when care was provided throughout the day shift on 04/18/2020. Interview with SRNA #2, on 10/08/2020 at 10:05 AM, revealed she also cared for Resident #1, on 04/18/2020. She stated at approximately 9:30 AM (unable to recall the exact time), the resident screamed out in pain and told the SRNA somebody broke it, referring to his/her right arm. SRNA #2 stated the resident continued to complain of pain each time care was provided during her shift, on 04/18/2020, and she notified LPN #1 each time. Interview with LPN #1, on 10/07/2020 at 4:30 PM, revealed on 04/18/2020, staff informed her at breakfast time (unable to recall exact time) that Resident #1 hollered out when they turned the resident. LPN #1 stated she assessed Resident #1's right shoulder and it was swollen, red, and painful; however, acknowledged that the assessment was not documented. Per the LPN, she was in the resident's more than once but could not say she assessed the resident every time the SRNAs reported the resident's ongoing complaints of pain. Review of Resident #1 Nurse's Notes, revealed no evidence the resident had a concern with his/her shoulder until 04/18/2020 at 5:35 PM, (approximately eight (8) hours) after the resident told staff his/her arm was broken). LPN #1 documented at 5:35 PM, the resident complained of pain in the right shoulder. The resident's physician was notified and an order was received for the X-ray. Further review of the nurse's notes revealed LPN #1 also documented, on 04/18/2020 at 7:28 PM, that when the LPN was made aware of the resident's shoulder pain (time not specified), the LPN checked the resident and found that the resident cried out in pain with his/her right shoulder and arm. Review of Resident #1's X-ray results, dated 04/18/2020 at 5:23 PM, revealed the resident had an Acute Fracture Dislocation of the right shoulder. Further review of Resident #1's record revealed he/she was transferred to the hospital for further care and treatment on 04/18/2020 at 8:02 PM. Review of Resident #1's hospital record revealed he/she was evaluated and later admitted to the hospital on [DATE] with diagnoses, which included a Right Humeral Neck Fracture and [MEDICAL CONDITION] Fibrillation with Rapid Ventricular Response, now with rate control. The hospital record also revealed a surgical consult was conducted on 04/21/2020, which determined Resident #1 was not a surgical candidate; therefore, his/her right arm was placed in an immobilizer for comfort. The hospital record also indicated Resident #1 was diagnosed with [REDACTED]. Interview with the Director of Nursing (DON), on 10/08/2020 at 1:25 PM, revealed LPN #1 should have assessed and monitored Resident #1 after his/her change in condition was identified and documented ongoing assessments of the resident's unrelieved pain. Interview with the Administrator, on 10/08/2020 at 1:15 PM, revealed she expected nursing staff to assess facility residents, and document the assessment findings when changes in a resident's condition was identified.

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to provide pain management for one (1) of three (3) sampled residents (Resident #1). On 04/18/2020 at approximately 9:30 AM, Resident #1 screamed out in pain and informed staff that his/her arm was hurting. Licensed Practical Nurse (LPN) #1 assessed Resident #1 on the morning of 04/18/2020, and discovered the resident's shoulder was swollen/red and that resident had complaints of pain when cared for by staff. Additional staff interviews (SRNA #1 and #2) revealed Resident #1 had pain throughout the shift on 04/18/2020 whenever care was provided. However, there was no assessment of the resident's pain. In addition, although LPN #1 administered the resident's scheduled pain medication, pain medication ordered as needed was not administered to the resident on 04/18/2020. Review of X-ray results, dated 04/18/2020 at 5:23 PM, revealed Resident #1 had an Acute Fracture Dislocation of the right shoulder and was transferred to the hospital for further care and treatment, on 04/18/2020 at 8:02 PM. The findings include: Review of the facility's policy, Pain Management Policy and Procedure, last revised 11/23/2016, revealed residents should be screened for pain and pain history upon admission and thereafter according to assessment findings. The policy also stated residents should receive treatment for [REDACTED]. The policy directed staff to complete a pain assessment when a new report of pain was voiced, and the resident's physician should be notified once the assessment was complete. Review of Resident #1's medical record revealed the facility admitted the resident on 12/31/2014, with [DIAGNOSES REDACTED]. Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed he/she was interviewable and had a Brief Interview for Mental Status (BIMS) score of ten (10). The MDS also revealed the resident received scheduled pain medications; however, a pain assessment interview was not conducted. Observation of Resident #1, on 10/07/2020 at 11:20 AM, revealed the resident did not appear to be in pain. An interview was attempted with Resident #1; however, the resident did not respond to questions. Review of Resident #1's Physician Orders, dated April 2020, revealed staff were directed to administer [MEDICATION NAME]-[MEDICATION NAME] seven and one half (7.5) milligrams (mg) - three hundred twenty five (325) mg, one (1) tablet three (3) times a day for pain. Resident #1's physician orders [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #1, on 10/07/2020 at 4:00 PM, and with SRNA #2 on 10/08/2020 at 10:05 AM, revealed Resident #1 complained of pain to the right arm during the early morning (unable to recall exact time) on 04/18/2020. According to SRNA #2, she cared for the resident, on 04/17/2020, and the resident had no complaints of pain; however, she stated the resident screamed in pain on 04/18/2020. The SRNAs stated the resident told them that someone broke his/her arm and continued to complain of pain every time they provided care for the resident, on 04/18/2020. SRNA #1 and #2 stated they reported to LPN #1 when the resident initially told them she had pain and each time the resident had pain. Review of Resident #1's medical record revealed no evidence an assessment was completed of Resident #1's pain on the morning of 04/18/2020. Further, review of Resident #1's MAR provided no evidence Tylenol was administered to Resident #1 in attempts to minimize Resident #1's ongoing complaints of pain on 04/18/2020. Interview with LPN #1, on 10/07/2020 at 4:30 PM, revealed at approximately breakfast time (unable to recall exact time) on 04/18/2020, staff reported that Resident #1 hollered out when they turned him/her. LPN #1 stated the resident's right shoulder was swollen and red, and Resident #1 told her that his/her right arm was hurting. LPN #1 stated staff also informed her that Resident #1 was fine the day before however, had cried when care was provided on 04/18/2020. The LPN stated she administered the resident's scheduled pain medication but did not administer any as needed pain medication in attempts to provide pain management for Resident #1. The LPN acknowledged the resident's scheduled pain medication was not effective because he/she had ongoing complaints of pain. The LPN stated she was unsure why, but stated she should have administered Tylenol to the resident. Further interview with LPN #1 confirmed she did not complete/document a pain assessment, on 04/18/2020 until 5:35 PM, (approximately eight hours after the change was identified). LPN #1 stated she was aware that she was required to conduct and document a pain assessment when a resident had a new complaint of pain, but she gets busy and forgets. Review of Resident #1's Pain Assessment completed by LPN #,1 on 04/18/2020 at 5:38 PM, revealed the resident exhibited the following indicators of pain or possible pain: Non-verbal sounds (crying, whining, gasping, moaning or groaning); and Vocal complaints of pain (that hurts, ouch, stop). According to the assessment, Resident #1 also exhibited facial expressions that indicated pain (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). Again, there was no evidence the resident was treated with physician ordered medication to treat pain as needed. Review of a Resident #1's Skin Observation Tool, completed by LPN #1, on 04/18/2020 at 5:44 PM, revealed the resident's shoulder has some [MEDICAL CONDITION] and very sore when moved. Review of Resident #1's medical record revealed an order dated 04/18/2020, to obtain an X-ray of the right shoulder down to the wrist due to complaints of pain. Review of Resident #1's medical record revealed the X-ray results were received, on 04/18/2020 at 5:23 PM, and revealed the resident had an Acute Fracture Dislocation of the right shoulder. Resident #1's record also revealed he/she was transferred to the hospital for further care and treatment, on 04/18/2020 at 8:02 PM. Interview with the Director of Nursing (DON), on 10/08/2020 at 1:25 PM, revealed staff were required to conduct a pain assessment when residents complainted of pain. According to the DON, staff should have completed a pain assessment for Resident #1 and administered any as needed pain medications that were ordered, in attempts to help manage the resident's pain. The DON also stated the resident's physician should have been notified immediately when the resident experienced unrelieved pain on 04/18/2020. Interview with the Administrator, on 10/08/2020 at 1:15 PM, revealed she expected staff to inform the physician immediately when residents experienced unrelieved pain.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an allegation of abuse was reported, no later than two (2) hours after the allegation was made, to the facility Administrator and other officials in accordance with State Law, for one (1) of three (3) sampled residents (Resident #1). On 04/18/2020, Resident #1 complained of pain to his/her right arm and when staff asked the resident what happened, Resident #1 reported to State Registered Nurse Aide (SRNA) #1 and SRNA #2 that someone/somebody broke it. The SRNAs reported the allegation to Licensed Practical Nurse (LPN) #1 who stated she immediately reported the allegation to the Director of Nursing (DON). There was no evidence that Resident #1's allegation was reported to the Administrator, or other officials as required. The findings include: Review of the facility's policy, Abuse Response and Reporting not dated, revealed alleged violations that involved abuse, neglect, exploitation, or mistreatment, which included injuries of unknown source were required to be reported immediately, but not later than two (2) hours after the allegation was made. The policy directed staff to report all allegations to a charge nurse, the Director of Nursing (DON), the Administrator, and the Social Services Director. The policy further stated allegations should be reported to other officials as well, which included the State Survey Agency and Adult Protective Services. Review of Resident #1's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses, which included Anxiety Disorder and [MEDICAL CONDITION]. Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated he/she was interviewable with a Brief Interview for Mental Status (BIMS) score of ten (10). An interview was attempted with Resident #1 on 10/07/2020; however, the resident was not interviewable. Review of his/her most recent MDS dated [DATE] revealed he/she was cognitively impaired with a BIMS score of four (4). Interview with SRNA #1 on 10/07/2020 at 4:00 PM, revealed early morning on 04/18/2020 (unable to recall the exact time) Resident #1 complained of pain in his/her right arm and when asked about the pain, the resident stated, They broke my arm. SRNA #1 stated she reported Resident #1's complaints of pain and the allegation of abuse to LPN #1 immediately. Interview with SRNA #2 on 10/08/2020 at 10:05 AM, revealed she cared for Resident #1 on 04/17/2020, and he/she had no complaints of pain. However, SRNA #2 stated on 04/18/2020 at approximately 9:30 AM (unable to recall exact time), Resident #1 screamed out in pain and informed the SRNA that somebody broke it, referring to his/her right arm. SRNA #2 also reported that she immediately reported Resident #1's allegation of abuse to LPN #1. Interview with LPN #1 on 10/07/2020 at 4:30 PM, revealed staff notified her at breakfast time (unable to recall exact time), on 04/18/2020, that Resident #1 had pain to the arm and stated, Someone hurt me. The LPN stated Resident #1's right shoulder was swollen/red and the resident told the LPN that someone hurt his/her arm. LPN #1 stated she immediately reported the allegation of abuse and the resident's complaints of pain to the DON. Interview with the DON on 10/08/2020 at 1:25 PM, revealed the DON confirmed that LPN #1 informed her of Resident #1's reports of pain on 04/18/2020. However, the DON stated that the LPN did not report the resident's allegation that someone had hurt him/her. The DON stated staff were required to immediately report allegations of abuse to her, the Administrator, or to the Social Services Director. The DON stated if staff had reported the allegation of abuse to her, she would have reported the allegation to the Administrator, and to other officials, as required. Interview with the Administrator on 10/08/2020 at 1:15 PM, revealed Resident #1's allegation of abuse had not been reported to her, but should have been. Per the Administrator, if notified by staff of Resident #1's alleged abuse on 04/18/2020, she would have ensured the allegation was reported to State Agencies and other officials, as directed by the facility policy.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an allegation of abuse was investigated and failed to take actions to protect residents from further potential abuse when one (1) of three (3) sampled residents (Resident #1) voiced an allegation of abuse on 04/18/2020. On 04/18/2020, Resident #1 complained of pain in his/her right arm and told State Registered Nurse Aides (SRNAs) that someone/somebody broke it. The SRNAs reported Resident #1's allegation to Licensed Practical Nurse (LPN) #1, who stated she immediately reported the allegation to the Director of Nursing. The facility initiated an investigation of an injury of unknown origin when it was determined the resident's shoulder was fractured; however, there was no evidence Resident #1's allegation was investigated or that any actions were taken to ensure residents were protected from further potential abuse, after the allegation was voiced on 04/18/2020, as required. The findings include: Review of the facility's Policy on Abuse, not dated, revealed the facility defined an injury of unknown source as an injury that should meet both of the following conditions: was not observed by any person or the source of the injury could not be explained by the resident; and, the injury was suspicious because of the extent or location of the injury. In addition, a review of the facility's policy, Abuse Investigation not dated, revealed the facility would investigate all alleged violations immediately and the resident would be afforded protection from abuse while the investigation was being completed. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION] and Anxiety Disorder. The resident's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of ten (10). Review of a facility investigation revealed the facility initiated an investigation of an injury of unknown source for Resident #1 on 04/18/2020, when the resident was identified to have a fractured right shoulder. According to the investigation, the facility interviewed Resident #1 and the resident was unable to tell staff what occurred to his/her arm. An interview was attempted with Resident #1 on 10/07/2020; however, the resident was no longer interviewable. Resident #1's most recent MDS dated [DATE], revealed the resident was cognitively impaired with a BIMS score of four (4). Interview with SRNA #1 on 10/07/2020 at 4:00 PM revealed she provided care for Resident #1 on 04/18/2020. She stated early morning (unable to recall exact time), Resident #1 complained of pain in his/her right arm. When asked about the pain, the resident stated, They broke my arm. The SRNA stated she immediately reported Resident #1's complaints of pain and allegation of abuse to LPN #1. Interview with SRNA #2 on 10/08/2020 at 10:05 AM, revealed she also provided care for Resident #1 on 04/18/2020, and reported to LPN #1 at approximately 9:30 AM, that the resident alleged, Somebody broke it (the resident's arm). Interview with LPN #1 on 10/07/2020 at 4:30 PM, confirmed the SRNAs reported someone hurt the resident. The LPN stated she immediately reported Resident #1's allegation of abuse and his/her complaints of pain to the DON. Further review of the facility's investigation revealed the resident's physician stated that with the resident's [DIAGNOSES REDACTED]. The facility concluded there was no reason to suspect abuse in regards to the resident's injury of unknown origin. However, although the facility interviewed SRNA #1, SRNA #2, and LPN #1, the facility failed to identify that the resident alleged that someone hurt him/her. Interview with the DON on 10/08/2020 at 1:25 PM, revealed LPN #1 informed her of Resident #1's complaints of pain on 04/18/2020; however, she stated LPN #1 did not report Resident #1's allegation that someone had hurt him/her. According to the DON, if staff had reported the allegation of abuse to her, she would have investigated the allegation and ensured residents were protected from further potential abuse, while the investigation was completed, as required. Interview with the Administrator on 10/08/2020 at 1:15 PM, revealed the DON reported to her on 04/18/2020, that Resident #1 had an injury of unknown origin. The Administrator stated if staff reported the allegation of abuse to her, she would have ensured the allegation was investigated and other residents were protected from further potential abuse until the investigation was complete, as outlined in the facility policy.

Based on interview, record review, and review of the Long Term Care Resident Assessment Instrument 3.0 User's Manual, it was determined the facility failed to ensure one (1) of four (4) closed records reviewed (Resident #1) had a discharge assessment completed and transmitted within 14 days after the resident expired in the facility on [DATE]. The findings include: Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated (MONTH) (YEAR), revealed a discharge with return not anticipated Minimum Data Set (MDS) assessment should be completed within fourteen (14) days of a resident's discharge. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's nurse's notes dated [DATE] revealed the resident expired at the facility. Further review of Resident #1's medical record revealed no documented evidence that the facility completed a discharge with return not anticipated MDS assessment for Resident #1. Interview conducted with the MDS Coordinator on [DATE] at 2:56 PM revealed the facility utilized the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the MDS Assessment as their resource for completing MDS assessments. The MDS Coordinator stated the MDS assessment should have been conducted for Resident #1 but had been missed. Interview with the Director of Nursing (DON) on [DATE] at 10:55 AM revealed the MDS Coordinator was responsible for ensuring MDS assessments were completed and transmitted timely. The DON stated Resident #1's assessment had been missed. Further interview with the DON revealed she had not identified any concerns with discharge MDS assessments not being completed.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of one (1) of twenty-two (22) sampled residents (Resident #97). Resident #97 was admitted to hospice services on 10/22/18. However, a review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] and a quarterly MDS dated [DATE] completed for the resident revealed the facility failed to ensure hospice services were coded on the assessments. The findings include: Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the MDS Assessment, dated (MONTH) (YEAR), revealed staff should check for question O 0100K, if a resident received hospice services. A review of Resident #97's medical record revealed the facility admitted the resident on 11/17/09, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of communication sheets from the hospice service revealed Resident #97 was still receiving hospice services. Review of Resident #97's quarterly MDS assessment dated [DATE], and a Significant Change in Status MDS assessment dated [DATE], revealed hospice services were not coded as being provided for the resident. Interview with the MDS Coordinator on 05/07/19 at 2:56 PM revealed the facility utilized the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the MDS Assessment, dated (MONTH) (YEAR), as a resource for MDS assessments. According to the MDS Coordinator, hospice services should have been coded on the Significant Change in Status MDS assessment and the quarterly assessments. The MDS Coordinator stated it had just been overlooked. Interview with the Director of Nursing (DON) on 05/08/19 at 10:55 AM, revealed hospice services should have been documented on the Significant Change in Status MDS Assessment and the quarterly MDS assessments. The DON stated she had not identified any concerns with MDS assessments not being coded accurately.

Based on interview, record review, and review of facility policy it was determined the facility failed to develop/implement a care plan for twenty-six (26) of thirty-seven (37) sampled residents (Residents #1, #14, #26 (6), #28, #30, #34, #35, #38, #40, #46, #48, #53 (12), #57, #59, #63, #64, #67, #70, #78, #80, #85 (5), #92, #94, #146, and #147 (H)) and thirty-five (35) Unsampled Residents (Residents #4, #6, #7, #9, #11, #22, #25, #27, #29, #32, #33, #37, #44, #50, #54, #55, #56, #65, #73, #75, #77, #79, #84, #87, #88, #93, #95, #396, #397, #399, #448, #449, B, F, and Z). On [DATE], Resident #26 (6) was designated as full code by the resident's representative. However, the facility failed to develop a care plan that addressed the resident's full code status. On [DATE], Resident #26 (6) had a decline in health status and the facility failed to provide basic life support prior to Emergency Medical Services' (EMS) arrival. When EMS arrived, Resident #26 (6) had no pulse and was not breathing. The resident was transferred to the hospital. Resident #26 (6) expired at the hospital on [DATE] at 5:11 PM (Refer to F580, F658, F678, and F842). Resident #63 had a signed Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) order dated [DATE], in place and in the resident's medical record. However, the facility failed to develop a care plan related to the resident's wishes. On [DATE], when the resident had a change in condition, the facility failed to provide the form to EMS. EMS initiated CPR to Resident #63 at the facility. The resident was transferred to the hospital, where the resident was placed on a ventilator, and expired on [DATE] (Refer to F578 and F770). In addition, the facility developed a care plan for Residents #53 (12), #147 (H), and #85 (5) that required the facility to notify the residents' physician of any nutritional changes. However, the facility failed to notify the residents' physician when the residents did not meet their nutritional needs. Subsequently, the residents sustained severe weight loss in the facility (Refer to F580, F692, F725, and F842). The facility's failure to develop/implement residents' care plans has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility's failure to ensure residents' rights were protected 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] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on [DATE]. After supervisory review, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on [DATE] at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. Further Sampled Residents #1, #28, #34, #35, #38, #57, #59, #64, #67, #70, #78, #92, #94, #147 and Unsampled Residents #4, #6, #7, #9, #11, #22, #25, #27, #29, #32, #33, #37, #44, #50, #54, #55, #56, #65, #73, #75, #77, #79, #84, #87, #88, #93, #95, #396, #397, #399, #448, #449, B, F, and Z, had a signed consent for Cardiopulmonary Resuscitation (CPR) to be provided should the need arise; however, the facility failed to develop a care plan that addressed the residents' wishes. The facility failed to provide tube feeding and/or water flushes as ordered and as required by the care plans for Residents #48, #53 (12), #85 (5), and #147 (H); and failed to implement the care plans for Residents #94, #70, #40, #30, #14, #3, #85 (5), #48, and #59 related to medication administration/monitoring. In addition, Residents #64's, #146's, and #85's (5) care plans required staff to provide oxygen as ordered; however, observation revealed the facility failed to provide the residents' oxygen as ordered. Further, the facility failed to provide Residents #80's, #85's (5), and #35's splints/hand rolls as required by their care plans; and failed to honor Resident #46's food preferences as required by the resident's care plan. The findings include: Review of the facility's Comprehensive Person-Centered Care Planning Policy and Procedure dated (MONTH) (YEAR) revealed the facility would develop, maintain, and follow resident-centered plans for each resident's individualized care needs. The policy stated the comprehensive care plan would be based on the resident's needs, goals, and preferences as identified through comprehensive assessments. According to the policy, the comprehensive care plan would include information that was pertinent to the delivery of care including any resident specific goals, wishes, or advanced directives. 1. a. Review of Resident #26's (6) medical record revealed the facility admitted the resident on [DATE], with a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Review of Resident #26's (6) Emergency Medical Services Do Not Resuscitate Order, not dated, and a review of a facility CPR form (untitled) dated [DATE] revealed the resident's representative signed consent for the resident to have CPR performed. The resident was designated as a full code. Review of Resident #26's (6) Physician orders [REDACTED]. Review of Resident #26's (6) care plan initiated [DATE], and last revised on [DATE], revealed no documented evidence that the facility developed a care plan with interventions to provide Resident #26's (6) wishes. Review of Resident #26's (6) Nurses' Notes dated [DATE] at 3:45 PM, revealed the resident's condition deteriorated; however, interview with the resident's physician on [DATE] at 11:04 AM revealed the facility failed to notify the resident's physician of the resident's change in condition. Further, review of the resident's Emergency Medical Services report dated [DATE], revealed the Licensed Practical Nurse (LPN) failed to notify EMS until 4:38 PM on [DATE], approximately fifty-three minutes (53) after the resident was assessed to have a change in condition. Upon EMS's arrival to the facility on [DATE] at 4:50 PM, Resident #26 (6) was found to be not breathing and had no pulse and CPR was initiated. The resident was transferred to the hospital where the resident was pronounced dead at 5:11 PM on [DATE]. 1. b. Review of Resident #63's medical record revealed the facility admitted the resident on [DATE], from acute care hospital, with [DIAGNOSES REDACTED]. Review of Resident #63's Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a Brief Interview Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of a Kentucky Emergency Medical Services Do Not Resuscitate (DNR) order (A standardized form that was developed and approved by the Kentucky Board of Medical Licensure which authorized EMS providers to honor Advanced Directives to withhold or terminate care. The EMS DNR order applies only to resuscitation attempts by health care providers in the prehospital settings, including long term care facilities and during transport to or from a health care facility) dated [DATE], and review of a facility Do Not Resuscitate Form dated [DATE], revealed the resident wished to have no Cardiopulmonary Resuscitation (CPR) should the need arise. Review of Resident #63's care plan dated [DATE], revealed no documented evidence the facility developed a care plan related to the resident's wishes to be a DNR and receive no CPR should the need arise. Record review on [DATE], at 6:40 PM, revealed a nursing note which stated Resident #63 became nonresponsive, pale, cyanotic (blue) nail beds, with a low blood pressure of ,[DATE] (normal ,[DATE]) and low respirations of 10 (normal 18). EMS arrived at the facility at 6:54 PM on [DATE]. Review of the EMS Prehospital Report dated [DATE], revealed upon arrival to the facility, the EMS crew was directed to the resident's room; report was given; no facility staff were present in the resident's room while aide was being rendered by EMS; and facility staff provided no paperwork regarding the resident. The EMS report stated the resident's daughter was present and gave EMS a report on the resident. The report stated the resident appeared critical with impending [MEDICAL CONDITION]/arrest, and CPR was initiated. The resident was intubated, and CPR continued until transport to the Emergency Department. Review of Resident #63's hospital record revealed on [DATE], the resident was placed on a ventilator once at the ED, and transported to a regional hospital, where the resident passed away on [DATE], after having another [MEDICAL CONDITION]. 1. c. Review of the medical records for sampled Residents #1, #28, #34, #35, #38, #57, #59, #64, #67, #70, #78, #92, #94, #147 and Unsampled Residents #4, #6, #7, #9, #11, #22, #25, #27, #29, #32, #33, #37, #44, #50, #54, #55, #56, #65, #73, #75, #77, #79, #84, #87, #88, #93, #95, #396, #397, #399, #448, #449, B, F, and Z revealed the residents/responsible party/legal guardian signed consent for the residents to receive Cardiopulmonary Resuscitation (CPR) and the facility designated the residents as a full code. However, review of the residents' comprehensive person-centered care plans revealed the residents did not have a care plan that addressed their wishes for CPR. An interview with the Minimum Data Set (MDS) Coordinator on [DATE] at 12:47 PM, revealed she was responsible for initiating resident care plans on admission. The MDS Coordinator stated she only developed care plans if a resident elected to be a DNR, but she was unable to state why Resident #63's care plan did not list the resident's wishes to be a DNR. Further, the MDS Coordinator stated she never developed a care plan related to resident's wishes if the resident requested a full code or had other explicit wishes expressed in an Advanced Directive. 2. a. Review of the medical record revealed the facility admitted Resident #53 (12) on [DATE], and readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE], revealed Resident #53 (12) was cognitively impaired, received a mechanically altered diet, and weighed 143 pounds. Review of Resident #53's (12) Comprehensive Person-Centered Care Plan dated [DATE], revealed the facility identified the resident was at risk for altered nutrition and had a newly placed feeding tube. The facility developed interventions to prevent dehydration and to maintain the resident's current body weight that included receiving tube feeding and water flushes as ordered, and notifying the resident's physician of any nutritional changes as needed. Review of Resident #53's (12) physician's orders [REDACTED]. However, review of Resident #53's (12) Intake and Output record for [DATE] through [DATE], revealed the resident did not meet his/her nutritional needs eighteen of twenty-two days. Further review revealed the resident's average daily fluid intake was approximately 703 ml, approximately 500 ml less than the physician ordered for the resident. Review of Resident #53's (12) weight record revealed on [DATE], Resident #53 (12) weighed 135 pounds, and had sustained an eight-pound weight loss in one week. Further review of Resident #53's (12) weight record revealed the resident continued to sustain weight loss and on [DATE] weighed 122 pounds, a total weight loss of 21 pounds (14 percent body weight) in fifteen days. A review of the resident's nutritionally at risk (NAR) notes revealed the facility documented the resident's physician was notified of the wieght loss; however, there was no documented evidence the facility identified that the resident was not receiving tube feeding as ordered by the resident's physician or that the physician was notified that the resident was not meeting his/her nutritional needs. 2. b. Review of the medical record revealed the facility admitted Resident #147 (H) on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 147's (H) Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was nine (9), which indicated the resident was moderately cognitively impaired. Review of Resident #147's (H) care plan dated [DATE], revealed the resident was at risk for alteration in nutrition related to dysphagia and diabetes mellitus. The facility developed interventions to prevent dehydration and to maintain the resident's current body weight that included notifying the resident's physician of any nutritional changes, and to receive nutrition and fluids as ordered. Review of Resident #147's (H) physician's orders [REDACTED]. However, observation on [DATE] at 7:08 PM, revealed the resident had only received 32 ml of water in the previous 8.5 hours, approximately 168 ml less than the physician ordered amount. Further review of a Dietary Notes revealed on [DATE], the Dietitian identified that Resident #147 (H) had an eleven-pound weight loss (weight 178). Review of Resident #147's (H) weight record revealed the resident lost four (4) additional pounds and weighed 174 on [DATE], an eight (8) percent weight loss in seventeen (17) days. There was no documented evidence the facility notified the resident's physician of the nutritional changes as required by the resident's care plan. 2. c. Review of Resident #85's (5) medical record revealed the facility admitted the resident on [DATE] and readmitted Resident #85 (5) on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #85's (5) Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status was unable to be assessed and the resident was not interviewable. The assessment further revealed the resident had a feeding tube and had sustained no weight loss. Review of Resident #85's (5) care plan dated [DATE], revealed the resident was at nutritional risk due to Diabetes Mellitus and being fed via a feeding tube. The facility developed interventions to prevent dehydration and to maintain the resident's maintain current body weight that included providing nutritional feeding and water flushes as ordered by the physician and notifying the resident's physician of any nutritional changes. Review of Resident #85's (5) physician's orders [REDACTED]. However, observation of Resident #85's (5) feeding tube pump on [DATE] at 4:32 PM, revealed 163 ml's of water had been administered to the resident in approximately eight (8) hours, approximately 237 ml less than was ordered by the physician. Further, review of Resident #85's (5) Intake and Output Record for [DATE] through [DATE], revealed the resident did not meet his/her fluid needs on eleven of eighteen days and did not meet his/her estimated calorie needs on thirteen of eighteen days. There was no documented evidence the facility notified the resident's physician. In addition, review of Resident #85's (5) weekly weights revealed on [DATE], the resident weighed 142 pounds, an eight (8) percent weight loss in fifteen (15) days. There was no documented evidence the facility notified the resident's physician as required by the resident's care plan. 2. d. Review of the medical record revealed the facility admitted Resident #48 on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 was cognitively impaired and had a feeding tube. Review of Resident #48's care plan dated [DATE], revealed the resident was at nutritional risk due to dysphagia and being fed via a feeding tube. The facility developed interventions to prevent dehydration and to maintain the resident's current body weight that included providing tube feeding and water flushes as ordered by the physician and notifying the resident's physician of any nutritional changes. Review of Resident #48s' physician's orders [REDACTED]. However, observation of Resident #48's feeding tube pump on [DATE] at 7:10 PM, revealed the resident had only received 57 ml of water in the previous 8.5 hours, approximately 143 ml less than the physician ordered amount. Further, review of Resident #48's Intake and Output Record for (MONTH) (YEAR), revealed the resident did not meet his/her assessed fluid or nutrition needs from [DATE] to [DATE]. There was no documented evidence the physician was notified of the nutritional changes. 3. a. Review of the medical record revealed the facility admitted Resident #94 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #94's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated Resident #94 was cognitively intact. Review of Resident #94's care plan initially dated [DATE], revealed the facility would perform blood glucose checks and administer insulin as ordered by the resident's physician. Review of Resident #94 physician's orders [REDACTED]. However, review of Resident #94's Medication Administration Record [REDACTED]. 3. b. Review of Resident #70's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #70's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated Resident #70 was cognitively intact. Review of Resident #70's care plan initially dated [DATE], revealed the facility would perform blood glucose checks and administer insulin as ordered by the resident's physician. Review of Resident #70's physician's orders [REDACTED]. However, Review of Resident #70's Medication Administration Record [REDACTED]. 3. c. Review of Resident #40's medical record revealed the facility admitted the resident on [DATE], and the resident had [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #40's cognition was unable to be assessed. Review of Resident #40's care plan initially dated [DATE], revealed the facility would administer the resident's medication as ordered by the resident's physician. Review of Resident #40's physician's orders [REDACTED]. However, a review of Resident #40's Medication Administration Record [REDACTED]. 3. d. Review of Resident #30's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #30's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #30 to have a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated Resident #30 was moderately cognitively impaired. Review of Resident #30's care plan initially dated [DATE], revealed the facility would administer the resident's medication as ordered by the resident's physician. Review of Resident #30's physician's orders [REDACTED]. However, review of Resident #30's Medication Administration Record [REDACTED]. 3. e. Review of the medical record revealed the facility admitted Resident #14 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #14's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #14's cognitive status could not be assessed. Review of Resident #14's care plan initially dated [DATE], revealed the facility would administer the resident's medication as ordered by the resident's physician. Review of Resident #14's physician's orders [REDACTED]. However, review of Resident #14's Medication Administration Record [REDACTED]. 3. f. Review of Resident #3's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated Resident #3 was cognitively intact. Review of Resident #3's care plan dated [DATE], revealed the facility developed a care plan for the resident with interventions to check the resident's blood sugar before meals and at bedtime as ordered by the resident's physician. Review of Resident #3's physician's orders [REDACTED]. However, review of Resident #3's Medication Administration Record [REDACTED]. 4. a. Review of the medical record revealed the facility admitted Resident #85 (5) on [DATE], with [DIAGNOSES REDACTED].#85 (5) was cognitively impaired. Review of Resident #85's (5) care plan dated [DATE], revealed the facility would administer Resident #85's (5) medication as ordered. Review of Resident #85's (5) physician's orders [REDACTED].#85's (5) Medication Administration Record [REDACTED]. 4. b. Review of Resident #48's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE], revealed Resident #48's cognition could not be assessed. Review of Resident #48's care plan dated [DATE], revealed the facility developed an intervention to administer the resident's medication as ordered. Review of Resident #48's physician's orders [REDACTED]. 4. c. Review of Resident #59's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #59's Quarterly MDS assessment dated [DATE], revealed the facility was unable to assess the resident's cognition. Review of Resident #59's care plan dated [DATE], revealed the facility developed a care plan with interventions to administer the resident's medication as ordered. Review of Resident #59's physician's orders [REDACTED].#59's MAR indicated [REDACTED]. 5. a. Review of Resident #64's medical record, revealed the facility admitted the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #64's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact. Review of physician's orders [REDACTED].#64, revealed an order for [REDACTED]. Review of Resident #64's Comprehensive Plan of Care dated [DATE], revealed the resident was to be administered oxygen as ordered by the physician. Observation of Resident #64 on [DATE], at 9:50 AM, 12:50 PM, and 3:30 PM, revealed the resident's oxygen tubing was observed to be on the floor at the head of the resident's bed, and not being administered to the resident. Interview with Resident #64 on [DATE] at 2:30 PM, revealed he/she was unable to reach the oxygen tubing that was on the floor. The resident stated he/she was not sure how the oxygen tubing got on the floor. 5.b. Review of the medical record for Resident #146, revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. The medical record also revealed a Minimum Data Set assessment had not yet been completed by the facility for Resident #146. Review of physician's orders [REDACTED]. Review of Resident #146's Comprehensive Plan of Care dated [DATE], revealed the resident was to receive oxygen as ordered by the physician. Observation of Resident #146 on [DATE] at 4:08 PM, 2:45 PM, 3:15 PM, and 4:00 PM, revealed the resident's oxygen was lying on the floor beside the resident's bed. The resident was not receiving oxygen. 5. c. Review of Resident #85's (5) medical record, revealed the facility readmitted Resident #85 (5) on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #85's (5) Comprehensive Plan of Care dated [DATE], revealed an intervention for Resident #85 (5) to be administered oxygen as ordered by the physician. Review of physician orders [REDACTED]. Observations of Resident #85 (5) on [DATE] at 9:27 AM, 10:34 AM, 3:31 PM, and on [DATE] at 11:06 AM revealed the resident was being administered oxygen at four (4) liters per minute via nasal cannula. 6. a. Review of the medical record for Resident #80 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #80's Quarterly Minimum Data Set (MDS) assessment completed on [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero, indicating the resident was severely cognitively impaired. Review of Resident #80's Comprehensive Care Plan in effect revealed the facility's restorative nursing program was to apply a left hand splint for two (2) hours in the morning and two (2) hours in evening. Further review revealed a hand roll was to be utilized to the resident's left hand when the hand splint was not in place. Review of Resident #80's Physician order [REDACTED]. hand when the splint was not applied. Observations of Resident #80 on [DATE] at 9:26 AM and 10:52 AM revealed the resident did not have a splint or hand roll present in his/her left hand. 6. b. Review of the medical record for Resident #85 (5) revealed the facility readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS Quarterly Assessment (TRUNCATED)

Based on observation of the facility's video footage, interviews, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of thirty-seven (37) residents' (Resident #63) right to formulate an Advance Directive and have the Advance Directive carried out per the resident's wishes. Upon admission to the facility, Resident #63 made his/her wishes known and had a signed Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) order (A standardized form that was developed and approved by the Kentucky Board of Medical Licensure which authorized EMS providers to honor Advanced Directives to withhold or terminate care. The EMS DNR order applies only to resuscitation attempts by health care providers in the Prehospital settings, including long term care facilities and during transport to or from a health care facility.) dated [DATE], in place and in the resident's medical record. However, on [DATE], when the resident was determined to be critically ill with impending [MEDICAL CONDITION]/arrest, the facility failed to provide the form to EMS. Subsequently, EMS provided CPR to Resident #63, and the resident was transferred to the hospital, where the resident was placed on a ventilator, and the resident expired on [DATE] (Refer to F656 and F770). The facility's failure to ensure residents' rights were protected 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] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on [DATE]. After supervisory review, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.25 Quality of Care (F692) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on [DATE] at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Advance Directives revised 2008 revealed the Nurse Supervisor was required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means was made. Interview with the Director of Nursing (DON), on [DATE] at 07:32 PM, revealed documentation, including the resident's face sheet, medication sheet, a report of the situation, and the Kentucky EMS DNR form should be provided to EMS upon transfer. She also stated the facility should provide report to EMS and the receiving facility. Review of Resident #63's medical record revealed the facility admitted the resident on [DATE], from an acute care hospital, with [DIAGNOSES REDACTED]. Review of Resident #63's Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had a Brief Interview Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of a Kentucky Emergency Medical Services Do Not Resuscitate order dated [DATE], revealed the resident wished to have no resuscitation should the need arise. Review of a facility Do Not Resuscitate Form dated [DATE], revealed the resident's daughter signed the form stating the resident was not to receive Cardiopulmonary Resuscitation in the event of cardiac or respiratory arrest. Review of a Nursing Note dated [DATE] at 6:40 PM, revealed Licensed Practical Nurse (LPN) #14 was summoned to the resident's room. The nurse assessed the resident to be nonresponsive, pale, with cyanotic (blue) nail beds, a blood pressure of ,[DATE] (normal ,[DATE]), pulse of 87, respirations of 10 (normal 18), and a temperature of 96.1 degrees. According to the Nursing Note, the resident's physician was notified and an order was received to send the resident to the Emergency Department (ED). Further review of the Nursing Notes dated [DATE] at 6:54 PM, revealed EMS was in the facility. Review of the EMS Prehospital report dated [DATE], revealed upon arrival to the facility, the EMS crew was directed to Resident #63's room, and no report was given. Upon entering the resident's room, the resident was found to be unresponsive with shallow, labored, and choppy breaths; and the resident's pupils were dilated and fixed. The report stated the resident appeared critical with impending [MEDICAL CONDITION]/arrest. The EMS Report stated the resident's daughter was in the room and provided an immediate history of events. The Report further stated as the crew approached the nurses' station with resident, they requested an ambu bag (provides ventilation to a patient who is not breathing or who is breathing inadequately), which was provided by the staff, and artificial respirations were initiated. The report stated the resident suffered [MEDICAL CONDITION] while on the elevator and chest compressions (CPR) were initiated and continued until transport to the Emergency Department. The report stated the resident was intubated (tube inserted to provide artificial respirations to the lungs). In addition, the EMS report revealed facility staff never provided a report on the resident's condition, and staff were never present in the resident's room while aide was being rendered by EMS. In addition, the Report revealed the facility did not provide any transfer paperwork to EMS. Interview with LPN #14, on [DATE] at 12:20 PM, revealed on the evening of [DATE], she was assigned to provide care for Resident #63. LPN #14 stated the resident became pale and unresponsive. She stated she obtained vital signs, then checked the resident's medical record and noted the resident had a signed Do Not Resuscitate order. LPN #14 stated she called the resident's physician and EMS. The LPN stated when EMS arrived, she reported the resident's condition and reported the resident had a DNR order. LPN #14 further stated as EMS was coming toward the elevator to leave with Resident #63, they asked for an ambu bag. The LPN stated she provided an ambu bag and did not question when EMS provided artificial resuscitation. Interview with Resident #63's Daughter on [DATE] at 5:00 PM, revealed on [DATE], the resident's blood pressure and oxygen level dropped and the nurse told the daughter that she was going to send the resident back to hospital. The Daughter stated the nurse also told her that the resident was a DNR, but she did not think the resident was dying at that point. Resident #63's Daughter stated she never saw the nurse again. The interview revealed when EMS arrived, they increased the resident's oxygen and told her that the resident's pupils were dilated. She stated she did not tell EMS to perform CPR and they did not ask about the resident's code status. The Daughter further stated no staff were present in the room while EMS was there and she saw no staff provide report or provide any paper work to EMS. The resident's Daughter stated the paramedic later told her the resident's heart quit in the elevator at the facility and EMS had to do CPR. However, review of facility's video footage from [DATE], at 6:56 PM until EMS left the facility with Resident #63 at 7:04 PM, there was no evidence LPN #14 provided report or any paper work to EMS. Review of video surveillance revealed at 6:56 PM, EMS exited the elevator. LPN #14, was seated inside the nurses' station in front of a computer. One of the two EMS crew members looked toward the nurses' station, and LPN #14 point down the hallway. EMS proceeded down the hallway to the resident's room. At 6:57 PM, the video revealed LPN #14 was still seated at the desk as EMS entered the resident's room. At 7:00 PM, LPN #14 was still seated at the nurses' station. At 7:02 PM, the EMS crew exited the resident's room with Resident #63 on the stretcher. As they approached the nurses' station, LPN #14 was observed to get up from a seated position, reappeared outside of the nurses' station at the resident's stretcher, and provided EMS with an ambu bag. Then, at 7:04 PM, EMS entered the elevator with the resident. The surveillance video revealed no evidence LPN #14 provided a report to EMS staff when they arrived to the floor, and no evidence the facility provided any paperwork to EMS. On [DATE] at 1:48 PM, an interview conducted with Paramedic #1 revealed on [DATE], he was one of the EMS crew members that responded to a non-emergent call to the facility for Resident #63. He confirmed that when they arrived to the floor where the resident resided, the nurse was sitting at the desk. The nurse told them Resident #63's name, and showed them where the resident's room was from the nurses' station. He further stated they did not receive any report regarding the resident's condition and the facility did not provide the resident's code status. Review of Resident #63's hospital record revealed on [DATE], the resident arrived to the ED at 7:21 PM via EMS with CPR in progress. Further review of the hospital record revealed the EMS report was present; however, there was no evidence the facility provided EMS or the hospital with a copy of the resident's EMS DNR order or any other paperwork regarding the resident's Advance Directives. Resident #63 was placed on a ventilator in the ED, and transported to a regional hospital, where the resident passed away on [DATE], after having another [MEDICAL CONDITION]. The facility implemented the following for removal of jeopardy: 1. On [DATE], the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on [DATE]. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the Admission Director. Code status designations will be documented in the physician's orders [REDACTED]. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on [DATE]. 3. On [DATE], a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on [DATE]. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between [DATE] through [DATE], and any new physician's orders [REDACTED]. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed [DATE] through [DATE] by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on [DATE] thru [DATE] related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On [DATE], the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on [DATE]. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On [DATE], training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On [DATE], a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On [DATE], a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On [DATE], the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on [DATE] to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective [DATE], the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on [DATE]. Education regarding the use of the audit forms was provided to the auditors on [DATE], by the Administrator and the long term care consultants. Effective [DATE], the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On [DATE], the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from [DATE] through [DATE]. The residents' physicians were notified with any new recommendations. From [DATE] through [DATE], a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on [DATE], a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on [DATE], and is no longer a resident. Resident #85 (5) was discharged from the facility on [DATE], and is no longer a resident at the facility. 17. On [DATE], a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on [DATE] and completed on [DATE], the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On [DATE], implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on [DATE] and continued through [DATE]. Employees not having been in-serviced by [DATE] will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on [DATE] and [DATE]. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From [DATE] to [DATE], a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from [DATE] through [DATE]. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On [DATE], the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On [DATE], the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On [DATE], the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on [DATE], is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on [DATE] by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on [DATE] with acceptance. On [DATE], the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administration's role with the abatement of jeopardy beginning [DATE]. The SSA verified the removal of immediate jeopardy by the following: 1. Review of the in-service roster dated [DATE], revealed the DON, MDS Nurse, and the QA Nurse had attended an in-service by the Administrator related to the development and implementation of a comprehensive care plan to ensure the wishes of each resident and their code status was included on the care plan. Interviews conducted with the MDS Nurse on [DATE] at 1:04 PM; the QA Nurse on [DATE] at 1:22 PM; and, the DON on [DATE] at 2:00 PM, revealed they attended the in-service provided by the Administrator and began providing in-services for other staff on [DATE]. 2. Review of the facility's policies and in-service rosters regarding Advance Directives and Code Status revealed the facility reviewed and updated the policies on [DATE]. The policies revealed the facility's new process to ensure Advance Directives/Wishes were honored was as follows: the physician would be notified after obtaining the resident's/ responsible party's consent, documenting the consent, and honoring the resident's wishes for Advance Directives and Code Status. The policy revealed the resident's wishes for Advance Directives and code status would be obtained upon admission by Social Services and the Admission Director. This would be documented in the physician's orders [REDACTED].

Based on interview, record review, and review of facility policy, it was determined the facility failed to notify the physician of a change of condition and need to alter treatment for [REDACTED].#26 (6), #147 (H), #85 (5), #53 (12), and #48). On [DATE], Resident #26 (6) sustained a fall which resulted in a laceration above the left eye and a subdural hematoma. However, the facility failed to notify Resident #26's (6) physician of the fall or injury. Further, on [DATE], Resident #26 (6) was assessed by staff to have a low blood pressure, pale skin, and labored breathing at approximately 3:45 PM. Subsequently, Resident #26 (6) expired at the hospital on [DATE] at 5:11 PM. Interview with the resident's physician on [DATE] revealed the facility failed to notify him that Resident #26 (6) had fallen, had a change in condition on [DATE], and the physician was never notified of the resident's death (Refer to F656, F658, F678, and F842). Resident #147 (H) was admitted to the facility on [DATE], and weighed 191 pounds on [DATE]. The dietitian recommended supplements/snacks to prevent weight loss on [DATE] and on [DATE]; however, the facility failed to notify the resident's physician of the need to alter treatment and the resident continued to loose weight. On [DATE], Resident #147 (H) weighed 174 pounds and had lost 8.9 percent of his/her body weight in eighteen (18) days; however, there was no evidence the facility notified the resident's physician of the weight loss and possible need to alter the resident's treatment (Refer to F656 and F692). Further, Resident #85 (5) was readmitted to the facility on [DATE], and was documented to weigh 155 pounds on [DATE] and on [DATE]. The facility failed to administer the resident's tube feeding as ordered from [DATE] through [DATE], and the resident sustained [REDACTED]. However, the facility failed to identify that the resident had sustained severe weight loss; subsequently, the resident's physician was not notified of the change in the resident's condition (severe weight loss) and possible need to alter treatment (Refer to F656, F692, F725, and F842). The facility's failure to ensure residents' physicians were notified timely of changes 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 determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on [DATE]. After supervisory review, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on [DATE] at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. In addition, the facility failed to notify Resident #85 (5), #53 (12), and #48's physician when the residents did not meet their required fluid needs for three or more consecutive days as required by the facility's policy (Refer to F656, F692, F725, and F842). The findings include: Review of the facility's policy for physician notification dated [DATE], revealed the facility would promptly notify the resident's physician of a change in the resident's medical condition including a change in the resident's vital signs, a need to alter treatment significantly, or a need to transfer a resident to the hospital. 1. a. Review of Resident #26's (6) medical record revealed the facility readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #26's (6) Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIM) score of two (2), indicating the resident was cognitively impaired. Review of a facility Allegation Report and Investigation initiated on [DATE], and finalized on [DATE], and video surveillance footage recorded on [DATE], revealed on [DATE], at approximately 5:50 PM, Resident #26 (6) attempted to get up unassisted out of a wheelchair and fell head first sustaining a laceration above the left eye. Resident #26 (6) was transported to the Emergency Department (ED) for evaluation and treatment, and was subsequently transferred to another hospital and diagnosed with [REDACTED]. Further review of the Allegation Report and Investigation initiated on [DATE], and finalized on [DATE], and a facility Incident Investigation dated [DATE], revealed that although the facility notified Emergency Medical Services to transport the resident to the hospital, there was no documented evidence that the facility notified Resident #26's (6) attending physician of the resident's fall and injury. In addition, review of physician orders [REDACTED]. Interview with Resident #26's (6) Physician on [DATE], at 11:04 AM, revealed he was never notified that Resident #26 (6) had sustained a fall at the facility on [DATE], or that the resident had been transported to the hospital and diagnosed with [REDACTED]. Interview with Licensed Practical Nurse (LPN) #8 on [DATE] at 2:57 PM, revealed he had notified Resident #26's (6) physician of the fall when the order was written on [DATE]. He stated he did not know why the order had not been signed by the physician or documented in the facility's investigation reports. 1. b. Continued review of Resident #26's (6) medical record revealed the facility readmitted the resident on [DATE], after treatment of [REDACTED]. Review of the Nursing Notes for Resident #26 (6) dated [DATE] at 11:52 AM, revealed the resident's blood pressure was ,[DATE] (normal is ,[DATE]), pulse was 78 (normal is 80), and respirations were 18 (normal is 18). Review of Resident #26's (6) Medication Administration Record [REDACTED]. Further review of Nursing Notes dated [DATE] at 6:30 AM revealed the resident's blood pressure was ,[DATE], pulse was 76, and respirations were 18. Further, on [DATE] at 12:00 PM, Resident #26's (6) pulse was 76, respirations were 18. Review of Resident #26's (6) Nursing Notes dated [DATE] at 3:45 PM, and an interview with Licensed Practical Nurse (LPN) #12 on [DATE] at 4:58 PM, revealed on [DATE], Resident #26's (6) skin became pale, breathing was labored, blood pressure was ,[DATE] (normal is ,[DATE]), and respirations were 24. LPN #12 stated she called the first floor Unit Manager (UM) to request assistance because the resident was actively dying. Further review of Resident #26's (6) Nursing Notes, revealed the resident's physician was notified of the change in the resident's condition on [DATE] at 5:09 PM. Continued interview with LPN #12 on [DATE] at 4:58 PM, revealed she contacted Resident #26's (6) Physician approximately ,[DATE] minutes after she contacted the UM, and the physician ordered the resident be transferred to the hospital. However, review of the resident's medical record revealed [REDACTED]. In addition, interview with Resident #26's (6) physician on [DATE] at 11:04 AM, revealed he was never notified that the resident had a change in condition and was transferred to the hospital. Review of the Emergency Medical Services (EMS) Prehospital Care Report dated [DATE], revealed when EMS arrived to Resident #26's (6) room at 4:50 PM, the resident had no pulse and was not breathing. EMS initiated CPR, and the resident was transferred to the hospital, where the resident was pronounced dead at 5:11 PM, three (3) minutes after arrival. Continued interview with Resident #26's (6) Physician on [DATE] at 11:04 AM, revealed in addition to not being notified that the resident had a change in condition, the facility did not notify him that Resident #26 (6) had expired. 2. Review of the facility's policy titled, Weight Program dated [DATE], revealed nursing staff would notify the resident's physician of any significant unplanned weight loss and the interventions strategies to prevent further loss. Interview with the Director of Nursing (DON) on [DATE], at 12:05 PM and [DATE] at 11:43 AM, revealed the Unit Manager was responsible for notifying the resident's physician of any significant or severe weight loss and documenting that the physician was notified. In addition, since (MONTH) (YEAR), the Nutritionally at Risk (NAR) Committee was initiated to ensure the resident's physician was notified of weight loss and documented the notification on the resident's NAR Progress Note. 2. a. Review of the medical record revealed the facility admitted Resident #147 (H) on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's weight roster revealed the resident weighed 191 pounds on [DATE]. Review of the Dietary Notes dated [DATE], revealed the resident was a new admission to the facility and weighed 189 pounds on [DATE]. The Registered Dietitian (RD) documented the resident was only eating 42 percent of meals and recommended the resident receive health shake supplements twice daily. However, there was no documented evidence the facility notified the resident's physician to obtain an order for [REDACTED]. Review of Dietary Notes dated [DATE], revealed the resident had sustained a thirteen-pound (13) weight loss since admission (weight was 178 pounds). The RD recommended the resident receive a multivitamin with minerals and snacks three (3) times per day. However, there was no documented evidence the facility notified the resident's physician of the weight loss or of the RD's recommendations. Further, review of Resident #147's (H) weight record revealed the resident lost four additional pounds and weighed 174 pounds on [DATE], an 8.9 percent weight loss in eighteen (18) days. Review of the resident's record revealed no documentation the resident's physician was notified of the resident's weight loss. Interview with the Registered Dietitian on [DATE] at 2:30 PM, revealed she reviewed residents' weights and made recommendations when needed. She stated she assumed the Unit Managers notified the residents' physicians of the recommendations and necessary action was taken. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #147's (H) weight loss. However, he expected the facility to notify him when a resident lost that much weight in just two (2) weeks. 2. b. Review of the medical record revealed the facility readmitted Resident #85 (5) on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #85's (5) weekly weights revealed on [DATE], the resident weighed 155 pounds. Review of Resident #85's (5) Intake and Output Record for (MONTH) (YEAR), revealed the resident did not meet his/her estimated calorie needs for thirteen of eighteen days from [DATE] through [DATE]. During the time period, the resident received an average of approximately 710 ml per day, approximately 500 ml less than the resident was assessed to require. Further review of Resident #85's (5) weekly weights revealed on [DATE], the resident's weight was down to 144 pounds, an 11 pound weight loss. On [DATE], the resident weighed 142 pounds, an eight (8) percent weight loss in fourteen (14) days. However, there was no evidence the resident's physician was notified that the resident had sustained severe weight loss. Further review of the Nutritionally at Risk (NAR) Progress Notes revealed the facility placed Resident #85 (5) in the NAR program on [DATE]. However, review of the NAR Progress Notes for [DATE] and [DATE], revealed the NAR Committee did not identify that the resident had sustained severe weight loss. Subsequently, there was no evidence the facility notified the resident's physician that the resident had sustained severe weight loss. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #85's (5) weight loss from [DATE] to [DATE]. The Physician stated he expected the facility to notify him when a resident lost that much weight, in just two (2) weeks. Interview with the Director of Nursing (DON) on [DATE], at 12:05 PM, on [DATE], at 12:05 PM and on [DATE] at 11:43 AM revealed in (MONTH) (YEAR), the facility initiated a Nutritionally at Risk (NAR) Committee that met weekly to review residents who had sustained weight loss. The DON stated the Unit Managers had always been responsible for notifying the resident's physician of any significant or severe weight loss. The DON was unable to explain why Resident #147 (H) and #85's (5) physicians were not notified when the residents sustained severe weight loss. The facility terminated the Unit Manager on [DATE], and an interview was unable to be conducted. 3. Review of the facility's Hydration Policy revised on [DATE], revealed each resident would be provided with sufficient fluid intake to maintain hydration. Further review of the policy revealed if a resident failed to receive 1500 ml of fluids for three (3) consecutive days, the resident would be evaluated for signs and symptoms of dehydration and the physician would be notified. 3. a. Continued review of Resident #85's (5) medical record revealed the resident had an order for [REDACTED]. However, review of Resident #85's (5) (MONTH) (YEAR), Medication Administration Record [REDACTED]. There was no documented evidence the facility evaluated the resident for signs and symptoms of dehydration until [DATE]. There was no evidence the facility notified the resident's physician of the resident's decreased fluid intake as required by the facility's policy. Review of a Dehydration Risk assessment dated [DATE], revealed the facility assessed Resident #85 (5) to have no signs or symptoms of dehydration; the resident's skin turgor was good and the resident's mucous membranes, tongue, and lips were moist. However, review of Resident #85's (5) laboratory values dated [DATE] and [DATE] revealed the resident's Blood Urea Nitrogen (BUN) and creatinine (BUN and creatinine levels test kidney function may temporarily increase if you are dehydrated, have a low blood volume, eat a large amount of meat, or take certain medications) increased from 18 (normal BUN is ,[DATE]) and 0.6 (normal creatinine is 0XXX,[DATE].0) on [DATE] to 41 and 0.9 on [DATE]. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #85's (5) decreased fluid intake from [DATE] through [DATE], but expected the facility to notify him when a resident did not receive the required fluid needs. 3. b. Review of the medical record revealed the facility admitted Resident #53 (12) on [DATE], and readmitted the resident on [DATE], after receiving a feeding tube on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of Resident #53's (12) physician's orders [REDACTED]. Review of Resident #53's (12) Intake and Output record for [DATE] through [DATE] revealed the resident did not meet his/her fluid intake for three (3) consecutive days on [DATE] through [DATE]; [DATE] through [DATE]; [DATE] through [DATE]; and [DATE] through [DATE]. Further review revealed Resident #53's (12) average fluid intake for [DATE] through [DATE] was approximately 703 ml, approximately 500 ml less than the resident required. However, there was no documented evidence the resident's physician was notified that the resident had not met his/her fluid needs. Review of Resident #53's (12) laboratory results dated [DATE] and [DATE] revealed the resident's Blood Urea Nitrogen (BUN) and creatinine levels increased from (MONTH) to (MONTH) (YEAR). On [DATE], the resident's BUN was 34 (normal is ,[DATE]) and the resident's creatinine was 0.7 (normal is 0.6 to 1.2). However, on [DATE], Resident #53's (12) BUN had increased to 44, and the creatinine was 0.6. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #53's (12) decreased fluid intake in (MONTH) (YEAR), but expected the facility to notify him when a resident did not receive their required fluid needs. 3. c. Review of Resident #48's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #48's physician's orders [REDACTED]. Review of Resident #48's Intake and Output record for (MONTH) (YEAR), revealed the resident did not meet his/her assessed fluid needs [DATE] through [DATE]. The resident only received an average of approximately 363 ml of fluid per day, approximately 437 ml less than the resident required per day. However, there was no evidence the facility completed a dehydration risk assessment until [DATE], twenty-three days later, and no documented evidence the resident's physician was notified that the resident had not met his/her fluid needs. Review of the [DATE] Dehydration Risk Evaluation for Resident #48 revealed the facility assessed the resident to have no signs or symptoms of dehydration, including no skin turgor concerns and the resident's mucous membranes, lips, and tongue were moist. Interview with Physician #1 on [DATE] at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #48's decreased fluid intake in (MONTH) (YEAR), but expected the facility to notify him when a resident did not receive their required fluid needs. Interview with the Director of Nursing (DON) on [DATE], at 12:05 PM, on [DATE], at 12:05 PM and on [DATE] at 11:43 AM, revealed in (MONTH) (YEAR), the DON began running an Intake and Output report every morning, and staff reviewed the report in the morning meeting to identify anyone who did not have an intake of at least 1500 ml per day. The DON stated if a resident did not receive 1500 ml per day, the Unit Manager was required to notify the resident's physician. However, further interview revealed when totaling residents' daily fluid intake, the DON inaccurately added the amount that was initialed by the nurse on the MAR indicated [REDACTED]. Subsequently, Residents # 85 (5), #53 (12) and #48's physicians were not notified when the residents did not meet their fluid needs for three (3) consecutive days as required by the facility's policy. The facility implemented the following for removal of jeopardy: 1. On [DATE], the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on [DATE]. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the Admission Director. Code status designations will be documented in the physician's orders [REDACTED]. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on [DATE]. 3. On [DATE], a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on [DATE]. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between [DATE] through [DATE], and any new physician's orders [REDACTED]. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed [DATE] through [DATE] by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on [DATE] thru [DATE] related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On [DATE], the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on [DATE]. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On [DATE], training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On [DATE], a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On [DATE], a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On [DATE], the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on [DATE] to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective [DATE], the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on [DATE]. Education regarding the use of the audit forms was provided to the auditors on [DATE], by the Administrator and the long term care consultant (TRUNCATED)

Based on interview, record review, review of facility policies, and review of Kentucky Board of Nursing Advisory Opinion Statements #29, it was determined the facility failed to provide services that met professional standards of quality for nine (9) of thirty-seven (37) sampled residents (Residents #26 (6), #58, #146, #94, #70, #40, #30, #14, and #3). On [DATE], Licensed Practical Nurse (LPN) #12 failed to notify Resident #26's (#6) physician that the resident was actively dying (appeared that death was imminent); failed to provide basic life support; and, failed to immediately notify Emergency Medical Services (EMS) when Resident #26 (#6) experienced a change in condition. When EMS arrived on [DATE] at 4:50 PM, Resident #26 (#6) was not breathing and had no pulse. EMS initiated Cardiopulmonary Resuscitation (CPR) and transferred the resident to the hospital. However, Resident #26 (#6) expired at 5:11 PM on [DATE], when resuscitation efforts were unsuccessful (Refer to F580, F656, F678, and 842). The facility's failure to provide services that met professional standards 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] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on [DATE]. After supervisory review, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on [DATE] at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. In addition, the facility failed to ensure Residents #58 and #146 received Intravenous (IV) antibiotics as ordered, and failed to ensure Residents #94, #70, #40, #30, #14, and #3 received a finger stick blood sugar test and sliding scale insulin (insulin dosage based on the result of the blood sugar test) as needed on [DATE]. Further, based on interview, record review, and review of the facility's lab policy, it was determined the facility failed to obtain laboratory test for Resident #63 as ordered by the resident's physician. On [DATE], Resident #63's physician wrote orders to obtain a stool specimen to test for [MEDICAL CONDITION] (C. Diff is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) and a Hemoccult test (tests for blood in the stool). However, the facility failed to obtain the physician ordered tests. The findings include: 1. Review of the Kentucky Board of Nursing Advisory Opinion Statement #05 titled, Advanced Life Support revised (MONTH) 2014, revealed Licensed Practical Nurses (LPN) may assist others in the performance of advanced life support procedures and provide basic life support procedures. Review of the Kentucky Board of Nursing Advisory Opinion Statement #29 titled, Cardiopulmonary/Respiratory Nursing Practice revised (MONTH) (YEAR), revealed nurses were responsible and accountable for making decisions that were based upon the individuals' educational preparation and current clinical competence in nursing, and required licensees to practice nursing with reasonable skill and safety. The Advisory Statement stated it was within the scope of an LPN to provide components of care, under the delegation and supervision of a Registered Nurse (RN), to clients experiencing altered or a potential for altered cardiopulmonary function that included participation with the RN in the assessment, planning, intervention, and evaluation of a resident's care, and providing oxygen therapy, suctioning, aerosol and inhalant medications, and maintenance of oral/nasal airway. Review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy revised (MONTH) 2011, revealed [MEDICAL CONDITION] may initially result in gasping respirations or appear to be [MEDICAL CONDITION] activity. Training for basic life support should include recognizing these atypical presentations. The policy further stated the chances of surviving sudden [MEDICAL CONDITION] may be increased if Cardiopulmonary Resuscitation (CPR) is initiated immediately. The policy stated facility staff had completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Review of the facility's policy for physician notification dated [DATE], revealed the facility would promptly notify the resident's physician of a change in the resident's medical condition included a change in the resident's vital signs, a need to alter treatment significantly, or a need to transfer a resident to the hospital. Review of Resident #26's (6) medical record revealed the facility admitted the resident on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #26's (6) Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident had severe cognitive impairment. Review of Resident #26's (6) Emergency Medical Services Do Not Resuscitate Order, not dated, and review of a facility CPR form (untitled) dated [DATE], revealed the resident wished to have CPR performed and was designated as a full code. In addition, review of Resident #26's (6) physician's orders [REDACTED]. Review of Resident #26's (6) Nursing Notes dated [DATE] at 3:45 PM, revealed Licensed Practical Nurse (LPN) #12 assessed Resident #26 (6) to have pale skin, labored breathing, a low blood pressure, and an elevated respiratory rate. Interview with LPN #12 on [DATE] at 2:45 PM; on [DATE] at 4:58 PM; and, on [DATE] at 11:13 AM and 1:30 PM, revealed she notified the Unit Manager that Resident #26 (6) was actively dying. According to LPN #12, she eventually contacted Resident #26's (6) physician to report the resident's change in condition, but she did not immediately contact Resident #26's (6) physician because she did not think the resident was that bad. However, an interview with Resident #26's (6) physician on [DATE] at 11:04 AM revealed he was never notified that the resident had a change in condition. Review of facility video footage for [DATE] revealed Licensed Practical Nurse (LPN) #12 was in Resident #26's (6) room at 3:40 PM, and exited the room less than one minute later. Further review of the video footage from 3:42 PM to 4:37 PM revealed LPN #12 entered and exited Resident #26's (6) room five times, staying approximately one minute or less each time. However, LPN #12 did not enter Resident #26's (6) room again until 4:46 PM, nine (9) minutes later, when LPN #12 entered Resident #26's (6) room with EMS. A review of the Fire-EMS Prehospital Care Report dated [DATE], and interview with Emergency Medical Services Provider #1 on [DATE] at 8:30 PM, revealed the facility did not contact EMS until 4:38 PM on [DATE], approximately fifty-three (53) minutes after the resident experienced a change in condition. According to the report, when EMS arrived to Resident #26's (6) room at 4:50 PM, Resident #26 (6) had no pulse and was not breathing. EMS initiated CPR, and transferred the resident to the hospital. Review of Resident #26's (6) Emergency Department (ED) record revealed the resident was pronounced dead on [DATE] at 5:11 PM. Further interview with LPN #12 on [DATE] at 2:45 PM on [DATE] at 4:58 PM, and on [DATE] at 11:13 AM and 1:30 PM, revealed she did not notify EMS immediately because she was trying to get the paper work ready for the resident's transfer. 2. Review of the facility's policy titled, Physician order [REDACTED]. Review of a Kentucky Board of Nursing Advisory Opinion Statement #14 Patient Care Orders, revised (MONTH) (YEAR), revealed users were held responsible and accountable for their decisions regarding the receipt and implementation of patient care orders based upon the individual's educational preparation and clinical competence in nursing. 2. a. Review of Resident #58's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #58's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have severe cognitive impairment. Review of Resident #58's physician telephone orders dated [DATE], revealed an order for [REDACTED].#58's Medication Administration Records (MAR), revealed the medication was administered as ordered by the physician. However, a review of the resident's Medication Administration History revealed the resident's medication was not administered per physician's orders [REDACTED]. Interview with LPN #2 on [DATE] at 5:33 PM revealed she did not administer Resident #58's [DATE] dose of medication at 10:00 PM as ordered by the physician because the medication was not available. The LPN stated she administered the medication on [DATE] at 12:32 AM, (two and one-half hours late) when the medication arrived. However, interview with Pharmacist #4 on [DATE] at 1:56 PM, revealed the resident's [MEDICATION NAME] arrived at the facility at 10:10 PM on [DATE]. Interview with Licensed Practical Nurse (LPN) #8 on [DATE] at 7:32 PM, revealed he was the nurse assigned to administer medications to Resident #58 on [DATE] at 10:00 PM. However, the LPN stated he did not realize the resident had Intravenous (IV) [MEDICATION NAME] due to be administered and did not administer the medication to the resident. Interview with Registered Nurse (RN) #3 on [DATE] at 7:01 PM revealed she was responsible for administering Resident #58's [MEDICATION NAME] medication on [DATE] at 4:00 AM. LPN #3 stated she forgot to document that the medication was administered. Continued review of Resident #58's MAR indicated [REDACTED]. Interview with the Infection Control Nurse on [DATE] at 12:08 PM, revealed when Resident #58's [MEDICATION NAME] was due on [DATE] at 4:00 PM, the facility had not received the resident's [MEDICATION NAME] trough level laboratory results. The nurse stated she contacted Resident #58's physician for an order to hold the medication until the results were obtained, and the physician instructed the Infection Control Nurse to administer the medication as previously ordered. However, the facility failed to follow the physician's orders [REDACTED]. Continued review of Resident #58's medical record revealed the facility obtained the laboratory specimen for the resident's [MEDICATION NAME] trough level as ordered; however, failed to administer the medication as ordered. A post survey interview with Pharmacist #10 on [DATE] at 10:19 AM, revealed the facility should obtain the specimen for the laboratory test, then administer the medication as ordered to ensure the resident received a therapuetic dose of the medication. On [DATE] at 12:18 PM, an interview with Physician #2 revealed the facility contacted him on [DATE] regarding holding Resident #58's [MEDICATION NAME] dose scheduled for [DATE] at 4:00 PM. The physician stated he instructed the facility not to hold the resident's medication and to administer the 4:00 PM dose of [MEDICATION NAME]. The physician stated he was not aware that the dosage was held despite his order, and was administered approximately seven (7) hours late. 2. b. Review of Resident #146's medical record revealed the resident was admitted to the facility on [DATE]. On [DATE], Resident #146 was transferred to the hospital and readmitted to the facility on [DATE], after treatment of [REDACTED]. Review of Resident #146's Physician order [REDACTED].#13 on [DATE] at 9:26 AM, revealed she was responsible for Resident #146's care when the facility readmitted the resident on [DATE]. According to LPN #13, she faxed the resident's discharge medication order for [MEDICATION NAME] to the pharmacy immediately upon receiving the orders from the hospital. Once the resident arrived at the facility, LPN #13 stated she entered the resident's medication orders into the computer and faxed another copy of the physician's orders [REDACTED]. Interview with the Quality Assurance (QA) Nurse on [DATE] at 4:19 PM, revealed she discovered Resident #146's [MEDICATION NAME] medication had not been delivered from the pharmacy when the medication was due to be administered to the resident [DATE]. The QA nurse stated she sent the physician's orders [REDACTED]. She stated the nurse who took the physician's orders [REDACTED]. Observation of Resident #146 on [DATE] at 6:20 PM revealed the resident's temperature was 104.1 degrees and staff were present in the resident's room. At approximately 7:25 PM, the resident was transported to the hospital. An interview with Resident #146's physician on [DATE] at 11:16 AM, revealed Resident #146's decline and readmission to the hospital was not a result of not receiving [MEDICATION NAME] on [DATE]. The physician stated the resident possibly had a resistant urinary tract infection and was also newly diagnosed with [REDACTED]. 3. Review of the facility's policy titled Administering Medications dated (MONTH) 2009, revealed medications must be administered in accordance with the orders, including any required time frame. 3. a. Review of the medical record revealed the facility admitted Resident #94 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #94's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated Resident #94 was cognitively intact. Review of Resident #94's physician's orders [REDACTED]. Review of Resident #94's Medication Administration Record [REDACTED]. Further review of the MAR, revealed in (MONTH) (YEAR), at 11:00 AM, Resident #94's blood glucose averaged 312, which required eight (8) units of [MEDICATION NAME] R based on the sliding scale. Interview with Resident #94 on [DATE] at 5:00 PM revealed the facility did not have enough staff to provide medications that day and medications were late. 3. b. Review of Resident #70's medical record revealed the facility admitted the resident on [DATE], and the resident had [DIAGNOSES REDACTED]. Review of Resident #70's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated Resident #70 was cognitively intact. Review of Resident #70 physician's orders [REDACTED]. Review of Resident #70's Medication Administration Record [REDACTED]. Further review of the MAR, revealed Resident #70's blood sugar at 11:00 AM in (MONTH) (YEAR) averaged 280, which required six (6) units of [MEDICATION NAME] Insulin. Interview with Resident #70 on [DATE] at 5:05 PM revealed he/she believed that staff checked his/her blood sugar when they were supposed to. The resident stated that he/she depended on staff to ensure his/her blood sugar was checked as ordered by the physician. 3. c. Review of Resident #40's medical record revealed the facility admitted the resident on [DATE], and the resident had [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #40's cognition was unable to be assessed. Review of Resident #40's physician's orders [REDACTED]. However, review of Resident #40's Medication Administration Record [REDACTED]. Further review of Resident #40's (MONTH) (YEAR) MAR, revealed the resident's blood sugar averaged 154 at 11:00 AM, in (MONTH) (YEAR), which required two (2) units of [MEDICATION NAME] Insulin. 3. d. Review of Resident #30's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #30 to have a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated Resident #30 was moderately cognitively impaired. Review of Resident #30's physician's orders [REDACTED]. However, review of Resident #30's Medication Administration Record [REDACTED]. Further review of the MAR, revealed Resident #30's blood glucose routinely averaged 263 at 11:30 AM in (MONTH) (YEAR), which required six (6) units of [MEDICATION NAME] R Insulin. 3. e. Review of the medical record revealed the facility admitted Resident #14 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #14's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #14's cognitive status could not be assessed. Review of Resident #14's physician's orders [REDACTED]. However, review of Resident #14's Medication Administration Record [REDACTED]. Further review of the MAR, revealed Resident #14's blood glucose averaged 281 in (MONTH) (YEAR), which required six (6) units of [MEDICATION NAME] Insulin. 3. f. Review of Resident #3's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated Resident #3 was cognitively intact. Review of Resident #3's Physicians Orders dated (MONTH) (YEAR), revealed the resident had an order for [REDACTED]. Review of Resident #3's Medication Administration Record [REDACTED]. Further review of the MAR, revealed Resident #3's blood glucose averaged 249 in (MONTH) (YEAR), which required four (4) units of [MEDICATION NAME] Insulin. Interview with Resident #3 on [DATE] at 6:00 PM revealed the resident could not recall whether staff checked his/her blood sugar on [DATE]. On [DATE] at 6:30 PM, an interview conducted with the second floor Unit Manager (UM) revealed she checked the residents' blood glucose levels and administered insulin as needed on [DATE], but she forgot to document that they were completed. However, on [DATE] at 5:45 PM observation of the facility's video footage, recorded on [DATE] from 10:30 AM to 12:47 PM, revealed a nurse did not enter Resident #14's or Resident #30's room. Further observation of video footage on [DATE] at 7:00 PM, with the Administrator and Nurse Consultant, revealed on [DATE], a nurse did not enter Resident #3 or Resident #70's room from 10:30 AM to 1:06 PM. In addition, interviews with SRNA #12 on [DATE] at 5:45 PM, and SRNA #3 on [DATE] at 4:20 PM, direct care staff who worked on the second floor on [DATE], revealed there was not a nurse on the floor where the residents resided from 10:30 AM until 2:30 PM. The staff stated the nurse who was assigned to the floor called in sick and another nurse provided care to the residents until 10:30 AM, when she had to leave. The staff stated there was a medication aide on the unit to administer oral medications to residents, but there was not a nurse to check residents' blood sugars or administer insulin injections. Interview with the Director of Nursing (DON) on [DATE] at 12:05 PM, revealed she was not aware staff did not provide blood glucose testing or administer insulin to insulin dependent residents on [DATE]. The DON stated she was aware the nurse who covered the second floor had to leave at 10:30, but she believed the nurse checked all residents' blood sugars and administered insulin before she left. 4. Review of the facility's Laboratory, Policy and Procedure, dated (MONTH) (YEAR), revealed upon receipt of a physician's orders [REDACTED]. The policy stated the nurse was also required to complete and submit an electronic or a hard copy laboratory requisition to the laboratory with the date the laboratory was due. The requisition was then to be filed in the appropriate month in the laboratory binder or filed at the nurses' station. Further review of the policy revealed the Unit Manager would monitor and verify that all physician orders [REDACTED]. In addition, the policy stated a routine quality assurance review of laboratory tests would occur as outlined in the facility's Quality Assurance and Performance Improvement (QAPI) program. Review of Resident #63's closed medical record revealed the facility admitted the resident on [DATE] from an acute care hospital, with [DIAGNOSES REDACTED]. Review of Resident #63's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Review of Resident #63's Bowel Roster revealed the resident had an extra-large watery liquid stool on [DATE] and [DATE]. Review of a Nurse's Note for Resident #63 dated [DATE], revealed the note stated, New order obtained to obtain stool for [MEDICAL CONDITION] and hemoccult stool. Review of Resident #63's physician's orders [REDACTED]. According to the order, the tests were being conducted because the resident had foul odor, loose stool. Further review revealed another physician's orders [REDACTED]. Observation of the laboratory binder on [DATE] at 1:30 PM, revealed Resident #63's order for a [DIAGNOSES REDACTED] and Hemoccult were not in the binder. Review of Resident #63's medical record revealed stool culture results dated [DATE]. However, there was no documented evidence the facility obtained a [DIAGNOSES REDACTED] or hemoccult stool test for the resident as ordered by the resident's physician on [DATE]. On [DATE] at 6:25 PM, an interview conducted with a Laboratory Supervisor at the contracted laboratory service utilized by facility, revealed the facility did not order a [DIAGNOSES REDACTED] or Hemoccult stool test for Resident #63 on [DATE]. The Laboratory Supervisor stated the facility ordered a stool culture only, which did not include testing for [MEDICAL CONDITION] and was not a hemoccult test; subsequently the [DIAGNOSES REDACTED] and hemoccult tests were not obtained. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] at 05:08 PM, revealed she was the nurse who received the laboratory result for the stool culture for Resident #63, and communicated the results to the physician on [DATE]. LPN #7 stated she did not recognize that the wrong test was ordered and obtained for Resident #63. Interview with the DON on [DATE] at 1:30 PM revealed that the [DIAGNOSES REDACTED] order could only be entered into the computer system as an order for [REDACTED]. Additional interview with the DON on [DATE] at 07:28 PM, revealed Unit Managers were responsible for monitoring laboratory tests to ensure they were completed accurately. She stated the Unit Manager was responsible for checking each physician's orders [REDACTED]. The facility implemented the following for removal of jeopardy: 1. On [DATE], the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on [DATE]. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the Admission Director. Code status designations will be documented in the physician's orders [REDACTED]. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on [DATE]. 3. On [DATE], a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on [DATE]. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between [DATE] through [DATE], and any new physician's orders [REDACTED]. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed [DATE] through [DATE] by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Di (TRUNCATED)

Based on interview, record review, and review of facility policy, it was determined the facility failed to provide basic life support to a resident requiring emergency care prior to the arrival of emergency medical personnel for one (1) of thirty-seven (37) sampled residents (Resident #26 (6)). On [DATE], at 3:45 PM, staff assessed Resident #26 (6) to have a low blood pressure, pale skin, and labored breathing. However, the facility failed to continue to assess the resident and provide basic life support and Cardiopulmonary Resuscitation (CPR) if needed. Further, the facility failed to activate EMS until fifty-three minutes after the resident's decline. When EMS arrived, Resident #26 (6) had no pulse and was not breathing, and expired at the hospital on [DATE] at 5:11 PM (Refer to F580, F656, F658, and F842). The facility's failure to ensure residents received basic life support 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] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on [DATE]. After supervisory review, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on [DATE] at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy revised (MONTH) 2011, revealed [MEDICAL CONDITION] may initially result in gasping respirations or appear to be [MEDICAL CONDITION] activity. Training for basic life support should include recognizing these atypical presentations. The chances of surviving sudden [MEDICAL CONDITION] may be increased if Cardiopulmonary Resuscitation (CPR) is initiated immediately. The policy further stated facility staff had completed training on the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. Review of Resident #26's (6) closed medical record revealed the facility admitted the resident on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident had severe cognitive impairment. Review of Resident 26's (6) Emergency Medical Services Do Not Resuscitate Order, not dated, and review of a facility CPR form (untitled) dated [DATE], revealed the resident wished to have CPR performed and was designated as a full code. Review of Resident #26's (6) physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN) #12 on [DATE] at 2:45 PM; on [DATE] at 4:58 PM; and on [DATE] at 11:13 AM and 1:30 PM, and review of the Nursing Notes dated [DATE] at 3:45 PM, revealed Resident #26's (6) skin was pale, breathing was labored, respirations were 24 (normal is 18), and blood pressure was ,[DATE] (normal is ,[DATE]). LPN #12 stated she reviewed Resident #26's (6) medical record, determined the resident was a full code, and called the first floor Unit Manager (UM) to request assistance because the resident was actively dying. LPN #12 stated Resident #26 (6) continued to decline and was going downhill. LPN #12 stated the resident's breathing got worse, and his/her blood pressure and pulse continued to drop. Continued interview with LPN #12 revealed she contacted EMS to transport the resident to the hospital and did not call a code because she . thought EMS would get there in time. However, LPN #12 stated she did not notify EMS immediately when the resident was assessed to have a change in condition because she was trying to get the paper work ready for the resident's transfer. Interview with Unit Manager (UM) #2 on [DATE] at 10:55 AM revealed on [DATE], LPN #12 notified her that Resident #26 (6) was sick and dying and asked about moving the resident's roommate. However, the UM stated she did not check on Resident #26 (6) until after EMS arrived and was transporting the resident out of the facility. Review of facility video footage for [DATE] confirmed Licensed Practical Nurse (LPN) #12 was in Resident #26's (6) room at 3:40 PM, and exited the room less than one minute later. Further review of the video footage from 3:42 PM to 4:37 PM revealed LPN #12 entered and exited Resident #26's (6) room five (5) times, staying approximately one minute or less each time, and was observed to have no medical equipment when entering or exiting the room. Observation revealed Resident #26 (6) was alone in his/her room, with no staff present for nine (9) minutes. At 4:46 PM, LPN #12 was observed to enter Resident #26's (6) room with EMS. Review of the Fire-EMS Prehospital Care Report dated [DATE], and interview with Emergency Medical Services Provider #1 on [DATE] at 8:30 PM, revealed they did not receive a call from the facility requesting emergency services for Resident #26 (6) until 4:38 PM on [DATE], approximately fifty-three (53) minutes after the resident was assessed to have a change in condition. According to the EMS report, facility staff reported that Resident #26 (6) had a low blood pressure and staff advised Patient had been congested. Further review of the report revealed when EMS arrived to Resident #26's (6) room at 4:50 PM, accompanied by staff (LPN #12), the resident had no pulse and was not breathing, and the staff member (LPN #12) stated, Well I believe (he/she) is already gone. Continued review of the EMS report revealed facility staff advised EMS that the resident was a full code, and Cardiopulmonary Resuscitation (CPR) was initiated by EMS staff. EMS continued CPR during transport to the hospital. Interview with Kentucky Medication Assistant (KMA) #1 on [DATE] at 5:56 PM revealed she was working on [DATE] when Resident #26 (6) passed away. She stated LPN #12 called UM #2 and told her that Resident #26 (6) was actively dying. She stated she went into Resident #26's (6) room with LPN #12 when EMS arrived, and LPN #12 yelled (He/She) is already dead, get the crash cart. Review of Resident #26's (6) Emergency Department (ED) record revealed the resident presented to the ED with CPR in progress by EMS at 5:09 PM, on [DATE], and was pronounced dead at 5:11 PM, three (3) minutes after arrival. The facility implemented the following for removal of jeopardy: 1. On [DATE], the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on [DATE]. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the Admission Director. Code status designations will be documented in the physician's orders [REDACTED]. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on [DATE]. 3. On [DATE], a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on [DATE]. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between [DATE] through [DATE], and any new physician's orders [REDACTED]. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed [DATE] through [DATE] by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on [DATE] thru [DATE] related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On [DATE], the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on [DATE]. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On [DATE], training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On [DATE], a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On [DATE], a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On [DATE], the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on [DATE] to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective [DATE], the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on [DATE]. Education regarding the use of the audit forms was provided to the auditors on [DATE], by the Administrator and the long term care consultants. Effective [DATE], the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On [DATE], the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from [DATE] through [DATE]. The residents' physicians were notified with any new recommendations. From [DATE] through [DATE], a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on [DATE], a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on [DATE], and is no longer a resident. Resident #85 (5) was discharged from the facility on [DATE], and is no longer a resident at the facility. 17. On [DATE], a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on [DATE] and completed on [DATE], the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On [DATE], implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on [DATE] and continued through [DATE]. Employees not having been in-serviced by [DATE] will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on [DATE] and [DATE]. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From [DATE] to [DATE], a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from [DATE] through [DATE]. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On [DATE], the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On [DATE], the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On [DATE], the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on [DATE], is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on [DATE] by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on [DATE] with acceptance. On [DATE], the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administration's role with the abatement of jeopardy beginning [DATE]. The SSA verified the removal of immediate jeopardy by the following: 1. Review of the in-service roster dated [DATE], revealed the DON, MDS Nurse, and the QA Nurse had attended an in-service by the Administrator related to the development and implementation of a comprehensive care plan to ensure the wishes of each resident and their code status was included on the care plan. Interviews conducted with the MDS Nurse on [DATE] at 1:04 PM; the QA Nurse on [DATE] at 1:22 PM; and, the DON on [DATE] at 2:00 PM, revealed they attended the in-service provided by the Administrator and began providing in-services for other staff on [DATE]. 2. Review of the facility's policies and in-service rosters regarding Advance Directives and Code Status revealed the facility reviewed and updated the policies on [DATE]. The policies revealed the facility's new process to ensure Advance Directives/Wishes were honored was as follows: the physician would be notified after obtaining the resident's/ responsible party's consent, documenting the consent, and honoring the resident's wishes for Advance Directives and Code Status. The policy revealed the resident's wishes for Advance Directives and code status would be obtained upon admission by Social Services and the Admission Director. This would be documented in the physician's orders [REDACTED]. Interviews conducted with the Unit Manager on [DATE] at 11:04 AM, SSD on [DATE] at 11:25 AM, Activities Director on [DATE] at 12:59 PM, MDS Nurse on [DATE] at 1:04 PM, QA Nurse on [DATE] at 1:22 PM, Assistant Administrator on [DATE] at 1:40 PM, DON on [DATE] at 2:00 PM, and the Administrator on [DATE] at 2:10 PM, revealed they had reviewed/updated the facility's policies regarding Advance Directives and Code Status. 3. Review of audit sheets completed by the Administrator, MDS Nurse, Assistant Administrator, DON, QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Worker revealed an audit was conducted for all residents to ensure the resident's code status/Advance Directive was accurately documented on the physician's orders [REDACTED]. Interviews conducted with the Admissions Director on [DATE] at 11:00 AM, Unit Manager on [DATE] at 11:04 AM, SSD on [DATE] at 11:25 AM, Activities Director on [DATE] at 12:59 PM, MDS Nurse on [DATE] at 1:04 PM, QA Nurse on [DATE] at 1:22 PM, Assistant Administrator on [DATE] at 1:40 PM, DON on [DATE] at 2:00 PM, and the Administrator on [DATE] at 2:10 PM, revealed they had conducted audits on every resident to ensure the resident's code status/Advance Directive was accurate on the physician's orders [REDACTED]. They also revealed the audits were then reviewed in the facility's QAPI meeting. 4. Review of audits completed by the DON, QA Nurse, Unit Manager, and MDS Nurse, revealed all residents had been reviewed for any change in their condition, Nurses' Notes reviewed, any new physician's orders [REDACTED]. Interviews conducted with the Unit Manager on [DATE] at 11:04 AM, the MDS Nurse on [DATE] at 1:04 PM, QA Nurse on [DATE] at 1:22 PM, and the DON on [DATE] at 2:00 PM, revealed they completed the reviews regarding any residents who were transferred to the hospital, including their nurses notes and any new physician's orders [REDACTED]. 5. Review of staff in-service rosters, posttests, and interviews dated [DATE], revealed LPN #12, LPN #14, and SRNA #4 attended in-services by the DON and SDC regarding: - Advance Directives - Code Status - Implementation of the care plan which included wishes of the resident related to their code status - Timely notification of the physician and responsible party - Documentation of the notification of the physician and responsible party Interview with LPN #12 on [DATE] at 10:30 AM, LPN #14 on [DATE] at 11:00 AM, and SRNA #4 on [DATE] at 12:15 PM, revealed they attended the in-services and also completed a posttest as well as an interview to ensure they were knowledgeable of the information provided in the training. 6. Review of staff

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure six (6) of thirty-seven (37) sampled residents maintained acceptable parameters of nutritional/hydration status. Residents #53 (12), #147 (H), and #85 (5) sustained severe weight loss while in the facility. Although the facility recognized Residents #53 (12) lost weight, the facility failed to recognize that the 14 percent severe weight loss (21 pounds) in 15 days possibly resulted from not meeting his/her tube feeding needs, and implemented no interventions to prevent further loss. In addition, the resident's physician recommended the resident's tube feeding be increased on 01/30/18; however, the facility failed to increase the feeding for two days (Refer F580 and F656). Four days after admission to the facility, the Dietitian recommended Resident #147 (H) receive a health shake because the resident's food intake was low. However, the facility failed to provide the health shakes as recommended. Resident #147 (H) sustained further weight loss that the facility failed to identify for seven days. When the Dietitian eventually identified the resident had sustained weight loss, she recommended a multivitamin and snacks for the resident; however, the facility again failed to implement the recommendations and the resident lost four (4) additional pounds for a total of 8.9 percent weight loss (17 pounds) in eighteen (18) days (severe weight loss) (F580 and F656). In addition, the facility failed to recognize Resident #85 (5) was not receiving tube feeding as ordered and had sustained an 8% weight loss in fifteen days; subsequently, the facility failed to implement interventions to prevent further weight loss (Refer to F580, F656, F725, and F842). The facility's failure to ensure residents maintained acceptable parameters of nutrition and received sufficient fluid intake has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/26/18, and determined to exist on 01/09/18 at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on 01/26/18. After supervisory review, Immediate Jeopardy was identified on 03/01/18 and determined to exist on 12/12/17 at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on 03/01/18 at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on 03/05/18, which alleged removal of the Immediate Jeopardy on 03/05/18. The State Survey Agency determined the Immediate Jeopardy was removed on 03/05/18, prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. In addition, the facility failed to provide Residents #48 and #53 the physician's orders [REDACTED].#1, #85 (5), #147 (H), #53 (12), and #48 received sufficient fluid intake to maintain proper hydration. Interviews with staff revealed the facility failed to have an effective system to ensure physician ordered water flushes were provided to residents. Although interviews with the Director of Nursing revealed the facility had a system in place for monitoring resident intake to ensure residents were receiving appropriate hydration, the facility failed to identify that the system was not effective. The findings include: 1. Review of the facility's policy titled Weight Program dated 12/16/16, revealed the Registered Dietitian (RD) and licensed nurses were responsible for reviewing each resident with identified weight loss and recommending appropriate interventions. Review of the facility's policy titled Nutritionally at Risk (NAR) dated 12/16/16, revealed the NAR Committee would monitor and intervene in the care of residents related to weight loss. Review of the facility's Enteral Nutrition policy dated (MONTH) 2008, revealed a dietitian would assess residents to ensure they were receiving enteral feedings to ensure nutritional adequacy. The policy further stated enteral feeding orders would be written to ensure consistent volume infusion. 1. a. Review of the medical record revealed the facility admitted Resident #53 (12) on 11/30/17, and readmitted the resident on 12/30/17, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #53 (12) was cognitively impaired, received a mechanically altered diet, and weighed 143 pounds. Further review of Resident #53's (12) record revealed the resident was readmitted to the facility on [DATE], after receiving a feeding tube. A review of the resident's progress notes dated 12/31/17, revealed the resident's readmission weight was 143 pounds. Review of Resident #53's (12) physician's orders [REDACTED]. Review of a Dietary Note dated 01/05/18, completed after Resident #53 (12) received a feeding tube, revealed the resident's weight was 143 pounds, and would receive all nutrition via tube feeding. The dietitian estimated the resident's nutritional needs were 1950-2275 calories per day, and [MEDICATION NAME] 1.5 at 60 ml per hour provided 1980 calories. Review of the resident's Intake and Output record for 01/01/18 through 01/22/18, revealed the resident did not meet his/her nutritional needs on eighteen of twenty-two days. The resident's tube feeding intake ranged from 0-1440 ml per day, with an average of approximately 840 ml of tube feeding per day, approximately 600 ml less per day than the resident required. Review of Resident #53's (12) weight record dated 01/08/18, revealed Resident #53 (12) weighed 135 pounds, an eight-pound weight loss. Review of a NAR Note dated 01/08/18, revealed the Committee recognized the resident had sustained an eight-pound weight loss, but failed to identify the resident was not receiving his/her tube feeding as ordered and failed to implement interventions to prevent further weight loss. Further review of Resident #53's (12) weight record revealed the resident continued to sustain weight loss and on 01/15/18 weighed 122 pounds, a total weight loss of 21 pounds (14 percent body weight) in fifteen days. Review of a NAR Note dated 01/15/18, revealed the Committee again recognized that the resident had sustained additional weight loss, but again failed to recognize that the resident was not meeting his/her nutritional needs and only recommended the resident be weighed daily for seven (7) days and to obtain a [MEDICATION NAME] and total protein laboratory tests (when these levels are low it may be a sign of malnutrition). A review of the laboratory test results dated 01/17/18 revealed the resident's [MEDICATION NAME] level was low at 8 (normal is 18-38) and the resident's protein level was 5.9 (normal is 6.7-8.2). Continued review of Resident #53's (12) dietary notes dated 01/30/18, revealed the residents weight was 136 pounds, and had sustained significant weight loss. The Dietitian recommended increasing the resident's tube feeding from [MEDICATION NAME] 1.5 at 60 ml per hour to 65 ml per hour to promote a stable weight. Continued review of Resident #53's physician's orders [REDACTED]. feeding to 65 ml per hour. However, observations of Resident #53's tube feeding pump on 01/31/18 at 10:25 AM and 11:00 AM, 02/01/18 at 10:15 AM, and 02/01/18 at 4:30 PM, revealed the facility had not increased the resident's tube feeding, and continued to administer the [MEDICATION NAME] 1.5 at 60 ml per hour. Interview on 02/02/18 at 2:25 PM with LPN #4, revealed she was the nurse assigned to Resident #53 on 01/30/18 and 01/31/08. Even though documentation revealed the nurse signed off on the order to increase the resident's tube feeding, LPN #4 stated she was not aware that the resident's tube feeding rate had changed. Interview with LPN #9 on 02/01/18 at 5:35 PM, revealed she was not aware Resident #53's physician had written an order for [REDACTED]. She stated she made walking rounds with the nurse on the previous shift and the resident's tube feeding was infusing at 60 ml per hour. LPN #9 stated the nurse from the previous shift did not report that the resident's tube feeding rate had changed, and the rate change was not listed on the shift report. Interview on 01/24/18, at 12:05 PM, and on 02/02/18 at 5:30 PM, with the Director of Nursing (DON), revealed Resident #53's tube feeding rate should have been changed and communicated to the oncoming staff. The DON stated staff were also required to note any changes on the report sheet. She stated that every morning Monday through Friday, she was responsible for monitoring caloric intake for residents receiving tube feeding. The DON further stated the facility had a Nutritionally at Risk Committee that met every Tuesday to review residents' weights and recommend nutritional interventions to be implemented. However, the DON was unable to explain why Residents #53 (12) did not have interventions implemented related to his/her severe weight loss. 1. b. Review of the medical record revealed the facility admitted Resident #147 (H) on 12/08/17, with [DIAGNOSES REDACTED]. A review of the resident's weight roster revealed the resident weighed 191 pounds on 12/10/17. Review of Resident #147's (H) Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was nine (9), which indicated the resident was moderately cognitively impaired. Review of the Dietary Notes dated 12/12/17, revealed Resident #147 (H) was a new admission and weighed 189 pounds on 12/11/17. The Note stated the resident received a pureed diet with thin liquids and was eating approximately 42 percent of meals. The Registered Dietitian (RD) recommended the resident receive health shake supplements twice daily; however, there was no documented evidence the facility provided health shake supplements to the resident. A review of Resident #147' (H) Weight Roster dated 12/19/17, the resident's weight was 175 pounds, a 16 pound weight loss in nine (9) days. However, there was no evidence the facility identified the weight loss or implemented interventions to prevent further loss. Further review of a Dietary Notes revealed the Dietitian assessed Resident #147 (H) on 12/26/17, seven days after the resident sustained [REDACTED]. The RD documented the resident's weight was recorded at 178 pounds and recommended initiating a multivitamin with minerals and snacks three (3) times per day; however, there was no documented evidence the facility notified the resident's physician of the RD's recommendations and no evidence the facility implemented the Dietitian's recommendations. Further review of Resident #147's (H) weight record revealed the resident lost four (4) additional pounds and weighed 174 on 12/28/17, an 8.9 percent weight loss in eighteen (18) days (severe weight loss). Further review of Resident #147's (H) nursing notes dated 12/29/17 at 3:36 AM revealed the facility transferred the resident to the hospital due to lethargy, slurred speech, diaphoresis, low blood pressure, and low oxygen saturation. Resident #147 (H) was readmitted to the facility on [DATE] with a feeding tube that was placed during the resident's hospital admission because the resident was aspirating (going into the lungs) food/fluids. Interview with the Director of Nursing (DON) on on 01/24/18, at 12:05 PM, on 01/24/18, at 12:05 PM and on 01/25/18 at 11:43 AM revealed in the facility did not initiate a Nutritionally at Risk (NAR) Committee until (MONTH) (YEAR), after Resident #147 (H) lost weight. The DON stated the Unit Manager had always been responsible for recognizing weight loss and notifying the resident's physician of any significant or severe weight loss. The DON stated the Unit Manager was responsible for communicating RD recommendations to the resident's physician. Interview with the RD on 02/15/18 at 2:30 PM, revealed she reviewed residents' weights weekly and made recommendations when needed. She stated she assumed the Unit Managers notified the residents' physicians of her recommendations and necessary action was taken. The RD was unable to explain why she did not identify the resident's weight loss prior to 12/26/18. Review of a Termination Form dated 01/24/18 revealed the Unit Manager was terminated due to unsatisfactory performance and was unable to be interviewed. 1. c. Review of the medical record revealed the facility readmitted Resident #85 (5) on 12/27/17, after an acute hospital stay from 12/14/17 through 12/27/17 for treatment of [REDACTED]. The Resident had [DIAGNOSES REDACTED]. Review of Resident #85's (5) Dietary assessment dated [DATE] revealed the resident weighed 142 pounds and required 1613-1935 calories per day. According to the Registered Dietitian (RD), the resident was receiving Glucerna 1.5 tube feeding at 50 ml per hour, which provided 1650 calories. The RD stated the resident had no significant weight changes. A review of the resident's weight roster revealed on 12/28/17, after readmission from the hospital, and on 01/01/18, the resident weighed 155 pounds. Review of the Dietary Notes dated 01/05/18, revealed the resident's weight was 155 pounds, which was a significant weight gain after the resident returned from a hospital stay. Further review revealed the resident required 1505-1806 calories of tube feeding to maintain his/her weight, and continued to receive Glucerna tube feeding at 50 milliliters (ml) per hour (1200 ml per day), which provided 1650 calories per day. However, review of Resident #85's (5) Intake and Output Record for (MONTH) (YEAR), revealed the resident did not meet his/her estimated calorie needs for thirteen of eighteen days from 01/01/18 through 01/18/18. During the time period, the resident received an average of approximately 710 ml per day, approximately 500 ml less than the resident was assessed to require. Further review of Resident #85's (5) weight roster revealed on 01/08/18, the resident's weight was down to 144 pounds, an 11 pound weight loss since admission. A review of the Nutritionally at Risk (NAR) Progress Notes revealed the facility placed Resident #85 (5) in the NAR program on 01/08/18; however, they did not recognize that the resident had sustained weight loss and implemented no interventions to prevent further loss. Further review of the resident's weight roster revealed the resident lost two more pounds and weighed 142 pounds on 01/15/18, an eight percent weight loss in fourteen (14) days A review of the NAR progress notes for 01/15/18, revealed the NAR Committee documented the resident had lost 1.3 pounds and did not identify that the resident had sustained severe weight loss or implement interventions to address the resident's weight loss. Further review of the RD's notes revealed she assessed the resident again on 01/18/18, and documented the resident's weight was 142; however, no recommendations were made and there was no evidence the RD recognized the resident's weight loss. Interview with the Registered Dietitian (RD) on 01/23/18 at 5:20 PM revealed she monitored residents' weights weekly; however, there was no documented evidence the RD recognized the resident had lost weight. Further interview with the RD on 01/25/18 at 2:30 PM, revealed she had overlooked Resident #85's (5) weight loss. Interview with Physician #1 on 01/25/18 at 11:16 AM, revealed he did not recall whether the facility notified him of Resident #85's (5) weight loss from 01/01/18 to 01/15/18; however, he expected the facility to notify him when a resident lost that much weight, in just two (2) weeks. 1. d. Review of the medical record revealed the facility admitted Resident #48 on 08/18/15, with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 was cognitively impaired and had a feeding tube. Review of Resident #48's physician's orders [REDACTED]. Review of the Registered Dietitian's Monthly Tube Feeding Review dated 12/08/17, revealed Resident #48 was receiving [MEDICATION NAME] 1.5 at 40 ml per hour, which provided 1,320 calories. The RD documented the resident was meeting his/her nutritional needs and weighed 151 on 12/03/17. However, review of Resident #48's intake and output record revealed the resident did not meet his/her tube feeding needs from 01/04/18 through 01/08/18. On 01/04/18, the facility documented the resident received 600 ml of tube feeding; on 01/05/18, the resident received 480 ml; on 01/06/18, the resident received 480 ml; on 01/07/18, the facility documented the resident had no tube feeding; and, on 01/08/18, the resident received 540 of tube feeding. Although the resident was ordered to received 4,800 ml of tube feeding from 01/04/18 through 01/08/18, the resident only received 2,100 ml's of tube feeding during this time period. Review of the resident's Weight Change History dated 12/31/17, 01/07/18, and 01/21/18 revealed the resident weighed 150, and had sustained no weight loss. Review of the Dietitian Monthly Review Note dated 01/09/18, revealed Resident #48 was assessed to require 1243-1491 calories per day. The dietitian documented the resident received 1320 calories per day and was meeting his/her nutritional needs, even though the resident had not met his tube feeding needs for the previous five (5) days. Interview with Kentucky Medication Aide (KMA) #2 on 01/23/18 at 2:46 PM, Registered Nurse (RN) #2 on 01/24/18 at 5:12 PM and 7:16 PM, Licensed Practical Nurse (LPN) #14 on 01/24/18 at 11:47 AM, LPN #13 on 01/19/18 at 9:10 AM, and LPN #9 on 01/24/18 at 11:30 AM and with LPN #15 on 01/24/18 at 5:12 PM, revealed they could not specifically say why no tube feeding was documented for some residents on the intake and output records. The staff stated that they documented the amount of tube feeding that infused on their shift, but did not monitor the total amount administered to the residents. The staff stated the Director of Nursing (DON) was responsible for monitoring residents' daily tube feeding intake. Continued interviews with KMA #2 on 01/23/18 at 2:46 PM, RN #2 on 01/24/18 at 7:16 PM, and with KMA #3 01/23/18 at 1:16 PM, Certified Nursing Assistant (CNA) #10 on 01/24/18 at 7:09 PM revealed frequently there was not a nurse available on the floor to provide care for residents, such as tube feeding administration, medications, and treatments. Interview with the Registered Dietitian (RD) on 01/23/18 at 5:20 PM revealed she monitored residents' weights weekly, discussed the resident's weekly during the Nutritionally at Risk (NAR) meeting, and watch them closely. Interview with the Director of Nursing (DON) on 01/24/18, at 12:05 PM and 01/25/18 at 11:43 AM, revealed she prints an Intake and Output (I and O) report every morning for each resident for the previous 24 hours. She stated she reviewed the report, and if a resident did not meet their tube feeding needs, Then I look at the MAR and add what the MAR says. However, interviews with Licensed Practical Nurse (LPN) #14 on 01/24/18 at 11:47 AM, LPN #13 on 01/19/18 at 9:10 AM, Registered Nurse (RN) #2 on 01/24/18 at 5:12 PM, LPN #9 on 01/24/18 at 11:30 AM and with LPN #15 on 01/24/18 at 5:12 PM, revealed they initialed the MAR to indicate they were aware of the amount of tube feeding that was ordered to be infused, not to indicate that was the actual amount the resident received. 2. Review of the facility's Hydration policy revised on 07/25/12, revealed each resident would be provided with sufficient fluid intake to maintain hydration. Further review of the policy, revealed if a resident failed to receive 1500 ml of fluids for three (3) consecutive days, the resident would be evaluated for signs and symptoms of dehydration. 2. a. Review of the medical record revealed the facility admitted Resident #1 on 01/10/18, with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Admission Nutritional assessment dated [DATE], revealed to meet the resident's fluid needs, the resident would require the ordered tube feeding and water flushes of 150 ml every four hours. Review of Resident #1's Intake and Output record revealed the resident did not meet his/her fluid needs on four of seven days (4 of 7) from 01/12/18 through 01/18/18. On 01/12/18, the resident received 120 ml; on 01/13/18, the resident received 600 ml; on 0/16/18, the resident received 500 ml; and, on 01/17/18, the resident received 750 ml of water via the feeding tube. 2. b. Review of the medical record revealed the facility admitted Resident #85 (5) on 06/27/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #85 (5) was not interviewable. Review of Resident #85's (5) Physician order [REDACTED]. Review of Resident #85's (5) Dietary assessment dated [DATE], revealed the resident required 1505-1806 cc's of water to maintain hydration. The Assessment stated the resident received Glucerna 1.5 at 50 ml per hour with 200 ml water flush every 4 hours, which provided 2035 cc of total fluid per day. Observation of Resident #85's (5) feeding tube pump 01/24/18 at 4:32 PM, revealed only 163 ml's of water had been administered to the resident in approximately eight (8) hours, approximately 237 ml less than was required for the resident. Further, review of Resident #85's (5) Medication Administration Record (MAR) revealed the resident did not meet his/her fluid needs on eleven of eighteen days from 01/01/18 through 01/16/18, and no fluid intake was documented on 01/22/18 or 01/23/18. Review of a Dehydration Risk assessment dated [DATE] revealed the facility assessed Resident #85 (5) to have no signs or symptoms of dehydration; the resident's skin turgor was good and the resident's mucous membranes, tongue, and lips were moist. However, review of Resident #85's (5) laboratory values dated 12/29/17 and 01/27/18 revealed the resident's Blood Urea Nitrogen (BUN) and creatinine (BUN and creatinine levels test kidney function and may temporarily increase if you are dehydrated, have a low blood volume, eat a large amount of meat, or take certain medications) increased from 18 (normal BUN is 6-20) and 0.6 (normal creatinine is 0.4-1.0) on 12/29/17 to 41 and 0.9, respectively on 01/27/18. A post survey interview was attemepted with Resident #85's (5) Physician on 04/06/18, but the Physician was not available. 2. c. Review of the medical record revealed the facility admitted Resident #147 (H) on 12/08/17, with [DIAGNOSES REDACTED]. Review of Resident #147's (H) Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was nine (9), which indicated the resident was moderately cognitively impaired. Review of Resident #147's (H) physician's orders [REDACTED]. However, observation on 01/24/18 at 7:08 PM, of Resident #147's (H) feeding tube pump revealed the resident had only received 32 ml of water in the previous 8.5 hours, approximately 168 ml less than the resident's required amount. 2. d. Review of the medical record revealed the facility admitted Resident #53 (12) on 11/30/17, and readmitted the resident on 12/30/17, with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE], revealed Resident #53 (12) was cognitively impaired. Review of Resident #53's (12) physician's orders [REDACTED]. Review of a Dietary Note for Resident #53 (12) dated 01/05/18, revealed the resident's estimated fluid needs were 1950-2275 ml of fluid per day. According to the Dietitian's Note, the resident received [MEDICATION NAME] 1.5 at 60 ml per hour with a 200 ml water flush every four hours to provide 2203 ml of fluid per day. However, review of Resident #53's (12) Intake and Output record for (MONTH) (YEAR), for 01/01/18 through 01/22/18 revealed the resident's average daily fluid intake was approximately 703 ml, approximately 500 ml less than the resident required. A review of Resident #53's (12) laboratory results dated [DATE] and 02/05/18 revealed the resident's Blood Urea Nitrogen (BUN) and creatinine levels increased from (MONTH) to (MONTH) (YEAR) (BUN and creatinine levels test kidney function may temporarily increase if you are dehydrated, have a low blood volume, eat a large amount of meat, or take certain medications). On 01/02/18, the resident's BUN was 34 (normal is 6-20). However, on 02/06/18, Resident #53's (12) BUN had increased to 44. A post survey interview was attemepted with Resident #53's (12) Physician on 04/06/18, but the Physician was not available. 2. e. Review of Resident #48's medical record revealed the facility admitted the resident on 08/18/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #48 was cognitively impaired and had a feeding tube. Review of Resident #48's physician's orders [REDACTED]. A review of the Monthly Tube Feeding Review dated 12/08/17, revealed Resident #48 required 1245-1494 ml of fluid to provide proper hydration. However, observation of Resident #48's tube feeding pump on 01/24/18 at 7:10 PM, revealed the resident had only received 57 ml of water in the previous 8.5 hours, approximately 143 ml less than the resident required in 6 hours. Further, review of Resident #48's Intake and Output Record for (MONTH) (YEAR), revealed the resident did not meet his/her assessed fluid 01/04/18 through 01/08/18, and only received an average of 363 ml of fluid per day, approximately 437 ml less than the resident required per day. Review of the Dietitian's Monthly Review Note dated 01/09/18, revealed Resident #48 was assessed to require 1243-1491 ml of water per day. The Dietitian documented the resident was receiving 1469 ml of fluid per day and was meeting his/her nutritional needs, even though the resident had not met his/her fluid needs for the previous five (5) days. Review of Resident #48's medical record revealed no evidence the facility assessed the resident's hydration status until 01/31/18, twenty-three days later. Review of the 01/31/18 Dehydration Risk Evaluation for Resident #48 revealed the facility assessed the resident to have no signs or symptoms of dehydration, including no skin turgor concerns and the resident's mucous membranes, lips, and tongue were moist. Interview with the Registered Dietitian (RD) on 01/23/18 at 5:20 PM revealed she monitored residents' intake weekly to obtain an average of the resident's daily fluid intake. However, the RD stated she did not take action if the resident failed to meet their needs. She stated she guessed the unit manager was responsible for notifying the resident's physician if they did not meet their fluid needs. Interviews with Licensed Practical Nurse (LPN) #14 on 01/24/18 at 11:47 AM, LPN #13 on 01/19/18 t 9:10 AM, and Registered Nurse (RN) #2 on 01/24/18 at 5:12 PM revealed they were aware that tube feeding pumps did not function correctly and did not consistently deliver the correct amount of water flushes to residents. The LPNs stated they checked the residents' feeding pump at the times indicated on the residents' Medication Administration Record (MAR). Continued interview revealed they often had to supplement the amount of water delivered to the resident with manual water flushes to ensure the resident received the amount of water ordered by the physician. Further, the LPNs stated they totaled the amount of water delivered by the pump and the amount of water manually infused and documented the total amount on each residents' I and O record. However, interviews with LPN #9 on 01/24/18 at 11:30 AM and with LPN #15 on 01/24/18 at 5:12 PM, revealed physician ordered water flushes were automatically infused by the feeding tube pump and they did not check the pump and supplement the amount of water the resident had received. The LPNs stated they initialed the MAR to indicate they were aware of the amount ordered to be infused, not to indicate that was the amount the resident received. The LPNs stated that at the end of each shift, the amount of water infused by the pump was documented on the Intake and Output Record, and the resident did not receive any additional fluids. Interview with the Director of Nursing (DON) on 01/24/18, at 12:05 PM,on 01/24/18, at 12:05 PM and on 01/25/18 at 11:43 AM, revealed prior to (MONTH) (YEAR), the facility did not have a system to monitor resident's fluid intake. However, in (MONTH) (YEAR), the DON began running an Intake and Output (I and O) report every morning for the previous 24 hours. She stated the I and O Report was reviewed in the morning meeting to identify anyone who did not have an intake of at least 1500 ml per day. If a resident did not meet 1500 ml, a nurse was required to do a hydration assessment and the Unit Manager was required to notify the resident's physician. The DON stated when totaling the daily fluid intake for residents, she added the amount that was initialed by the nurse on the MAR to the total on the Intake record to determine the resident's total fluid intake. However, the DON was not aware that not all nursing staff were ensuring the feeding tube pump delivered an adequate amount of water to the resident. The DON had not i (TRUNCATED)

Based on interview, record review, review of facility policies, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility submitted a Plan of Correction (P[NAME]) in response to Immediate Jeopardy level deficiencies cited on [DATE], and alleged compliance effective [DATE]. In addition, the facility submitted a Plan of Correction for deficiencies cited on [DATE], alleging compliance [DATE]. However, during a noncompliance revisit conducted on [DATE], it was determined the facility's Administrator failed to ensure the deficiencies were corrected as alleged in the facility's P[NAME], and failed to ensure regulatory compliance as required by the Administrator's job description. Immediate Jeopardy was identified to exist again at the facility on [DATE]. The facility's failure to be administered effectively 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] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on [DATE]. After supervisory review, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on [DATE] at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's Job Description dated (MONTH) 2013, revealed the primary responsibility of the Administrator was to oversee the overall observation, leadership, and management of the facility. The Administrator would ensure appropriate resident care, quality assurance, and regulatory management. 1. An abbreviated survey was conducted at the facility on [DATE], and Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans; 42 CFR 483.25 Quality of Care; and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care due to the facility's failure to ensure an effective system was in place to conduct laboratory testing as ordered by the resident's physician and in accordance with standards of practice. The facility submitted a Plan of Correction (P[NAME]) on [DATE], and alleged compliance effective [DATE]. Another abbreviated survey was conducted on [DATE], and deficient practice was identified at 483.45 Pharmacy Services due to the facility's failure to ensure medications were available to administer to residents. The facility submitted a P[NAME] on [DATE], and alleged compliance effective [DATE]. However, review of Resident #146's medical record revealed no documented evidence the facility administered the resident's physician ordered [MEDICATION NAME] (Intravenous (IV) antibiotic to treat infection) on [DATE], at 6:30 AM, to treat the resident's Urinary Tract Infection. The resident was transferred and readmitted to the hospital on [DATE] at 7:25 PM, approximately thirteen (13) hours later, with [DIAGNOSES REDACTED]. Review of the facility's Post Admission Quality Assurance Reviews, completed on [DATE] and on [DATE] after Resident #146's readmission to the facility from the acute care hospital stay, revealed the facility documented that the resident's medications were ordered from the pharmacy and no concerns were identified. However, interview with the QA Nurse on [DATE] at 1:30 PM, revealed she did not confirm the resident's physician orders [REDACTED]. She stated she discovered on [DATE], after the resident's medication was past due, that the resident's physician orders [REDACTED]. She stated Resident #146's medication was not available when it was due to be administered on [DATE]. Further, review of Resident #63's closed medical record revealed the resident had a physician's orders [REDACTED]. However, record review revealed the facility entered the physician's orders [REDACTED]. There was no documented evidence the facility obtained the test for [DIAGNOSES REDACTED] or hemoccult as ordered by the physician. Observation of a laboratory binder on [DATE] at 1:30 PM, revealed the facility failed to track the resident's ordered laboratory tests for [DIAGNOSES REDACTED] and Hemoccult in the binder maintained at the nurses' station as required by the facility's plan of correction. Interview with the Director of Nursing on [DATE] at 12:05 PM, revealed the facility was tracking lab orders on a white board and had no documented evidence that the facility implemented their plan of correction and monitored to ensure Resident #63's laboratory tests were completed as ordered. 2. Based on the findings of a non-compliance revisit and annual recertification survey, Immediate Jeopardy was identified again on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Medical Records (F842). The facility was notified of the Immediate Jeopardy on [DATE]. Resident #63 had a signed Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) order dated [DATE]. However, on [DATE], when the resident was determined to be critically ill with impending [MEDICAL CONDITION]/arrest, the facility failed to provide the form to EMS. EMS provided CPR to Resident #63 and transferred the resident to the hospital, where the resident was placed on a ventilator and expired on [DATE] (Refer to F578, F656, and F770). The Administrator failed to identify that the KY EMS form was not provided and the resident's end of life wishes were not honored, and no action was taken to ensure residents' wishes were honored. Subsequently, three days later, the facility failed to provide basic life to Resident #26 (6) and honor the resident's wishes when the resident experienced a change in condition. On [DATE], Resident #26 (6) was assessed by staff to have a low blood pressure, pale skin, and labored breathing at approximately 3:45 PM. The facility failed to notify the resident's physician of the change in the resident's condition, failed to provide basic life support, and failed to immediately notify Emergency Medical Services (EMS) when Resident #26 (6) experienced a change in condition. When EMS arrived on [DATE] at 4:50 PM, Resident #26 (6) was not breathing and had no pulse. EMS initiated Cardiopulmonary Resuscitation (CPR) and transferred the resident to the hospital. However, Resident #26 (6) expired at 5:11 PM on [DATE], when resuscitation efforts were unsuccessful (Refer to F580, F656, F658, F678, and 842). Interview with the Administrator on [DATE] at 2:30 PM, revealed she assisted in developing the plans of correction. The Administrator stated her role in implementing the plans of correction consisted of reviewing the audits, determining education needs of staff, completing disciplinary action if needed, and monitoring weekly to ensure the plans of correction were implemented. Further interview with the Administrator revealed the facility's Plans of Correction were not effective in identifying that Resident #146 did not receive physician ordered medication or that Resident #63 did not receive a physician ordered laboratory test. Further interview revealed the Administrator had not identified any concerns regarding Resident #63 or #26's (6) end of life wishes. The facility implemented the following for removal of jeopardy: 1. On [DATE], the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on [DATE]. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the Admission Director. Code status designations will be documented in the physician's orders [REDACTED]. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on [DATE]. 3. On [DATE], a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on [DATE]. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between [DATE] through [DATE], and any new physician's orders [REDACTED]. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed [DATE] through [DATE] by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on [DATE] thru [DATE] related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On [DATE], the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on [DATE]. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On [DATE], training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On [DATE], a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On [DATE], a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On [DATE], the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on [DATE] to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective [DATE], the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on [DATE]. Education regarding the use of the audit forms was provided to the auditors on [DATE], by the Administrator and the long term care consultants. Effective [DATE], the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On [DATE], the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from [DATE] through [DATE]. The residents' physicians were notified with any new recommendations. From [DATE] through [DATE], a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on [DATE], a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on [DATE], and is no longer a resident. Resident #85 (5) was discharged from the facility on [DATE], and is no longer a resident at the facility. 17. On [DATE], a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on [DATE] and completed on [DATE], the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On [DATE], implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on [DATE] and continued through [DATE]. Employees not having been in-serviced by [DATE] will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on [DATE] and [DATE]. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From [DATE] to [DATE], a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from [DATE] through [DATE]. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On [DATE], the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On [DATE], the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On [DATE], the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on [DATE], is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on [DATE] by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on [DATE] with acceptance. On [DATE], the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administration's role with the abatement of jeopardy beginning [DATE]. The SSA verified the removal of immediate jeopardy by the following: 1. Review of the in-service roster dated [DATE], revealed the DON, MDS Nurse, and the QA Nurse had attended an in-service by the Administrator related to the development and implementation of a comprehensive care plan to ensure the wishes of each resident and their code status was included on the care plan. Interviews conducted with the MDS Nurse on [DATE] at 1:04 PM; the QA Nurse on [DATE] at 1:22 PM; and, the DON on [DATE] at 2:00 PM, revealed they attended the in-service provided by the Administrator and began providing in-services for other staff on [DATE]. 2. Review of the facility's policies and in-service rosters regarding Advance Directives and Code Status revealed the facility reviewed and updated the policies on [DATE]. The policies revealed the facility's new process to ensure Advance Directives/Wishes were honored was as follows: the physician would be notified after obtaining the resident's/ responsible party's consent, documenting the consent, and honoring the resident's wishes for Advance Directives and Code Status. The policy revealed the resident's wishes for Advance Directives and code status would be obtained upon admission by Social Services and the Admission Director. This would be documented in the physician's orders [REDACTED]. Interviews conducted with the Unit Manager on [DATE] at 11:04 AM, SSD on [DATE] at 11:25 AM, Activities Director on [DATE] at 12:59 PM, MDS Nurse on [DATE] at 1:04 PM, QA Nurse on [DATE] at 1:22 PM, Assistant Administrator on [DATE] at 1:40 PM, DON on [DATE] at 2:00 PM, and the Administrator on [DATE] at 2:10 PM, revealed they had reviewed/updated the facility's policies regarding Advance Directives and Code Status. 3. Review of audit sheets completed by the Administrator, MDS Nurse, Assistant Administrator, DON, QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Worker revealed an audit was conducted for all residents to ensure the resident's code status/Advance Directive was accurately documented on the physician's orders [REDACTED]. Interviews conducted with the Admissions Director on [DATE] at 11:00 AM, Unit Manager on [DATE] at 11:04 AM, SSD on [DATE] at 11:25 AM, Activities Director on [DATE] at 12:59 PM, MDS Nurse on [DATE] at 1:04 PM, QA Nurse on [DATE] at 1:22 PM, Assistant Administrator on [DATE] at 1:40 PM, DON on [DATE] at 2:00 PM, and the Administrator on [DATE] at 2:10 PM, revealed they had conducted audits on every resident to ensure the resident's code status/Advance Directive was accurate on the physician's orders [REDACTED]. They also revealed the audits were then reviewed in the facility's QAPI meeting. 4. Review of audits completed by the DON, QA Nurse, Unit Manager, and MDS Nurse, revealed all residents had been reviewed for any change (TRUNCATED)

Based on interview, record review, and review of facility policies, it was determined the governing body failed to ensure policies were implemented regarding the management and operation of the facility. The facility submitted a Plan of Correction in response to Immediate Jeopardy deficiencies cited on [DATE], and alleged compliance effective [DATE]. In addition, the facility submitted a Plan of Correction for deficiencies cited on [DATE], alleging compliance [DATE]. However, during a noncompliance revisit conducted on [DATE], it was determined the facility failed to implement their plans of correction as described in the documents issued to the State Survey Agency, and Immediate Jeopardy was again identified to exist. The Governing Body's failure to ensure the facility's policies were implemented 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] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on [DATE]. After supervisory review, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on [DATE] at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Governing Body policy, undated, revealed the Governing Body was responsible for establishing and implementing policies regarding the management and operation of the facility. The policy revealed the Governing Body employeed a management company to direct the overall management of the facility. The Governing Body also appointed an Administrator who was responsible for the daily operation of the facility. On [DATE], an abbreviated survey was conducted at the facility and Immediate Jeopardy was determined to exist at 42 CFR 483.21 Comprehensive Person-Centered Care Plans; 42 CFR 483.25 Quality of Care; and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care due to the facility's failure to ensure an effective system was in place to conduct laboratory testing as ordered by the resident's physician and in accordance with standards of practice. The facility submitted a Plan of Correction (P[NAME]) on [DATE], and alleged compliance effective [DATE]. On [DATE], another abbreviated survey was conducted and deficient practice was identified at 483.45 Pharmacy Services due to the facility's failure to ensure medications were available to administer to residents. The facility submitted a P[NAME] on [DATE], and alleged compliance effective [DATE]. However, based on the findings of a non-compliance revisit and an annual recertification survey, Immediate Jeopardy was again identified on [DATE] (fifteen (15) days after the facility alleged compliance) and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Medical Records (F842). Interview with a Governing Body Member on [DATE] at 2:00 PM via telephone and a post survey interview conducted on [DATE], at 6:10 PM, via telephone revealed the Governing Body consisted of herself and the Co-owner of the facility. The Member stated that neither she nor the Co-owner had a medical background and therefore the facility had entered into a management agreement with a consultant company to manage the day to day operations of the facility. The Board Member stated that a Governing Body meeting was conducted monthly at the facility which consisted of the Administrator, the Management Company Team, and the Governing Body Members. The Member stated that the Governing Body Members were not provided with written reports, but were advised of general problems such as staffing issues or personnel action that needed their approval such as termination of employees. The Board Member stated that she was aware that deficient practice had been identified during the previous surveys, but was not aware of specific details of the deficient practice or resident specific information. The Board member stated the Governing Body was dependent upon the Management Company to ensure policies and procedures were implemented. Review of a Management Agreement entered into by the facility and the Management Company on [DATE], revealed the facility had retained the Management Company to supervise and manage the operation of the facility. The Agreement states that the Management Company will manage all aspects of the facility's operation in an efficient manner and periodically consult with the owners authorized represenatives and keep them advised as to all fisical and operational matters relating to the facility. The agreement also states that all general policy decisions would be made by the owner. (Refer to F578, 580, F656, F658, F678, and F692, F835, F842 and F868.) The facility implemented the following for removal of jeopardy: 1. On [DATE], the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on [DATE]. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the Admission Director. Code status designations will be documented in the physician's orders [REDACTED]. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on [DATE]. 3. On [DATE], a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on [DATE]. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between [DATE] through [DATE], and any new physician's orders [REDACTED]. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed [DATE] through [DATE] by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on [DATE] thru [DATE] related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On [DATE], the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on [DATE]. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On [DATE], training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On [DATE], a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On [DATE], a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On [DATE], the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on [DATE] to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective [DATE], the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on [DATE]. Education regarding the use of the audit forms was provided to the auditors on [DATE], by the Administrator and the long term care consultants. Effective [DATE], the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On [DATE], the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from [DATE] through [DATE]. The residents' physicians were notified with any new recommendations. From [DATE] through [DATE], a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on [DATE], a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on [DATE], and is no longer a resident. Resident #85 (5) was discharged from the facility on [DATE], and is no longer a resident at the facility. 17. On [DATE], a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on [DATE] and completed on [DATE], the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On [DATE], implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on [DATE] and continued through [DATE]. Employees not having been in-serviced by [DATE] will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on [DATE] and [DATE]. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From [DATE] to [DATE], a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from [DATE] through [DATE]. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On [DATE], the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On [DATE], the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On [DATE], the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on [DATE], is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on [DATE] by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on [DATE] with acceptance. On [DATE], the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administration's role with the abatement of jeopardy beginning [DATE]. The SSA verified the removal of immediate jeopardy by the following: 1. Review of the in-service roster dated [DATE], revealed the DON, MDS Nurse, and the QA Nurse had attended an in-service by the Administrator related to the development and implementation of a comprehensive care plan to ensure the wishes of each resident and their code status was included on the care plan. Interviews conducted with the MDS Nurse on [DATE] at 1:04 PM; the QA Nurse on [DATE] at 1:22 PM; and, the DON on [DATE] at 2:00 PM, revealed they attended the in-service provided by the Administrator and began providing in-services for other staff on [DATE]. 2. Review of the facility's policies and in-service rosters regarding Advance Directives and Code Status revealed the facility reviewed and updated the policies on [DATE]. The policies revealed the facility's new process to ensure Advance Directives/Wishes were honored was as follows: the physician would be notified after obtaining the resident's/ responsible party's consent, documenting the consent, and honoring the resident's wishes for Advance Directives and Code Status. The policy revealed the resident's wishes for Advance Directives and code status would be obtained upon admission by Social Services and the Admission Director. This would be documented in the physician's orders [REDACTED]. Interviews conducted with the Unit Manager on [DATE] at 11:04 AM, SSD on [DATE] at 11:25 AM, Activities Director on [DATE] at 12:59 PM, MDS Nurse on [DATE] at 1:04 PM, QA Nurse on [DATE] at 1:22 PM, Assistant Administrator on [DATE] at 1:40 PM, DON on [DATE] at 2:00 PM, and the Administrator on [DATE] at 2:10 PM, revealed they had reviewed/updated the facility's policies regarding Advance Directives and Code Status. 3. Review of audit sheets completed by the Administrator, MDS Nurse, Assistant Administrator, DON, QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Worker revealed an audit was conducted for all residents to ensure the resident's code status/Advance Directive was accurately documented on the physician's orders [REDACTED]. Interviews conducted with the Admissions Director on [DATE] at 11:00 AM, Unit Manager on [DATE] at 11:04 AM, SSD on [DATE] at 11:25 AM, Activities Director on [DATE] at 12:59 PM, MDS Nurse on [DATE] at 1:04 PM, QA Nurse on [DATE] at 1:22 PM, Assistant Administrator on [DATE] at 1:40 PM, DON on [DATE] at 2:00 PM, and the Administrator on [DATE] at 2:10 PM, revealed they had conducted audits on every resident to ensure the resident's code status/Advance Directive was accurate on the physician's orders [REDACTED]. They also revealed the audits were then reviewed in the facility's QAPI meeting. 4. Review of audits completed by the DON, QA Nurse, Unit Manager, and MDS Nurse, revealed all residents had been reviewed for any change in their condition, Nurses' Notes reviewed, any new physician's orders [REDACTED]. Interviews conducted with the Unit Manager on [DATE] at 11:04 AM, the MDS Nurse on [DATE] at 1:04 PM, QA Nurse on [DATE] at 1:22 PM, and the DON on [DATE] at 2:00 PM, revealed they completed the reviews regarding any residents who were transferred to the hospital, including their nurses notes and any new physician's orders [REDACTED]. 5. Review of staff in-service rosters, posttests, and interviews dated [DATE], revealed LPN #12, LPN #14, and SRNA #4 attended in-services by the DON and SDC regarding: - Advance Directives - Code Status - Implementation of the care plan which included wishes of the resident related to their code status - Timely notification of the physician and responsible party - Documentation of the notification of the physician and responsible party Interview with LPN #12 on [DATE] at 10:30 AM, LPN #14 on [DATE] at 11:00 AM, and SRNA #4 on [DATE] at 12:15 PM, revealed they attended the in-services and also completed a posttest as well as an interview to ensure they were knowledgeable of the information provided in the training. 6. Review of staff in-service rosters, posttests, and interviews dated [DATE] through [DATE], revealed all staff had attended the in-services given by the DON and SDC on: - Advance Directives - Code Status - Development and implementation of the care plan which included wishes of the resident related to their code status - Timely notification of the physician and responsible party - Documentation of the notification of the physician and responsible party - Provision of the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes -Determination of a resident's code status according to the facility's protocols -Assessing and responding to a resident in distress - Initiation of a code -Communication of a resident's wishes regarding Advance Directives and code status -Honoring a resident's wishes in a full code status - Documentation of care delivered Interviews conducted with LPN #9 on [DATE] at 4:05 PM, SRNA #23 on [DATE] at 4:10 PM, SRNA #24 on [DATE] at 4:15 PM, Dietary Employee #1 on [DATE] at 4:25 PM, Dietary Manager on [DATE] at 4:30 PM, Dietary Employee #2 on [DATE] at 4:35 PM, KMA #3 on [DATE] at 4:50 PM, SRNA #5 on [DATE] at 9:10 AM, SRNA #12 on [DATE] at 9:15 AM, SRNA #14 on [DATE] at 9:25 AM, LPN #1 on [DATE] at 9:30 AM, and SRNA #25 on [DATE] at 9:40 AM, SSD on [DATE] at 11:25 AM, Activities Director on [DATE] at 12:59 PM, and the MDS Nurse on [DATE] at 1:04 PM, revealed they had attended the in-services, and completed a posttest and an interview to ensure they (TRUNCATED)

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure three (3) of thirty-seven (37) residents (Residents #58, #26 (6), and #85 (5)) medical records were complete and correctly documented. The facility inaccurately documented Resident #26's (6) vital signs, failed to accurately document Resident #58's intravenous antibiotic medication and documented a physician's orders [REDACTED]. In addition, staff documented the amount of tube feeding that Resident #85 (5) had received before the resident had actually received the feeding and failed to accurately document Resident #85's (5) transfer to an acute care hospital (Refer to F580, F656, F658, F678). The facility's failure to ensure residents' medical records were complete and accurate 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] at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656 and F658), 42 CFR 483.24 Quality of Life (F678), and 42 CFR 483.70 Administration (F842). The facility was notified of the Immediate Jeopardy on [DATE]. After supervisory review, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837). The facility was notified of the Immediate Jeopardy on [DATE] at 42 CFR 483.25 Quality of Care (F692), and 42 CFR 483.70 Administration (F835 and F837). An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at at 42 CFR 483.10 Resident Rights (F578 and F580), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F658), 42 CFR 483.24 Quality of Life (F678), 42 CFR 483.25 Quality of Care (F692 ) and 42 CFR 483.70 Administration (F835, F837, and 842), and to an E at 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F656), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: 1. A review of the facility's Notification of Changes/Documentation policy, not dated, revealed when a resident had a change in condition, a nursing note had to be charted about the condition, who was contacted, and what interventions were being implemented. Review of Resident #26's (6) closed medical record revealed the facility admitted the resident on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Nursing Notes dated [DATE] at 3:45 PM, revealed Licensed Practical Nurse (LPN) #12 documented that Resident #26's (6) skin was pale, breathing was labored, and blood pressure was ,[DATE] (normal is ,[DATE]). Continued review of Resident #26's (6) Nursing Notes revealed on [DATE] at 5:09 PM, LPN #12 documented that the physician was notified about the resident's condition and new orders were received to send the resident to the hospital for evaluation, the resident's blood pressure was ,[DATE], pulse 60, respirations 24, and oxygen saturation was 97%. However, review of the Fire-EMS Prehospital Care Report dated [DATE], revealed when EMS arrived to the resident's room at 4:50 PM, nineteen minutes before the Nursing Note was written, the resident had no pulse and was not breathing, and was transferred to the hospital at 5:01 PM with CPR in progress. In addition, interview with Resident #26's (6) physician on [DATE] at 11:04 AM revealed the facility never notified him that the resident had a change in condition or was transferred to the hospital. Review of Resident #26's (6) Emergency Department (ED) record revealed the resident presented to the ED with CPR in progress by EMS at 5:09 PM, which was the same time that LPN #12 documented that the resident had vital signs at the facility. Further review revealed Resident #26 (6) was pronounced dead at 5:11 PM, on [DATE]. Interview with the Director of Nursing on [DATE] at 11:41 AM, revealed the facility had no system in place to review nursing documentation to ensure medical records were complete and accurate. 2. a. Review of the facility's policy titled, Documenting in the Medication Administration Record [REDACTED]. If any dose of medication was refused, with-held, or given at an alternate time, an explanatory note was required to be made on the MAR providing the reason the medication was not given as ordered. Review of Resident #58's medical record revealed the facility admitted the resident on [DATE] and was readmitted on [DATE], after an acute hospital stay for treatment of [REDACTED]. The resident had [DIAGNOSES REDACTED]. Review of a Physician Telephone Order dated [DATE], for Resident #58 revealed an order for [REDACTED].#58's Medication Administration History from [DATE] through [DATE], revealed on [DATE], the resident's [MEDICATION NAME] was administered approximately two and one-half hours after it was scheduled to be administered. On [DATE] at 10:00 PM, the resident did not receive the physician ordered [MEDICATION NAME] at 10:00 PM. In addition, on [DATE], the resident's medication was administered approximately 15 hours late, and the resident received another dose within approximately two (2) hours. Further review of the MAR indicated [REDACTED]. Further, review of Resident #58's MAR indicated [REDACTED]. However, review of the Medication Administration History, revealed that the resident's 4:00 PM dose was not administered until 10:42 PM, approximately seven (7) hours late. Review of Resident #58's (MONTH) (YEAR) physician's orders [REDACTED]. However, an interview with Physician #2 on [DATE] at 12:18 PM, Resident #58's physician, revealed he did not give an order to hold Resident #58's 4:00 PM dose of [MEDICATION NAME] on [DATE]. Physician #2 stated the facility contacted him and asked if the dose of [MEDICATION NAME] could be held until they received the results of the [MEDICATION NAME] trough. The Physician stated he instructed the nurse not to hold the medication and to administer the 4:00 PM dose of [MEDICATION NAME]. Interview with the Infection Control Nurse on [DATE] at 12:08 PM, revealed she contacted Resident #58's physician for an order to hold the resident's 4:00 PM dose of [MEDICATION NAME] medication on [DATE], until laboratory results were obtained. The Infection Control Nurse stated the physician instructed her not to hold the dose and to administer the medication as ordered. The Infection Control Nurse stated she was not sure who wrote the order to hold the dose. Interview with the Director of Nursing (DON) on [DATE] at 12:05 PM, revealed the facility had no system in place to compare the MAR indicated [REDACTED]. The DON stated that the MAR indicated [REDACTED]. The DON stated if the medication was not given at the time the MAR indicated [REDACTED]. 3. a. Review of the facility's policy titled Change in a Resident's Condition or Status, dated (MONTH) 2011, revealed the nurse supervisor/charge nurse should record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the medical record for Resident #85 (5) revealed the facility readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #85's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was zero (0), which indicated the resident was severely cognitively impaired. The MDS also revealed the resident was totally dependent on staff for Activities of Daily Living (ADL). On [DATE] at 9:30 AM, an observation of Resident #85 (5) was attempted; however, the resident was not present in his/her room. Interview with Licensed Practical Nurse (LPN) #13 on [DATE] at 11:51 AM revealed the resident had been transferred to an acute care hospital on [DATE] at approximately 5:00 PM, for evaluation due to a change in the medical condition, and was admitted to the hospital. However, review of Resident #85's medical record on [DATE] at 9:40 AM revealed no documentation that the resident had a change in condition or had been transferred out of the facility. Further review of the medical record revealed no documented evidence that a physician's orders [REDACTED]. Interview with LPN #13 on [DATE] at 11:51 AM revealed she was the nurse on duty on [DATE], when Resident #85 (5) was transferred to the hospital. LPN #13 stated she notified the physician of the change in the resident's condition and obtained an order to transfer the resident to a hospital. The LPN stated the resident's responsible party was present when the change of condition occurred, and accompanied the resident to the hospital. LPN #13 stated she forgot to document the resident's condition and transfer in the resident's Nursing Notes, and forgot to write the physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 6:49 PM revealed the nurse taking the physician's orders [REDACTED].#85 (5) had a change of condition or had been transferred from the facility because there was no documentation of the occurrence. 3. b. Further review of Resident #85's medical record revealed physician orders [REDACTED]. Review of Resident #85's Medication Administration Record [REDACTED]. Interview with LPN #12 on [DATE] at 1:30 PM, the nurse providing care for Resident #85, revealed she was unable to state why the tube feeding was documented for the future, when it had not been administered to the resident. The facility implemented the following for removal of jeopardy: 1. On [DATE], the Administrator provided an in-service to the Director of Nursing, Minimum Data Set (MDS) Nurse, and the Quality Assurance (QA) Nurse regarding the development and implementation of a comprehensive care plan that included the wishes of each resident related to code status. 2. The policies and procedures were reviewed and updated regarding physician notification and obtaining, documenting, and honoring the wishes of each resident for Advance Directives/Code Status by the PIP Committee on [DATE]. The resident's wishes for Advance Directives and code status will be obtained upon admission by Social Services and the Admission Director. Code status designations will be documented in the physician's orders [REDACTED]. Residents choosing a DNR code status will sign a completed No Code or DNR consent form that will be maintained in the resident's medical record. Residents without an Advance Directive will be considered a Full Code. The Advance Directives and Code Status policies were reviewed, updated, and approved by the QAPI Committee on [DATE]. 3. On [DATE], a comprehensive audit was completed by the Administrator, MDS Nurse, Assistant Administrator, Director of Nursing (DON), QA Nurse, Unit Manager, Activities Director, Admissions Director, and Social Workers for every resident in the facility. The audit was a review of each resident's Advance Directive and code status that included physician orders, Advance Directive designation forms, consent forms, paper record, electronic record, and face sheets with no variances noted. The residents' comprehensive care plans were also reviewed and updated as needed to assure residents' Advance Directives and wishes for code status were included on the plan of care. These audits were conducted at the direction of the Quality Assurance and Performance Improvement (QAPI) Committee and completed on [DATE]. Members of the QAPI committee included: The Administrator, Director of Nursing, Unit Managers, Medical Director, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director. Completed audits were submitted to the QAPI Committee for additional review. 4. The Director of Nursing, Quality Assurance Nurse, Unit Manager, and MDS Nurse completed a focus review to ensure proper notification occurred for changes in resident condition. The audit included review of residents transferred to the hospital within the prior week, all Nurse's Notes documented between [DATE] through [DATE], and any new physician's orders [REDACTED]. 5. Licensed staff that were involved with the care of Resident #26 (6) and Resident #63 received additional training related to identification and communication of a resident's wishes regarding Advance Directives and code status, as well as including and honoring those wishes through implementation of the resident's care plan. The training included timely notification of a resident's physician and responsible party, as well as documentation of the notification. The training also included development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status. Post-tests and staff interviews were completed to ensure comprehension of the training material. The training was completed [DATE] through [DATE] by the Director of Nursing, Staff Development Director. 6. All licensed and certified nursing staff and the Interdisciplinary Care Plan team (IDT) which consisted of MDS Nurse, Social Worker, Activity Director, and the Director of Dietary Services all received additional training beginning on [DATE] thru [DATE] related to: - identification and communication of a resident's wishes regarding Advance Directives and code status - honoring resident's code status wishes through the implementation of the resident's care plan -providing the necessary care and services such as emergency care, basic life support, and CPR to those residents in accordance with the resident's Advance Directives and wishes regarding code status -how to determine the code status of each resident according to facility protocols - assessing and responding to a resident in distress - timely notification of the physician - initiating a code - honoring the wishes of each resident with a full-code status - documenting care delivered - development and implementation of the comprehensive care plan which included the wishes of each resident related to their code status The training was completed by the Director of Nursing, Staff Development Director, and the Administrator. Post-tests and staff interviews were completed to ensure comprehension of the training material. Any staff member in the nursing department who was off work for any reason will not be permitted to work until training and post testing are completed. 7. On [DATE], the Administrator posted a listing of each resident and their desired code status at each nursing unit. The Administrator completed the list after the Advance Directives and CPR desires of each resident were validated through the audit completed on [DATE]. Monitoring would include a daily review of this list by the Administrator or Assistant Administrator Monday through Friday. The weekend manager would review and update the listing on Saturday and Sunday. 8. Notification to a resident's physician, resident, and resident representative is monitored daily (Monday - Friday) in the Clinical Meeting. Attendees of the Clinical Meeting include the Director of Nursing, MDS Nurse, Social Workers, QA Nurse, and Unit Manager. The Clinical Meeting conducts a review of the following: 24-hour report, physician's telephone orders, nurse's notes, laboratory reports, resident events, changes in residents' condition, new admissions, and discharges. Any concerns identified are corrected immediately. 9. On [DATE], training, direction, and responsibility was assigned to Social Services for listing residents' wishes regarding Advance Directive on the residents' comprehensive care plan. The MDS Nurse will verify that Advance Directives are included on the care plan. This review will occur during Care Plan Conferences following the Resident Assessment Instrument (RAI) schedule. 10. On [DATE], a focus Performance Improvement Plan (PIP) Committee was formed by the QAPI Committee to review and monitor the facility's processes for obtaining and honoring residents' Advance Directives, code status, development and implementation of a care plan that meets the code status wishes of the resident, procedures for calling a code, and the conditions for implementing CPR to a full code resident. The PIP committee members included: The Administrator, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Social Services and Activity Director. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. Weekly QAPI meetings would continue to occur until sustained compliance was achieved. 11. The QAPI Committee will monitor and ensure sustained compliance is maintained through a weekly meeting. The members of this meeting will review all audits, training, and corrective actions generated by the focus PIP Committee. QAPI meetings will occur until sustained compliance is achieved. Information reviewed in this meeting will include: - Verbal report and a current Code Status List is reviewed and updated daily with any changes in the resident's Advance Directives and CPR status and is submitted by the Administrator or Assistant Administrator - The MDS Nurse will submit a verbal report and audit tool(s) related to the validation of the resident's code status during resident care plan conferences - The DON or QA Nurse will review the findings of the 24-hour report, physician's telephone orders, nurse's notes, laboratory tests, resident events, and changes in residents' condition identified in the morning clinical meetings and through routine clinical assessments, evaluations, and nurse management rounds, as well as a review of new admissions and discharges. The Daily Audit Tool will also be used to validate proper notification to physicians and the resident representative. - The DON or SDC will submit a verbal report, in-service logs and training agenda(s) regarding training or post testing completed. - The Social Worker will submit a verbal report and census list regarding any changes in Advance Directives or code status, including new admissions and re-admissions. - The DON or QA Nurse will give a verbal report and submit an audit tool related to any resident transfers to the hospital for urgent or critical care. The reports will include verification of proper notification, communication regarding resident's Advance Directives/code status prior to transfer, the Center's response to the resident's wishes, and the outcome of the transfer. - The committee will also discuss any new concerns identified through audits and reviews and applicable corrective action or changes. 12. On [DATE], a Long Term Care (LTC) consultant who is licensed as a Long Term Care Health Administrator in the state of Kentucky provided training to the Administrator of the facility for compliance with the federal and state regulations, quality assurance and performance improvement, efficient and effective use of resources, human resource development, and responsibilities of the Governing Body. Additionally, education was provided that according to §483.70 the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 13. On [DATE], the Administrator developed a Performance Improvement Team (PIT) to develop a Performance Improvement Plan (PIP) for the purposes of maintaining an effective nutrition/hydration status program. The PIT had the first meeting on [DATE] to develop, review, and monitor the resident nutrition/hydration status program. The PIT committee members include: the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, and the internal auditors of nutrition/hydration status. 14. Effective [DATE], the Administrator and Director of Nursing have developed audit forms with the assistance of long term care consultants for all recently cited care and service areas. Auditors were appointed by the Administrator with the assistance of long term care consultants on [DATE]. Education regarding the use of the audit forms was provided to the auditors on [DATE], by the Administrator and the long term care consultants. Effective [DATE], the audits will identify residents at risk for the cited deficiencies in the areas of assisted nutrition and hydration. The Administrator and Director of Nursing are involved with all compliance and corrective actions taken to correct any alleged deficiency and have assured that the following corrective actions have identified any resident who may be affected. 15. On [DATE], the Administrator reviewed the members of the Quality Assurance Committee. These members conform with the requirements of the current regulations and include the Administrator, Medical Director, Director of Nursing, Unit Managers, MDS Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director and Activities Director. 16. Residents #1, #85 (5), #48, #53 (12), and #147 (H) were assessed by the RD from [DATE] through [DATE]. The residents' physicians were notified with any new recommendations. From [DATE] through [DATE], a licensed nurse conducted a dehydration risk assessment and no additional interventions were recommended. In addition, on [DATE], a fluid intake audit was completed for Residents #48, #53, and #147, and the residents were meeting or exceeding their fluid needs. Resident #1 was discharged from the facility on [DATE], and is no longer a resident. Resident #85 (5) was discharged from the facility on [DATE], and is no longer a resident at the facility. 17. On [DATE], a representative from Medline Industries (Medline is the facility provider for feeding tube pumps), completed a Quality Assurance audit of all feeding pumps to ensure function and accuracy. All pumps were found to be in working order. Beginning on [DATE] and completed on [DATE], the representative and the Director of Nursing (DON) provided education regarding operation and use of the pumps to all licensed nurses and nurses completed a return demonstration. 18. On [DATE], implementation began to convert electronic documentation of Food and Fluid Consumption to paper documentation. Education began on [DATE] and continued through [DATE]. Employees not having been in-serviced by [DATE] will not be allowed to work until education is completed. Food and fluids consumed daily with resident meals, snacks, and medication administration will be recorded on the Food and Fluid Consumption Sheet. The night shift Charge Nurse will calculate the fluids consumed and compare to the recommended fluid needs calculated by the RD. Residents not meeting the estimated daily fluid needs will be noted on the 24-hour report log for increased monitoring. The resident/resident representative and the resident's physician will be notified if a resident does not consume a daily average of 50% of routine meals without substitutes and supplements for three (3)consecutive days. Food and fluid intake documentation will be monitored daily Monday through Friday by the Unit Managers and the Weekend Manager will monitor on Saturday and Sunday. 19. Licensed Nurses completed Dehydration Risk Assessments for all residents on [DATE] and [DATE]. Any concerns identified during this evaluation were addressed immediately with physician notification, care plan review, and care plan updates as indicated. From [DATE] to [DATE], a fluid intake audit was completed by comparing the individual fluid needs of all residents to each residents' average fluid consumption from [DATE] through [DATE]. This audit was completed by the Director of Nursing, Unit Manager, MDS Nurse, Administrator, and Assistant Administrator. Any resident not meeting their estimated fluid need was evaluated, notifications were made if indicated to the physician and resident/resident representative, and care plans were reviewed and updated as needed. 20. On [DATE], the Tube Feeding Intake Worksheet was implemented to monitor and track formula and fluids administered to residents with tube feeding. This worksheet will be completed at the end of each shift by the licensed nurse. The Unit Manager, Weekend Manager, or designated Nurse Manager will review the Tube Feeding Intake Worksheet daily to ensure residents receiving tube feeding formula and/or fluids receive the amount prescribed by the physician. If reviews indicate that the intake administered is below the prescribed amount, a quality assurance check will be performed on the feeding pump, a dehydration risk assessment will be completed by a licensed nurse, and the physician and resident/resident representative will be notified. An additional review of the Tube Feeding Intake Worksheet will occur daily Monday through Friday by the Quality Assurance Nurse (QA Nurse). 21. On [DATE], the DON reviewed all resident weights for significant/severe weight loss. Any resident identified as having new weight loss was evaluated, the resident/responsible representative and the resident's physician were notified, and the resident's comprehensive care plan was reviewed and updated, if indicated. 22. Routine and weekly weights will be obtained by the Restorative Aides, recorded on a resident weight worksheet, and submitted to the Unit Manager for review. Weights will be logged into the medical record after review by the Unit Manager. Once weights are logged, the Director of Nursing will review the computer-generated weight change report weekly on Tuesday prior to the Nutrition at Risk Committee (NAR) meeting. Residents identified to be at risk for nutrition and hydration decline are monitored by the Interdisciplinary NAR Committee. Members of the NAR Committee include the Director of Nursing, the Unit Managers, the Registered Dietitian, the Dietary Manager, the MDS Nurse, and the QA Nurse. The NAR Committee reviews at risk residents' intake, weight, and hydration status. The NAR Committee will review the daily Food and Fluid Consumption Sheets, the daily Tube Feeding Intake Worksheets, and the computer generated weight variance report that are completed each Tuesday by the DON. 23. The Dietary Manager will conduct an additional nutrition and hydration audit daily (Monday through Friday) to ensure any resident not meeting minimal nutrition and hydration requirements have been addressed as needed. 24. The Governing Body is providing oversight through a contract with a Management Company. On [DATE], the Long Term Care Consultants with the Management Company (a Registered Nurse and a Licensed Health Care Administrator) provided education to the Governing Body related to the responsibilities of the Governing Body as promulgated in §483.70. The education included the responsibilities of the Governing Body to include the establishment and implementation of policies regarding the management and operation of the facility. The Governing Body has directed that all resources and administration abate deficient practice at nutrition/hydration to include corrective actions for those residents affected. The Management Company oversees the daily operations of the facility and utilizes contracted consultants as necessary for the operation. The consultants have extensive experience and education in the area of operating long term care facilities and are not employees of the facility, but rather act as an outside resource in providing advice and consultation to the management staff of the facility. The Administrator, who was appointed by the Governing Body on [DATE], is responsible for the daily management of the facility, and reports and is accountable to the Governing Body. The Governing Board meets with the Management Company each month. 25. The PIP Committee meets daily to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the immediate jeopardy has been verified. 26. The Quality Assurance and Performance Improvement (QAPI) policies were reviewed on [DATE] by the Long Term Care Consultant and the Administrator with no changes noted. The QAPI policies are in conformance with the current regulatory standards and no changes were necessary. The QAPI Committee reviewed the QAPI policies on [DATE] with acceptance. On [DATE], the Administrator provided education to the Quality Assurance and Assessment (QAA) Committee related to the policies and the structure of the Quality Assurance and Assessment (QAA) program. The Administrator with the assistance of the long term care consultant developed new tools that are to be used for the Performance Improvement Team (PIT) that includes a new tool for a Performance Improvement Plan (PIP). These new tools are used for the PIP for the abatement of Immediate Jeopardy. Weekly QAPI meetings will be held and will continue to occur until sustained compliance is achieved. The completed PIP will be submitted to the weekly meetings of the QAPI Committee for approval and suggestions. 27. The Administration of the facility to include the Administrator and Director of Nursing are conferring daily with long term care consultants to monitor administration's role with the abatement of jeopardy beginning [DATE]. The SSA verified the removal of immediate jeopardy by the following: 1. Review of the in-service roster dated [DATE], revealed the

Based on interview, record review, and review of the facility's policies/procedures, it was determined the facility failed to ensure physicians' orders were carried out to meet the needs of four (4) of seven (7) sampled residents (Residents #1, #4, #5, and #7). Resident #1's Physician ordered a [MEDICATION NAME] (an aminoglycoside antibiotic medication to treat infection) trough level (the minimum amount of medication in the bloodstream) for Resident #1 to be obtained on [DATE], to ensure the resident received a therapeutic dose of [MEDICATION NAME] and to ensure the resident did not receive a toxic level of medication. However, the facility failed to carry out the physician's orders [REDACTED].#1 developing [MEDICATION NAME] toxicity. Resident #1 expired on [DATE], due to aminoglycoside nephrotoxicity (kidney damage related to [MEDICATION NAME] medication). In addition, the facility failed to carry out physician orders [REDACTED].#5, and #7 and obtain laboratory tests to monitor the aminoglycoside antibiotic levels. The facility's failure to ensure physician orders [REDACTED]. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 - J, F281 - K, and F282 - J); 42 CFR 483.25 Quality of Care (F309 - K); 42 CFR 483.45 Pharmacy Services (F329 - K and F428 - K); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502 - K). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F309) and 42 CFR 483.45 Pharmacy Services (F329). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 and F282), and E level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F281); 42 CFR 483.25 Quality of Care (F309); 42 CFR 483.45 Pharmacy Services (F329 and F428); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of a Kentucky Board of Nursing Advisory Opinion Statement #14 Patient Care Orders, revised (MONTH) (YEAR), revealed users were held responsible and accountable for their decisions regarding the receipt and implementation of patient care orders based upon the individual's educational preparation and clinical competence in nursing. Review of the Physician Services policy dated [DATE] revealed each resident's attending physician directed the care of the resident, and practices of the physician would maintain or improve the resident's level of functioning. 1. Review of Resident #1's Physicians' Orders dated [DATE], revealed an order to obtain a [MEDICATION NAME] trough level on [DATE] to ensure the resident received a therapeutic dose of [MEDICATION NAME] medication. Further review of Resident #1's medical record revealed no evidence the physician's orders [REDACTED]. Resident #1 was transported to the hospital on [DATE], where the resident's [MEDICATION NAME] level was determined to be toxic resulting in aminoglycoside induced nephrotoxicity and ultimately the resident's death on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 1:05 PM, revealed the facility conducted morning meetings weekly Monday through Friday, and reviewed all physicians' orders to ensure the orders were on the resident's electronic health record (medication administration record, or MAR). The DON stated the Unit Manager was responsible for monitoring a separate laboratory computer system to ensure physician ordered laboratory tests were entered into the system and obtained as ordered. However, the facility did not have a system for monitoring to ensure the laboratory tests were obtained as ordered by the physician. Interview with the Unit Manager on [DATE] at 9:05 AM revealed she failed to ensure Resident #1's assigned nurse entered the resident's physician orders [REDACTED]. She stated the level was not obtained. The Unit Manager stated she was not aware the level was not obtained until [DATE], after the resident was transferred to the hospital and the resident's physician called to see if the resident's [MEDICATION NAME] level had been monitored as he had previously ordered. Interview with Resident #1's Physician on [DATE] at 10:10 AM revealed he expected the facility to carry out all physician orders. According to the Physician, the facility's failure to obtain the [MEDICATION NAME] level for Resident #1 resulted in the resident receiving a toxic dose of [MEDICATION NAME] medication and the resident's death. 2. Record review revealed the facility readmitted Resident #4 on [DATE], with a [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. In addition, on [DATE] another physician's orders [REDACTED]. However, there was no documented evidence the facility obtained the physician ordered laboratory tests for Resident #4 on [DATE], after the dose of medication, or on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 1:05 PM, revealed the facility had no evidence the laboratory tests for Resident #4 had been obtained as ordered by the resident's physician. 3. Review of Resident #5's physician's orders [REDACTED]. However, review of Resident #5's medical record revealed no documented evidence the facility obtained the [MEDICATION NAME] peak and trough levels for Resident #5 on [DATE]. Although the facility obtained the [MEDICATION NAME] trough level and creatinine level for the resident, it was not obtained until [DATE] (one day late). Interview with the Director of Nursing (DON) on [DATE] at 1:05 PM, revealed the facility had no evidence the laboratory tests for Resident #5 had been obtained as ordered by the resident's physician. 4. Review of physician's orders [REDACTED]. However, review of Resident #7's laboratory results revealed the facility did not obtain a [MEDICATION NAME] peak medication level until [DATE] (the day after the test was ordered by the physician) and there was no evidence the facility ever obtained a [MEDICATION NAME] trough level or creatinine level. An interview with Licensed Practical Nurse (LPN) #7 on [DATE] at 11:15 AM, revealed she incorrectly entered the orders for laboratory tests for Resident #7, and the tests were not obtained as ordered on [DATE] and [DATE]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 is no longer a resident at Mountain Manor of Paintsville (the Center). On [DATE], Resident #1 was transferred from the facility to the hospital and was subsequently admitted to the hospital with [REDACTED]. Resident #1 expired at the hospital. 2) The licensed nurse responsible for admitting Resident #1 on [DATE] is no longer employed at the Center. 3) On [DATE], an audit to review transcription of physician orders [REDACTED]. 4) On [DATE] to [DATE], an expanded audit was initiated by the Director of Nursing and Unit Managers to include a review of all physician orders [REDACTED]. The audit included review of the transcription and implementation of current physicians' orders, residents' active Medication Administration Records (MARs), and Treatment Administration Record (TAR). Any concerns identified were corrected immediately. 5) On [DATE], under the direction of the Quality Assurance and Performance Improvement (QAPI) committee (Quality Assurance and Performance Improvement committee members include: the Administrator, Director of Nursing, Unit Managers, Medical Director, Minimum Data Set Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director), a Performance Improvement Plan (PIP) committee was created. The PIP Committee members include: the Administrator, Director of Nursing, Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, Social Services Director, and Activity Director. 6) All licensed nurses identified as having administering IV antibiotics to Resident #1 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. In-services were conducted by the Director of Nursing and the Staff Development Coordinator. In-servicing was completed on [DATE] and [DATE]. 7) On [DATE], the following policies and procedures have been reviewed and updated as needed by the QAPI Committee: Physician Orders, Labs, and Pharmacy Services. a) Physician order [REDACTED]. [REDACTED]. Routine order reviews will consist of reviewing physicians' orders for accurate transcription and evidence of implementation, Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, and MDS Nurse). On Saturday and Sunday physician orders [REDACTED]. In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will review and verify physician orders. New admission and readmission orders [REDACTED]. In the event the on-call nurse is unable to complete review, the Director of Nursing will be responsible to complete. Beginning on [DATE], physician orders [REDACTED]. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. b) Lab policy revision included a routine review of lab orders and results of the labs by the Nurse Management Team (Nurse Management Team consists of: Director of Nursing, Unit Managers, Quality Assurance Nurse, MDS Nurse, and Staff Development Coordinator), as well as an additional and separate verification of labs by the QA Nurse. Routine lab review will be completed Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, QA Nurse, and MDS Nurse). On Saturday and Sunday lab review will be reviewed and verified by the designated nurse manager on call (Nurse Managers on call: Unit Manager, Staff Development Coordinator, QA Nurse, and MDS Nurse). In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will be responsible for the review. Lab orders, requisitions, and results will be tracked in lab binders at each nurses' station. On [DATE], a meeting was held by the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Pharmacy Service policies were reviewed on [DATE] by the QAPI Committee with no changes indicated. Beginning on [DATE], antibiotic medication orders that require lab monitoring will include an order for [REDACTED]. Labs will be obtained per the physician order. The IV antibiotic will be placed on hold after the third dose pending the results of lab level. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. The Administrator contracted two additional consultant pharmacists experienced in Long Term Care to review physicians' orders and pharmacy consultation for residents with medications requiring special lab monitoring. The review was completed on [DATE]. On [DATE], the Administrator and Director of Nursing sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) On [DATE] through [DATE], in-services were provided to Licensed Nurses regarding policy and procedure updates. In-servicing was conducted by the Director of Nursing and Staff Development Coordinator. Post-tests and return demonstrations were required to validate training. Licensed Nurses were not permitted to work until education was completed and confirmed by post-testing. Training was complete on [DATE]. All policy revisions were added to new hire orientation material on [DATE]. 9) On [DATE], the Administrator appointed a Quality Assurance Nurse to provide oversight and coordination of the Center's ongoing Quality Assurance and Performance Improvement program. The Quality Assurance Nurse will conduct additional audits of physicians' orders for accurate transcription and evidence of implementation and will verify compliance of physicians' orders transcription and lab monitoring related to medications requiring lab monitoring. Audits and reviews will be completed daily, Monday through Friday, and submitted to the PIP Committee for monitoring and further recommendations as indicated. 10) To ensure sustained compliance, the daily (Monday through Friday) PIP Committee meets to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the Immediate Jeopardy has been verified by CMS through the Kentucky Cabinet for Health and Family Services ([MEDICAL CONDITION]). Weekly QAPI meetings will continue to occur until sustained compliance is achieved. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1) Review of the medical record for Resident #1 revealed the resident was discharged to the hospital on [DATE], and expired while at the hospital. 2) Review of the personnel file for LPN #6 revealed the LPN had not been employed at the facility since [DATE]. 3) Review of audit sheets dated [DATE] revealed the DON and Unit Managers audited the medical records of residents who had physician orders [REDACTED]. The audit had been completed by the DON and Unit Managers. Interviews on [DATE] with the DON at 9:50 AM, Unit Manager (UM) #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they had assisted with the audits for residents who had received antibiotics to ensure all physician orders [REDACTED]. 4) Review of audit sheets dated [DATE] through [DATE] revealed the Director of Nursing and Unit Managers audited physician orders [REDACTED]. The audits included reviews of the transcription and implementation of current physicians' orders, the resident's active Medication Administration Record (MAR), and Treatment Administration Record (TAR). Interviews on [DATE] with the DON at 9:50 AM, UM #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they assisted with the audits for residents who were admitted or readmitted to the facility from [DATE] through [DATE] to ensure all physician orders [REDACTED]. 5) Review of QAPI as well as PIP meeting minutes dated [DATE] revealed a QAPI meeting was held and a PIP Committee was formed. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the Staff Development Coordinator (SDC) on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the Activity Director (AD) on [DATE] at 9:22 AM, the Social Services Director (SSD) on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed a QAPI meeting was held on [DATE], and a PIP Committee was formed. Staff stated the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed, and QAPI meetings would also continue to be held weekly. 6) Review of an in-service roster dated [DATE] and [DATE] revealed RN #2, LPN #7, LPN #13, and UM #2 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. Interviews with LPN #7 on [DATE] at 2:30 PM, RN #2 on [DATE] at 4:00 PM, and UM #2 on [DATE] at 10:06 AM, revealed they had received an in-service on [DATE], related to transcription of orders and medications which required a drug level. 7) Review of QAPI Committee minutes dated [DATE] and review of the facility's policies for Physician Orders, Labs, and Pharmacy Services revealed the policies were reviewed/revised on [DATE]. Review of the New Employee Orientation Packet revealed the current physician's orders [REDACTED]. Interview with the SDC on [DATE] at 9:06 AM revealed the facility had not hired a new nurse since the implementation of the changes in the policies. However, the new policies for physician's orders [REDACTED]. a) and b) Review of the physician's orders [REDACTED]. Interviews conducted with the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed they were meeting daily to review all new physician orders [REDACTED]. The interviews revealed there was a nurse manager on call on Saturday and Sunday to review any new orders within eight (8) hours of transcription by the admitting nurse and verify the orders were transcribed and implemented. Further interviews revealed they were ensuring that laboratory tests for antibiotics that required laboratory monitoring were entered and laboratory tests completed. Staff interviews revealed the intravenous antibiotic would be placed on hold after the third dose pending the results of the laboratory level and would not be continued until laboratory values were evaluated by the resident's physician. Review of a roster dated [DATE] and interviews with the Administrator on [DATE] at 9:30 AM, and the DON on [DATE] at 9:50 AM, revealed a meeting was held with the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Record review revealed on [DATE] consultant pharmacists reviewed resident medical records for all residents with medications requiring special lab monitoring. Further interview with the Administrator on [DATE] at 9:30 AM and the DON on [DATE] at 9:50 AM revealed they sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) Review of in-service rosters dated [DATE] and [DATE] revealed the SDC and the DON provided an in-service for all licensed nurses on the reviewed/revised laboratory, pharmacy, and physician orders [REDACTED]. Interviews conducted with LPN #4 on [DATE] at 1:27 PM, LPN #1 on [DATE] at 1:52 PM, LPN #7 on [DATE] at 2:30 PM, and RN #2 on [DATE] at 4:00 PM, revealed they had received in-service training regarding the facility's laboratory, pharmacy, and physician orders [REDACTED]. The staff stated they were required to have a second nurse to review orders and were required to enter physician laboratory orders in the computer and document the order in a laboratory book at the nurses' station. In addition, the nurses stated that for any antibiotic that required a laboratory level, the medication would be held by the pharmacy until a laboratory level was obtained and reported. 9) Review of a personnel change in position form dated [DATE], revealed a QA Nurse position had been filled. Review of audit tools completed by the QA Nurse dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the QA Nurse documented that compliance of physician's orders [REDACTED]. Further review of audit sheets revealed the QA nurse also reviewed the audits that had been completed by the nurse management team. Interview with the QA Nurse on [DATE] at 9:42 AM, revealed she had completed audits on physician's orders [REDACTED]. The QA Nurse stated she had reported her findings to the QAPI meeting and would continue to do so. 10) Review of QAPI and PIP meeting minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the committees had been meeting daily Monday through Friday and monitored results of all audits and reviews. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the SSD on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed the QAPI Committee as well as the PIP Committee had been meeting daily Monday through Friday and reviewed the results of the audits and reviews. The interviews revealed the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure services were provided as outlined in the resident's comprehensive plan of care for one (1) of seven (7) residents (Resident #4). Resident #4's care plan required the facility to obtain laboratory tests as ordered. Resident #4 had physician orders [REDACTED]. The facility failed to obtain the laboratory tests. The resident's physician ordered an [MEDICATION NAME] level to be obtained on [DATE]; however, the facility obtained the level one day late, on [DATE]. Resident #4's [MEDICATION NAME] level was high on [DATE]; however, the facility failed to communicate the resident's lab results to the pharmacy and continued to administer [MEDICATION NAME] medication to Resident #4 in the absence of required monitoring. (Refer to F281, F309, F329, F428, and F502.) The facility's failure to ensure resident care plans were implemented 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] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 - J, F281 - K, and F282 - J); 42 CFR 483.25 Quality of Care (F309 - K); 42 CFR 483.45 Pharmacy Services (F329 - K and F428 - K); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502 - K). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F309) and 42 CFR 483.45 Pharmacy Services (F329). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 and F282), and E level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F281); 42 CFR 483.25 Quality of Care (F309); 42 CFR 483.45 Pharmacy Services (F329 and F428); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's care plan policy revised (MONTH) 2006 revealed a resident's care plan would be available to staff who were responsible for providing care to the resident. Record review revealed the facility readmitted Resident #4 on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. Observation and interview with Resident #4 on [DATE] at 2:20 PM revealed the resident was awake, alert, and stated that he/she had an infection in the right hip. Review of Resident #4's care plan revealed the facility revised the resident's care plan on [DATE], to reflect an infection of the right hip surgical site. Further review revealed the facility developed interventions to include obtaining a Comprehensive Metabolic Panel (CMP), Urinalysis (UA), and [MEDICATION NAME] trough after the third dose of [MEDICATION NAME] medication. The care plan further stated staff should obtain the [MEDICATION NAME] trough levels as ordered by the resident's physician. Review of physician's orders [REDACTED].#4 had orders for a CMP, UA, and [MEDICATION NAME] trough level to be obtained after the third dose of [MEDICATION NAME] was administered. Review of Resident #4's Medication Administration Record (MAR) revealed the resident's third dose of [MEDICATION NAME] was scheduled for [DATE]; however, there was no evidence the facility obtained the physician ordered laboratory tests for Resident #4. Further review of physician's orders [REDACTED]. However, there was no evidence the facility obtained an [MEDICATION NAME] trough level for Resident #4 as ordered on [DATE]. Interview with the Second Floor Unit Manager on [DATE] at 1:10 PM revealed the facility failed to identify that the laboratory tests for Resident #4 were not obtained in accordance with physician's orders [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 is no longer a resident at Mountain Manor of Paintsville (the Center). On [DATE], Resident #1 was transferred from the facility to the hospital and was subsequently admitted to the hospital with [REDACTED]. Resident #1 expired at the hospital. 2) The licensed nurse responsible for admitting Resident #1 on [DATE] is no longer employed at the Center. 3) On [DATE], an audit to review transcription of physician orders [REDACTED]. 4) On [DATE] to [DATE], an expanded audit was initiated by the Director of Nursing and Unit Managers to include a review of all physician orders [REDACTED]. The audit included review of the transcription and implementation of current physicians' orders, residents' active Medication Administration Records (MARs), and Treatment Administration Record (TAR). Any concerns identified were corrected immediately. 5) On [DATE], under the direction of the Quality Assurance and Performance Improvement (QAPI) committee (Quality Assurance and Performance Improvement committee members include: the Administrator, Director of Nursing, Unit Managers, Medical Director, Minimum Data Set Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director), a Performance Improvement Plan (PIP) committee was created. The PIP Committee members include: the Administrator, Director of Nursing, Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, Social Services Director, and Activity Director. 6) All licensed nurses identified as having administering IV antibiotics to Resident #1 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. In-services were conducted by the Director of Nursing and the Staff Development Coordinator. In-servicing was completed on [DATE] and [DATE]. 7) On [DATE], the following policies and procedures have been reviewed and updated as needed by the QAPI Committee: Physician Orders, Labs, and Pharmacy Services. a) Physician order [REDACTED]. [REDACTED]. Routine order reviews will consist of reviewing physicians' orders for accurate transcription and evidence of implementation, Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, and MDS Nurse). On Saturday and Sunday physician orders [REDACTED]. In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will review and verify physician orders. New admission and readmission orders [REDACTED]. In the event the on-call nurse is unable to complete review, the Director of Nursing will be responsible to complete. Beginning on [DATE], physician orders [REDACTED]. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. b) Lab policy revision included a routine review of lab orders and results of the labs by the Nurse Management Team (Nurse Management Team consists of: Director of Nursing, Unit Managers, Quality Assurance Nurse, MDS Nurse, and Staff Development Coordinator), as well as an additional and separate verification of labs by the QA Nurse. Routine lab review will be completed Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, QA Nurse, and MDS Nurse). On Saturday and Sunday lab review will be reviewed and verified by the designated nurse manager on call (Nurse Managers on call: Unit Manager, Staff Development Coordinator, QA Nurse, and MDS Nurse). In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will be responsible for the review. Lab orders, requisitions, and results will be tracked in lab binders at each nurses' station. On [DATE], a meeting was held by the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Pharmacy Service policies were reviewed on [DATE] by the QAPI Committee with no changes indicated. Beginning on [DATE], antibiotic medication orders that require lab monitoring will include an order for [REDACTED]. Labs will be obtained per the physician order. The IV antibiotic will be placed on hold after the third dose pending the results of lab level. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. The Administrator contracted two additional consultant pharmacists experienced in Long Term Care to review physicians' orders and pharmacy consultation for residents with medications requiring special lab monitoring. The review was completed on [DATE]. On [DATE], the Administrator and Director of Nursing sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) On [DATE] through [DATE], in-services were provided to Licensed Nurses regarding policy and procedure updates. In-servicing was conducted by the Director of Nursing and Staff Development Coordinator. Post-tests and return demonstrations were required to validate training. Licensed Nurses were not permitted to work until education was completed and confirmed by post-testing. Training was complete on [DATE]. All policy revisions were added to new hire orientation material on [DATE]. 9) On [DATE], the Administrator appointed a Quality Assurance Nurse to provide oversight and coordination of the Center's ongoing Quality Assurance and Performance Improvement program. The Quality Assurance Nurse will conduct additional audits of physicians' orders for accurate transcription and evidence of implementation and will verify compliance of physicians' orders transcription and lab monitoring related to medications requiring lab monitoring. Audits and reviews will be completed daily, Monday through Friday, and submitted to the PIP Committee for monitoring and further recommendations as indicated. 10) To ensure sustained compliance, the daily (Monday through Friday) PIP Committee meets to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the Immediate Jeopardy has been verified by CMS through the Kentucky Cabinet for Health and Family Services ([MEDICAL CONDITION]). Weekly QAPI meetings will continue to occur until sustained compliance is achieved. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1) Review of the medical record for Resident #1 revealed the resident was discharged to the hospital on [DATE], and expired while at the hospital. 2) Review of the personnel file for LPN #6 revealed the LPN had not been employed at the facility since [DATE]. 3) Review of audit sheets dated [DATE] revealed the DON and Unit Managers audited the medical records of residents who had physician orders [REDACTED]. The audit had been completed by the DON and Unit Managers. Interviews on [DATE] with the DON at 9:50 AM, Unit Manager (UM) #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they had assisted with the audits for residents who had received antibiotics to ensure all physician orders [REDACTED]. 4) Review of audit sheets dated [DATE] through [DATE] revealed the Director of Nursing and Unit Managers audited physician orders [REDACTED]. The audits included reviews of the transcription and implementation of current physicians' orders, the resident's active Medication Administration Record (MAR), and Treatment Administration Record (TAR). Interviews on [DATE] with the DON at 9:50 AM, UM #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they assisted with the audits for residents who were admitted or readmitted to the facility from [DATE] through [DATE] to ensure all physician orders [REDACTED]. 5) Review of QAPI as well as PIP meeting minutes dated [DATE] revealed a QAPI meeting was held and a PIP Committee was formed. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the Staff Development Coordinator (SDC) on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the Activity Director (AD) on [DATE] at 9:22 AM, the Social Services Director (SSD) on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed a QAPI meeting was held on [DATE], and a PIP Committee was formed. Staff stated the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed, and QAPI meetings would also continue to be held weekly. 6) Review of an in-service roster dated [DATE] and [DATE] revealed RN #2, LPN #7, LPN #13, and UM #2 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. Interviews with LPN #7 on [DATE] at 2:30 PM, RN #2 on [DATE] at 4:00 PM, and UM #2 on [DATE] at 10:06 AM, revealed they had received an in-service on [DATE], related to transcription of orders and medications which required a drug level. 7) Review of QAPI Committee minutes dated [DATE] and review of the facility's policies for Physician Orders, Labs, and Pharmacy Services revealed the policies were reviewed/revised on [DATE]. Review of the New Employee Orientation Packet revealed the current physician's orders [REDACTED]. Interview with the SDC on [DATE] at 9:06 AM revealed the facility had not hired a new nurse since the implementation of the changes in the policies. However, the new policies for physician's orders [REDACTED]. a) and b) Review of the physician's orders [REDACTED]. Interviews conducted with the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed they were meeting daily to review all new physician orders [REDACTED]. The interviews revealed there was a nurse manager on call on Saturday and Sunday to review any new orders within eight (8) hours of transcription by the admitting nurse and verify the orders were transcribed and implemented. Further interviews revealed they were ensuring that laboratory tests for antibiotics that required laboratory monitoring were entered and laboratory tests completed. Staff interviews revealed the intravenous antibiotic would be placed on hold after the third dose pending the results of the laboratory level and would not be continued until laboratory values were evaluated by the resident's physician. Review of a roster dated [DATE] and interviews with the Administrator on [DATE] at 9:30 AM, and the DON on [DATE] at 9:50 AM, revealed a meeting was held with the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Record review revealed on [DATE] consultant pharmacists reviewed resident medical records for all residents with medications requiring special lab monitoring. Further interview with the Administrator on [DATE] at 9:30 AM and the DON on [DATE] at 9:50 AM revealed they sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) Review of in-service rosters dated [DATE] and [DATE] revealed the SDC and the DON provided an in-service for all licensed nurses on the reviewed/revised laboratory, pharmacy, and physician orders [REDACTED]. Interviews conducted with LPN #4 on [DATE] at 1:27 PM, LPN #1 on [DATE] at 1:52 PM, LPN #7 on [DATE] at 2:30 PM, and RN #2 on [DATE] at 4:00 PM, revealed they had received in-service training regarding the facility's laboratory, pharmacy, and physician orders [REDACTED]. The staff stated they were required to have a second nurse to review orders and were required to enter physician laboratory orders in the computer and document the order in a laboratory book at the nurses' station. In addition, the nurses stated that for any antibiotic that required a laboratory level, the medication would be held by the pharmacy until a laboratory level was obtained and reported. 9) Review of a personnel change in position form dated [DATE], revealed a QA Nurse position had been filled. Review of audit tools completed by the QA Nurse dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the QA Nurse documented that compliance of physician's orders [REDACTED]. Further review of audit sheets revealed the QA nurse also reviewed the audits that had been completed by the nurse management team. Interview with the QA Nurse on [DATE] at 9:42 AM, revealed she had completed audits on physician's orders [REDACTED]. The QA Nurse stated she had reported her findings to the QAPI meeting and would continue to do so. 10) Review of QAPI and PIP meeting minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the committees had been meeting daily Monday through Friday and monitored results of all audits and reviews. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the SSD on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed the QAPI Committee as well as the PIP Committee had been meeting daily Monday through Friday and reviewed the results of the audits and reviews. The interviews revealed the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed.

Based on observation, interview, record review, and review of the facility's policies/procedures and hospital records it was determined the facility failed to ensure four (4) of seven (7) sampled residents (Residents #1, #4, #5, and #7) received the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being. The facility readmitted Resident #1 on [DATE], with a physician's orders [REDACTED]. The facility failed to enter the physician's orders [REDACTED]. The facility continued to administer the medication without knowledge of the medication levels in the resident's system. Resident #1 was transferred to the hospital on [DATE], and was diagnosed with [REDACTED].#1's death on [DATE]. In addition, the facility failed to ensure Resident #4's [MEDICATION NAME] (antibiotic) trough levels, Urinalysis (UA), and Comprehensive Metabolic Panel (CMP) were obtained on [DATE], and failed to obtain a subsequent [MEDICATION NAME] level that was ordered to be obtained on [DATE], until [DATE]. The facility failed to ensure that the [MEDICATION NAME] level obtained late on [DATE] was communicated to the pharmacy as required by the resident's physician to ensure the resident received a therapeutic dose of medication. Therefore, Resident #4 continued to receive [MEDICATION NAME] medication in the absence of required monitoring. The facility failed to ensure Residents #5 and #7 received appropriate laboratory testing while receiving aminoglycoside medication. In addition, although the facility ultimately obtained an aminoglycoside level for Resident #5, the facility failed to communicate the laboratory results to the pharmacy to ensure the resident was receiving a therapeutic dose of medication. The facility's failure to ensure residents received the necessary care and services to maintain their highest practicable physical and psychosocial well-being has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 - J, F281 - K, and F282 - J); 42 CFR 483.25 Quality of Care (F309 - K); 42 CFR 483.45 Pharmacy Services (F329 - K and F428 - K); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502 - K). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F309) and 42 CFR 483.45 Pharmacy Services (F329). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 and F282), and E level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F281); 42 CFR 483.25 Quality of Care (F309); 42 CFR 483.45 Pharmacy Services (F329 and F428); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Electronic Order Entry Policy, dated [DATE], revealed staff was required to transcribe orders into the resident's electronic health record which is utilized to generate a Medication Administration Record (MAR). The policy further stated that to ensure physician orders [REDACTED]. Upon admission or readmission two (2) nurses were required to confirm physician orders [REDACTED]. In addition, the policy revealed all orders should be reviewed daily by a designated staff member to ensure orders have been transcribed correctly in the electronic health record. Review of the Procedure for Placing Laboratory orders, not dated, revealed all physician orders [REDACTED]. Interview with the Unit Manager on [DATE] at 9:05 AM, revealed that although the contracted laboratory service obtained all routine laboratory tests, any laboratory tests that needed to be obtained immediately or at a specific time, such as aminoglycoside (type of high potent antibiotic) levels, would be obtained by facility staff. An interview with Pharmacist #2 on [DATE] at 12:45 PM and on [DATE] at 1:50 PM revealed certain medications like aminoglycosides required dosage adjustment based on laboratory levels to ensure that the amount of medication in the resident's bloodstream is therapeutic and does not build up to a toxic level. The pharmacist stated aminoglycoside medications required a peak level (peak is the highest amount of medication in the blood after the medication is given; the peak is drawn approximately thirty minutes after the medication is administered) and a trough level (the minimum amount of medication in the bloodstream and is drawn immediately prior to the medication being administered on the second or third day of treatment). The pharmacist further stated the physician may choose to monitor and adjust the medication dosage themselves or may write a specific physician's orders [REDACTED]. 1. A review of the closed medical record for Resident #1 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Admission Minimum Data Set (MDS) assessment for Resident #1 dated [DATE], revealed the resident was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of six (6). Further review of the MDS assessment revealed the resident had no urinary tract infections in the last thirty (30) days, and had no [MEDICAL CONDITIONS], or end stage [MEDICAL CONDITION]. Continued review of Resident #1's closed medical record revealed the resident was readmitted to the facility on [DATE], after hip surgery, with physician orders [REDACTED]. Resident #1 also had a physician's orders [REDACTED]. Review of Resident #1's Medication Administration Record (MAR) revealed the facility administered [MEDICATION NAME] to the resident daily from [DATE] through [DATE] (eight days). However, there was no evidence the facility obtained a [MEDICATION NAME] level on [DATE], as required. Review of a Nurse's Note dated [DATE] at 8:58 AM revealed Resident #1's oxygen saturation and blood pressure were low and the resident's physician ordered the resident be sent to the hospital. Review of Resident #1's hospital record revealed when the hospital obtained a [MEDICATION NAME] level on [DATE] at 10:00 AM (approximately 25 hours since the last dose of medication was administered), Resident #1's [MEDICATION NAME] blood level was critically high at 17.9 mcg/ml (micrograms per milliliter)(normal range for a [MEDICATION NAME] peak is 4 to 10 mcg/ml and normal [MEDICATION NAME] trough is 0.5 to 2 mcg/ml); Blood Urea Nitrogen (BUN) was critically high at 138 (normal 7 to 18); and serum sodium was critically high at 163 (normal is ,[DATE]) (high BUN and sodium levels are indicative of kidney failure). Review of a hospital discharge summary dated [DATE] revealed the resident was admitted to the hospital on [DATE], after the resident began to deteriorate. The resident developed aminoglycoside induced nephrotoxicity after the facility failed to obtain a [MEDICATION NAME] level as previously ordered. Further review of the discharge summary revealed the physician recommended Resident #1 receive [MEDICAL TREATMENT]; however, the resident's family declined and elected for the resident to have comfort measures. Resident #1 expired on [DATE] at the hospital due to Acute [MEDICAL CONDITION] and Aminoglycoside Induced Nephrotoxicity. Interview with the Unit Manager on [DATE] at 9:05 AM revealed upon admission/readmission new physician orders [REDACTED]. system. The Unit Manager stated when Resident #1 was readmitted to the facility on [DATE], she was assisting the resident's admitting nurse. The Unit Manager stated she initiated transcribing Resident #1's orders into the electronic health record but failed to complete the task, assuming the admitting nurse would enter the remaining orders. The Unit Manager stated that although she was required to ensure admitting nurses transcribed admission orders [REDACTED]. Further interview revealed all new physician orders [REDACTED]. However, the omitted order was not identified by the facility during the next morning meeting held on [DATE]. The Unit Manager stated she was not aware that the facility failed to obtain Resident #1's [MEDICATION NAME] level until [DATE], when Resident #1's physician contacted the facility inquiring whether the facility had conducted the laboratory test. Interview with the Director of Nursing (DON) on [DATE] at 1:05 PM revealed all physician orders [REDACTED]. However, the computer used in the morning meeting was not able to access the facility's laboratory system. According to the DON, she was not aware that the facility failed to obtain Resident #22's [MEDICATION NAME] level on [DATE], until the Unit Manager notified her on [DATE] that the laboratory test was not obtained. Interview with Resident #1's Physician on [DATE] at 10:10 AM revealed he ordered Resident #1's [MEDICATION NAME] level to be obtained on [DATE], and further dosing of the [MEDICATION NAME] was dependent upon the laboratory results. However, according to the Physician, the facility's failure to obtain the [MEDICATION NAME] level resulted in the resident receiving a toxic dose of [MEDICATION NAME] medication causing the resident to have acute [MEDICAL CONDITION] which contributed to the resident's death. Interview with Pharmacist #3 on [DATE] at 11:25 AM, revealed when the pharmacy was required to dose a medication, the resident's physician was required to write an order directing the pharmacy to be responsible for dosing the medication. The pharmacist stated when they dosed medication, the facility was required to fax the physician's orders [REDACTED]. 2. Record review revealed the facility readmitted Resident #4 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. Observation and interview with Resident #4 on [DATE] at 2:20 PM revealed the resident was awake, alert, and stated that he/she had an infection in the right hip. Review of Resident #4's physician's orders [REDACTED]. Review of physician orders [REDACTED]. accordingly. Resident #4 had physician's orders [REDACTED]. Review of Resident #4's Medication Administration Record (MAR) revealed the laboratory orders for an [MEDICATION NAME] trough level and a urinalysis were transcribed to the resident's MAR for the laboratory tests to be drawn on [DATE]. However, there was no evidence the facility transcribed the order for the CMP. In addition, review of the MAR and the resident's medical record revealed no documented evidence that an [MEDICATION NAME] trough level, the UA, or the CMP laboratory tests were obtained on [DATE] as per physician orders. Further review of Resident #4's physician's orders [REDACTED]. The resident's physician also ordered an [MEDICATION NAME] trough level thirty (30) minutes prior to the medication being administered on [DATE], and a peak level to be obtained one (1) hour after the dose was administered on [DATE]. Review of Resident #4's MAR revealed the orders were transcribed to the MAR and the peak level was completed on [DATE]. However, there was no evidence the trough medication level was obtained for Resident #4 until [DATE] (one day after the level was ordered to be obtained). Review of Resident #4's [MEDICATION NAME] laboratory results dated [DATE] at 7:04 AM, revealed the resident's trough level was elevated at 17.8 (normal trough level is less than 8.0). However, there was no evidence the laboratory results were communicated to the pharmacy on [DATE] for an adjustment in the resident's [MEDICATION NAME] medication dosage. Interview with Pharmacist #3 on [DATE] at 11:25 AM, revealed the pharmacy did not receive Resident #4's laboratory results that were obtained on [DATE], until [DATE]. Further interview with the pharmacist and review of facsimiles from the pharmacy dated [DATE], revealed the pharmacy faxed a recommendation to the facility on [DATE], to stop administering [MEDICATION NAME] to the resident because the resident's [MEDICATION NAME] level was too high and to obtain another [MEDICATION NAME] level on [DATE]. However, review of Resident #4's MAR for (MONTH) (YEAR) revealed the facility continued to administer [MEDICATION NAME] to the resident and did not stop the medication as recommended. There was no documented evidence the facility obtained an [MEDICATION NAME] level on [DATE] as recommended by the pharmacy. Review of Resident #4's laboratory results revealed the facility obtained an [MEDICATION NAME] trough level on [DATE], after the pharmacy again faxed instructions on [DATE], to stop the [MEDICATION NAME] and obtain another trough level. Review of the laboratory results for Resident #4 revealed the [MEDICATION NAME] trough level was within normal limits. Interview with the Second Floor Unit Manager on [DATE] at 1:10 PM revealed the facility had no formal procedure in place to identify who was responsible to ensure laboratory results were sent to the pharmacy and pharmacy recommendations acted upon. The Unit Manager stated whatever random staff happened to remove pharmacy recommendations from the facsimile (fax) machine was the person responsible for writing the physician's orders [REDACTED]. In addition, the Unit Manager stated there was no system to monitor to ensure laboratory results were sent to the pharmacy or to ensure pharmacy recommendations were acted upon. She stated once a pharmacy recommendation was removed from the facsimile, it was maintained in a file above the fax machine. The Unit Manager stated she was not aware the pharmacy had faxed recommendations for Resident #4 that were not acted upon. 3. Record review revealed the facility admitted Resident #5 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility was unable to conduct a BIMS due to the resident being severely cognitively impaired. Review of the Medication Administration Record (MAR) revealed on [DATE] Resident #5 had an order for [REDACTED]. Review of Resident #5's physician orders [REDACTED]. Review of Resident #5's Medication Administration Record (MAR) revealed the orders for a [MEDICATION NAME] peak and trough level, [MEDICATION NAME] trough level, and serum creatinine level were documented on the MAR to be obtained on [DATE]. Further review of the MAR revealed the facility documented that the physician ordered laboratory tests were obtained and the results were sent to the pharmacy; however, the resident had no laboratory results dated [DATE], and the facility was unable to provide evidence the laboratory tests were obtained and sent to Pharmacy. Additionally, the facility obtained the resident's [MEDICATION NAME] trough level and creatinine level one day late, on [DATE]. Review of Resident #5's [MEDICATION NAME] trough level on [DATE] revealed the level was elevated at 25 (normal reference range was 10 to 20). Review of nurse's notes on [DATE] at 6:06 PM, revealed the contracted laboratory service notified the facility that the resident's [MEDICATION NAME] level was a panic level. However, there was no evidence the facility sent the laboratory result to the pharmacy as ordered. Resident #5 continued to receive [MEDICATION NAME] until [DATE]. Further review of Resident #5's MAR revealed the resident continued to receive [MEDICATION NAME] every 48 hours in the absence of required laboratory medication monitoring. No adjustment to the resident's medication was made until [DATE], when the medication was scheduled to be discontinued. Interview with Pharmacist #2 on [DATE] at 1:50 PM, revealed the pharmacy had no evidence the facility faxed Resident #5's laboratory results on [DATE] as ordered. The pharmacist further stated that although the facility's physician orders [REDACTED]. [REDACTED].#5's medication. 4. Review of the medical record for Resident #7 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Admission Minimum Data Set (MDS) assessment completed for Resident #7 dated [DATE] revealed the facility assessed the resident to be cognitively intact with a BIMS score of fifteen (15). Review of Resident #7's physician's orders [REDACTED]. The resident also had physician orders [REDACTED]. However, a review of Resident #7's Medication Administration Record (MAR) revealed no evidence the facility documented the need for staff to obtain the laboratory tests on [DATE] and [DATE]. Further review of Resident #7's laboratory results revealed the facility did not obtain the resident's peak medication level until [DATE] (one day after the physician ordered for the test to be completed) and there was no documented evidence the trough level and creatinine level were ever obtained. An interview with Licensed Practical Nurse (LPN) #7 on [DATE] at 11:15 AM revealed the LPN incorrectly entered the order for the [MEDICATION NAME] levels in the patient's electronic health record; therefore, the laboratory orders did not print out on the resident's MAR. The laboratory test was not obtained as ordered on [DATE] and [DATE]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 is no longer a resident at Mountain Manor of Paintsville (the Center). On [DATE], Resident #1 was transferred from the facility to the hospital and was subsequently admitted to the hospital with [REDACTED]. Resident #1 expired at the hospital. 2) The licensed nurse responsible for admitting Resident #1 on [DATE] is no longer employed at the Center. 3) On [DATE], an audit to review transcription of physician orders [REDACTED]. 4) On [DATE] to [DATE], an expanded audit was initiated by the Director of Nursing and Unit Managers to include a review of all physician orders [REDACTED]. The audit included review of the transcription and implementation of current physicians' orders, residents' active Medication Administration Records (MARs), and Treatment Administration Record (TAR). Any concerns identified were corrected immediately. 5) On [DATE], under the direction of the Quality Assurance and Performance Improvement (QAPI) committee (Quality Assurance and Performance Improvement committee members include: the Administrator, Director of Nursing, Unit Managers, Medical Director, Minimum Data Set Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director), a Performance Improvement Plan (PIP) committee was created. The PIP Committee members include: the Administrator, Director of Nursing, Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, Social Services Director, and Activity Director. 6) All licensed nurses identified as having administering IV antibiotics to Resident #1 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. In-services were conducted by the Director of Nursing and the Staff Development Coordinator. In-servicing was completed on [DATE] and [DATE]. 7) On [DATE], the following policies and procedures have been reviewed and updated as needed by the QAPI Committee: Physician Orders, Labs, and Pharmacy Services. a) Physician order [REDACTED]. [REDACTED]. Routine order reviews will consist of reviewing physicians' orders for accurate transcription and evidence of implementation, Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, and MDS Nurse). On Saturday and Sunday physician orders [REDACTED]. In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will review and verify physician orders. New admission and readmission orders [REDACTED]. In the event the on-call nurse is unable to complete review, the Director of Nursing will be responsible to complete. Beginning on [DATE], physician orders [REDACTED]. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. b) Lab policy revision included a routine review of lab orders and results of the labs by the Nurse Management Team (Nurse Management Team consists of: Director of Nursing, Unit Managers, Quality Assurance Nurse, MDS Nurse, and Staff Development Coordinator), as well as an additional and separate verification of labs by the QA Nurse. Routine lab review will be completed Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, QA Nurse, and MDS Nurse). On Saturday and Sunday lab review will be reviewed and verified by the designated nurse manager on call (Nurse Managers on call: Unit Manager, Staff Development Coordinator, QA Nurse, and MDS Nurse). In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will be responsible for the review. Lab orders, requisitions, and results will be tracked in lab binders at each nurses' station. On [DATE], a meeting was held by the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Pharmacy Service policies were reviewed on [DATE] by the QAPI Committee with no changes indicated. Beginning on [DATE], antibiotic medication orders that require lab monitoring will include an order for [REDACTED]. Labs will be obtained per the physician order. The IV antibiotic will be placed on hold after the third dose pending the results of lab level. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. The Administrator contracted two additional consultant pharmacists experienced in Long Term Care to review physicians' orders and pharmacy consultation for residents with medications requiring special lab monitoring. The review was completed on [DATE]. On [DATE], the Administrator and Director of Nursing sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) On [DATE] through [DATE], in-services were provided to Licensed Nurses regarding policy and procedure updates. In-servicing was conducted by the Director of Nursing and Staff Development Coordinator. Post-tests and return demonstrations were required to validate training. Licensed Nurses were not permitted to work until education was completed and confirmed by post-testing. Training was complete on [DATE]. All policy revisions were added to new hire orientation material on [DATE]. 9) On [DATE], the Administrator appointed a Quality Assurance Nurse to provide oversight and coordination of the Center's ongoing Quality Assurance and Performance Improvement program. The Quality Assurance Nurse will conduct additional audits of physicians' orders for accurate transcription and evidence of implementation and will verify compliance of physicians' orders transcription and lab monitoring related to medications requiring lab monitoring. Audits and reviews will be completed daily, Monday through Friday, and submitted to the PIP Committee for monitoring and further recommendations as indicated. 10) To ensure sustained compliance, the daily (Monday through Friday) PIP Committee meets to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the Immediate Jeopardy has been verified by CMS through the Kentucky Cabinet for Health and Family Services ([MEDICAL CONDITION]). Weekly QAPI meetings will continue to occur until sustained compliance is achieved. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1) Review of the medical record for Resident #1 revealed the resident was discharged to the hospital on [DATE], and expired while at the hospital. 2) Review of the personnel file for LPN #6 revealed the LPN had not been employed at the facility since [DATE]. 3) Review of audit sheets dated [DATE] revealed the DON and Unit Managers audited the medical records of residents who had physician orders [REDACTED]. The audit had been completed by the DON and Unit Managers. Interviews on [DATE] with the DON at 9:50 AM, Unit Manager (UM) #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they had assisted with the audits for residents who had received antibiotics to ensure all physician orders [REDACTED]. 4) Review of audit sheets dated [DATE] through [DATE] revealed the Director of Nursing and Unit Managers audited physician orders [REDACTED]. The audits included reviews of the transcription and implementation of current physicians' orders, the resident's active Medication Administration Record (MAR), and Treatment Administration Record (TAR). Interviews on [DATE] with the DON at 9:50 AM, UM #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they assisted with the audits for residents who were admitted or readmitted to the facility from [DATE] through [DATE] to ensure all physician orders [REDACTED]. 5) Review of QAPI as well as PIP meeting minutes dated [DATE] revealed a QAPI meeting was held and a PIP Committee was formed. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the Staff Development Coordinator (SDC) on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the Activity Director (AD) on [DATE] at 9:22 AM, the Social Services Director (SSD) on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed a QAPI meeting was held on [DATE], and a PIP Committee was formed. Staff stated the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed, and QAPI meetings would also continue to be held weekly. 6) Review of an in-service roster dated [DATE] and [DATE] revealed RN #2, LPN #7, LPN #13, and UM #2 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. Interviews with LPN #7 on [DATE] at 2:30 PM, RN #2 on [DATE] at 4:00 PM, and UM #2 on [DATE] at 10:06 AM, revealed they had received an in-service on [DATE], related to transcription of orders and medications which required a drug level. 7) Review of QAPI Committee minutes dated [DATE] and review of the facility's policies for Physician Orders, Labs, and Pharmacy Services revealed the policies were reviewed/revised on [DATE]. Review of the New Employee Orientation Packet revealed the current physician's orders [REDACTED].

Based on observation, interview, record review, and review of the facility's policies/procedures and hospital records it was determined the facility failed to ensure four (4) of seven (7) sampled residents (Residents #1, #4, #5, and #7) were free from unnecessary drugs. The facility administered aminoglycoside medications (an antibiotic medication that requires laboratory monitoring) to Residents #1, #4, #5, and #7 without adequate monitoring to ensure the residents were receiving a safe, therapeutic dosage of medication. On [DATE], the facility readmitted Resident #1 with a physician's orders [REDACTED]. The facility failed to obtain the physician ordered laboratory test on [DATE] and continued to administer the medication without monitoring the resident's medication level. Resident #1 was transferred to the hospital on [DATE], and was diagnosed with [REDACTED].#1's death on [DATE]. In addition, Resident #4 was receiving [MEDICATION NAME] (an aminoglycoside antibiotic) and had physician orders [REDACTED]. The facility failed to ensure the levels were obtained as ordered by the physician. Resident #4's [MEDICATION NAME] level was high on [DATE]; however, the facility failed to communicate the resident's lab results to the pharmacy as required by the resident's physician and Resident #4 continued to receive [MEDICATION NAME] medication in the absence of required monitoring. The facility failed to ensure Residents #5 and #7 received appropriate laboratory testing while receiving aminoglycoside medication. The facility failed to ensure medications that require monitoring were adequately monitored. The facility's failure to ensure residents were free from unnecessary drugs 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] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 - J, F281 - K, and F282 - J); 42 CFR 483.25 Quality of Care (F309 - K); 42 CFR 483.45 Pharmacy Services (F329 - K and F428 - K); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502 - K). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F309) and 42 CFR 483.45 Pharmacy Services (F329). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 and F282), and E level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F281); 42 CFR 483.25 Quality of Care (F309); 42 CFR 483.45 Pharmacy Services (F329 and F428); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with Pharmacist #2 on [DATE] at 12:45 PM, and on [DATE] at 1:50 PM revealed certain medications like aminoglycosides required dosage adjustment based on laboratory levels to ensure that the amount of medication in the resident's bloodstream was therapeutic and did not build up to a toxic level. The pharmacist stated aminoglycoside medications required a peak level (peak is the highest amount of medication in the blood after the medication is given; the peak is drawn approximately thirty minutes after the medication is administered) and a trough level (the minimum amount of medication in the bloodstream and is drawn immediately prior to the medication being administered on the second or third day of treatment). The pharmacist further stated the physician may choose to monitor and adjust the medication dosage themselves or may write a specific physician order [REDACTED]. 1. Review of Resident #1's closed medical record revealed the facility readmitted the resident on [DATE], with physician orders [REDACTED]. However, further review of Resident #1's medical record revealed there was no evidence the facility obtained a [MEDICATION NAME] level on [DATE] as required. Review of Resident #1's Medication Administration Record (MAR) revealed the facility continued to administer [MEDICATION NAME] to the resident daily from [DATE] through [DATE], with no evidence that the resident's clinical condition was reviewed for the continued need for the medication or adjustment of the dosage. On [DATE] at 8:58 AM, Resident #1 was transferred to the hospital due to a change in the resident's condition. Review of Resident #1's hospital record revealed the resident's [MEDICATION NAME] level at the hospital on [DATE] at 10:00 AM, was critically high at 17.9 mcg/ml (normal range for a [MEDICATION NAME] peak is 4 to 10 mcg/ml and normal [MEDICATION NAME] trough is 0.5 to 2 mcg/ml). Resident #1 expired on [DATE] at the hospital due to Acute [MEDICAL CONDITION] and Aminoglycoside Induced Nephrotoxicity. Interview with Resident #1's Physician on [DATE] at 10:10 AM revealed he ordered Resident #1's [MEDICATION NAME] level to be obtained on [DATE]. The physician stated he was not aware that the level was not obtained as ordered until the resident was hospitalized on [DATE] and diagnosed with [REDACTED]. According to the Physician, the facility's failure to obtain and monitor the [MEDICATION NAME] level resulted in the resident toxicity of this medication causing the resident to have acute [MEDICAL CONDITION] which contributed to the resident's death. 2. Record review revealed the facility readmitted Resident #4 on [DATE]. Review of physician's orders [REDACTED]. accordingly. Resident #4 also had a physician's orders [REDACTED]. However, there was no evidence the laboratory test was obtained, or that the facility monitored this medication. The facility continued to administer [MEDICATION NAME] medication to the resident. Resident #4 also had an order for [REDACTED]. However, there was no evidence the trough medication level was obtained for Resident #4 until [DATE] (one day after the level was ordered to be obtained). The facility failed to adequately monitor this medication. Review of Resident #4's [MEDICATION NAME] laboratory results dated [DATE] at 07:04 AM, revealed the resident's trough level was elevated at 17.8 (normal trough level is less than 8.0). However, there was no evidence the facility communicated the laboratory results to the pharmacy on [DATE], for an adjustment in the resident's [MEDICATION NAME] medication dosage, and the facility continued to administer [MEDICATION NAME] medication to the resident. The facility failed to adequately monitor this medication. Interview with Pharmacist #3 on [DATE] at 11:25 AM, revealed the pharmacy did not receive Resident #4's laboratory results that were obtained on [DATE], until [DATE]. Further interview with the pharmacist and a review of facsimiles (faxes) from the pharmacy dated [DATE], revealed the pharmacy faxed a recommendation to the facility on [DATE], to stop administering [MEDICATION NAME] to the resident because the resident's [MEDICATION NAME] level was too high and to obtain another [MEDICATION NAME] level on [DATE]. However, review of Resident #4's MAR for (MONTH) (YEAR) revealed the facility continued to administer [MEDICATION NAME] to the resident and did not stop the medication as recommended. There was no documented evidence the facility obtained an [MEDICATION NAME] level on [DATE] as recommended by the pharmacy. The facility failed to adequately monitor this medication. Review of Resident #4's laboratory results revealed the facility obtained an [MEDICATION NAME] trough level on [DATE], after the pharmacy again faxed instructions on [DATE] to stop the [MEDICATION NAME] and obtain another trough level. A review of the laboratory results for Resident #4 revealed the [MEDICATION NAME] trough level was within normal limits. 3. Record review revealed the facility admitted Resident #5 on [DATE], with [DIAGNOSES REDACTED]. Review of the Medication Administration Record (MAR) revealed on [DATE], Resident #5 had an order for [REDACTED]. Review of Resident #5's physician's orders [REDACTED]. There was no evidence the facility obtained the [MEDICATION NAME] laboratory levels for the resident on [DATE]. However, the facility continued to administer [MEDICATION NAME] medication to the resident. The facility failed to adequately monitor this medication. Although the facility obtained Resident #5's [MEDICATION NAME] trough level on [DATE], one day after it was ordered to be obtained, there was no evidence the facility notified the pharmacy that the resident's [MEDICATION NAME] trough level was elevated to a panic level at 25 (normal reference range was 10 to 20). Review of Resident #5's MAR revealed the resident continued to receive [MEDICATION NAME] every 48 hours in the absence of required laboratory medication monitoring. No adjustment to the resident's medication was made until [DATE], when the medication was scheduled to be discontinued. The facility failed to adequately monitor this medication. Interview with Pharmacist #2 on [DATE] at 1:50 PM, revealed the pharmacy had no evidence the facility faxed Resident #5's laboratory results on [DATE] as ordered. The pharmacist further stated that although the facility's physician orders [REDACTED]. [REDACTED].#5's medication. The facility failed to ensure this medication was monitored adequately. 4. Review of the medical record for Resident #7 revealed the facility admitted the resident on [DATE], and on [DATE] the resident's physician ordered [MEDICATION NAME] (an aminoglycoside antibiotic medication to treat infection), a [MEDICATION NAME] peak level one (1) hour after the medication was administered on [DATE], and a trough medication level thirty (30) minutes prior to the medication being administered on [DATE]. However, a review of Resident #7's laboratory results revealed the facility did not obtain the resident's peak medication level until [DATE] (one day after the physician ordered for the test to be completed), and there was no documented evidence the trough level was ever obtained. Review of the peak level revealed the level was 3.5 (reference range ,[DATE]). An interview with Pharmacist #1 on [DATE] at 1:20 PM, revealed he completed drug regimen reviews for the residents while they were receiving the aminoglycoside medications and did not identify that the medications were being administered without the required laboratory monitoring. **The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 is no longer a resident at Mountain Manor of Paintsville (the Center). On [DATE], Resident #1 was transferred from the facility to the hospital and was subsequently admitted to the hospital with [REDACTED]. Resident #1 expired at the hospital. 2) The licensed nurse responsible for admitting Resident #1 on [DATE] is no longer employed at the Center. 3) On [DATE], an audit to review transcription of physician orders [REDACTED]. 4) On [DATE] to [DATE], an expanded audit was initiated by the Director of Nursing and Unit Managers to include a review of all physician orders [REDACTED]. The audit included review of the transcription and implementation of current physicians' orders, residents' active Medication Administration Records (MARs), and Treatment Administration Record (TAR). Any concerns identified were corrected immediately. 5) On [DATE], under the direction of the Quality Assurance and Performance Improvement (QAPI) committee (Quality Assurance and Performance Improvement committee members include: the Administrator, Director of Nursing, Unit Managers, Medical Director, Minimum Data Set Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director), a Performance Improvement Plan (PIP) committee was created. The PIP Committee members include: the Administrator, Director of Nursing, Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, Social Services Director, and Activity Director. 6) All licensed nurses identified as having administering IV antibiotics to Resident #1 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. In-services were conducted by the Director of Nursing and the Staff Development Coordinator. In-servicing was completed on [DATE] and [DATE]. 7) On [DATE], the following policies and procedures have been reviewed and updated as needed by the QAPI Committee: Physician Orders, Labs, and Pharmacy Services. a) Physician order [REDACTED]. [REDACTED]. Routine order reviews will consist of reviewing physicians' orders for accurate transcription and evidence of implementation, Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, and MDS Nurse). On Saturday and Sunday physician orders [REDACTED]. In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will review and verify physician orders. New admission and readmission orders [REDACTED]. In the event the on-call nurse is unable to complete review, the Director of Nursing will be responsible to complete. Beginning on [DATE], physician orders [REDACTED]. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. b) Lab policy revision included a routine review of lab orders and results of the labs by the Nurse Management Team (Nurse Management Team consists of: Director of Nursing, Unit Managers, Quality Assurance Nurse, MDS Nurse, and Staff Development Coordinator), as well as an additional and separate verification of labs by the QA Nurse. Routine lab review will be completed Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, QA Nurse, and MDS Nurse). On Saturday and Sunday lab review will be reviewed and verified by the designated nurse manager on call (Nurse Managers on call: Unit Manager, Staff Development Coordinator, QA Nurse, and MDS Nurse). In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will be responsible for the review. Lab orders, requisitions, and results will be tracked in lab binders at each nurses' station. On [DATE], a meeting was held by the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Pharmacy Service policies were reviewed on [DATE] by the QAPI Committee with no changes indicated. Beginning on [DATE], antibiotic medication orders that require lab monitoring will include an order for [REDACTED]. Labs will be obtained per the physician order. The IV antibiotic will be placed on hold after the third dose pending the results of lab level. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. The Administrator contracted two additional consultant pharmacists experienced in Long Term Care to review physicians' orders and pharmacy consultation for residents with medications requiring special lab monitoring. The review was completed on [DATE]. On [DATE], the Administrator and Director of Nursing sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) On [DATE] through [DATE], in-services were provided to Licensed Nurses regarding policy and procedure updates. In-servicing was conducted by the Director of Nursing and Staff Development Coordinator. Post-tests and return demonstrations were required to validate training. Licensed Nurses were not permitted to work until education was completed and confirmed by post-testing. Training was complete on [DATE]. All policy revisions were added to new hire orientation material on [DATE]. 9) On [DATE], the Administrator appointed a Quality Assurance Nurse to provide oversight and coordination of the Center's ongoing Quality Assurance and Performance Improvement program. The Quality Assurance Nurse will conduct additional audits of physicians' orders for accurate transcription and evidence of implementation and will verify compliance of physicians' orders transcription and lab monitoring related to medications requiring lab monitoring. Audits and reviews will be completed daily, Monday through Friday, and submitted to the PIP Committee for monitoring and further recommendations as indicated. 10) To ensure sustained compliance, the daily (Monday through Friday) PIP Committee meets to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the Immediate Jeopardy has been verified by CMS through the Kentucky Cabinet for Health and Family Services ([MEDICAL CONDITION]). Weekly QAPI meetings will continue to occur until sustained compliance is achieved. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1) Review of the medical record for Resident #1 revealed the resident was discharged to the hospital on [DATE], and expired while at the hospital. 2) Review of the personnel file for LPN #6 revealed the LPN had not been employed at the facility since [DATE]. 3) Review of audit sheets dated [DATE] revealed the DON and Unit Managers audited the medical records of residents who had physician orders [REDACTED]. The audit had been completed by the DON and Unit Managers. Interviews on [DATE] with the DON at 9:50 AM, Unit Manager (UM) #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they had assisted with the audits for residents who had received antibiotics to ensure all physician orders [REDACTED]. 4) Review of audit sheets dated [DATE] through [DATE] revealed the Director of Nursing and Unit Managers audited physician orders [REDACTED]. The audits included reviews of the transcription and implementation of current physicians' orders, the resident's active Medication Administration Record (MAR), and Treatment Administration Record (TAR). Interviews on [DATE] with the DON at 9:50 AM, UM #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they assisted with the audits for residents who were admitted or readmitted to the facility from [DATE] through [DATE] to ensure all physician orders [REDACTED]. 5) Review of QAPI as well as PIP meeting minutes dated [DATE] revealed a QAPI meeting was held and a PIP Committee was formed. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the Staff Development Coordinator (SDC) on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the Activity Director (AD) on [DATE] at 9:22 AM, the Social Services Director (SSD) on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed a QAPI meeting was held on [DATE], and a PIP Committee was formed. Staff stated the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed, and QAPI meetings would also continue to be held weekly. 6) Review of an in-service roster dated [DATE] and [DATE] revealed RN #2, LPN #7, LPN #13, and UM #2 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. Interviews with LPN #7 on [DATE] at 2:30 PM, RN #2 on [DATE] at 4:00 PM, and UM #2 on [DATE] at 10:06 AM, revealed they had received an in-service on [DATE], related to transcription of orders and medications which required a drug level. 7) Review of QAPI Committee minutes dated [DATE] and review of the facility's policies for Physician Orders, Labs, and Pharmacy Services revealed the policies were reviewed/revised on [DATE]. Review of the New Employee Orientation Packet revealed the current physician's orders [REDACTED]. Interview with the SDC on [DATE] at 9:06 AM revealed the facility had not hired a new nurse since the implementation of the changes in the policies. However, the new policies for physician's orders [REDACTED]. a) and b) Review of the physician's orders [REDACTED]. Interviews conducted with the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed they were meeting daily to review all new physician orders [REDACTED]. The interviews revealed there was a nurse manager on call on Saturday and Sunday to review any new orders within eight (8) hours of transcription by the admitting nurse and verify the orders were transcribed and implemented. Further interviews revealed they were ensuring that laboratory tests for antibiotics that required laboratory monitoring were entered and laboratory tests completed. Staff interviews revealed the intravenous antibiotic would be placed on hold after the third dose pending the results of the laboratory level and would not be continued until laboratory values were evaluated by the resident's physician. Review of a roster dated [DATE] and interviews with the Administrator on [DATE] at 9:30 AM, and the DON on [DATE] at 9:50 AM, revealed a meeting was held with the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Record review revealed on [DATE] consultant pharmacists reviewed resident medical records for all residents with medications requiring special lab monitoring. Further interview with the Administrator on [DATE] at 9:30 AM and the DON on [DATE] at 9:50 AM revealed they sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) Review of in-service rosters dated [DATE] and [DATE] revealed the SDC and the DON provided an in-service for all licensed nurses on the reviewed/revised laboratory, pharmacy, and physician orders [REDACTED]. Interviews conducted with LPN #4 on [DATE] at 1:27 PM, LPN #1 on [DATE] at 1:52 PM, LPN #7 on [DATE] at 2:30 PM, and RN #2 on [DATE] at 4:00 PM, revealed they had received in-service training regarding the facility's laboratory, pharmacy, and physician orders [REDACTED]. The staff stated they were required to have a second nurse to review orders and were required to enter physician laboratory orders in the computer and document the order in a laboratory book at the nurses' station. In addition, the nurses stated that for any antibiotic that required a laboratory level, the medication would be held by the pharmacy until a laboratory level was obtained and reported. 9) Review of a personnel change in position form dated [DATE], revealed a QA Nurse position had been filled. Review of audit tools completed by the QA Nurse dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the QA Nurse documented that compliance of physician's orders [REDACTED]. Further review of audit sheets revealed the QA nurse also reviewed the audits that had been completed by the nurse management team. Interview with the QA Nurse on [DATE] at 9:42 AM, revealed she had completed audits on physician's orders [REDACTED]. The QA Nurse stated she had reported her findings to the QAPI meeting and would continue to do so. 10) Review of QAPI and PIP meeting minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the committees had been meeting daily Monday through Friday and monitored results of all audits and reviews. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the SSD on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed the QAPI Committee as well as the PIP Committee had been meeting daily Monday through Friday and reviewed the results of the audits and reviews. The interviews revealed the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure irregularities in residents' drug regimen review were reported to the resident's physician and the Director of Nursing (DON) for three (3) of seven (7) sampled residents (Residents #1, #5, and #7). On [DATE], the pharmacist conducted a routine drug regimen review for Resident #1. However, the pharmacist failed to identify that on [DATE], a Gentamicin drug level was not obtained for Resident #1, and the resident continued to receive Gentamicin medication (an aminoglycoside antibiotic medication to treat infection) without evidence of adequate monitoring, which would indicate whether the dose should be reduced or discontinued. Resident #1 expired at the hospital on [DATE] due to adverse consequences which resulted from Gentamicin toxicity. In addition, Residents #5 and #7 were receiving aminoglycoside antibiotic medication during routine drug regimen reviews. However, the facility failed to identify that the required laboratory monitoring was not being conducted. The facility's failure to ensure the pharmacist reported drug regimen irregularities to the attending physician and the Director of Nursing (DON) 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] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 - J, F281 - K, and F282 - J); 42 CFR 483.25 Quality of Care (F309 - K); 42 CFR 483.45 Pharmacy Services (F329 - K and F428 - K); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502 - K). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F309) and 42 CFR 483.45 Pharmacy Services (F329). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 and F282), and E level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F281); 42 CFR 483.25 Quality of Care (F309); 42 CFR 483.45 Pharmacy Services (F329 and F428); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Medication Regimen Review policy, undated, revealed the consultant pharmacist would perform a comprehensive medication regimen review of each resident at least monthly or more frequently if needed. The medication regimen review would include evaluating the resident's response to medication therapy in order to maintain the resident's highest practicable level of functioning and minimize potential adverse consequences related to medication therapy. Further review of the policy revealed the consultant pharmacist reviewed resident medication orders to identify irregularities and to ensure laboratory results were obtained and acted upon. 1. Review of the medication regimen review for Resident #1 dated [DATE] revealed no documented evidence the pharmacist identified an irregularity related to Resident #1's antibiotic therapy. Review of Resident #1's physician's orders [REDACTED]. However, there was no evidence the facility obtained the Gentamicin level. On [DATE], the pharmacist conducting the medication regimen review failed to identify that the facility did not obtain a Gentamicin trough level for Resident #1 on [DATE], as ordered by the resident's physician. In addition, the pharmacist also failed to identify that the resident was receiving Gentamicin daily in the absence of any laboratory monitoring. Further review of Resident #1's medical record revealed on [DATE] (two days after the pharmacist reviewed the resident's medications) the facility transferred the resident to the hospital due to low oxygen saturation and blood pressure. When the resident arrived at the hospital, the resident's Gentamicin level was critically high and the resident was diagnosed with [REDACTED]. Resident #1 expired at the hospital on [DATE]. 2. Review of a medication regimen review for Resident #7 dated [DATE] revealed the pharmacist identified no irregularities with the resident's medication and made no recommendations. Review of Resident #7's physician's orders [REDACTED]. However, review of Resident #7's medical record revealed the facility did not obtain the resident's peak medication level until [DATE] (one day after the physician ordered for the test to be completed) and there was no documented evidence the trough level and creatinine level were obtained. Further review revealed there was no evidence the pharmacist identified the facility's failure to obtain the physician ordered laboratory tests for Resident #7 to ensure the resident was receiving a therapeutic dose of medication. 3. Review of a medication regimen review for Resident #5 dated [DATE] revealed the pharmacist identified no irregularities with the resident's medication and made no recommendations. Review of Resident #5's physician's orders [REDACTED]. However, review of Resident #5's medical record revealed no evidence the facility obtained the Tobramycin peak and trough levels for Resident #5 on [DATE]. There was no evidence the pharmacist identified the facility's failure to obtain the physician ordered laboratory tests for Resident #7 to ensure the resident was receiving a therapeutic dose of medication. An interview with Pharmacist #1 on [DATE] at 1:20 PM, who completed drug regimen reviews for the residents, revealed he did not identify the facility's failure to obtain an aminoglycoside level for the residents. The pharmacist stated the facility frequently failed to obtain physician ordered laboratory tests. He further stated the pharmacy often identified when laboratory tests were not obtained and had to contact the facility to ensure the laboratory tests were conducted in order to avoid adverse consequences. According to the pharmacist, had he identified that Resident #1's Gentamicin level was not obtained, he would have made recommendations to obtain the level. **The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 is no longer a resident at Mountain Manor of Paintsville (the Center). On [DATE], Resident #1 was transferred from the facility to the hospital and was subsequently admitted to the hospital with [REDACTED]. Resident #1 expired at the hospital. 2) The licensed nurse responsible for admitting Resident #1 on [DATE] is no longer employed at the Center. 3) On [DATE], an audit to review transcription of physician orders [REDACTED]. 4) On [DATE] to [DATE], an expanded audit was initiated by the Director of Nursing and Unit Managers to include a review of all physician orders [REDACTED]. The audit included review of the transcription and implementation of current physicians' orders, residents' active Medication Administration Records (MARs), and Treatment Administration Record (TAR). Any concerns identified were corrected immediately. 5) On [DATE], under the direction of the Quality Assurance and Performance Improvement (QAPI) committee (Quality Assurance and Performance Improvement committee members include: the Administrator, Director of Nursing, Unit Managers, Medical Director, Minimum Data Set Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director), a Performance Improvement Plan (PIP) committee was created. The PIP Committee members include: the Administrator, Director of Nursing, Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, Social Services Director, and Activity Director. 6) All licensed nurses identified as having administering IV antibiotics to Resident #1 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. In-services were conducted by the Director of Nursing and the Staff Development Coordinator. In-servicing was completed on [DATE] and [DATE]. 7) On [DATE], the following policies and procedures have been reviewed and updated as needed by the QAPI Committee: Physician Orders, Labs, and Pharmacy Services. a) Physician order [REDACTED]. [REDACTED]. Routine order reviews will consist of reviewing physicians' orders for accurate transcription and evidence of implementation, Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, and MDS Nurse). On Saturday and Sunday physician orders [REDACTED]. In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will review and verify physician orders. New admission and readmission orders [REDACTED]. In the event the on-call nurse is unable to complete review, the Director of Nursing will be responsible to complete. Beginning on [DATE], physician orders [REDACTED]. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. b) Lab policy revision included a routine review of lab orders and results of the labs by the Nurse Management Team (Nurse Management Team consists of: Director of Nursing, Unit Managers, Quality Assurance Nurse, MDS Nurse, and Staff Development Coordinator), as well as an additional and separate verification of labs by the QA Nurse. Routine lab review will be completed Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, QA Nurse, and MDS Nurse). On Saturday and Sunday lab review will be reviewed and verified by the designated nurse manager on call (Nurse Managers on call: Unit Manager, Staff Development Coordinator, QA Nurse, and MDS Nurse). In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will be responsible for the review. Lab orders, requisitions, and results will be tracked in lab binders at each nurses' station. On [DATE], a meeting was held by the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Pharmacy Service policies were reviewed on [DATE] by the QAPI Committee with no changes indicated. Beginning on [DATE], antibiotic medication orders that require lab monitoring will include an order for [REDACTED]. Labs will be obtained per the physician order. The IV antibiotic will be placed on hold after the third dose pending the results of lab level. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. The Administrator contracted two additional consultant pharmacists experienced in Long Term Care to review physicians' orders and pharmacy consultation for residents with medications requiring special lab monitoring. The review was completed on [DATE]. On [DATE], the Administrator and Director of Nursing sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) On [DATE] through [DATE], in-services were provided to Licensed Nurses regarding policy and procedure updates. In-servicing was conducted by the Director of Nursing and Staff Development Coordinator. Post-tests and return demonstrations were required to validate training. Licensed Nurses were not permitted to work until education was completed and confirmed by post-testing. Training was complete on [DATE]. All policy revisions were added to new hire orientation material on [DATE]. 9) On [DATE], the Administrator appointed a Quality Assurance Nurse to provide oversight and coordination of the Center's ongoing Quality Assurance and Performance Improvement program. The Quality Assurance Nurse will conduct additional audits of physicians' orders for accurate transcription and evidence of implementation and will verify compliance of physicians' orders transcription and lab monitoring related to medications requiring lab monitoring. Audits and reviews will be completed daily, Monday through Friday, and submitted to the PIP Committee for monitoring and further recommendations as indicated. 10) To ensure sustained compliance, the daily (Monday through Friday) PIP Committee meets to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the Immediate Jeopardy has been verified by CMS through the Kentucky Cabinet for Health and Family Services (CHFS). Weekly QAPI meetings will continue to occur until sustained compliance is achieved. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1) Review of the medical record for Resident #1 revealed the resident was discharged to the hospital on [DATE], and expired while at the hospital. 2) Review of the personnel file for LPN #6 revealed the LPN had not been employed at the facility since [DATE]. 3) Review of audit sheets dated [DATE] revealed the DON and Unit Managers audited the medical records of residents who had physician orders [REDACTED]. The audit had been completed by the DON and Unit Managers. Interviews on [DATE] with the DON at 9:50 AM, Unit Manager (UM) #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they had assisted with the audits for residents who had received antibiotics to ensure all physician orders [REDACTED]. 4) Review of audit sheets dated [DATE] through [DATE] revealed the Director of Nursing and Unit Managers audited physician orders [REDACTED]. The audits included reviews of the transcription and implementation of current physicians' orders, the resident's active Medication Administration Record (MAR), and Treatment Administration Record (TAR). Interviews on [DATE] with the DON at 9:50 AM, UM #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they assisted with the audits for residents who were admitted or readmitted to the facility from [DATE] through [DATE] to ensure all physician orders [REDACTED]. 5) Review of QAPI as well as PIP meeting minutes dated [DATE] revealed a QAPI meeting was held and a PIP Committee was formed. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the Staff Development Coordinator (SDC) on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the Activity Director (AD) on [DATE] at 9:22 AM, the Social Services Director (SSD) on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed a QAPI meeting was held on [DATE], and a PIP Committee was formed. Staff stated the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed, and QAPI meetings would also continue to be held weekly. 6) Review of an in-service roster dated [DATE] and [DATE] revealed RN #2, LPN #7, LPN #13, and UM #2 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. Interviews with LPN #7 on [DATE] at 2:30 PM, RN #2 on [DATE] at 4:00 PM, and UM #2 on [DATE] at 10:06 AM, revealed they had received an in-service on [DATE], related to transcription of orders and medications which required a drug level. 7) Review of QAPI Committee minutes dated [DATE] and review of the facility's policies for Physician Orders, Labs, and Pharmacy Services revealed the policies were reviewed/revised on [DATE]. Review of the New Employee Orientation Packet revealed the current physician's orders [REDACTED]. Interview with the SDC on [DATE] at 9:06 AM revealed the facility had not hired a new nurse since the implementation of the changes in the policies. However, the new policies for physician's orders [REDACTED]. a) and b) Review of the physician's orders [REDACTED]. Interviews conducted with the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed they were meeting daily to review all new physician orders [REDACTED]. The interviews revealed there was a nurse manager on call on Saturday and Sunday to review any new orders within eight (8) hours of transcription by the admitting nurse and verify the orders were transcribed and implemented. Further interviews revealed they were ensuring that laboratory tests for antibiotics that required laboratory monitoring were entered and laboratory tests completed. Staff interviews revealed the intravenous antibiotic would be placed on hold after the third dose pending the results of the laboratory level and would not be continued until laboratory values were evaluated by the resident's physician. Review of a roster dated [DATE] and interviews with the Administrator on [DATE] at 9:30 AM, and the DON on [DATE] at 9:50 AM, revealed a meeting was held with the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Record review revealed on [DATE] consultant pharmacists reviewed resident medical records for all residents with medications requiring special lab monitoring. Further interview with the Administrator on [DATE] at 9:30 AM and the DON on [DATE] at 9:50 AM revealed they sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) Review of in-service rosters dated [DATE] and [DATE] revealed the SDC and the DON provided an in-service for all licensed nurses on the reviewed/revised laboratory, pharmacy, and physician orders [REDACTED]. Interviews conducted with LPN #4 on [DATE] at 1:27 PM, LPN #1 on [DATE] at 1:52 PM, LPN #7 on [DATE] at 2:30 PM, and RN #2 on [DATE] at 4:00 PM, revealed they had received in-service training regarding the facility's laboratory, pharmacy, and physician orders [REDACTED]. The staff stated they were required to have a second nurse to review orders and were required to enter physician laboratory orders in the computer and document the order in a laboratory book at the nurses' station. In addition, the nurses stated that for any antibiotic that required a laboratory level, the medication would be held by the pharmacy until a laboratory level was obtained and reported. 9) Review of a personnel change in position form dated [DATE], revealed a QA Nurse position had been filled. Review of audit tools completed by the QA Nurse dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the QA Nurse documented that compliance of physician's orders [REDACTED]. Further review of audit sheets revealed the QA nurse also reviewed the audits that had been completed by the nurse management team. Interview with the QA Nurse on [DATE] at 9:42 AM, revealed she had completed audits on physician's orders [REDACTED]. The QA Nurse stated she had reported her findings to the QAPI meeting and would continue to do so. 10) Review of QAPI and PIP meeting minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the committees had been meeting daily Monday through Friday and monitored results of all audits and reviews. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the SSD on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed the QAPI Committee as well as the PIP Committee had been meeting daily Monday through Friday and reviewed the results of the audits and reviews. The interviews revealed the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed.

Based on interview, record review, and review of the facility's policies/procedures, it was determined the facility failed to ensure laboratory services were obtained to meet the needs of four (4) of seven (7) sampled residents (Residents #1, #4, #5, and #7). Resident #1 had physician orders [REDACTED]. The facility failed to ensure the laboratory test was obtained as ordered by the physician. Subsequently, the facility continued to administer [MEDICATION NAME] medication to Resident #1 without the required monitoring. On [DATE], Resident #1 was transferred to the hospital and diagnosed with [REDACTED].#1's death on [DATE]. In addition, the facility failed to appropriately obtain aminoglycoside medication levels for Residents #4, #5, and #7 as ordered by the residents' physicians. The facility's failure to ensure laboratory services were obtained to meet the needs of residents 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] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 - J, F281 - K, and F282 - J); 42 CFR 483.25 Quality of Care (F309 - K); 42 CFR 483.45 Pharmacy Services (F329 - K and F428 - K); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502 - K). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F309) and 42 CFR 483.45 Pharmacy Services (F329). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 and F282), and E level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F281); 42 CFR 483.25 Quality of Care (F309); 42 CFR 483.45 Pharmacy Services (F329 and F428); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Procedure for Placing Lab orders, dated [DATE], revealed all physician orders [REDACTED]. Interview with the Unit Manager on [DATE] at 9:05 AM, revealed the facility's contracted lab service obtained all routine laboratory tests. However, facility staff had to obtain any laboratory tests that needed to be obtained immediately or at a specific time, such as aminoglycoside levels. According to the Unit Manager and a review of the facility's policy titled Electronic Order Entry Policy, dated [DATE], revealed staff was required to transcribe orders into the resident's electronic health record. The orders then populated on the resident's Medication Administration Record (MAR) to alert staff when the lab was due to be obtained. 1. Review of Resident #1's closed medical record revealed the resident returned to the facility after an acute hospital stay with orders to receive [MEDICATION NAME] intravenously (IV) for nine (9) days. In addition, the facility was also to obtain a [MEDICATION NAME] trough level on [DATE], to determine the therapeutic dose of medication for the resident to ensure the resident's needs were met. Review of Resident #1's MAR for (MONTH) (YEAR) revealed no documented evidence the order for a [MEDICATION NAME] trough level was transcribed to the MAR in accordance with the facility's policy. Therefore, the [MEDICATION NAME] trough level was not obtained by facility staff on [DATE], as ordered by the resident's physician. The resident continued to receive IV [MEDICATION NAME] daily from [DATE] through [DATE] (eight days) without medication monitoring to ensure the resident was receiving a therapeutic dose of [MEDICATION NAME]. As a result of the facility's failure to obtain the laboratory services as ordered for Resident #1, the resident's [MEDICATION NAME] level was determined to be critically high at 17.9 mcg/ml (micrograms/milliliter) (normal range for a [MEDICATION NAME] peak is 4 to 10 mcg/ml) on [DATE], when the resident was transferred to the hospital. Resident #1 expired on [DATE] at the hospital due to Acute [MEDICAL CONDITION] and Aminoglycoside Induced Nephrotoxicity (kidney damage related to [MEDICATION NAME] medication). Interview with the Unit Manager on [DATE] at 9:05 AM revealed she was assisting Resident #1's assigned nurse with admitting the resident on [DATE], and began entering the resident's physician orders [REDACTED]. The Unit Manager stated she was unable to complete the admission process, and asked the assigned nurse to finish entering the resident's physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 1:05 PM, revealed the facility reviewed all physicians' orders to ensure the orders were on the resident's MAR; however, they did not ensure that physician ordered laboratory tests were obtained. Interview with Resident #1's Physician on [DATE] at 10:10 AM revealed he expected all laboratory tests for residents to be obtained timely as ordered. The Physician stated the facility's failure to obtain the [MEDICATION NAME] level for Resident #1 resulted in the resident receiving a toxic dose of [MEDICATION NAME] medication, which caused the resident's death. 2. Record review revealed the facility readmitted Resident #4 on [DATE], after an acute care hospital stay with orders for [MEDICATION NAME] to treat a surgical wound infection to the right hip. Review of Physician order [REDACTED]. In addition, Resident #4 had physician orders [REDACTED]. However, further review of Resident #4's medical record revealed no documented evidence the facility obtained the physician ordered laboratory tests. Interview with the Second Floor Unit Manager on [DATE] at 1:10 PM, revealed when lab orders were received by the physician, staff was required to enter the order into the resident's electronic medical record, which generated a MAR to alert staff when lab tests were required to be obtained. However, even though Resident #4's physician ordered laboratory tests were listed on the resident's MAR, the lab tests were not obtained. The Unit Manager stated the facility had no formal system in place to ensure laboratory tests were obtained as ordered. 3. Record review revealed the facility readmitted Resident #5 on [DATE], from an acute care hospital stay after being diagnosed with [REDACTED]. Further review of Resident #5's Physician order [REDACTED]. According to Resident #5's MAR, the facility documented that the physician ordered laboratory tests were obtained for the resident on [DATE]. However, review of Resident #5's medical record revealed no documented evidence the facility obtained the [MEDICATION NAME] peak and trough levels for Resident #5 on [DATE]. Even though the facility obtained a [MEDICATION NAME] trough level and Creatinine level for the resident, the laboratory tests were obtained late (on [DATE]). Interview with the Director of Nursing (DON) on [DATE] at 1:05 PM, revealed she had no explanation as to why the resident's MAR indicated the lab tests were obtained because the facility could find no evidence that the lab tests were obtained. The DON further stated that the facility had no system in place to verify that laboratory tests were being obtained as ordered by the physician. 4. Review of the medical record for Resident #7 revealed the facility admitted the resident on [DATE], after an acute care hospital stay with a [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. However, review of Resident #7's laboratory results revealed the facility did not obtain a [MEDICATION NAME] peak medication level until [DATE] (the day after the test was ordered by the physician). Further review revealed there was no documented evidence the facility ever obtained a [MEDICATION NAME] trough level or creatinine level for Resident #7 on [DATE]. An interview with Licensed Practical Nurse (LPN) #7 on [DATE] at 11:15 AM, revealed the LPN incorrectly entered the orders for Resident #7's laboratory tests in the patient's electronic health record and the order for the tests did not print out on the patient's MAR. Thus, staff was not aware that the tests needed to be obtained; the facility failed to get the tests as ordered. **The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 is no longer a resident at Mountain Manor of Paintsville (the Center). On [DATE], Resident #1 was transferred from the facility to the hospital and was subsequently admitted to the hospital with [REDACTED]. Resident #1 expired at the hospital. 2) The licensed nurse responsible for admitting Resident #1 on [DATE] is no longer employed at the Center. 3) On [DATE], an audit to review transcription of physician orders [REDACTED]. 4) On [DATE] to [DATE], an expanded audit was initiated by the Director of Nursing and Unit Managers to include a review of all physician orders [REDACTED]. The audit included review of the transcription and implementation of current physicians' orders, residents' active Medication Administration Records (MARs), and Treatment Administration Record (TAR). Any concerns identified were corrected immediately. 5) On [DATE], under the direction of the Quality Assurance and Performance Improvement (QAPI) committee (Quality Assurance and Performance Improvement committee members include: the Administrator, Director of Nursing, Unit Managers, Medical Director, Minimum Data Set Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director), a Performance Improvement Plan (PIP) committee was created. The PIP Committee members include: the Administrator, Director of Nursing, Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, Social Services Director, and Activity Director. 6) All licensed nurses identified as having administering IV antibiotics to Resident #1 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. In-services were conducted by the Director of Nursing and the Staff Development Coordinator. In-servicing was completed on [DATE] and [DATE]. 7) On [DATE], the following policies and procedures have been reviewed and updated as needed by the QAPI Committee: Physician Orders, Labs, and Pharmacy Services. a) Physician order [REDACTED]. [REDACTED]. Routine order reviews will consist of reviewing physicians' orders for accurate transcription and evidence of implementation, Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, and MDS Nurse). On Saturday and Sunday physician orders [REDACTED]. In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will review and verify physician orders. New admission and readmission orders [REDACTED]. In the event the on-call nurse is unable to complete review, the Director of Nursing will be responsible to complete. Beginning on [DATE], physician orders [REDACTED]. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. b) Lab policy revision included a routine review of lab orders and results of the labs by the Nurse Management Team (Nurse Management Team consists of: Director of Nursing, Unit Managers, Quality Assurance Nurse, MDS Nurse, and Staff Development Coordinator), as well as an additional and separate verification of labs by the QA Nurse. Routine lab review will be completed Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, QA Nurse, and MDS Nurse). On Saturday and Sunday lab review will be reviewed and verified by the designated nurse manager on call (Nurse Managers on call: Unit Manager, Staff Development Coordinator, QA Nurse, and MDS Nurse). In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will be responsible for the review. Lab orders, requisitions, and results will be tracked in lab binders at each nurses' station. On [DATE], a meeting was held by the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Pharmacy Service policies were reviewed on [DATE] by the QAPI Committee with no changes indicated. Beginning on [DATE], antibiotic medication orders that require lab monitoring will include an order for [REDACTED]. Labs will be obtained per the physician order. The IV antibiotic will be placed on hold after the third dose pending the results of lab level. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. The Administrator contracted two additional consultant pharmacists experienced in Long Term Care to review physicians' orders and pharmacy consultation for residents with medications requiring special lab monitoring. The review was completed on [DATE]. On [DATE], the Administrator and Director of Nursing sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) On [DATE] through [DATE], in-services were provided to Licensed Nurses regarding policy and procedure updates. In-servicing was conducted by the Director of Nursing and Staff Development Coordinator. Post-tests and return demonstrations were required to validate training. Licensed Nurses were not permitted to work until education was completed and confirmed by post-testing. Training was complete on [DATE]. All policy revisions were added to new hire orientation material on [DATE]. 9) On [DATE], the Administrator appointed a Quality Assurance Nurse to provide oversight and coordination of the Center's ongoing Quality Assurance and Performance Improvement program. The Quality Assurance Nurse will conduct additional audits of physicians' orders for accurate transcription and evidence of implementation and will verify compliance of physicians' orders transcription and lab monitoring related to medications requiring lab monitoring. Audits and reviews will be completed daily, Monday through Friday, and submitted to the PIP Committee for monitoring and further recommendations as indicated. 10) To ensure sustained compliance, the daily (Monday through Friday) PIP Committee meets to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the Immediate Jeopardy has been verified by CMS through the Kentucky Cabinet for Health and Family Services ([MEDICAL CONDITION]). Weekly QAPI meetings will continue to occur until sustained compliance is achieved. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1) Review of the medical record for Resident #1 revealed the resident was discharged to the hospital on [DATE], and expired while at the hospital. 2) Review of the personnel file for LPN #6 revealed the LPN had not been employed at the facility since [DATE]. 3) Review of audit sheets dated [DATE] revealed the DON and Unit Managers audited the medical records of residents who had physician orders [REDACTED]. The audit had been completed by the DON and Unit Managers. Interviews on [DATE] with the DON at 9:50 AM, Unit Manager (UM) #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they had assisted with the audits for residents who had received antibiotics to ensure all physician orders [REDACTED]. 4) Review of audit sheets dated [DATE] through [DATE] revealed the Director of Nursing and Unit Managers audited physician orders [REDACTED]. The audits included reviews of the transcription and implementation of current physicians' orders, the resident's active Medication Administration Record (MAR), and Treatment Administration Record (TAR). Interviews on [DATE] with the DON at 9:50 AM, UM #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they assisted with the audits for residents who were admitted or readmitted to the facility from [DATE] through [DATE] to ensure all physician orders [REDACTED]. 5) Review of QAPI as well as PIP meeting minutes dated [DATE] revealed a QAPI meeting was held and a PIP Committee was formed. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the Staff Development Coordinator (SDC) on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the Activity Director (AD) on [DATE] at 9:22 AM, the Social Services Director (SSD) on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed a QAPI meeting was held on [DATE], and a PIP Committee was formed. Staff stated the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed, and QAPI meetings would also continue to be held weekly. 6) Review of an in-service roster dated [DATE] and [DATE] revealed RN #2, LPN #7, LPN #13, and UM #2 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. Interviews with LPN #7 on [DATE] at 2:30 PM, RN #2 on [DATE] at 4:00 PM, and UM #2 on [DATE] at 10:06 AM, revealed they had received an in-service on [DATE], related to transcription of orders and medications which required a drug level. 7) Review of QAPI Committee minutes dated [DATE] and review of the facility's policies for Physician Orders, Labs, and Pharmacy Services revealed the policies were reviewed/revised on [DATE]. Review of the New Employee Orientation Packet revealed the current physician's orders [REDACTED]. Interview with the SDC on [DATE] at 9:06 AM revealed the facility had not hired a new nurse since the implementation of the changes in the policies. However, the new policies for physician's orders [REDACTED]. a) and b) Review of the physician's orders [REDACTED]. Interviews conducted with the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed they were meeting daily to review all new physician orders [REDACTED]. The interviews revealed there was a nurse manager on call on Saturday and Sunday to review any new orders within eight (8) hours of transcription by the admitting nurse and verify the orders were transcribed and implemented. Further interviews revealed they were ensuring that laboratory tests for antibiotics that required laboratory monitoring were entered and laboratory tests completed. Staff interviews revealed the intravenous antibiotic would be placed on hold after the third dose pending the results of the laboratory level and would not be continued until laboratory values were evaluated by the resident's physician. Review of a roster dated [DATE] and interviews with the Administrator on [DATE] at 9:30 AM, and the DON on [DATE] at 9:50 AM, revealed a meeting was held with the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Record review revealed on [DATE] consultant pharmacists reviewed resident medical records for all residents with medications requiring special lab monitoring. Further interview with the Administrator on [DATE] at 9:30 AM and the DON on [DATE] at 9:50 AM revealed they sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) Review of in-service rosters dated [DATE] and [DATE] revealed the SDC and the DON provided an in-service for all licensed nurses on the reviewed/revised laboratory, pharmacy, and physician orders [REDACTED]. Interviews conducted with LPN #4 on [DATE] at 1:27 PM, LPN #1 on [DATE] at 1:52 PM, LPN #7 on [DATE] at 2:30 PM, and RN #2 on [DATE] at 4:00 PM, revealed they had received in-service training regarding the facility's laboratory, pharmacy, and physician orders [REDACTED]. The staff stated they were required to have a second nurse to review orders and were required to enter physician laboratory orders in the computer and document the order in a laboratory book at the nurses' station. In addition, the nurses stated that for any antibiotic that required a laboratory level, the medication would be held by the pharmacy until a laboratory level was obtained and reported. 9) Review of a personnel change in position form dated [DATE], revealed a QA Nurse position had been filled. Review of audit tools completed by the QA Nurse dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the QA Nurse documented that compliance of physician's orders [REDACTED]. Further review of audit sheets revealed the QA nurse also reviewed the audits that had been completed by the nurse management team. Interview with the QA Nurse on [DATE] at 9:42 AM, revealed she had completed audits on physician's orders [REDACTED]. The QA Nurse stated she had reported her findings to the QAPI meeting and would continue to do so. 10) Review of QAPI and PIP meeting minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the committees had been meeting daily Monday through Friday and monitored results of all audits and reviews. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the SSD on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed the QAPI Committee as well as the PIP Committee had been meeting daily Monday through Friday and reviewed the results of the audits and reviews. The interviews revealed the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed.

Based on interview, record review, and review of the facility's policies/procedures, it was determined the facility failed to review and revise the comprehensive care plan for two (2) of seven (7) sampled residents (Residents #1 and #5). On [DATE], the facility readmitted Resident #1 with a [DIAGNOSES REDACTED]. Resident #1 also had a physician's orders [REDACTED]. However, there was no evidence the facility reviewed/revised Resident #1's care plan to include the [DIAGNOSES REDACTED]. Subsequently, Resident #1 expired on [DATE], due to [MEDICATION NAME] toxicity. Resident #5 was receiving aminoglycoside antibiotics that required laboratory monitoring; however, the facility failed to develop a care plan with interventions to ensure the resident received adequate monitoring. The facility's failure to ensure resident care plans were reviewed/revised 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] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 - J, F281 - K, and F282 - J); 42 CFR 483.25 Quality of Care (F309 - K); 42 CFR 483.45 Pharmacy Services (F329 - K and F428 - K); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502 - K). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F309) and 42 CFR 483.45 Pharmacy Services (F329). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F280 and F282), and E level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F281); 42 CFR 483.25 Quality of Care (F309); 42 CFR 483.45 Pharmacy Services (F329 and F428); and 42 CFR 483.50 Laboratory, Radiology, and Other Diagnostic Services (F502) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's care plan policy dated (MONTH) 2010 revealed the facility would maintain a comprehensive care plan for each resident that would be based on a thorough assessment and include identified problems, risk factors associated with the identified problem, measureable outcomes, and the professional responsible for each element of the resident's care. The policy also stated the care plan would aid in preventing or reducing declines in residents' functional status and would reflect current recognized standards of practice. Review of the facility's care plan policy revised (MONTH) 2006 revealed changes in each resident's condition would be reported to the Minimum Data Set (MDS) Coordinator so that review/revision of the care plan could be made. 1. Review of Resident #1's closed record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Admission Minimum Data Set (MDS) assessment for Resident #1 dated [DATE] revealed the facility assessed the resident to be cognitively impaired with a Brief Interview for Mental Status (BIMS) score of six (6). Further review of the MDS assessment revealed the resident had no urinary tract infections in the last thirty (30) days, and no [MEDICAL CONDITIONS], or end stage [MEDICAL CONDITION]. Continued review of Resident #1's medical record revealed the resident was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Resident #1 also had a physician's orders [REDACTED]. Review of Resident #1's comprehensive care plan effective [DATE] revealed no documented evidence the facility revised the resident's care plan to include the resident's new [DIAGNOSES REDACTED]. Further review of Resident #1's medical record revealed no evidence the facility obtained a [MEDICATION NAME] trough level for the resident on [DATE], as ordered by the physician. Review of a Nursing Note dated [DATE] at 8:58 AM, revealed the facility transferred the resident to the hospital due to low oxygen saturation (78%) and low blood pressure (,[DATE]). It was determined at the hospital that Resident #1's [MEDICATION NAME] blood level was critically high at 17.9 (normal trough level is 0XXX,[DATE].0). Review of the Hospital Discharge Summary dated [DATE] revealed Resident #1 was diagnosed with [REDACTED]. 2. Record review revealed the facility readmitted Resident #5 on [DATE], after being hospitalized for [REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility was unable to conduct a BIMS due to the resident being severely cognitively impaired. Review of Resident #5's care plan effective [DATE] revealed the facility failed to revise the resident's care plan to include the resident's pneumonia [DIAGNOSES REDACTED]. Interview with the MDS Coordinator on [DATE] at 11:20 AM, revealed when a resident received a new physician order, nursing staff was required to send the order to the MDS staff for updating residents' care plans. Interview with MDS Nurse #2 on [DATE] at 11:30 AM, revealed nursing staff failed to send admission orders [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 is no longer a resident at Mountain Manor of Paintsville (the Center). On [DATE], Resident #1 was transferred from the facility to the hospital and was subsequently admitted to the hospital with [REDACTED]. Resident #1 expired at the hospital. 2) The licensed nurse responsible for admitting Resident #1 on [DATE] is no longer employed at the Center. 3) On [DATE], an audit to review transcription of physician orders [REDACTED]. 4) On [DATE] to [DATE], an expanded audit was initiated by the Director of Nursing and Unit Managers to include a review of all physician orders [REDACTED]. The audit included review of the transcription and implementation of current physicians' orders, residents' active Medication Administration Records (MARs), and Treatment Administration Record (TAR). Any concerns identified were corrected immediately. 5) On [DATE], under the direction of the Quality Assurance and Performance Improvement (QAPI) committee (Quality Assurance and Performance Improvement committee members include: the Administrator, Director of Nursing, Unit Managers, Medical Director, Minimum Data Set Coordinator, Staff Development Coordinator, Pharmacy Representative, Social Services Director, and Activity Director), a Performance Improvement Plan (PIP) committee was created. The PIP Committee members include: the Administrator, Director of Nursing, Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator, Social Services Director, and Activity Director. 6) All licensed nurses identified as having administering IV antibiotics to Resident #1 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. In-services were conducted by the Director of Nursing and the Staff Development Coordinator. In-servicing was completed on [DATE] and [DATE]. 7) On [DATE], the following policies and procedures have been reviewed and updated as needed by the QAPI Committee: Physician Orders, Labs, and Pharmacy Services. a) Physician order [REDACTED]. [REDACTED]. Routine order reviews will consist of reviewing physicians' orders for accurate transcription and evidence of implementation, Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, and MDS Nurse). On Saturday and Sunday physician orders [REDACTED]. In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will review and verify physician orders. New admission and readmission orders [REDACTED]. In the event the on-call nurse is unable to complete review, the Director of Nursing will be responsible to complete. Beginning on [DATE], physician orders [REDACTED]. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. b) Lab policy revision included a routine review of lab orders and results of the labs by the Nurse Management Team (Nurse Management Team consists of: Director of Nursing, Unit Managers, Quality Assurance Nurse, MDS Nurse, and Staff Development Coordinator), as well as an additional and separate verification of labs by the QA Nurse. Routine lab review will be completed Monday through Friday during the morning Clinical Meeting (attendees of the morning clinical meeting include: the Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, QA Nurse, and MDS Nurse). On Saturday and Sunday lab review will be reviewed and verified by the designated nurse manager on call (Nurse Managers on call: Unit Manager, Staff Development Coordinator, QA Nurse, and MDS Nurse). In the event the Nurse Manager on call is unable to complete the review, the Director of Nursing will be responsible for the review. Lab orders, requisitions, and results will be tracked in lab binders at each nurses' station. On [DATE], a meeting was held by the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Pharmacy Service policies were reviewed on [DATE] by the QAPI Committee with no changes indicated. Beginning on [DATE], antibiotic medication orders that require lab monitoring will include an order for [REDACTED]. Labs will be obtained per the physician order. The IV antibiotic will be placed on hold after the third dose pending the results of lab level. IV antibiotic therapy will not be continued until lab values are evaluated by the MD. The Administrator contracted two additional consultant pharmacists experienced in Long Term Care to review physicians' orders and pharmacy consultation for residents with medications requiring special lab monitoring. The review was completed on [DATE]. On [DATE], the Administrator and Director of Nursing sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) On [DATE] through [DATE], in-services were provided to Licensed Nurses regarding policy and procedure updates. In-servicing was conducted by the Director of Nursing and Staff Development Coordinator. Post-tests and return demonstrations were required to validate training. Licensed Nurses were not permitted to work until education was completed and confirmed by post-testing. Training was complete on [DATE]. All policy revisions were added to new hire orientation material on [DATE]. 9) On [DATE], the Administrator appointed a Quality Assurance Nurse to provide oversight and coordination of the Center's ongoing Quality Assurance and Performance Improvement program. The Quality Assurance Nurse will conduct additional audits of physicians' orders for accurate transcription and evidence of implementation and will verify compliance of physicians' orders transcription and lab monitoring related to medications requiring lab monitoring. Audits and reviews will be completed daily, Monday through Friday, and submitted to the PIP Committee for monitoring and further recommendations as indicated. 10) To ensure sustained compliance, the daily (Monday through Friday) PIP Committee meets to focus on implementing the plan outlined herein, monitor results of audits and reviews, and provides additional direction as needed. The daily (Monday through Friday) PIP Committee meetings will continue until removal of the Immediate Jeopardy has been verified by CMS through the Kentucky Cabinet for Health and Family Services ([MEDICAL CONDITION]). Weekly QAPI meetings will continue to occur until sustained compliance is achieved. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1) Review of the medical record for Resident #1 revealed the resident was discharged to the hospital on [DATE], and expired while at the hospital. 2) Review of the personnel file for LPN #6 revealed the LPN had not been employed at the facility since [DATE]. 3) Review of audit sheets dated [DATE] revealed the DON and Unit Managers audited the medical records of residents who had physician orders [REDACTED]. The audit had been completed by the DON and Unit Managers. Interviews on [DATE] with the DON at 9:50 AM, Unit Manager (UM) #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they had assisted with the audits for residents who had received antibiotics to ensure all physician orders [REDACTED]. 4) Review of audit sheets dated [DATE] through [DATE] revealed the Director of Nursing and Unit Managers audited physician orders [REDACTED]. The audits included reviews of the transcription and implementation of current physicians' orders, the resident's active Medication Administration Record (MAR), and Treatment Administration Record (TAR). Interviews on [DATE] with the DON at 9:50 AM, UM #1 at 10:06 AM, and UM #2 at 10:30 AM, revealed they assisted with the audits for residents who were admitted or readmitted to the facility from [DATE] through [DATE] to ensure all physician orders [REDACTED]. 5) Review of QAPI as well as PIP meeting minutes dated [DATE] revealed a QAPI meeting was held and a PIP Committee was formed. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the Staff Development Coordinator (SDC) on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the Activity Director (AD) on [DATE] at 9:22 AM, the Social Services Director (SSD) on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed a QAPI meeting was held on [DATE], and a PIP Committee was formed. Staff stated the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed, and QAPI meetings would also continue to be held weekly. 6) Review of an in-service roster dated [DATE] and [DATE] revealed RN #2, LPN #7, LPN #13, and UM #2 received additional in-service education regarding administration and monitoring requirements of antibiotic therapy. Interviews with LPN #7 on [DATE] at 2:30 PM, RN #2 on [DATE] at 4:00 PM, and UM #2 on [DATE] at 10:06 AM, revealed they had received an in-service on [DATE], related to transcription of orders and medications which required a drug level. 7) Review of QAPI Committee minutes dated [DATE] and review of the facility's policies for Physician Orders, Labs, and Pharmacy Services revealed the policies were reviewed/revised on [DATE]. Review of the New Employee Orientation Packet revealed the current physician's orders [REDACTED]. Interview with the SDC on [DATE] at 9:06 AM revealed the facility had not hired a new nurse since the implementation of the changes in the policies. However, the new policies for physician's orders [REDACTED]. a) and b) Review of the physician's orders [REDACTED]. Interviews conducted with the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed they were meeting daily to review all new physician orders [REDACTED]. The interviews revealed there was a nurse manager on call on Saturday and Sunday to review any new orders within eight (8) hours of transcription by the admitting nurse and verify the orders were transcribed and implemented. Further interviews revealed they were ensuring that laboratory tests for antibiotics that required laboratory monitoring were entered and laboratory tests completed. Staff interviews revealed the intravenous antibiotic would be placed on hold after the third dose pending the results of the laboratory level and would not be continued until laboratory values were evaluated by the resident's physician. Review of a roster dated [DATE] and interviews with the Administrator on [DATE] at 9:30 AM, and the DON on [DATE] at 9:50 AM, revealed a meeting was held with the Administrator, Director of Nursing, and contract lab provider to discuss lab policy and procedures. c) Record review revealed on [DATE] consultant pharmacists reviewed resident medical records for all residents with medications requiring special lab monitoring. Further interview with the Administrator on [DATE] at 9:30 AM and the DON on [DATE] at 9:50 AM revealed they sent a certified letter to the contract long term care pharmacy requiring that a pharmacist review necessary lab value results prior to dispensing high risk medications that require lab monitoring. 8) Review of in-service rosters dated [DATE] and [DATE] revealed the SDC and the DON provided an in-service for all licensed nurses on the reviewed/revised laboratory, pharmacy, and physician orders [REDACTED]. Interviews conducted with LPN #4 on [DATE] at 1:27 PM, LPN #1 on [DATE] at 1:52 PM, LPN #7 on [DATE] at 2:30 PM, and RN #2 on [DATE] at 4:00 PM, revealed they had received in-service training regarding the facility's laboratory, pharmacy, and physician orders [REDACTED]. The staff stated they were required to have a second nurse to review orders and were required to enter physician laboratory orders in the computer and document the order in a laboratory book at the nurses' station. In addition, the nurses stated that for any antibiotic that required a laboratory level, the medication would be held by the pharmacy until a laboratory level was obtained and reported. 9) Review of a personnel change in position form dated [DATE], revealed a QA Nurse position had been filled. Review of audit tools completed by the QA Nurse dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the QA Nurse documented that compliance of physician's orders [REDACTED]. Further review of audit sheets revealed the QA nurse also reviewed the audits that had been completed by the nurse management team. Interview with the QA Nurse on [DATE] at 9:42 AM, revealed she had completed audits on physician's orders [REDACTED]. The QA Nurse stated she had reported her findings to the QAPI meeting and would continue to do so. 10) Review of QAPI and PIP meeting minutes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the committees had been meeting daily Monday through Friday and monitored results of all audits and reviews. Interviews conducted with the Medical Director on [DATE] at 9:20 AM, the Administrator on [DATE] at 9:30 AM, the SDC on [DATE] at 9:06 AM, the MDS Coordinator on [DATE] at 9:15 AM, the AD on [DATE] at 9:22 AM, the SSD on [DATE] at 9:31 AM, the QA Nurse on [DATE] at 9:42 AM, the DON on [DATE] at 9:50 AM, UM #1 on [DATE] at 10:06 AM, and UM #2 on [DATE] at 10:30 AM, revealed the QAPI Committee as well as the PIP Committee had been meeting daily Monday through Friday and reviewed the results of the audits and reviews. The interviews revealed the PIP Committee would continue to meet daily Monday through Friday until Immediate Jeopardy was removed.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the resident's physician and legal representative were notified of a significant change in condition and the need to alter treatment for one (1) of twenty-four (24) sampled residents (Resident #1). On 09/12/12, documentation in the nurse's notes revealed Resident #1 had a scabbed area less than 0.1 centimeter (cm) in diameter with redness noted around a scabbed area to the left great toe. Interview with the Minimum Data Set (MDS) Assistant revealed on 10/15/12 she assessed a wound to Resident #1's left great toe and noted the wound was moist with necrotic (dead tissue) black tissue, brown purulent drainage, and a foul odor. The MDS Assistant stated she immediately informed Licensed Practical Nurse (LPN) #1 of the assessment of Resident #1's wound on 10/15/12. However, there was no documented evidence the physician and legal representative were notified on 10/15/12, concerning the change in condition to Resident #1's left great toe. On 10/17/12 (2 days after the MDS Assistants assessment on 10/15/12) LPN #3 notified Resident #1's physician of drainage and odor to the resident's left great toe wound and obtained new orders. On 10/18/12, at 10:30 AM a nurse's note revealed Resident #1's legal representative insisted on observing the wound to Resident #1's left great toe after the legal representative was informed that new orders had been received on 10/17/12, related to the resident's wound. LPN #1 and the Assistant Director of Nursing (ADON) were present during the observation of the wound on 10/18/12, at 10:30 AM and LPN #1 documented the toe was "red/inflamed" with a "necrotic area," "yellow sloughing" (a mass or layer of dead tissue separated from the surrounding or underlying tissue), and had an odor. Resident #1 was transported to an acute care facility on 10/18/12, and the resident's left great toe was amputated on 10/20/12, due to "wet gangrene" (death of tissue due to a loss of blood supply with a bacterial infection), and the resident remains at the acute care facility. (Refer to F309.) The failure of the facility to ensure staff immediately notified the resident's physician and responsible party when residents experienced a change of condition placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 12/11/12, and determined to exist on 10/15/12. The facility was notified of the Immediate Jeopardy on 12/11/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/13/12, with the facility alleging removal of the Immediate Jeopardy on 10/25/12. Immediate Jeopardy was verified to be removed on 10/25/12, as alleged prior to exiting with the facility on 12/13/12, with remaining noncompliance at 42 CFR 483.10 Resident Rights, at a scope and severity of "D", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance process. The findings include: Review of the facility policy entitled "Change in a Resident's Condition or Status" (undated) revealed the facility was to notify the resident's attending physician and representative of changes in the resident's condition/status. The policy revealed Nursing Services would be responsible for notifying the resident's attending physician and representative when there had been a significant change in the resident's physical status, when there had been a need to alter the resident's treatment significantly or when deemed appropriate in the best interests of the resident. The review further revealed all notifications should be made as soon as practical, "but in no case shall such notification exceed twenty-four (24) hours." The policy also revealed, "All changes in the resident's medical condition must be properly recorded in the resident's medical record in accordance with our charting and documentation policies and procedures." 1. An interview on 10/25/12, at 1:00 PM with the MDS Assistant revealed Resident #1 was initially admitted to the facility on [DATE], for rehabilitation following a Right BKA to learn how to ambulate with prosthesis prior to the resident's discharge home. The MDS Assistant stated she conducted a head to toe assessment of Resident #1 on 10/15/12, during the completion of an MDS assessment. The interview revealed at the time the assessment was conducted, the MDS Assistant was very concerned about the resident's wound to the left great toe; however did not document the status of the wound. According to the MDS Assistant, at the time of her assessment, Resident #1's wound was moist, had a foul odor, brown purulent drainage, black necrotic tissue, and was red from the wound on the tip of the toe to the first joint of the left great toe. The MDS Assistant revealed she reported her concerns about Resident #1's wound to LPN #1. The interview revealed the MDS Assistant thought LPN #1 would notify Resident #1's physician of the wound condition. An interview on 10/24/12, at 4:30 PM with LPN #1 revealed Resident #1's left great toe had a "small black spot" when she last assessed the wound but could not recall the date. However, according to the LPN, on 10/18/12, Resident #1's family member insisted on observing the wound and, at that time, the resident's entire toe was red with black necrotic tissue, sloughing to the side. LPN #1 stated staff was to assess a resident wound with each treatment and the physician was to be notified of any changes in the wound. LPN #1 stated she did not recall being informed that the wound on Resident #1's great toe had changed or had an odor. An interview on 10/24/12, at 12:50 PM with LPN #3 revealed when she performed wound care to the wound on Resident #1's left great toe on 10/12/12, the wound had not changed and appeared to be a dry callus. However, according to LPN #3 when she assessed the wound on 10/17/12, the wound had an odor and drainage, and the LPN notified the physician and received new orders. LPN #3 could not explain why she notified the physician on 10/17/12, when she signed the wound care as being completed on 10/16/12, according to the Treatment Administration Record (TAR). Review of Resident #1's closed record revealed the facility admitted the resident on 06/26/12, with [DIAGNOSES REDACTED]. On 09/12/12, approximately two and one half months after admission, documentation in the nurse's notes at 9:30 AM by LPN #1 revealed the resident had a scabbed area less than 0.1 centimeter (cm) in diameter with redness noted around a scabbed area to the left great toe. The note revealed Resident #1's physician and representative were notified at that time and new orders were received for treatment to the area on the left great toe and for a referral to the Wound Care Clinic (WCC). Review of Resident #1's WCC notes dated 09/13/12, revealed the wound to the resident's left great toe was assessed to be a Diabetic Ulcer that measured 2.2 cm x 1.8 cm x 0.1 cm. Continued review of the WCC notes revealed Resident #1 received treatment on 09/20/12 and at that time the resident's wound measured 0.7 cm x 0.6 cm x 0.1 cm and the base of the wound was pale pink, with scabbed epithelium partial coverage to the wound. The note revealed there was no eschar, no yellow sloughing, and no drainage or on odor noted. The resident was not seen again at the WCC due to the facility's failure to arrange transportation for the 09/27/12, follow up appointment. (Refer to F309.) There was no further documentation from the WCC addressing the status of Resident #1's wound. Continued review of Resident #1's medical record revealed a Treatment Administration Record (TAR) for September and October 2012, which revealed staff was to cleanse the wound on the resident's left great toe with normal saline, cover the wound with [MEDICATION NAME] AG (a silver impregnated antimicrobial dressing which reduces the number of bacteria in the wound) and a "4 x 4" gauze, then wrap the wound with a "Kling" dressing every forty-eight (48) hours. A review of the TAR revealed LPN #1 performed wound care to Resident #1's left great toe on 10/04/12, 10/10/12, 10/14/12 and on 10/18/12. The TAR further revealed LPN #3 performed wound care to Resident #1's left great toe on 10/02/12, 10/06/12, 10/08/12, 10/12/12, and on 10/16/12. Although staff documented the wound care every forty-eight (48) hours on the TAR from 10/02/12, through 10/16/12, there was no documentation from 09/28/12 through 10/16/12 that described the status of Resident #1's wound on the left great toe until 10/17/12. On 10/17/12, at 2:50 PM, LPN #3 documented the wound to the resident's left great toe had an odor and drainage; notified the resident's physician of the assessment made on 10/17/12; and received new orders for a culture of the wound and another referral to the WCC. Continued review of the nurse's note revealed on 10/18/12, at 10:30 AM Resident #1's family member insisted on observing the wound, and LPN #1 and the ADON removed the dressing covering the resident's wound. Documentation revealed the resident's toe was red and inflamed, had a necrotic area, yellow sloughing, and had an odor. According to documentation by LPN #1, Resident #1's family member insisted the resident be transported to an acute care facility for evaluation and treatment. A review of the Surgical Report dated 10/20/12, revealed Resident #1's left great toe was amputated due to ulceration with wet gangrene. An interview on 10/25/12, at 11:30 AM with Resident #1's Primary Physician confirmed she had not been informed of the decline in the status of Resident #1's wound until 10/17/12. According to the Physician, she expected the nurses to assess the resident's wounds while performing wound care and to be notified of any changes in the wound. The interview revealed the Physician was unaware Resident #1 had not kept the follow up appointment at the WCC as ordered by the WCC until after the resident was sent to the hospital on [DATE]. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 10/31/11, with [DIAGNOSES REDACTED]. Resident #2's medical record revealed the resident was readmitted from an acute care facility on 08/06/12, with a pressure ulcer to the left buttock and blisters to both heels. The Wound Evaluation Flow Sheet revealed the wounds were assessed on 08/07/12 and the wound to the left buttock measured 3 cm x 3.5 cm x 4 cm, the left heel wound measured 5 cm x 5 cm, and the right heel wound measured 5 cm x 5 cm. On 08/19/12, the left heel measured 6.1 cm x 8.6 cm x unable to determine (UTD), the right heel had no measurements and the area on the left buttock measured 3 cm x 3.4 cm x 5 cm. There was no documentation that the resident's physician was notified of the increase in size of the resident's wounds. Interview conducted on 12/13/12, at 1:30 PM, with Resident #2's physician revealed he could not recall being made aware of an increase in the size of Resident #2's wounds in August 2012. 3. Review of Resident #3's medical record revealed the facility admitted the resident on 10/04/12, with multiple Pressure Ulcers. Review of Resident #3's Wound Evaluation Flow Sheet revealed on 10/04/12, the resident had an area to a bunion on the left foot that measured 0.6 cm x 0.4 cm x unable to determine (UTD) the depth, an area to the left outer ankle with measurements of 0.4 cm x 0.4 cm x UTD, an area to the left heel that measured 1.7 cm x 2.3 cm x UTD, a Stage II to the coccyx with measurements of 3 cm x 3 cm x 0.2 cm, and an area to the right heel with no measurements. Further review of Resident #3's Wound Evaluation Flow Sheet revealed no other assessments of the wounds until the facility conducted a facility wide "skin sweep" (is when the facility conducts skin assessments on all residents to ensure accurate assessments) during the weekend of 10/19-20/12. The flow sheet revealed on 10/20/12, the bunion to the resident's left foot measured slightly larger at 0.6 cm x 0.5 cm x UTD, the area to the left outer ankle measured slightly larger at 0.4 cm x 0.5 cm x UTD, the area to the left heel measured the same, the Stage II to the coccyx measured larger at 7 cm x 3.5 cm x UTD, the area to the right heel measured 3.4 cm x 4.1 cm x UTD and the area to the left third toe measuring 0.6 cm x 0.8 cm x UTD. There was no documentation the resident's physician was notified of the increase in size of the resident's wounds. An interview with the DON on 11/01/12, at 2:35 PM revealed licensed nurses were to notify a resident's physician of any changes in the resident's condition. The interview revealed the facility did not conduct audits to ensure physicians were notified of a resident's change in condition. An interview on 11/01/12, at 3:45 PM with the Administrator revealed all nurses were responsible to notify a residents' physician of any change in a resident's condition as soon as the nurse becomes aware of the change. The interview revealed the facility monitored a sample of charts monthly to ensure notification was conducted for all change of condition; however, the monitoring had been discontinued. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on 12/13/12, which alleged removal of IJ effective 10/25/12. An extended survey was conducted on 12/11-13/12, which determined the IJ was removed on 10/25/12 as alleged. --A review of the AOC revealed the following: On 10/18/12, Licensed Practical Nurse (LPN) #1 was terminated by the Director of Nursing (DON) due to the failure to assess/document Resident #1's wound, notify the physician and responsible party of the change in the resident's wound and the failure to make arrangements for the resident's transportation to the wound clinic. On 10/18/12, the DON notified Resident #1's physician the family requested the resident be transported back to the acute care facility the resident had previously been treated, prior to admission to this facility. On 10/19/12, the DON reviewed Resident #1's medical record and continued to investigate. On 10/19/12, Registered Nurses (RN) #4, #6 and LPNs #2, #4, and #13 conducted skin/wound assessments on all residents. Initiated on 10/19/12, and completed on 10/21/12, the DON in-serviced all licensed staff regarding physician and responsible party notification of change in condition. On 10/21/12, the DON notified Resident #1's physician by fax regarding the missed appointment to the wound care clinic. On 10/22/12, RN #2 notified each physician of their respective resident's wounds addressing the stage and location of each wound after the facility's Medical Director had reviewed/signed each physician's notification. On 10/24/12, a new Wound nurse started employment and will be assessing and providing treatments to all wounds five (5) days a week. RN #2 will be assessing and providing treatments to all wounds the other two (2) days a week. The Wound Nurse or RN #2 will fax each resident's physician a bi weekly notification of the resident's wound type, location, description, and current treatment. As part of the facility's CQI for monitoring skin assessments upon admission, the DON has 1) Reviewed all skin assessments on new admissions and readmissions and compared the skin assessment with her own skin assessment of the resident to ensure all areas have been identified, staged and measured accurately. 2) Reviewed the new admissions and readmissions chart to ensure the physician and family were notified of any skin areas, that appropriate treatment is being utilized to all skin areas and all skin areas were appropriately documented on the wound monitoring flow sheet for the resident. The DON and RN #2 will review all residents' weekly nurses summary (which include a skin assessment) and assess each resident to ensure the skin assessment matches and ensure the physician was notified of any new alterations in skin integrity or changes in condition. The nurse completing the weekly skin assessments will notify the physician of any changes, obtain new orders, and update the resident's plan of care with the new orders. --The surveyors validated the corrective actions taken by the facility as follows: Interview on 12/12/12, at 4:40 PM with the DON and review of LPN #1's Employee Disciplinary Report dated 10/18/12, revealed the LPN was terminated due to the failure to assess/document Resident #1's wound, notify the physician and responsible party of Resident #1 concerning the change in the resident's wound and the failure to make arrangements for the resident's transportation to the wound clinic. Interview on 12/12/12, at 4:40 PM with the DON and review of a faxed letter revealed on 10/18/12, the DON notified Resident #1's physician the family requested the resident be transported back to the acute care facility the resident had previously been treated, prior to admission to this facility. Interview on 12/12/12, at 4:40 PM with the DON and review notes dated 10/19/12, revealed the DON reviewed Resident #1's medical record investigating the resident's wound and appointment issues. Interviews on 12/12/12, at 2:15 PM with LPN #4, on 12/13/12, at 11:00 AM with RN #4, at 11:10 AM with LPN #2, at 1:15 PM with RN #6, at 1:20 PM with LPN #13, and review of notes revealed on 10/19/12, the above licensed staff conducted skin/wound assessments on all residents. Interview on 12/12/12, at 4:40 PM with the DON and review in-service records dated 10/19/12, through 10/21/12, revealed the DON in-serviced all licensed staff regarding physician and responsible party notification of change in condition. Interviews on 12/12/12, at 11:00 AM with RN #2, at 2:15 PM with LPN #4, at 5:00 PM with LPN #12, on 12/13/12, at 2:00 PM with LPN #9, at 11:00 AM with RN #4, at 11:10 AM with LPN #2, at 1:15 PM with RN #6 and at 1:20 PM with LPN #13 confirmed the licensed staff were in-serviced on physician and responsible party notification of change in condition. Interviews on 12/12/12, at 4:40 PM with the DON and review of a letter with a faxed confirmation dated 10/21/12, revealed the DON notified Resident #1's physician regarding the missed appointment to the wound care clinic. Interviews on 12/12/12, at 11:00 AM with RN #2, on 12/13/12, at 1:30 PM with the Medical Director and review notification letters dated 10/22/12, revealed RN #2 notified each physician of their respective resident's wounds addressing the stage and location of each wound after the facility's Medical Director had reviewed/signed each physician's notification. Interview on 12/12/12, at 2:45 PM with the newly hired wound care nurse revealed she started employment on 10/24/12, and will be assessing and providing treatments to all wounds five (5) days a week. Interview on 12/12/12, at 11:00 AM with RN #2, revealed RN #2 will be assessing and providing treatments to all wounds the other two (2) days a week. The interviews revealed the wound care nurse or RN #2 will fax each resident's physician a bi-weekly notification of the resident's wound type, location, description, and current treatment. Review of the newly hired wound care nurses' employee file revealed she started employment at the facility on 10/24/12. Further review of physician notifications letters revealed faxes were being sent bi weekly to the resident's physician notifying the physician of the resident's wound type, location, description, and current treatment. Interview on 12/12/12, at 4:40 PM with the DON and review of documentation of the only resident that had been admitted since 10/25/12, revealed as part of the facility's CQI for monitoring skin assessments upon admission, the DON reviewed the resident's skin assessments and compared the skin assessment with her own skin assessment of the resident to ensure all areas have been identified, staged and measured accurately. The DON further reviewed the resident's chart to ensure the physician and family were notified of any skin areas, that appropriate treatment was being utilized to all skin areas and all skin areas were appropriately documented on the wound monitoring flow sheet for the resident. Interview on 12/12/12, at 4:40 PM with the DON, at 11:00 AM with RN #2 and review their personal hand written notes revealed the DON and RN #2 will review all weekly nurses summary of each resident, including skin assessment and assess each resident to ensure the skin assessment matches and ensure the physician was notified of any new alterations in skin integrity or changes in condition. The nurse completing the weekly skin assessments will notify the physician of any changes, obtain new orders, and update the resident's plan of care with the new orders.

Based on interviews, record review, and a review of the facility's policy, the facility failed to ensure services provided by the facility were provided in accordance with each resident's written plan of care for five (5) of twenty-four (24) sampled residents (Residents #1, #2, #3, #7 and #14). Facility staff assessed Resident #14 to require the assistance of a minimum of two staff persons for transfers. On 04/09/11, one staff person transferred Resident #14 from the bed to a wheelchair and the resident sustained [REDACTED]. (Refer to F323.) Facility staff addressed in a care plan for Resident #1 that staff would observe the resident's wound to the left great toe for signs/symptoms of infection such as an increase in drainage and to notify the physician of any of the signs. However, on 10/15/12, Resident #1 was assessed to have foul purulent drainage and staff failed to notify the resident's physician. Resident #1 was transported to an acute care facility on 10/18/12, upon the insistence of the resident's family member and the resident's left great toe was amputated on 10/20/12. (Refer to F309, F514). The facility also failed to notify the physician of alteration in wound size for two (2) residents (Resident #2 and #3) and failed to provide wound treatments as ordered by the physician for Resident #3. In addition, Resident #7 was assessed to require turning and repositioning every two hours while in bed; however, observation on 10/29/12, and 10/30/12, revealed staff failed to provide turning and repositioning as directed on the plan of care. The failure of the facility to ensure services provided were in accordance with each residents' written plan of care placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 12/11/12, and determined to exist on 10/15/12. The facility was notified of the Immediate Jeopardy on 12/11/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/13/12, and alleged removal of the Immediate Jeopardy on 10/25/12. Immediate Jeopardy was verified to be removed on 10/25/12, as alleged prior to exiting with the facility on 12/13/12, with remaining noncompliance at 42 CFR 483.20 Resident Assessment, at a scope and severity of "G" while the facility develops and implements a plan of correction and the facility's Quality Assurance. The findings include: A review of the facility's policy titled, Care Plans-Comprehensive (revised 10/20/08) revealed it was the policy of the facility to develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs. Further review of the policy revealed the comprehensive care plan had been designed to incorporate identified problem areas, and to prevent declines in the resident's functional status and/or functional level. The policy revealed the Certified Nursing Assistant (CNA) care plans were developed from the comprehensive care plan and would identify specific care area needs and approaches necessary for the CNA to provide daily care to individual residents. 1. Review of the record revealed the facility admitted Resident #14 on 01/07/11, with [DIAGNOSES REDACTED]. A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], and the last Comprehensive Annual assessment dated [DATE], revealed the facility assessed Resident #14 to be at risk for falls related to impaired balance and coordination during transitions. The assessments revealed Resident #14 had an unsteady gait, a decreased awareness for safety, cognitive impairment, hearing problems, limited range of motion to the left upper extremity secondary to a previous [MEDICAL CONDITION], incontinence, generalized weakness and required the use of a wheelchair for mobility. The MDS Assessment revealed the facility had assessed the resident to require extensive physical assistance of, at a minimum, two (2) staff persons with transfers. Continued review of the (MDS) Assessment revealed CNAs were to assist the resident with all transfers and were to apply non-skid footwear to the resident's feet for safety. The review of the MDS Assessment contained a document entitled Care Area Assessment (CAAs), dated 01/13/11, revealed nursing staff developed a Care Area Trigger (CAT) Worksheet that identified Resident #14 to have a "Problem for Falls", and addressed care plan considerations for staff to assist the resident with mobility and two (2) staff to be utilized to transfer the resident. A review of the Comprehensive Care Plan developed on 01/27/2011, reviewed with the quarterly assessment on 04/14/12, and the most recent review dated 10/09/12, also revealed Resident #14 was at risk for falls with injury, had impaired mobility, generalized weakness, and required assistance with transfers. Furthermore, a review of the CNA Care Record dated April 2012, and the most recent CNA Care Record dated October 2011, revealed Resident #14 had been assessed to be at risk for falls, had weakness of the left hand and arm, and required the use of a gait belt and the assistance of two for transfers. The CNA Care Record also revealed staff members were to report any sign of injury to the nurse. Review of the nurse's notes, the Incident Report Tracking log, and Patient Transfer Sheet, revealed on 04/09/12, at approximately 9:30 AM, CNA #15 transferred Resident #14 from the bed to a wheelchair without assistance and, as a result, Resident #14 sustained injury to the left ankle and was transported to an Emergency Department for evaluation. An interview conducted on 10/31/12, at 2:15 PM, with CNA #15 revealed she had been trained to review CNA Care Records to determine resident needs prior to providing assistance with care. CNA #15 stated she was aware that Resident #14 required the assistance of two staff members for transfers, and confirmed she failed to follow the plan of care and did not obtain assistance with transferring Resident #14 from the bed to a wheelchair on 04/09/12. CNA #15 stated staff members were busy assisting other residents on 04/09/12, and she had transferred Resident #14 to a wheelchair, without problems, in order to take the resident to the shower room for a shower. CNA #15 stated she was not aware Resident #14 had an injury until the afternoon of 04/09/12, at which time the nurse questioned the CNAs that were on duty on 04/09/12, about Resident #14's swollen ankle. CNA #15 also stated after she had taken Resident #14 to the shower room approximately 9:30 AM, CNA #13 assisted her with Resident #14's shower and they had not observed any abnormal areas to the resident's skin at that time. Interview on 10/31/12, at 2:45 PM with CNA #13 confirmed staff was required to provide resident care as outlined on the CNA Care Records. The interview revealed the CNA was aware Resident #14 was care planned to require two (2) staff for transfers. CNA #13 stated Resident #14 had already been transported to the shower room on 04/09/12, by CNA #15. Interview on 11/01/12, at 4:00 PM, with Licensed Practical Nurse (LPN) #4 revealed she had been responsible to provide and direct care for Resident #14 on 04/09/12. LPN #4 stated, at the start of the shift, CNAs were provided a copy of each resident's planned care needs and were expected to follow the plan of care. LPN #4 stated she was not aware CNA #15 had failed to follow the plan of care for Resident #14 and had transferred the resident without assistance until the details of the incident was discussed with the surveyor. LPN #4 stated the incident report was forwarded to the Director of Nursing. Interview with the Director of Nursing (DON) on 11/01/12, at 2:30 PM, revealed staff was expected to follow each resident's plan of care. The DON confirmed CNA #15 failed to follow the plan of care and transferred Resident #14 from the bed to a wheelchair without assistance. According to the DON, it was discovered during the facility's investigation that Resident #14 sustained an injury to the left ankle as the result of hitting the left ankle against the wheelchair foot pedal during the improper transfer. 2. A review of Resident #1's closed medical record revealed the resident was admitted on [DATE], for rehabilitation due to a Right [MEDICAL CONDITION] (BKA) with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change MDS Comprehensive assessment dated [DATE], revealed the resident was assessed to be at risk for development of pressure ulcers. Review of Resident #1's Comprehensive Care Plan dated 07/16/12, revealed the facility had addressed the resident's risk of alteration in skin integrity secondary to history of skin tears, assistance required for bed mobility, general weakness, right BKA, [MEDICAL CONDITION], history of [MEDICAL CONDITION] diabetes, and VRE carrier. Some interventions on the care plan were for staff to check the resident's skin condition daily during care and report any changes to the nurse, and for staff to provided skin care as ordered by the physician. Review of Resident #1's nurse's noted dated 09/12/12, at 9:30 AM, Licensed Practice Nurse (LPN) #1 documented Resident #1 had a new scabbed area to the left great toe measuring less than 0.1 centimeter (cm) in diameter. LPN #1 notified the physician and obtained orders for treatment to the wound and a referral to the WCC. Continued review of Resident #1's care plan revealed the care plan was revised on 09/20/12, with additional interventions to include the following: 1) for staff to cleanse area to the left great toe with normal saline, dry and apply [MEDICATION NAME] AG (a silver impregnated antimicrobial dressing which reduces the number of bacteria in the wound), then a 4 X 4 gauze and wrap with "Kling" (a roll of gauze bandage) every forty-eight (48) hours, and 2) for staff to observe for signs and symptoms of infection such as an increase in drainage, an elevated temperature, an rapid pulse, or a decreased blood pressure and to notify the physician of any of the signs. Review of Resident #1's facility Wound Evaluation Flow Sheet and a Wound Care Clinic note (note documented by staff at a Wound Care Clinic outside the facility) dated 09/13/12, revealed the wound to Resident #1's toe measured 2.2 cm X 1.8 cm X 0.1 cm. According to the Wound Care Clinic note, the wound was a diabetic ulcer. Further review of the Wound Care Clinic notes dated 09/20/12, revealed the wound to the resident's toe was a scabbed area with a pale, pink base, measuring 0.7 cm X 0.6 cm X 0.1 cm with no eschar, no yellow sloughing, no drainage, and no odor. Review of the facility's Wound Evaluation Flow Sheet dated 09/28/12, revealed the wound to Resident #1's toe measured 1.4 cm X 0.2 X 0.1 cm. However, there was no documented evidence the physician was notified of the increase in size of the wound. Review of Resident #1's Treatment Administration Record (TAR) for September and October 2012, revealed staff documented the resident's toe was cleansed with Normal Saline and treated with [MEDICATION NAME] AG (a silver impregnated antimicrobial dressing which reduces the number of bacteria in the wound) every forty-eight hours from 09/28/12 through 10/16/12. The TAR revealed LPN #1 performed wound care to Resident #1's left great toe on 10/04/12, 10/10/12 and on 10/14/12. The TAR further revealed LPN #3 performed wound care to Resident #1's left great toe on 10/02/12, 10/06/12, 10/08/12, 10/12/12, and on 10/16/12. However, review of Resident #1's medical record revealed no evidence the resident's wound to the toe was assessed at least weekly as required by the facility's policy and the according to professional standards from 09/28/12 until 10/17/12, for a nineteen day period. Review of Resident #1's nurse's notes dated 10/17/12, at 2:50 PM by LPN #3 revealed the area to the resident's left great toe had an odor and drainage, the physician was notified, and new orders were obtained. A nurse's note dated 10/18/12 at 10:30 AM by LPN #1 revealed Resident #1's family member insisted on observing the resident's toe. LPN #1 and the Assistant Director of Nursing (ADON) removed the dressing to reveal the toe was red and inflamed with a necrotic area, yellow sloughing, and a foul odor. Further review revealed the resident was transported to an acute care facility on 10/18/12 at 3:15 PM. Review of Resident #1's History and Physical dated 10/18/12, from the acute care facility revealed the resident had [MEDICAL CONDITION] of the toe associated with a Diabetic Ulcer that appeared to have central gangrene. A Vascular Surgical Consultation was ordered. Review of Resident #1's Vascular Surgical Consultation Report dated 10/19/12 revealed the resident had a quarter sized ulceration to the left great toe, with purulent drainage, and a foul odor when the dressing was removed. The entire great toe was [DIAGNOSES REDACTED]tous (red) up to the base of the foot. The surgeon's recommendation was for amputation of Resident #1's toe. Review of Resident #1's Surgical Report dated 10/20/12, revealed the resident's left great toe was amputated secondary to ulceration with wet gangrene. An interview on 10/25/12, at 1:00 PM with the Minimum Data Set (MDS) Assistant revealed on 10/15/12, she conducted a head to toe assessment on Resident #1 during the completion of the resident's Discharge MDS assessment. The interview revealed the resident's wound to the left great toe was moist, with black necrotic tissue, brown purulent drainage, a foul odor, and redness to the first joint of the toe. The MDS Assistant stated she reported the findings to LPN #1, who was responsible for the resident's care, and assumed the LPN, would assess the resident's wound and call the resident's physician. However, a review of Resident #1's medical record revealed no evidence the resident's wound was assessed until 10/17/12. An interview on 10/24/12, at 4:30 PM with LPN #1 and on 10/24/12, at 12:50 PM with LPN #3 revealed wounds were required to be assessed during every wound care for changes and every Friday the assessment was documented on a Wound Flow Sheet. LPN #1 and #3 were not able to explain why there was no documentation that Resident #1's wound was assessed for the first two (2) weeks of October, even though they had provided the wound care to Resident #1's toe every forty-eight (48) hours, according to the TAR. LPN #1 stated that the reason nothing was documented might have been that staff was too busy. An interview on 10/25/12, at 11:30 AM with Resident #1's Primary Physician revealed the physician expected the nurses to assess the resident's wounds while performing wound care. Interviews on 10/23/12, at 6:15 PM with the Administrator and the Director of Nursing (DON) revealed the nurse assigned to the resident on Friday of each week was required to assess residents' wounds unless the resident's dressing was not scheduled to be changed on Friday. In that case, the resident's wound was required to be assessed on the day the dressing was changed, either Wednesday or Thursday. The interview revealed staff was required to assess the wound, including measurements, and document the assessment on the Wound Evaluation Flow Sheet. The interview revealed they were not aware Resident #1's wound to the toe had not been assessed at least weekly until the resident's son requested to see the resident's wound and the resident was transferred to the hospital. Interview on 10/24/12, at 7:30 PM with Registered Nurse (RN) #2 revealed all nurses were trained upon hire to assess and document all wounds on every Friday or the closes treatment day to Friday. 3. Review of Resident #3's medical record revealed the facility admitted the resident on 10/04/12 with multiple Pressure Ulcers and [DIAGNOSES REDACTED]. Review of Resident #3's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was at risk for pressure ulcers and was admitted with several pressure ulcers at various stages. Review of Resident #3's plan of care dated 10/24/12, revealed the facility addressed the resident's risk for impaired skin integrity related to stage II pressure ulcer to the coccyx, unstageable ulcers to bilateral heels, stage II to left ankle and identified interventions for nursing 1) to complete a skin assessment every week and report any alterations to the physician and 2) to provide treatments as ordered by the physician. Review of Resident #3's Treatment Administration Record (TAR) for October 2012, revealed Licensed Practical Nurse (LPN) #7 documented the treatment had been provided to the resident's feet on 10/27/12 and 10/28/12. In addition, documentation revealed LPN #6 provided the treatment on 10/29/12. Observation on 10/30/12, at 3:00 PM of Resident #3's wound care performed by LPN #3 revealed the area to the resident's coccyx had red tissue surrounding the open wound which, based on measurements obtained by the LPN, measured 8.3 cm x 6.2 cm, and the open wound measured 5.4 cm x 4.7 cm x 0.5 cm. The coccyx wound was pink with yellow/white sloughing noted. The observation revealed the "Kling" dressings to both heels had a date of 10/26/12, written in black marker on both dressings. LPN #3 acknowledged the initials on the dressings were hers and stated although she had not worked for the last three (3) days, the wound care to the resident's feet was ordered to be completed every day. The resident's right inner ankle was slightly red with no open wounds, the right heel was boggy and dark measuring 2.2 cm x 3.4 cm, and the left outer ankle was yellow, with a slight amount of yellow drainage noted on the old dressing, and measured 1.2 cm x 1 cm x 0.1 cm. The left heel had a dark area that measured 1.5 cm x 1.2 cm. The bunion to the outer side of the resident's left foot was dark and measured 0.4 cm x 0.4 cm and the third toe on the left foot had black edge on a dark area that measured 0.4 cm x 0.8 cm. Interview on 10/30/12, at 6:17 PM with LPN #7 revealed she had signed that the treatments to Resident #3's heels on 10/27/12 and 10/28/12 had been provided; however, the LPN acknowledged she had not completed the treatments. LPN #7 stated she ran out of time, but had reported the treatments had not been provided to the night nurse (LPN #8) who was supposed to provide the treatments. During an interview on 10/30/12, at 6:40 PM with LPN #8, the LPN stated she had not provided treatments to Resident #3's heels on 10/27/12 and 10/28/12. LPN #8 also stated she had not been notified that Resident #3's treatments needed to be provided. Interview on 10/30/12, at 5:20 PM with LPN #6 confirmed the LPN signed off the treatment to Resident #3's heels on 10/29/12, but did not complete the treatment. LPN #6 stated she provided wound care to the resident's coccyx, but was called out of the room before providing wound care to the resident's heels. The interview revealed the LPN "forgot" to go back and provide the wound care to the resident's heels. 4. Review of Resident #2's medical record revealed the facility admitted the resident on 10/31/11, with [DIAGNOSES REDACTED]. Resident #2's medical record revealed the resident was readmitted from an acute care facility on 08/06/12 with a pressure ulcer to the left buttock and blisters to both heels. The Wound Evaluation Flow Sheet revealed the wounds were assessed on 08/07/12 (one day after re-admission) and the wound to the left buttock measured 3 cm x 3.5 cm x 4 cm; the left heel wound measured 5 cm x 5 cm; and the right heel wound measured 5 cm x 5 cm. Review of Resident #2's Significant Change MDS assessment dated [DATE], revealed a decline in the resident's cognition, Activities of Daily Living (ADL) status, continence, and new development of pressure ulcers following a hospitalization . Review of Resident #2's plan of care dated 11/20/11; revealed the facility addressed the resident's risk for alteration in skin integrity and identified the resident to be at risk for the development of pressure ulcers. Continued review of the plan of care revealed facility staff identified interventions for nursing to complete skin assessment every week and notify the physician of any alterations in the resident's skin integrity. Continued review of Resident #2's Wound Evaluation Flow Sheet dated 08/19/12, revealed documentation that the resident's left heel wound measured 6.1 cm x 8.6 cm x UTD, and the wound on the resident's left buttocks measured 3 cm x 3.4 cm x 5 cm. There were no documented measurements of the wound to the resident's right heel. The Wound Evaluation Flow Sheet revealed the next documented assessment of Resident #2's wound to the left buttock was on 09/07/12, (nineteen days after the previous assessment on 08/07/12, and the wound measured 3 cm x 3 cm x UTD. However, there was no documentation of an assessment and/or measurement of the wounds on Resident #2's heels. Further review of the Wound Evaluation Flow Sheets revealed on 09/14/12 (approximately five weeks after the previous assessment on 08/19/12) the wound to the resident's left heel measured 2 cm x 2 cm and the right heel wound measured 2.5 cm x 1 cm. Review of the Wound Evaluation Flow Sheet revealed the next measurement of the resident's left heel was on 10/21/12 (four weeks after the previous assessment on 09/14/12) and revealed the wound measured 3 cm x 1.8 cm. Interview on 10/23/12, at 7:30 PM, with Registered Nurse (RN) #2, revealed she was unsure why nursing staff had failed to document weekly wounds assessments for Resident #2. 5. Review of Resident #7's medical record revealed the facility admitted the resident on 08/23/12, with [DIAGNOSES REDACTED]. A review of Resident #7's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be cognitively intact. Further review revealed the facility assessed Resident #7 to require extensive assistance with bed mobility. A review of Resident #7's comprehensive plan of care dated 09/12/12 revealed the resident was at risk for alteration in skin integrity because the resident required assistance with position changes and bed mobility. The facility approach was to provide weight-bearing assistance to change the resident's position every two (2) hours and as needed. A review of the October Certified Nursing Assistant (CNA) care plan revealed staff was required to reposition Resident #7 every two (2) hours. Observation of Resident #7 on 10/30/12, at 8:57 AM, 9:38 AM, 11:18 AM, 12:27 PM, 3:20 PM, 4:50 PM and 6:30 PM revealed the resident was lying in bed on his/her right side. Interview with Resident #7 on 10/25/12, at 11:55 AM revealed staff did not assist the resident with turning and repositioning every two (2) hours. Resident #7 stated, "they (staff) don't offer" to turn and reposition the resident. Resident #7 further stated staff encouraged the resident to stay off his/her right side, but stated, "Sometimes I forget". A second interview with Resident #7 on 10/30/12, at 7:50 PM revealed, it "would be nice if staff helped (her/him) turn". Interview with CNA #5 on 10/30/12, at 12:42 PM, and CNA #13 at 12:00 PM revealed they were not aware Resident #7 required assistance with turning and repositioning every two (2) hours. Both CNA #5 and CNA #13 stated Resident #7 turned her/himself in bed and were not aware Resident #7's care plan stated the resident required assistance with turning and repositioning every two (2) hours. Interview with Registered Nurse (RN) #2 on 10/30/12, at 3:15 PM revealed CNAs were required to review care plans daily for each resident and provide the care that the care plan required. Review of an in-service conducted 01/31/12; revealed CNAs were instructed to review the CNA care plan/assignment sheet and carry it at all times. The in-service informed staff the care plan listed all the care needs of residents. The in-service stressed failure to follow the CNA assignment sheet could result in resident and employee injury and staff would be subject to written warnings or termination for not following the care plan/assignment sheet. Further review revealed resident safety was a priority and every effort should be made to avoid resident/staff injury during transfers. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on 12/13/12, which alleged removal of IJ effective 10/25/12. An extended survey was conducted on 12/11-13/12, which determined the IJ was removed on 10/25/12 as alleged. --A review of the AOC revealed the following: On 10/19/12, the DON reviewed Resident #1's medical record and continued to investigate. On 10/19/12, the Minimum Data Set (MDS) Coordinator reviewed Resident #1's MDS assessment and care plan for accuracy and also reviewed the two (2) most recent MDS assessments of all resident for accuracy. Initiated on 10/19/12 and completed on 10/21/12, the DON in-serviced all licensed staff regarding the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, 7) the revisions to the transportation policy/procedures. On 10/21/12, RN #2 and LPN #12 compared the skin/wound assessments completed on 10/19/12, for all residents with the documentation in each resident's plan of care, wound documentation flow sheet and TARs to ensure accuracy of the medical records. LPN #12 also compared the skin/wound assessments with the most recent MDS assessment to ensure all alteration in the residents' skin integrity had been accurately care planned. RN #2 re-assessed/re-measured all new alteration in the residents' skin integrity that had been identified on the skin/wound assessments to ensure the areas were documented accurately on each resident's wound documentation flow sheet. On 10/23/12, the MDS staff (MDS Coordinator, MDS Assistant and LPN #12) reviewed all weekly nurses' summary including skin assessments to ensure the resident's plan of care were up to date. The staff also reviews all residents' new orders daily (seven (7) days a week) and updates each resident's plan of care. The Assistant Administrator/QA Coordinator will report all monitoring results in the quarterly CQI meetings. --The surveyors validated the corrective actions taken by the facility as follows: Interview on 12/12/12, at 4:40 PM with the DON and review notes dated 10/19/12, revealed the DON reviewed Resident #1's medical record investigating the resident's wound and appointment issues. Interview on 12/12/12, at 3:15 PM with the MDS Coordinator and review of notes dated 10/19/12, revealed the MDS Coordinator reviewed Resident #1's MDS assessment and care plan for accuracy and also reviewed the two (2) most recent MDS assessments of all resident for accuracy. Interview on 12/12/12, at 4:40 PM with the DON and review in-service records dated 10/19/12, through 10/21/12, revealed the DON in-serviced all licensed staff regarding the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, and 7) the revisions to the transportation policy/procedures. Interviews on 12/12/12, at 11:00 AM with RN #2, at 2:15 PM with LPN #4, at 5:00 PM with LPN #12, on 12/13/12, at 2:00 PM with LPN #9, at 11:00 AM with RN #4, at 11:10 AM with LPN #2, at 1:15 PM with RN #6 and at 1:20 PM with LPN #13 confirmed the licensed staff were in-serviced on the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, and 7) the revisions to the transportation policy/procedures. Interviews on 12/12/12, at 11:00 AM with RN #2, at 5:00 PM with LPN #12 and review of notes dated 10/21/12, revealed RN #2 and LPN #12 compared the skin/wound assessments completed on 10/19/12, for all residents with the documentation in each resident's plan of care, wound documentation flow sheet and TARs to ensure accuracy of the medical records. The interview and record review also revealed LPN #12 compared the skin/wound assessments with the most recent MDS assessment to ensure all alteration in the residents' skin integrity had been accurately care planned. The interview and record review further revealed RN #2 re-assessed/re-measured all new alteration in the residents' skin integrity that had been identified on the skin/wound assessments to ensure the areas were documented accurately on each resident's wound documentation flow sheet. Interviews on 12/12/12, at 3:15 PM with the MDS Coordinator, at 10:55 AM with the MDS Assistant On 10/23/12, the MDS staff (MDS Coordinator, MDS Assistant and LPN #12) reviewed all weekly nurses' summary including skin assessments to ensure the resident's plan of care were up to date. The staff also reviews all residents' new orders daily (seven (7) days a week) and updates each resident's plan of care. Interviews on 12/13/12, at 2:55 PM with the Administrator, and at 3:10 PM with the Assistant Administrator revealed the Assistant Administrator/QA Coordinator will report all monitoring results in the quarterly CQI meetings.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure residents received and facility staff provided the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for two (2) of twenty-four (24) sampled residents (Residents #1 and #14). On 09/12/12, facility staff assessed Resident #1 and noted the resident had a scabbed wound to the left great toe. Facility staff notified the resident's physician of the wound and new orders were obtained that included to refer the resident to a Wound Care Clinic (WCC). Resident #1 was seen at the WCC on 09/13/12, 09/20/12, and staff was to schedule a follow-up appointment for Resident #1 to be seen in the WCC on 09/27/12; however, there was no documented evidence Licensed Practical Nurse (LPN) #1 arranged transportation for the resident's follow up appointment for the 09/27/12, appointment, and the resident was not assessed/treated at the WCC. Facility staff documented an assessment of the wound on Resident #1's left great toe on 09/28/12, (fifteen days after the last documented assessment of the wound on 09/13/12) and noted the wound was red with pink surrounding tissue measuring 1.4 centimeters (cm) x 0.2 cm x 0.1 cm. The Minimum Data Set (MDS) Assistant revealed in an interview that she had conducted an assessment of Resident #1 on 10/15/12, and the resident's toe was moist with black necrotic tissue, brown purulent drainage, a foul odor and redness to the first joint of the toe. According to the MDS assistant, she did not document the assessment but reported her concerns related to the resident's wound to LPN #1 to notify the physician. However, a review of documentation revealed LPN #1 failed to notify the physician of the change in Resident #1's wound on 10/15/12. Although facility staff documented treatments were administered to the wound on Resident #1's left foot from 09/28/12, to 10/16/12, facility staff failed to document an assessment of the wound until 10/17/12, nineteen (19) days after the previous assessment of the wound on 09/28/12. A review of the nurses notes dated 10/17/12, revealed the wound to the resident's left toe had an odor, was draining, and that facility staff notified the resident's physician and orders were received to culture the wound and refer the resident to the WCC. Facility staff also notified Resident #1's family member of the changes and new orders. On 10/18/12, Resident #1's family member insisted on observing the wound on the resident's left great toe. Documentation revealed the wound was assessed and LPN #1 documented the wound was red and inflamed, had a yellow sloughing and an odor, and was necrotic. Resident #1 was transported to an acute care facility on 10/18/12. Resident #1's toe was amputated on 10/20/12, due to a [DIAGNOSES REDACTED].) In addition, facility staff failed to ensure physician's orders for wound treatments were followed for Resident #14, and failed to document an assessment of Resident #14's wound from 06/29/12 until 07/27/12 (a timeframe of twenty-eight days). The failure of the facility to ensure residents received and facility staff provided the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy and Substandard Quality of Care was identified on 12/11/12, and determined to exist on 10/15/12. The facility was notified of the Immediate Jeopardy on 12/11/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/13/12, with the facility alleging removal of the Immediate Jeopardy on 10/25/12. Immediate Jeopardy was verified to be removed on 10/25/12, as alleged prior to exiting with the facility on 12/13/12, with remaining noncompliance at 42 CFR 483.25 Quality of Care, with a scope and severity of "D", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance. The findings include: Review of the facility policy entitled "Skin Care" revised September 2001, revealed all wounds were to measured and recorded weekly. Review of the facility policy entitled "Wound Documentation" (undated) revealed pressure ulcers, diabetic ulcers and other wounds deemed necessary to measure should be measured weekly by licensed staff. The policy revealed documentation should include wound location, stage, size, tunneling, undermining, necrotic tissue, sloughing tissue, eschar, drainage, and granulation, description of surrounding tissue, pain and support surface. Review further revealed if the wound did not show improvement or there were changes (such as warmth, redness of surrounding tissue, necrotic tissue or odor) the physician should be notified. Review of the facility policy entitled "Transportation Policy" dated May 2008, revealed the facility would assist resident by making transportation arrangements for resident's scheduled appointments. The review revealed nursing staff was responsible to make transportation arrangements as soon as aware of the resident's appointment. The policy further stated staff would maintain a record of appointments, would obtain confirmation of transportation arrangements, and would check the appointment book daily to ensure appointments were kept. Interview on 11/01/12, at 3:45 PM with the Administrator revealed the facility did not have a policy related to facility staff following physician's orders. However, according to the Administrator, following physician orders was a "standard of practice" and nursing staff were to follow physician's orders in the provision of resident care. 1. A review of Resident #1's closed medical record revealed the resident was admitted on [DATE], for rehabilitation due to a Right [MEDICAL CONDITION] (BKA) with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change MDS Comprehensive assessment dated [DATE], revealed the resident was assessed to be at risk for development of pressure ulcers. Review of Resident #1's Comprehensive Care Plan dated 07/16/12, revealed the facility had addressed the resident's risk of alteration in skin integrity secondary to history of skin tears, assistance required for bed mobility, general weakness, right BKA, [MEDICAL CONDITION], history of [MEDICAL CONDITION] diabetes, and VRE carrier. Some interventions on the care plan were for staff to check the resident's skin condition daily during care and report any changes to the nurse, and for staff to provided skin care as ordered by the physician. Continued review of Resident #1's medical record revealed nurse's noted dated 09/12/12, at 9:30 AM, by Licensed Practice Nurse (LPN) #1 that noted Resident #1 had a new scabbed area to the left great toe that measured less than 0.1 centimeter (cm) in diameter. LPN #1 notified the physician and obtained orders for treatment to the wound and a referral to the WCC. Review of Resident #1's Wound Care Clinic's (WCC) note dated 09/13/12, revealed the wound was assessed and determined to be a Diabetic Ulcer measuring 2.2 cm x 1.8 cm x 0.1 cm. The WCC sent orders back to the facility on [DATE], for multiple tests, antibiotics, treatment of [REDACTED]. On 09/20/12, documentation by the WCC revealed the wound was a scabbed wound with a pale pink base, measuring 0.7 cm x 0.6 cm x 0.1 cm with no eschar, no yellow sloughing, no drainage and no odor. The WCC sent orders back to the facility on [DATE], for oral antibiotic and for a follow up appointment in one (1) week, on 09/27/12. However, there was no documented evidence LPN #1 made transportation arrangements for the resident's follow up appointment on 09/27/12, and the resident was not seen again at the WCC. Continued review of Resident #1's care plan revealed the care plan was revised on 09/20/12, with additional interventions to include the following: 1) for staff to cleanse area to the left great toe with normal saline, dry and apply [MEDICATION NAME] AG then a 4 x 4 gauze and wrap with "Kling" every forty-eight (48) hours, and 2) for staff to observe for signs and symptoms of infection such as an increase in drainage, an elevated temperature, an rapid pulse, or a decreased blood pressure and to notify the physician of any of the signs. Review of a Wound Evaluation Flow Sheet revealed facility staff had documented Resident #1's wound measurements on 09/13/12, as "2.2 cm x 1.8 cm x 0.1 cm," and on 09/28/12, as "1.4 cm x 0.2 x 0.1 cm"; however, there were no other measurements documented on the flow sheet. Review of the Wound Evaluation Flow Sheet revealed the sheet contained instructions on the top of the sheet stating the sheet was to be completed by a nurse upon identification of a wound and at least weekly from the date of identification. According to the instructions, the staff failed to conduct a wound assessment for weeks of 09/21/12, 10/05/12 and 10/12/12. A review of a Treatment Administration Record (TAR) for September and October 2012, revealed every forty-eight hours, staff was to cleanse Resident #1's left great toe wound with normal saline, cover with [MEDICATION NAME] AG and a 4 x 4 gauze, and then wrapped with Kling, the treatment was to be performed every forty-eight (48) hours. The TAR revealed LPN #1 performed wound care to Resident #1's left great toe on 10/04/12, 10/10/12, 10/14/12 and on 10/18/12. The TAR further revealed LPN #3 performed wound care to Resident #1's left great toe on 10/02/12, 10/06/12, 10/08/12, 10/12/12 and on 10/16/12. Further review of nurse's notes revealed on 10/17/12, at 2:50 PM LPN #3 documented the wound to Resident #1's left great toe had an odor and drainage. Documentation revealed Resident #1's physician was notified of the assessment and the physician requested facility staff to obtain a culture of the wound and to refer the resident to the WCC. The documentation further revealed the resident's family member was also notified of the change and the new orders. Review of Resident #1's nurse's notes dated 10/18/12, at 10:30 AM, Resident #1's family member insisted on observing the resident's wound. Documentation revealed LPN #1 and the Assistant Director of Nursing (ADON) removed the dressing for the resident's left great toe and the wound was observed to be red and inflamed with a necrotic, yellow sloughing and an odor. Further review revealed the resident was transported to an acute care facility on 10/18/12, at 3:15 PM for further assessment and treatment. A review of a "History and Physical" report dated 10/18/12 revealed a physician at the acute care facility noted Resident #1 had [MEDICAL CONDITION] of the toe associated with a Diabetic Ulcer that appeared to have central gangrene, and the physician recommended a consultation with a Vascular Surgical. Review of a Vascular Surgical Consultation Report dated 10/19/12, revealed Resident #1 had a quarter sized ulceration to the left great toe with purulent drainage. The report revealed a foul odor was noted when the dressing was removed and the entire great toe up to the base of the foot was [DIAGNOSES REDACTED]tous. Based on documentation in the report, the Vascular Surgeon recommended amputation of Resident #1's great toe. A review of a Surgical Report dated 10/20/12, revealed Resident #1's the left great toe was amputated secondary to ulceration with wet gangrene. An interview with the Minimum Data Set (MDS) Assistant on 10/25/12, at 1:00 PM revealed she had conducted a Discharge Assessment of Resident #1 on 10/15/12. According to the MDS Assistant, at that time, Resident #1's toe was assessed to be moist, with black necrotic tissue, brown purulent drainage, a foul odor and up to the first joint of the toe was red. According to the MDS assistant, the Discharge Assessment only addressed pressure ulcer and because the resident's wound was not a pressure ulcer, she did not document the assessment; however, the MDS assistant stated she reported her concerns to LPN #1 and thought LPN #1 would notify Resident #1's physician of the assessment. However, a review of documentation revealed Resident #1's physician was not notified of the resident's wound on 10/15/12, and the care plan was not revised to reflect the change in the resident's wound. An interview on 10/24/12, at 4:30 PM with LPN #1 revealed wounds were assessed/measured every Friday and documented on the wound flow sheet. LPN #1 revealed Resident #1's left great toe had "a small black spot" when she last assessed the wound but could not remember the date. The LPN stated she did not know why there was no documentation of an assessment of the wound during the first two (2) weeks of October 2012. LPN #1 acknowledged on 10/18/12, Resident #1's family member insisted on observing the resident's wound and, at that time, the resident's entire toe was red with black necrotic tissue, with sloughing to the side. LPN #1 stated staff was to assess a resident's wound with each treatment and the physician was to be notified of any changes in the wound; (however, there was no documented evidence from 09/12/12 until 10/18/12). LPN #1 stated she did not recall being informed that the wound on the Resident #1's great toe had changed or had an odor. The LPN also could not recall why she did not make transportation arrangements for the follow up appointment to the WCC for 09/27/12. An interview on 10/24/12, at 12:50 PM with LPN #3 revealed wounds were to be assessed/measured every Friday during wound care and documented on the wound flow sheet. LPN #3 revealed the wound on Resident #1's great toe appeared as a dry callused wound when she performed wound care to the wound on 10/12/12. However, according to LPN #3 when she assessed the wound on 10/17/12, the wound had an odor and drainage, so the LPN notified the physician and orders were obtained. LPN #3 did not know why there were no wound assessments/measurements on the wound flow sheet for Resident #1 during first two (2) weeks in October 2012. An interview on 10/25/12, at 11:30 AM with Resident #1's Primary Physician confirmed she had not been informed of the decline in the status of Resident #1's wound unit 10/17/12. According to the physician, she expected the nurses to follow physician's orders, to assess the resident's wounds while performing wound care, and to be notified of any changes in the wound. The interview revealed the physician was unaware Resident #1 missed the follow up appointment at the WCC until after the resident was transported to the hospital on [DATE]. Interviews on 10/23/12, at 6:15 PM and on 11/01/12, at 2:35 PM with the Director of Nursing (DON) revealed when a wound was identified on a resident the nurse was required to notify the resident's physician, obtain orders for treatment, assess the wound to include measurements and document the assessment on the Wound Evaluation Flow Sheet. The DON stated all wound should be assessed/measured and documented at least once a week, by the nurse assigned to the resident while providing wound care every Friday unless the resident's dressing was not scheduled to be changed on Friday. In that case, the resident's wound was required to be assessed on the day the dressing was changed, either Wednesday or Thursday. The interview revealed nurses received in-service training twice a year on assessments, measurements and documentation of wounds. The interview revealed the facility did not conduct any audits to ensure physicians were notified of a resident's change in condition; however, licensed nurses were to notify a resident's physician of any changes in the resident's condition. The DON stated she was unaware Resident #1 had missed the follow up appointment at the WCC, until investigating the resident's wound deterioration. According to the DON, staff was responsible to provide care in accordance with each resident's plan of care. The interview revealed the Quality Assurance (QA) nurses (the Assistant Director of Nursing (ADON) and RN #2) were responsible for conducting the QA of wounds on first and second floor. (Refer to F520.) Interviews on 10/23/12, at 6:15 PM and on 11/01/12, at 3:45 PM with the Administrator revealed when a wound was identified on a resident the nurse was required to notify the resident's physician, obtain orders for treatment, assess the wound to include measurements and document the assessment on the Wound Evaluation Flow Sheet. The Administrator revealed the facility monitored a sample of charts monthly to ensure notification was conducted for all change of condition; however, the monitoring had been discontinued due to meeting the goal. According to the Administrator, staff was responsible to provide care in accordance to the president's plan of care. 2. Review of the medical record revealed the facility admitted Resident #14 on 01/07/11, with [DIAGNOSES REDACTED]. A review of Resident #14's care plan revealed facility staff revised the care plan on 05/04/12, with additional interventions to include the following: 1) to cleanse the area to the resident's left lateral ankle with normal saline, apply Santyl ointment (an active enzymatic therapy that removes necrotic tissue from wounds), a 4 x 4 gauze and wrap the wound with "Kling" (a roll of gauze bandage) every day; and 2) for staff to cleanse the resident's bilateral breast folds with soap and water, dry, and apply [MEDICATION NAME] (a prescription anti-fungal medication used to treat fungal infections) powder twice a day. The care plan also revealed nursing staff were to complete a skin assessment every week and report any alterations to the physician. A review of the monthly Physicians orders for October 2012, revealed staff were to cleanse the folds underneath Resident #14's breast with soap and water, pat dry, and apply [MEDICATION NAME] powder (an antifungal agent) to the breast folds every shift. Review of a Wound Evaluation Flow Sheet revealed facility staff had documented Resident #14's wound measurements of the resident's left, lateral ankle on 05/18/12, as "1.5 cm x 1.5 cm x 0.0 cm," and on 06/01/12 (fourteen days after the last assessment) as "1.0 cm x 1.2 x 0.0 cm", then weekly for the next three weeks until 06/29/12. However, there were no other measurements documented on the flow sheet until 07/27/12 (twenty-eight days later). Review of the Wound Evaluation Flow Sheet revealed the sheet was to be completed by a nurse upon identification of a wound and at least weekly from the date of identification. However, a review of the sheet revealed staff failed to conduct a wound assessment for weeks of 05/21/12, 07/02/12, 07/09/12 and 07/16/12. Observation on 10/29/12, at 7:35 PM revealed Licensed Practical Nurse (LPN) #2 applied [MEDICATION NAME] powder to Resident #14's breast folds; however, LPN #2 failed to cleanse the breast folds with soap and water and dry the area prior to applying the [MEDICATION NAME] powder. Interview on 10/29/12, at 7:45 PM with LPN #2 revealed she failed to read the entire physician's order prior to the treatment for [REDACTED]. Interview on 11/01/12, at 2:30 PM with the Director of Nursing (DON) revealed staff should review physician's orders prior to treatments to ensure treatments were performed in accordance with physician's orders. The DON stated the facility did not monitor to ensure physician's orders were followed. Interview on 11/01/12, at 3:45 PM with the Administrator revealed nurses were to follow physician's orders and this was a nursing "standard of practice." The Administrator stated the facility monitored to ensure physician's orders were entered into the computer system correctly; however, there was no monitoring conducted to ensure physician's orders were followed. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on 12/13/12, which alleged removal of IJ effective 10/25/12. An extended survey was conducted on 12/11-13/12, which determined the IJ was removed on 10/25/12 as alleged. --A review of the AOC revealed the following: On 10/18/12, Licensed Practical Nurse (LPN) #1 was terminated by the Director of Nursing (DON) due to the failure to assess/document Resident #1's wound, notify the physician and responsible party of the change in the resident's wound and the failure to make arrangements for the resident's transportation to the wound clinic. On 10/18/12, the DON notified Resident #1's physician the family requested the resident be transported to the acute care facility the resident had previously been treated prior to admission to this facility. On 10/19/12, the DON reviewed Resident #1's medical record and continued to investigate. On 10/19/12, the Minimum Data Set (MDS) Coordinator reviewed Resident #1's MDS assessment and care plan for accuracy and also reviewed the two (2) most recent MDS assessments of all residents for accuracy. On 10/19/12, Registered Nurses (RN) #4, #6 and LPNs #2, #4, and #13 conducted skin/wound assessments on all residents. Initiated on 10/19/12 and completed on 10/21/12, the DON in-serviced all licensed staff regarding the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, 7) the revisions to the transportation policy/procedures. On 10/19/12, the Administrator and the DON reviewed and revised the facility's transportation policy and procedure. The Medical Director was in agreement with the revision of the policy. The revisions included combining the appointment book and transportation book into one (1) book. The book is kept at each nurses' station and contains the following: 1) Transportation Policy, 2) Instructions for making appointments, 3) Phone numbers of each transportation service and notification requirements for each service, 4) Transportation Log, 5) Appointment Calendar, and 6) Transportation Forms. On 10/20/12, the Administrator, the DON and RN #2 developed a Transportation Log to track appointments/transportation arrangements and an instructional sheet as a guide for staff for making appointments, where forms are located, different transportation services and contact information which will be kept in the front of the Appointment/Transportation books for staff reference. On 10/20/12, the DON reviewed Resident #1's chart to identify if any other appointments had been missed. The DON and RN #2 reviewed all residents' charts with weekly outside medical appointments to ensure arrangements had been made for transportation to each appointment with no problems identified. On 10/20/12, LPN #3 was reprimanded and placed on probation by the DON due to the failure to assess/document Resident #1's wound. On 10/20/12, RN #2 compared the skin/wound assessments completed on 10/19/12, for all residents to each resident's Treatment Administration Records (TARs) and each resident's individual wound documentation flow sheets to ensure all alteration in the residents' skin integrity had been accurately documented. On 10/21/12, the DON notified Resident #1's physician by fax regarding the missed appointment to the wound care clinic. On 10/21/12, RN #2 and LPN #12 compared the skin/wound assessments completed on 10/19/12, for all residents with the documentation in each resident's plan of care, wound documentation flow sheet and TARs to ensure accuracy of the medical records. LPN #12 also compared the skin/wound assessments with the most recent MDS assessment to ensure all alteration in the residents' skin integrity had been accurately care planned. RN #2 re-assessed/re-measured all new alteration in the residents' skin integrity that had been identified on the skin/wound assessments to ensure the areas were documented accurately on each resident's wound documentation flow sheet. On 10/21/12, RN #2 placed the "Pressure Ulcer documentation guideline" and "How to Identify and Stage Pressure Ulcers" sheets (utilized for in-service) were placed in the nursing policy/procedure manuals and in the wound care monitoring books kept at each nursing station for staff reference. On 10/21/12, the Administrator and the DON reviewed the facility's Pressure Ulcer policy and the Wound Documentation policy and no revisions required. The Medical Director was also in agreement. On 10/21/12, LPNs #10 and #14, reviewed all residents' charts with outside medical appointments to ensure transportation arrangements had been made. On 10/22/12, RN #2 notified each physician of their respective resident's wounds addressing the stage and location of each wound after the facility's Medical Director had reviewed/signed each physician's notification. On 10/24/12, the Administrator and the DON reviewed and revised the Wound Documentation Flow Sheet which was larger, more organized, with descriptive terms used to describe wounds. On 10/24/12, the Assistant Administrator started in-servicing all licensed staff on how to utilize the revised Wound Documentation Flow Sheet. The Assistant Administrator also placed an instructional sheet in the Wound Care books at each nursing station to inform staff of how to utilize the revised Wound Documentation Flow Sheet and that all wounds should be measured and documented weekly. On 10/24/12, a new wound care nurse started employment and will be assessing and providing treatments to all wounds five (5) days a week. RN #2 will be assessing and providing treatments to all wounds the other two (2) days a week. The wound care nurse or RN #2 will fax each resident's physician a bi weekly notification of the resident's wound type, location, description and current treatment. As part of the facility's CQI for monitoring skin assessments upon admission, the DON has 1) Reviewed all skin assessments on new admissions and readmissions and compared the skin assessment with her own skin assessment of the resident to ensure all areas have been identified, staged and measured accurately. 2) Reviewed the new admissions and readmissions chart to ensure the physician and family were notified of any skin areas, that appropriate treatment is being utilized to all skin areas and all skin areas were appropriately documented on the wound monitoring flow sheet for the resident. As part of the facility's CQI for monitoring the transportation arrangement, the Assistant Administrator or the Activity Director will review the transportation logs on each unit to ensure all transportation arrangements have been made and any problems identified will be reported to the nursing administration immediately for correction. The DON and RN #2 will review all residents' weekly nurses summary (which include a skin assessment) and assess each resident to ensure the skin assessment matches and ensure the physician was notified of any new alterations in skin integrity or changes in condition. The nurse completing the weekly skin assessments will notify the physician of any changes, obtain new orders and update the resident's plan of care with the new orders. The Administrator formed a QA subcommittee which consists of each department head/manager that will meet weekly to review the monitoring tools recently developed to improve the facility's QA program. The Assistant Administrator/QA Coordinator will report all monitoring results in the quarterly CQI meetings. --The surveyors validated the corrective actions taken by the facility as follows: Interview on 12/12/12, at 4:40 PM with the DON and review of LPN #1's Employee Disciplinary Report dated 10/18/12, revealed the LPN was terminated due to the failure to assess/document Resident #1's wound, notify the physician and responsible party of Resident #1 concerning the change in the resident's wound and the failure to make arrangements for the resident's transportation to the wound clinic. Interview on 12/12/12, at 4:40 PM with the DON and review of a faxed letter revealed on 10/18/12, the DON notified Resident #1's physician the family requested the resident be transported back to the acute care facility the resident had previously been treated, prior to admission to this facility. Interview on 12/12/12, at 4:40 PM with the DON and review notes dated 10/19/12, revealed the DON reviewed Resident #1's medical record investigating the resident's wound and appointment issues. Interview on 12/12/12, at 3:15 PM with the MDS Coordinator and review of notes dated 10/19/12, revealed the MDS Coordinator reviewed Resident #1's MDS assessment and care plan for accuracy and also reviewed the two (2) most recent MDS assessments of all resident for accuracy. Interviews on 12/12/12 at 2:15 PM with LPN #4; on 12/13/12 at 11:00 AM with RN #4; at 11:10 AM with LPN #2; at 1:15 PM with RN #6; at 1:20 PM with LPN #13; and review of notes revealed on 10/19/12, the above licensed staff conducted skin/wound assessments on all residents. Interview on 12/12/12, at 4:40 PM with the DON and review of in-service records dated 10/19/12 through 10/21/12 revealed the DON in-serviced all licensed staff regarding the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, and 7) the revisions to the transportation policy/procedures. Interviews on 12/12/12 at 11:00 AM with RN #2; at 2:15 PM with LPN #4; at 5:00 PM with LPN #12; on 12/13/12 at 2:00 PM with LPN #9; at 11:00 AM with RN #4; at 11:10 AM with LPN #2; at 1:15 PM with RN #6; and at 1:20 PM with LPN #13 confirmed the licensed staff were in-serviced on the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, and 7) the revisions to the transportation policy/procedures. Interviews on 12/12/12, at 4:40 PM with the DON, on 12/13/12, at 2:55 PM with the Administrator and review of the facility's transportation policy/procedure revealed the policy was revised on 10/19/12, by the DON and Administrator. Interview on 12/13/12, at 1:30 PM with the Medical Director and review of the facility's transportation policy/procedure revealed the Medical Director was in agreement with the revision of the policy. Observations conducted on 12/12/12, at 3:00 PM on the Secure Unit, at 3:10 PM on the 2nd floor and at 3:20 PM on the 1st floor revealed an Appointment/Transportation book kept at each nursing station. The book contained the following: 1) Transportation Policy, 2) Instructions for making appointments, 3) Phone numbers of each transportation service and notification requirements for each service, 4) Transportation Log, 5) Appointment Calendar, 6) Transportation Forms and 7) Instructional sheet. Interviews on 12/12/12 at 11:00 AM with RN #2; at 2:15 PM with LPN #4; at 5:00 PM with LPN #12, on 12/13/12, at 2:00 PM with LPN #9, at 11:00 AM with RN #4, at 11:10 AM with LPN #2; at 1:15 PM with RN #6 and at 1:20 PM with LPN #13 revealed the licensed staff were knowledgeable of the contents and use of the Appointment/Transportation book. Interviews on 12/12/12, at 4:40 PM with the DON, on 12/12/12, at 11:00 AM with RN #2, on 12/13/12, at 2:55 PM with the Administrator, and review of the facility's transportation policy/procedure revealed

Based on interview, record review, and facility policy review, it was determined Administration failed to ensure the facility was administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical wellbeing for two (2) of twenty-four (24) sampled residents (Resident #1 and #14). The Administration failed to ensure policy and procedures were implemented for wound care. Facility staff noted on 09/12/12, Resident #1 had a wound on the left great toe. However, Administration failed to ensure facility staff assessed and documented Resident #1's wound on a weekly basis in accordance with facility policy and procedures; failed to ensure necessary care and services were provided to Resident #1's wound in an effort to aide healing; failed to ensure arrangements had been made for Resident #1 to be assessed at a Wound Care Clinic (WCC) as ordered by the resident's physician; and failed to ensure the physician was notified of a significant change in the wound on Resident #1's left great toe. Documentation revealed the wound on Resident #1's left great toe worsened and on 10/20/12, the resident's toe was amputated. (Refer to F157, F282, and F309). In addition, Administration failed to ensure policy and procedures were implemented related to care plans. Nurses failed to follow the care plan for Resident #14 to ensure adequate assistance was provided during the transfer and, as a result, Resident #14 sustained an injury to the left ankle that required wound care. (Refer to F282 and F323). Administration also failed to ensure the Quality Assurance (QA) Committee identified quality deficiencies and implemented corrective actions related to weekly wound assessment/care. (Refer to F520). The failure of the facility to ensure the facility was administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical wellbeing placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 12/11/12, and determined to exist on 10/15/12. The facility was notified of the Immediate Jeopardy on 12/11/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/13/12, with the facility alleging removal of the Immediate Jeopardy on 10/25/12. Immediate Jeopardy was verified to be removed on 10/25/12, as alleged prior to exiting with the facility on 12/13/12, with remaining noncompliance at 42 CFR 483.75 Administration, with a scope and severity of "D," while the facility develops and implements a Plan of Correction and the facility's Quality Assurance. The findings include: Review of the facility policy entitled "Change in a Resident's Condition or Status" (undated) revealed the facility was to notify the resident's attending physician and representative of changes in the resident's condition/status. The policy revealed Nursing Services would be responsible for notifying the resident's attending physician and representative when there had been a significant change in the resident's physical status, when there had been a need to alter the resident's treatment significantly or when deemed appropriate in the best interests of the resident. The review further revealed all notifications should be made as soon as practical, "but in no case shall such notification exceed twenty-four (24) hours." The policy also revealed, "All changes in the resident's medical condition must be properly recorded in the resident's medical record in accordance with our charting and documentation policies and procedures" Review of the facility policy entitled "Skin Care" revised September 2001, revealed staff were to measure and record wounds on a weekly basis. Review of the facility policy entitled "Wound Documentation" undated revealed pressure ulcers, diabetic ulcers and other wounds should be measured weekly by licensed staff. The policy revealed documentation should include wound location, stage, size, tunneling, undermining, necrotic tissue, sloughing tissue, eschar, drainage, granulation, description of surrounding tissue, pain, and support surface. Review further revealed if the wound did not show improvement or there were changes (such as warmth, redness of surrounding tissue, necrotic tissue or odor) the physician should be notified. Review of the facility policy entitled "Transportation Policy" dated May 2008; revealed staff would assist residents by making transportation arrangements for resident's scheduled appointments. The review revealed nursing staff was responsible to make transportation arrangements as soon as they were aware of the resident's appointment. The policy further revealed staff should maintain a record of appointments should obtain confirmation of transportation arrangements and should check the appointment book daily to ensure appointments were kept. 1. On 09/12/12, facility staff assessed Resident #1 and noted the resident had a scabbed area on the left great toe, the resident's physician was notified, and orders were received for wound care treatment and to arrange for the resident to be assessed at a Wound Care Clinic (WCC). Resident #1 was seen at the Wound Care Clinic (WCC) on 09/13/12, 09/20/12, and staff was to schedule a follow-up appointment for Resident #1 to be seen in the WCC on 09/27/12; however, staff (Licensed Practical Nurse (LPN) #1) failed to arrange transportation for the resident's follow up appointment on 09/27/12, and, as a result, the resident did not receive an assessment/treatment on that date by the WCC. An interview on 10/24/12, at 4:30 PM, with LPN #1 revealed the nurse had been responsible to make arrangements for Resident #1's transportation to appointments. LPN #1 stated she could not recall why she failed to make transportation arrangements for Resident #1's follow up appointment on 09/27/12 to the WCC. On 09/28/12, (15 days after the assessment of the wound on 09/13/12) staff documented an assessment of the wound on Resident #1's left great toe and noted the wound was red with pink surrounding tissue measuring 1.4 centimeters (cm) X 0.2 cm X 0.1 cm. Although facility staff documented treatments were administered to the wound on Resident #1's left foot from 09/28/12, to 10/16/12, facility staff failed to document an assessment of the wound until 10/17/12, nineteen (19) days after the previous assessment of the wound on 09/28/12. A review of the nurses notes dated 10/17/12, revealed the wound to the resident's left toe had an odor was draining. The Minimum Data Set (MDS) Assistant revealed in an interview that she had conducted an assessment of Resident #1 on 10/15/12, and the resident's toe was moist with black necrotic tissue, brown purulent drainage, a foul odor, and redness to the first joint of the toe. The interview revealed the wound status was reported to LPN #1 to report to the resident's physician; however, the physician was not notified of the change in the resident's condition on that date. Documentation revealed LPN #1 assessed Resident #1's wound on 10/18/12, and documented the wound was red and inflamed, had a yellow sloughing and an odor, and was necrotic. Resident #1 was transported to an acute care facility on 10/18/12, and the resident's left great toe was amputated on 10/20/12, due to "wet" gangrene. Interviews on 10/23/12, at 6:15 PM and on 11/01/12, at 2:35 PM with the Director of Nursing (DON) revealed a resident's wound should be assessed/measured and documented at least once a week. The interview revealed although the facility did not conduct audits to ensure physicians were notified of a change in a resident's condition, licensed nurses were to notify a resident's physician of any changes in the resident's condition. The DON stated the nurse caring for the resident was responsible for making transportation arrangements for resident's appointments. Interviews on 10/23/12, at 6:15 PM and on 11/01/12, at 3:45 PM with the Administrator revealed when a wound was identified, the nurse was required to notify the resident's physician, obtain orders for treatment, assess/measure the wound, and document the assessment on the Wound Evaluation Flow Sheet. The Administrator revealed the facility had monitored a sample of charts on a monthly basis to ensure staff conducted physician notification for all change in resident condition; however, the Administrator stated the monitoring had been discontinued due to staff compliance in meeting the goal established. The Administrator also stated the nurse caring for the resident was responsible for making transportation arrangements for the resident's appointments. An interview on 10/25/12, at 11:30 AM with Resident #1's Primary Physician confirmed she had not been informed of the decline in the status of Resident #1's wound unit 10/17/12. According to the physician, she expected the nurses to follow physician's orders, to assess the resident's wounds while performing wound care and to be notified of any changes in the wound. 2. A review of the facility's policy titled, Care Plans-Comprehensive (revised 10/20/08) revealed it was the policy of the facility to develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs. Further review of the policy revealed the comprehensive care plan had been designed to incorporate identified problem areas, and to prevent declines in the resident's functional status and/or functional level. The policy revealed the Certified Nursing Assistant (CNA) care plans were developed from the comprehensive care plan and would identify specific care area needs and approaches necessary for the CNA to provide daily care to individual residents. The facility assessed and identified in a plan of care that Resident #14 required the assistance of a minimum of two staff for transfers. However, on 04/09/12, one staff person transferred the resident from the bed to a wheelchair and the resident sustained [REDACTED]. As a result of the injury, Resident #14 required evaluation at an Emergency Department on two separate occasions. On 04/09/12, Resident #14 was transferred to the Emergency Department for evaluation due to swelling, pain, and redness of the left ankle. On 04/18/12, Resident #14 experienced swelling of the ankle, increased pain (refused for staff to touch the ankle), and had developed a necrotic area at the injured site. On 04/18/12, Resident #14 was again transferred to the Emergency Department for evaluation, was diagnosed with [REDACTED]. In addition, on 04/26/12, a hematoma formed at the injured site and wound care was required for the left ankle. The Director of Nursing (DON) stated in an interview on 11/01/12, at 2:30 PM, that staff members were required to follow the resident plan of care. The DON confirmed Certified Nursing Assistant (CNA) #15 failed to follow the plan of care and transferred Resident #14 from the bed to a wheelchair without assistance and Resident #14 sustained an injury to the left ankle. 3. A review of the facility's policy titled "Quality Control," (undated) revealed the facility had a quality control program that that identified specific deficiencies, measured the level of quality services by each department, and continually furnish information that would aid the facility in taking corrective action for problems that were identified. In addition, the policy revealed quality control records would be maintained and would be discussed quarterly during committee meetings. The policy also stated any items requiring corrective action would be discussed with the Administrator as they arose. A review of the facility's Resident Roster Matrix revealed there were nineteen (19) residents in the facility with wounds. A review of medical records for ten (10) of the residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, #12 and #14) with wounds revealed facility staff had not always conducted a weekly assessment of the wounds in accordance with facility policy. An interview with the Assistant Director of Nursing (ADON) on 10/23/12, at 7:10 PM and with Registered Nurse (RN) #2 on 10/23/12, at 7:30 PM revealed they had the responsibility to perform Quality Assurance (QA) activities related to resident wounds and acknowledged staff had not always documented skin assessments of wounds on a weekly basis. The ADON and RN #2 stated they failed to ensure their findings were reported to the QA committee to ensure corrective actions were identified in an effort to prevent wound deterioration and promote wound healing. An interview on 11/01/12, at 1:10 PM with the Assistant Administrator revealed she was also the QA Coordinator. The Assistant Administrator stated she had not been informed that the weekly wound assessments had not been conducted. An interview on 10/25/12, at 5:45 PM with the Administrator revealed the facility monitored wound care by conducting Continuous Quality Improvement (CQI) of wounds. The interview revealed facility policy was for the nurses to assess wounds once a week and record the assessment on the Wound Flow Sheet and the wound logbook. According to the Administrator, she was unaware nurses had not conducted weekly wound assessments until the facility initiated an investigation into the deterioration of Resident #1's wound, or that all results of staff monitoring, including wound care assessments, had not been reported to the QA committee. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on 12/13/12, which alleged removal of IJ effective 10/25/12. An Extended Survey was conducted on 12/11-13/12, which determined the IJ was removed on 10/25/12 as alleged. --A review of the AOC revealed the following: On 10/19/12, the DON reviewed Resident #1's medical record and continued to investigate. Initiated on 10/19/12 and completed on 10/21/12, the DON in-serviced all licensed staff regarding the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, 7) the revisions to the transportation policy/procedures. On 10/19/12, the Administrator and the DON reviewed and revised the facility's transportation policy and procedure. The Medical Director was in agreement with the revision of the policy. The revisions included combining the appointment book and transportation book into one (1) book. The book is kept at each nurses' station and contains the following: 1) Transportation Policy, 2) Instructions for making appointments, 3) Phone numbers of each transportation service and notification requirements for each service, 4) Transportation Log, 5) Appointment Calendar, and 6) Transportation Forms. On 10/20/12, the Administrator, the DON, and RN #2 developed a Transportation Log to track appointments/transportation arrangements and an instructional sheet as a guide for staff for making appointments, where forms are located, different transportation services and contact information which will be kept in the front of the Appointment/Transportation books for staff reference. On 10/21/12, the Administrator and the DON reviewed the facility's Pressure Ulcer policy and the Wound Documentation policy and no revisions required. The Medical Director was also in agreement. On 10/21/12, the DON notified the Medical Director of the issues identified related to the investigation of Resident #1's wound and missed appointment with the WCC. The Medical Director was also notified and in agreement with the facility's corrective measures taken. On 10/22/12, RN #2 notified each physician of their respective resident's wounds addressing the stage and location of each wound after the facility's Medical Director had reviewed/signed each physician's notification. The Administrator formed a QA subcommittee which consists of each department head/manager that will meet weekly to review the monitoring tools recently developed to improve the facility's QA program. The Assistant Administrator/QA Coordinator will report all monitoring results in the quarterly CQI meetings. --The surveyors validated the corrective actions taken by the facility as follows: Interview on 12/12/12, at 4:40 PM with the DON and review notes dated 10/19/12, revealed the DON reviewed Resident #1's medical record investigating the resident's wound and appointment issues. Interview on 12/12/12, at 4:40 PM with the DON and review in-service records dated 10/19/12, through 10/21/12, revealed the DON in-serviced all licensed staff regarding the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, and 7) the revisions to the transportation policy/procedures. Interviews on 12/12/12, at 11:00 AM with RN #2, at 2:15 PM with LPN #4, at 5:00 PM with LPN #12, on 12/13/12, at 2:00 PM with LPN #9, at 11:00 AM with RN #4, at 11:10 AM with LPN #2, at 1:15 PM with RN #6 and at 1:20 PM with LPN #13 confirmed the licensed staff were in-serviced on the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, and 7) the revisions to the transportation policy/procedures. Interviews on 12/12/12, at 4:40 PM with the DON, on 12/13/12, at 2:55 PM with the Administrator and review of the facility's transportation policy/procedure revealed the policy was revised on 10/19/12, by the DON and Administrator. Interview on 12/13/12, at 1:30 PM with the Medical Director and review of the facility's transportation policy/procedure revealed the Medical Director was in agreement with the revision of the policy. Observations conducted on 12/12/12, at 3:00 PM on the Secure Unit, at 3:10 PM on the second floor and at 3:20 PM on the first floor revealed an Appointment/Transportation book kept at each nursing station. The book contained the following: 1) Transportation Policy, 2) Instructions for making appointments, 3) Phone numbers of each transportation service and notification requirements for each service, 4) Transportation Log, 5) Appointment Calendar, 6) Transportation Forms and 7) Instructional sheet. Interviews on 12/12/12, at 11:00 AM with RN #2, at 2:15 PM with LPN #4, at 5:00 PM with LPN #12, on 12/13/12, at 2:00 PM with LPN #9, at 11:00 AM with RN #4, at 11:10 AM with LPN #2, at 1:15 PM with RN #6 and at 1:20 PM with LPN #13 revealed the licensed staff were knowledgeable of the contents and use of the Appointment/Transportation book. Interviews on 12/12/12, at 4:40 PM with the DON, on 12/12/12, at 11:00 AM with RN #2, on 12/13/12, at 2:55 PM with the Administrator, and review of the facility's transportation policy/procedure revealed on 10/20/12, the Administrator, the DON and RN #2 developed a Transportation Log to track appointments/transportation arrangements and an instructional sheet as a guide for staff for making appointments, where forms are located, different transportation services and contact information which will be kept in the front of the Appointment/Transportation books for staff reference. Interviews on 12/12/12, at 4:40 PM with the DON, on 12/13/12, at 2:55 PM with the Administrator and review of the facility's policies revealed the Pressure Ulcer policy and the Wound Documentation policy were reviewed 10/21/12, by the DON and Administrator. Interview on 12/13/12, at 1:30 PM with the Medical Director was in agreement with not revising the policies. Interviews on 12/12/12, at 4:40 PM with the DON, on 12/13/12, at 1:30 PM with the Medical Director and review of an e-mail revealed on 10/21/12, the DON notified the Medical Director of the issues identified related to the investigation of Resident #1's wound and missed appointment with the WCC. The Medical Director was also notified and in agreement with the facility's corrective measures taken. Interviews on 12/12/12, at 11:00 AM with RN #2, on 12/13/12, at 1:30 PM with the Medical Director and review notification letters dated 10/22/12, revealed RN #2 notified each physician of their respective resident's wounds addressing the stage and location of each wound after the facility's Medical Director had reviewed/signed each physician's notification. Interviews on 12/12/12, at 4:40 PM with the DON, on 12/13/12, at 2:55 PM with the Administrator, at 3:10 PM with the Assistant Administrator, at 1:40 PM with the Activity Director and review of the QA subcommittee meeting minutes for 10/23/12, revealed the Administrator formed a QA subcommittee which consists of each department head/manager that meet weekly to review the monitoring tools recently developed to improve the facility's QA program. Interviews on 12/13/12, at 2:55 PM with the Administrator, and at 3:10 PM with the Assistant Administrator revealed the Assistant Administrator/QA Coordinator will report all monitoring results in the quarterly CQI meetings.

The facility failed to ensure clinical records were complete and accurately maintained in accordance with accepted professional standards and practices for eight (8) out of twenty-four (24) sampled residents (Residents #1, #2, #3, #5, #8, #9, #14 and #16). Resident #1 developed a scabbed area to the left great toe on 09/12/12. Staff measured the wound on 09/12/12, and again on 09/28/12. The facility failed to assess the wound again until 10/17/12, nineteen days later, when the area was noted to be draining and had a foul odor. On 10/18/12, Resident #1's family member asked to observe the resident's toe. The resident's toe was red and inflamed, had an odor, yellow slough (a mass or layer of dead tissue separated from the surrounding or underlying tissue), and a necrotic (dead tissue) area. Resident #1 was transported to an acute care facility on 10/18/12, for treatment to the left toe, at the insistence of the resident's family after the family member observed the resident's toe had worsened. Resident #1's left great toe was amputated on 10/20/12, due to wet gangrene (death of tissue due to a loss of blood supply with a bacterial infection). The facility also failed to ensure weekly wound assessments were conducted in accordance with facility policy and professional standards for Resident #2, #3, #5, #8, #9 and #14. (Refer to F309 and F314) In addition, Resident #16 had a physician's order for twenty (20) milliequivalents of Potassium Chloride (composed of potassium /chlorine) capsules to be administered orally every day. However, during the facility's changeover to a new computer system that had been implemented to develop the resident's Medication Administration Records (MAR), in June 2012, 20 milliequivalents of Potassium [MEDICATION NAME] (potassium salt/citric acid) capsules was documented on Resident #16's MAR indicated [REDACTED]. Documentation revealed from 06/07/12, through 07/13/12, staff documented twenty-two (22) out of thirty-seven (37) days that twenty (20) milliequivalents of Potassium [MEDICATION NAME] was administered even though according to the pharmacist, Potassium [MEDICATION NAME] had not been supplied to the facility and was not available for staff to administer. The MAR indicated [REDACTED]. The failure of the facility to ensure clinical records were complete and accurately maintained in accordance with accepted professional standards and practices placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 12/11/12, and determined to exist on 10/15/12. The facility was notified of the Immediate Jeopardy on 12/11/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/13/12, with the facility alleging removal of the Immediate Jeopardy on 10/25/12. Immediate Jeopardy was verified to be removed on 10/25/12, as alleged prior to exiting with the facility on 12/13/12, with remaining noncompliance at 42 CFR 483.75 Administration, with a scope and severity of "D," while the facility develops and implements a Plan of Correction and the facility's Quality Assurance. The findings include: A review of the facility's policy titled, "Documentation of Medication Administration," with a revision date of April 2007, revealed staff was required to document the name and strength of a drug. A review of the facility's policy titled, "Electronic Order Entry Policy", with a date of 09/19/12, revealed when a physician's order was received it should be transcribed onto the MAR indicated [REDACTED]. Review of the facility policy entitled "Change in a Resident's Condition or Status" (undated) revealed the facility was to notify the resident's attending physician and representative of changes in the resident's condition/status. The policy revealed Nursing Services would be responsible for notifying the resident's attending physician and representative when there had been a significant change in the resident's physical status, when there had been a need to alter the resident's treatment significantly or when deemed appropriate in the best interests of the resident. The review further revealed all notifications should be made as soon as practical, "but in no case shall such notification exceed twenty-four (24) hours." The policy also revealed, "All changes in the resident's medical condition must be properly recorded in the resident's medical record in accordance with our charting and documentation policies and procedures" Review of the facility policy entitled "Skin Care" revised September 2001, revealed all wounds were required to be measured and recorded weekly. Review of the facility policy entitled "Wound Documentation" undated revealed pressure ulcers, diabetic ulcers and other wounds deemed necessary to measure should be measured weekly by licensed staff. The policy revealed documentation should include wound location, stage, size, tunneling, undermining, necrotic tissue, sloughing tissue, eschar, drainage, granulation, description of surrounding tissue, pain, and support surface. Review further revealed if the wound did not show improvement or there were changes (such as warmth, redness of surrounding tissue, necrotic tissue or odor) the physician should be notified. Interviews on 11/01/12, at 2:35 PM with the Director of Nursing (DON), and at 3:45 PM with the Administrator, revealed it was a nursing standard of practice to assess wounds at least once a week. 1. Review of Resident #1's closed medical record revealed the resident was admitted [DATE], for rehabilitation after a Right [MEDICAL CONDITION] (BKA) and [DIAGNOSES REDACTED]. Resident #1's nurse's note dated 09/12/12, at 9:30 AM by Licensed Practice Nurse (LPN) #1 revealed the resident had a scabbed area to the left great toe measuring less than 0.1 centimeter (cm) in diameter. Review of Resident #1's facility Wound Evaluation Flow Sheet and a Wound Care Clinic note (note documented by staff at a Wound Care Clinic outside the facility) dated 09/13/12, revealed the wound to Resident #1's toe measured 2.2 cm x 1.8 cm x 0.1 cm. According to the Wound Care Clinic note, the wound was a diabetic ulcer. Further review of the Wound Care Clinic notes dated 09/20/12, revealed the wound to the resident's toe was a scabbed area with a pale, pink base, measuring 0.7 cm x 0.6 cm x 0.1 cm with no eschar, no yellow sloughing, no drainage, and no odor. Review of the facility's Wound Evaluation Flow Sheet dated 09/28/12, revealed the wound to Resident #1's toe measured 1.4 cm x 0.2 x 0.1 cm. However, there was no documented evidence the physician was notified of the increase in size of the wound. Review of Resident #1's Treatment Administration Record (TAR) for September and October 2012, revealed staff documented the resident's toe was cleansed with Normal Saline and treated with [MEDICATION NAME] AG (a silver impregnated antimicrobial dressing which reduces the number of bacteria in the wound) every forty-eight hours from 09/28/12 through 10/16/12. The TAR revealed LPN #1 performed wound care to Resident #1's left great toe on 10/04/12, 10/10/12 and on 10/14/12. The TAR further revealed LPN #3 performed wound care to Resident #1's left great toe on 10/02/12, 10/06/12, 10/08/12, 10/12/12, and on 10/16/12. However, review of Resident #1's medical record revealed no evidence the resident's wound to the toe was assessed at least weekly as required by the facility's policy and the according to professional standards from 09/28/12 until 10/17/12, for a nineteen day period. Review of Resident #1's nurse's notes dated 10/17/12, at 2:50 PM by LPN #3 revealed the area to the resident's left great toe had an odor and drainage, the physician was notified, and new orders were obtained. A nurse's note dated 10/18/12 at 10:30 AM by LPN #1 revealed Resident #1's family member insisted on observing the resident's toe. LPN #1 and the Assistant Director of Nursing (ADON) removed the dressing to reveal the toe was red and inflamed with a necrotic area, yellow sloughing, and a foul odor. Further review revealed the resident was transported to an acute care facility on 10/18/12 at 3:15 PM. Review of Resident #1's Surgical Report dated 10/20/12, revealed the resident's left great toe was amputated secondary to ulceration with wet gangrene. An interview on 10/25/12, at 1:00 PM with the Minimum Data Set (MDS) Assistant revealed on 10/15/12, she conducted a head to toe assessment on Resident #1 during the completion of the resident's Discharge MDS assessment. The interview revealed the resident's wound to the left great toe was moist, with black necrotic tissue, brown purulent drainage, a foul odor, and redness to the first joint of the toe. The MDS Assistant stated she reported the findings to LPN #1, who was responsible for the resident's care, and assumed the LPN would assess the resident's wound and call the resident's physician. However, a review of Resident #1's medical record revealed no evidence the resident's wound was assessed until 10/17/12. An interview on 10/24/12, at 4:30 PM with LPN #1 and on 10/24/12, at 12:50 PM with LPN #3 revealed wounds were required to be assessed during every wound care for changes and every Friday the assessment was documented on a Wound Flow Sheet. LPN #1 and #3 were not able to explain why there was no documentation that Resident #1's wound was assessed for the first two (2) weeks of October, even though they had provided the wound care to Resident #1's toe every forty-eight (48) hours, according to the TAR. LPN #1 stated that the reason nothing was documented might have been that staff was too busy. An interview on 10/25/12, at 11:30 AM with Resident #1's Primary Physician revealed the physician expected the nurses to assess the resident's wounds while performing wound care. Interviews on 10/23/12, at 6:15 PM with the Administrator and the Director of Nursing (DON) revealed the nurse assigned to the resident on Friday of each week was required to assess residents' wounds unless the resident's dressing was not scheduled to be changed on Friday. In that case, the resident's wound was required to be assessed on the day the dressing was changed, either Wednesday or Thursday. The interview revealed staff was required to assess the wound, including measurements, and document the assessment on the Wound Evaluation Flow Sheet. The interview revealed they were not aware Resident #1's wound to the toe had not been assessed at least weekly until the resident's son requested to see the resident's wound and the resident was transferred to the hospital. Interview on 10/24/12, at 7:30 PM with Registered Nurse (RN) #2 revealed all nurses were trained upon hire to assess and document all wounds on every Friday or the closes treatment day to Friday. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 10/31/11, with [DIAGNOSES REDACTED]. Resident #2's medical record revealed the resident was readmitted from an acute care facility on 08/06/12 with a pressure ulcer to the left buttock and blisters to both heels. The Wound Evaluation Flow Sheet revealed the wounds were assessed on 08/07/12 and the wound to the left buttock measured 3 cm x 3.5 cm x four cm, the left heel wound measured 5 cm x 5 cm, and the right heel wound measured 5 cm x 5 cm. On 08/19/12, the left heel measured 6.1 cm x 8.6 cm x UTD, the right heel had no measurements and the left buttocks measured 3 cm x 3.4 cm x 5 cm. Review of the Wound Evaluation Flow Sheet revealed the next assessment was on 09/07/12 (4 weeks later) the left buttock measured 3 cm x 3 cm x UTD. There was no evidence the resident's heels were assessed. Further review of the Wound Evaluation Flow Sheets revealed on 09/14/12, (5 weeks later) the left heels measured 2 cm x 2 cm and the right heel measured 2.5 cm x 1 cm. Physical Therapy was providing treatment to Resident #2's buttock, which was assessed by Physical Therapy. Review of the Wound Evaluation Flow Sheet revealed the next measurement for the left heel was not until a facility wide skin sweep was conducted on 10/21/12 (four weeks later), which measured the wound to be 3 cm x 1.8 cm. Observation on 10/23/12, at 3:40 PM, of Resident #2's wound care with LPN #2 revealed the left heel had a dark, dry, scabbed area with redness and a small amount of swelling around the wound. The wound measured 3 cm x 1.5 cm with no drainage or odor. The observation revealed the right heel had no wound and the resident's buttocks had a [DEVICE] with an occlusive dressing. Interview on 10/23/12, at 7:30 PM, with Registered Nurse (RN) #2, revealed she was unsure why nurses had failed to document weekly wounds assessments for Resident #2. 3. Review of Resident #3's medical record revealed the facility admitted the resident on 10/04/12, with multiple Pressure Ulcers. Review of Resident #3's Wound Evaluation Flow Sheet revealed on 10/04/12, the resident had an area to a bunion on the left foot that measured 0.6 cm x 0.4 cm x unable to determine (UTD) the depth, an area to the left outer ankle with measurements of 0.4 cm x 0.4 cm x UTD, an area to the left heel that measured 1.7 cm x 2.3 cm x UTD, a Stage II to the coccyx with measurements of 3 cm x 3 cm x 0.2 cm, and an area to the right heel with no measurements. Further review of Resident #3's Wound Evaluation Flow Sheet revealed no other assessments of the wounds until the facility conducted a facility wide skin sweep during the weekend of 10/19-20/12. The flow sheet revealed on 10/20/12, the bunion to the resident's left foot measured slightly larger at 0.6 cm x 0.5 cm x UTD, the area to the left outer ankle measured slightly larger at 0.4 cm x 0.5 cm x UTD, the area to the left heel measured the same, the Stage II to the coccyx measured larger at 7 cm x 3.5 cm x UTD, the area to the right heel measured 3.4 cm x 4.1 cm x UTD and the area to the left third toe measuring 0.6 cm x 0.8 cm x UTD. Review of Resident #3's TARs for October 2012, revealed LPN #1 provided the resident's treatments on 10/04/12, 10/05/12, 10/09/12, 10/10/12, 10/14/12, 10/15/12 and on 10/18/12. The TAR further reviewed LPN #3 provided the resident's treatments on 10/06/12, 10/07/12, 10/08/12, 10/11/12, 10/12/12, 10/16/12, and on 10/17/12. According to the TAR, LPN #7 provided the resident's treatment on 10/13/12. Observation on 10/30/12, at 3:00 PM of Resident #3's wound care with LPN #3 revealed the area to the coccyx had red tissue surrounding the open wound which measured 8.3 cm x 6.2 cm, the opened wound measured 5.4 cm x 4.7 cm x 0.5 cm. The coccyx wound was pink with yellow/white sloughing noted. The right inner ankle was slightly red with no open wounds. The right heel was boggy and dark measuring 2.2 cm x 3.4 cm. The left outer ankle was yellow with a slight amount of yellow drainage noted on the old dressing and measured 1.2 cm x 1 cm x 0.1 cm. The left heel had a dark area that measured 1.5 cm x 1.2 cm. The bunion to the outer side of the left foot was dark and measured 0.4 cm x 0.4 cm and the third toe on the left foot had black edge on a dark area that measured 0.4 cm x 0.8 cm. Interviews on 10/24/12, at 12:50 PM with LPN #3, at 4:30 PM with LPN #1 and on 10/30/12, at 6:17 PM with LPN #7, revealed all wounds were to be assessed and documented once a week every Friday on the Wound Evaluation Flow Sheet. The LPNs were unable to explain why there were no weekly wound assessments of Resident #3's wounds documented once a week even though the LPNs had provided the resident's treatments. 4. Review of the medical record revealed the facility admitted Resident #14 on 01/07/11, with [DIAGNOSES REDACTED]. A review of Resident #14's care plan revealed facility staff revised the care plan on 05/04/12, with additional interventions to include the following: 1) for staff to cleanse area to the left lateral ankle with normal saline, apply Santyl ointment (an active enzymatic therapy that removes necrotic tissue from wounds), apply a 4 x 4 gauze and wrap with "Kling" (a roll of gauze bandage) every day, and 2) for staff to cleanse the resident's bilateral breast folds with soap and water, dry the area, and apply [MEDICATION NAME] powder (a prescription anti-fungal medication used to treat fungal infections) twice a day. The care plan also stated nursing would complete a skin assessment every week and report any alterations to the physician. Review of a Wound Evaluation Flow Sheet revealed facility staff had documented Resident #14's wound measurements on 05/18/12, as "1.5 cm x 1.5 cm x 0.0 cm," and on 06/01/12 (fourteen days after the previous assessment) as "1.0 cm x 1.2 x 0.0 cm" then weekly for the next three weeks until 06/29/12. However, there were no other measurements documented on the flow sheet from 06/29/12, until 07/27/12, (a timeframe of twenty-eight days). Review of the Wound Evaluation Flow Sheet revealed the sheet was to be completed by a nurse upon identification of a wound and at least weekly from the date of identification. However, based on documentation, the staff failed to conduct a wound assessment for weeks of 05/21/12, 07/02/12, 07/09/12, and 07/16/12. 5. A review of Resident #5's medical record revealed the facility admitted the resident on 01/14/12, with [DIAGNOSES REDACTED]. Continued review of Resident #5's medical record revealed nurse's noted dated 09/05/12 that revealed the resident's physician was notified the resident had a Stage II pressure ulcer to the coccyx. Treatment orders were obtained to cleanse the coccyx with normal saline, pat dry, apply [MEDICATION NAME] AG then a 4 x 4 gauze, and secure with [MEDICATION NAME] every seventy-two (72) hours. However, there was no documentation of the appearance or size of the pressure wound. Review of Resident #5's care plan revealed facility staff revised the care plan on 09/05/12, and included the additional interventions for staff to cleanse the area to the resident's coccyx with normal saline, pat dry and apply [MEDICATION NAME] AG, then a 4 x 4 gauze and cover with [MEDICATION NAME] every seventy-two (72) hours. Review of a Wound Evaluation Flow Sheet revealed facility staff failed to document the status of Resident #5's pressure ulcer until 09/14/12 (eighteen days after first identified), when the ulcer measured "1.4 cm x 1.0 cm x 0.2 cm. Review of instructions on the Wound Evaluation Flow Sheet, the sheet was to be completed by a nurse upon identification of a wound and at least weekly from the date of identification. Based on a review of documentation on the Wound Evaluation Flow Sheet, staff failed to conduct a wound assessment for weeks of 08/26/12 and 09/02/12. A review of a Treatment Administration Record (TAR) for September and October 2012, revealed staff was to cleanse Resident #5's coccyx pressure ulcer with normal saline, pat dry, cover with [MEDICATION NAME] AG and a 4 x 4 gauze, and then secure with [MEDICATION NAME] the treatment was to be performed every seventy-two (72) hours. The TAR revealed wound care was performed as ordered by the physician; however failed to document an assessment weekly. 6. A review of Resident #8's medical record revealed the facility admitted the resident on 09/21/10, with [DIAGNOSES REDACTED]. Continued review of Resident #8's medical record revealed nurse's notes dated 08/31/12 that revealed the physician was notified the resident had a Stage II pressure ulcer to the right buttock. Treatment orders were obtained to cleanse the resident's right buttock with normal saline, pat dry then apply [MEDICATION NAME] ointment (an antibacterial used to treat skin infections), cover the area with a [MEDICATION NAME] (a non-adherent absorbent cotton dressing pad), then secure with [MEDICATION NAME] (a self-adhesive, non-woven fabric for dressing retention) every day. However, there was no documentation of the appearance or size of the pressure wound until 09/16/12. Review of Resident #8's care plan revealed the care plan was revised on 09/04/12, and 09/16/12 with additional interventions for staff to cleanse area to the right buttock with normal saline, apply [MEDICATION NAME] ointment then cover with [MEDICATION NAME] pad and secure with [MEDICATION NAME] every day. The care plan revealed nursing staff was to complete a skin assessment every week and to notify the physician of any alterations. Review of a Wound Evaluation Flow Sheet revealed facility staff had failed to document the status of Resident #8's pressure ulcer from 09/16/12 until 10/06/12 (a timeframe of twenty days) and, based on documentation, the ulcer measured "0.4 cm x 0.2 cm x 0.1 cm" on both dates. However, the next measurement on 10/19/12, (thirteen days after the previous assessment), revealed the ulcer measured "4.0 cm X 0.8 cm X 0.1 cm." Review of instructions the Wound Evaluation Flow Sheet revealed the sheet was to be completed by a nurse upon identification of a wound and at least weekly from the date of identification. However, the staff failed to conduct an assessment of the wound on a weekly basis as instructed on the Wound Evaluation Flow Sheet, and failed to assess the wound for several weeks. A review of Resident #8's Treatment Administration Record (TAR) for September and October 2012, revealed staff to cleanse the resident's right buttock with normal saline, pat dry then apply [MEDICATION NAME] ointment (an antibacterial used to treat skin infections), cover the area with a [MEDICATION NAME] (a non-adherent absorbent cotton dressing pad), then secure with [MEDICATION NAME] (a self-adhesive, non-woven fabric for dressing retention) every day. The TAR revealed staff performed wound care as ordered by the physician; however failed to document an assessment weekly. 7. A review of Resident #9's medical record revealed the facility admitted the resident on 03/29/11, with [DIAGNOSES REDACTED]. Review of Resident #9's care plan revealed facility staff revised the care plan on 10/04/12, to include the Stage II pressure ulcer to the right outer hip; however, no additional interventions were noted at that time. According to the care plan, nursing staff was to complete a skin assessment every week and to notify the physician of any alterations. Review of a Wound Evaluation Flow Sheet revealed facility staff had documented on 10/06/12, that the pressure ulcer to the resident's right outer hip measured "3.2 cm X 2.0 cm X 0.1 cm." The next assessment was conducted on 10/20/12 (fourteen days later) and revealed the ulcer measured "2.5 cm X 2.5 cm X 0.1 cm." A review of Resident #9's Treatment Administration Record (TAR) for September and October 2012, revealed staff performed wound care as ordered by the physician; however failed to document an assessment weekly. 8. A review of the medical record for Resident #16 revealed the facility admitted the resident on 08/09/10, with [DIAGNOSES REDACTED]. A review of physician's orders dated 06/15/10 revealed the resident had a physician's order for twenty (20) milliequivalents of Potassium Chloride to be administered to every day. A review of the consultant pharmacist report for Resident #16 dated 07/10/12, revealed the pharmacist documented Resident #16 had been receiving twenty (20) milliequivalents of Potassium Chloride tablets. However, the pharmacist documented Potassium [MEDICATION NAME] had been entered into the new computer system and the medications were not interchangeable. The pharmacist asked the facility to clarify the order. A review of the MAR for Resident #16 revealed on 06/07/12, facility staff had entered the physician's order on the resident's MAR indicated [REDACTED]. A review of the MAR for Resident #16 revealed staff documented the resident had received twenty (20) milliequivalents of Potassium [MEDICATION NAME] on 06/07/12, 06/09/12, 06/10/12, 06/11/12, 06/12/12, 06/16/12, 06/22/12, 06/23/12, 06/24/12, 06/25/12, 06/27/12, 06/28/12, 06/29/12, 06/30/12, 07/01/12, 07/03/12, 07/04/12, 07/06/12, 07/09/12, 07/12/12, and 07/13/12. An interview conducted with Registered Nurse (RN) #5 on 10/31/12, at 1:50 PM, revealed she had administered medications to Resident #16 on 06/12/12, 06/16/12, 06/27/12, 06/30/12, and 07/01/12. The RN stated she had administered Potassium Chloride to Resident #16 on the dates identified. The RN stated she pulled the medication from the medication drawer, saw "Potassium," and had assumed it was the correct medication. The RN stated she should have checked the MAR indicated [REDACTED] An interview conducted with Licensed Practical Nurse (LPN) #4 on 10/31/12, at 2:10 PM, revealed the LPN had been responsible for administering medications to Resident #16 on 06/21/12, and 06/25/12. The LPN stated she could not recall but had probably saw the word "potassium" written on the box and administered the medication. The LPN stated she knew she was required to check the MAR indicated [REDACTED]. An interview conducted with Certified Medication Aide (CMA) #1 on 10/31/12, at 2:15 PM, revealed she had administered medications to Resident #16 on 06/07/12 and 07/09/12. The CMA stated she could not recall the dates and was unsure what medication she administered to the resident. The CMA stated she was required to check the MAR indicated [REDACTED]. LPN #5 acknowledged in interview conducted on 10/31/12, at 5:35 PM that based on documentation she had administered medication for Resident #16 on 06/22/12. The LPN stated she would have given the drug that was in the drawer and could not recall if the medication was Potassium [MEDICATION NAME] or Potassium Chloride. An interview conducted with RN #2 on 11/01/12, at 9:25 AM, revealed she had administered medications for Resident #16 on 06/23/12. The RN stated she was the Nursing Supervisor and had assisted in developing the MAR for the residents. The RN stated she had corrected the MAR indicated [REDACTED]. The RN stated Potassium was listed in several dosages and forms in the computerized system, and that when entering the physician's orders into the computerized system she thought Potassium [MEDICATION NAME] had been keyed in by accident. The RN stated she had not caught the error during reviews of the MAR's. An interview conducted with RN #4 on 11/01/12, at 9:40 AM, revealed she had been administered medications to Resident #16 on 06/09/12, 06/10/12, 06/11/12, 06/24/12, 06/28/12, 06/29/12, 07/03/12, 07/04/12, 07/12/12, and 07/13/12. The RN stated she "guessed" she had just saw the word "Potassium" and had administered the medication that was in the resident's medication drawer. The RN acknowledged she should have checked the medication with the MAR indicated [REDACTED]. An interview conducted with the Consultant Pharmacist (RPH) for the facility on 10/31/12, at 2:35 PM, revealed she had identified the transcription error on 07/10/12. The RPH stated the pharmacy had previously developed the facility's MAR's but the facility had implemented a new computer system for generating the resident MAR's. The RPH stated she had not reviewed the new MAR's until 07/10/12 and at that time the RPH printed what had previously been in the pharmacy system, compared that information with the facility's new MARs, and had identified the error. The RPH stated Potassium [MEDICATION NAME] had not been sent to the facility because it was not available for use, and that facility staff had actually administered the medication Potassium Chloride as prescribed by the physician. An interview conducted with the Director of Nursing (DON) on 11/01/12, at 9:45 AM, revealed the facility had begun utilizing the facility generated MAR's on 06/07/12. The DON stated RN #2 had been responsible for checking the MAR's on the second floor for accuracy prior to the facility utilizing the MAR's on 06/07/12. The DON stated when she received the RPH review of Resident #16's MAR; she immediately gave it to RN #2 to correct the error. The DON stated currently RN #2 and the Assistant Director of Nursing (ADON) were responsible for monitoring all new physician's orders every day, Monday through Friday, and the Minimum Data Set (MDS) nurses were responsible for checking all new physician orders on the weekends. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on 12/13/12, which alleged removal of IJ effective 10/25/12. An Extended Survey was conducted on 12/11-13/12, which determined the IJ was removed on 10/25/12 as alleged. --A review of the AOC revealed the following: On 10/18/12, Licensed Practical Nurse (LPN) #1 was terminated by the Director of Nursing (DON) due to the failure to assess/document Resident #1's wound, notify the physician and responsible party of the change in the resident's wound and the failure to make arrangements for the resident's transportation to the wound clinic. On 10/19/12, the DON reviewed Resident #1's medical record and continued to investigate. On 10/19/12, the Minimum Data Set (MDS) Coordinator reviewed Resident #1's MDS assessment and care plan for accuracy and also reviewed the two (2) most recent MDS assessments of all resident for accuracy. On 10/19/12, Registered Nurses (RN) #4, #6 and LPNs #2, #4, and #13 conducted skin/wound assessments on all residents. Initiated on 10/19/12 and completed on 10/21/12, the DON in-serviced all licensed staff regarding the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, 7) the revisions to the transportation policy/procedures. On 10/20/12, LPN #3 was reprimanded and placed on probation by the DON due to the failure to assess/document Resident #1's wound. On 10/20/12, RN #2 compared the skin/wound assessments completed on 10/19/12, for all residents to each resident's Treatment Administration Records (TARs) and each resident's individual wound documentation flow sheets to ensure all alteration in the residents' skin integrity had been accurately documented. On 10/21/12, RN #2 and LPN #12 compared the skin/wound assessments completed on 10/19/12, for all residents with the documentation in each resident's plan of care, wound documentation flow sheet, and TARs to ensure accuracy of the medical records. LPN #12 also compared the skin/wound assessments with the most recent MDS assessment to ensure all alteration in the residents' skin integrity had been accurately care planned. RN #2 re-assessed/re-measured all new alteration in the residents' skin integrity that had been identified on the skin/wound assessments to ensure the areas were documented accurately on each resident's wound documentation flow sheet. On 10/21/12, RN #2 placed the "Pressure Ulcer documentation guideline" and "How to Identify and Stage Pressure Ulcers" sheets (utilized for in-service) were placed in the nursing policy/procedure manuals and in the wound care monitoring books kept at each nursing station for staff reference. On 10/21/12, the Administrator and the DON rev

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure the Quality Assessment and Assurance Committee (QAAC) was effective to ensure nursing staff followed facility policies and procedures for the assessment of wounds weekly. On 09/12/12, facility staff assessed Resident #1 and documented the resident had a calloused area on the tip of the left great toe. Staff also conducted assessments of the area on 09/13/12 and 09/28/12. On 10/18/12, staff assessed Resident #1's wound to be red, inflamed, and necrotic with sloughing, and purulent drainage and an odor. Resident #1 was transported to an acute care facility on 10/18/12, and the resident's left great toe was amputated on 10/20/12. Interview with staff revealed there were nineteen residents in the facility with wounds, twelve (12) of the nineteen (19) residents were selected for record review and revealed facility staff did not consistently conduct a weekly assessment of the wound in accordance with facility policy for eight (8) resident (Residents #2, #3, #5, #6, #7, #8, #9, and #14). Interviews with the Assistant Director of Nursing (ADON) and Registered Nurse (RN) #2 revealed they had the responsibility to perform Quality Assurance (QA) activities related to resident wounds. Per interviews, they were aware nursing staff failed to consistently documented a skin assessment of wounds on a weekly basis; however, failed to ensure actions were identified as part of the QA that would be required to ensure staff assessed all wounds on a weekly basis, or as ordered, in an effort to prevent wound deterioration and promote wound healing. Further interview revealed no one was responsible for conducting QA activities related to resident wounds on the Secure Unit. (Refer to F282, F309, F314, and F514.) The failure of the facility to ensure the Quality Assessment and Assurance Committee (QAAC) was effective placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 12/11/12, and determined to exist on 10/15/12. The facility was notified of the Immediate Jeopardy on 12/11/12. The facility provided an acceptable credible Allegation of Compliance (AOC) on 12/13/12, with the facility alleging removal of the Immediate Jeopardy on 10/25/12. Immediate Jeopardy was verified to be removed on 10/25/12, as alleged prior to exiting with the facility on 12/13/12, with remaining noncompliance at 42 CFR 483.75 Administration, with a scope and severity of "D", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance. The findings include: A review of the facility's policy titled "Quality Control," (undated) revealed the facility had a quality control program that that identified specific deficiencies, measured the level of quality services by each department, and continually furnish information that would aid the facility in taking corrective action for problems that were identified. In addition, the policy revealed quality control records would be maintained and would be discussed quarterly during committee meetings. The policy also stated any items requiring corrective action would be discussed with the Administrator as they arose. A review of Resident #1's closed medical record revealed the facility admitted the resident on 06/26/12 for rehabilitation due to a Right [MEDICAL CONDITION] (BKA) and [DIAGNOSES REDACTED]. Continued review of the medical record revealed Licensed Practical Nurse (LPN) #1 documented at 9:30 PM on 09/12/12 (approximately two and one-half months after admission) that Resident #1 had a scabbed area to the left great toe that measured less than 0.1 centimeter (cm) in diameter. Review of a Wound Evaluation Flow Sheet revealed facility staff had documented Resident #1's wound measurements on 09/13/12 as "2.2 cm x 1.8 cm x 0.1 cm," and on 09/28/12 as "1.4 cm x 0.2 x 0.1 cm"; however, staff failed to conduct and document wound assessments on a weekly basis as required by facility policy. Continued review of the medical record revealed at 10:30 AM on 10/18/12, (twenty (20) days after the previous assessment) Resident #1's family member insisted on observing the resident's wound. Documentation revealed LPN #1 and the Assistant Director of Nursing (ADON) removed the dressing from the resident's left great toe and the wound was observed to be red, inflamed, with a necrotic area, yellow sloughing and an odor. Further review of the medical record revealed the resident was transported to an acute care facility on 10/18/12, at 3:15 PM for further assessment and treatment. A review of a Surgical Report dated 10/20/12, revealed Resident #1's the left great toe was amputated secondary to ulceration with wet gangrene. An interview on 10/23/12, at 6:15 PM the Director of Nursing (DON) revealed staff should assess, measure, and document the status of the wounds of residents at least once a week. The interview revealed the facility provided nurses in-service training twice a year related to the assessment, measurement, and documentation of wounds. A review of the Wound Evaluation Flow Sheets for the eight (8) sampled residents (Residents #2, #3, #5, #6, #7, #8, #9, and #14) chosen from the nineteen (19) residents in the facility with wounds revealed the facility failed to ensure nursing staff consistently assessed/documented the status of the residents' wounds once a week in accordance with facility policy. An interview on 10/23/12, at 7:10 PM with the ADON revealed she gathered information on the first floor nursing unit of resident wounds for purposes of Quality Assurance (QA). The ADON stated she completed a Continuous Quality Indicator (CQI) assessment sheet once a month and had identified staff nurses failed to conduct weekly wound assessment as required. The ADON stated she had reported the problems to the former Assistant Administrator, but this problem was not discussed/addressed in the quarterly QAAC meetings. An interview on 10/23/12, at 7:30 PM with RN #2 revealed she gathered information on the second floor nursing unit of resident wounds for purposes of Quality Assurance (QA). RN #2 also stated she completed a CQI assessment sheet once a month and had also identified nurses had failed to conduct weekly wound assessments. The interview revealed she had not reported this problem to any Administrative staff or discussed/addressed the problem in the quarterly QAAC meetings. An interview on 10/25/12, at 5:10 PM with the Director of Nursing (DON) revealed the facility's policy for wound assessments was to assess measure and document the wound assessment on the Wound Flow Sheet. According to the DON, staff was to conduct the assessments one time a week, on Fridays. The DON stated she had assisted with obtaining information for QA in September 2012, and had noticed several weekly wound assessments had not been completed. The DON stated she made a list of residents that needed a wound assessment, requested the week-end nurses obtain the assessments and had "followed up" to ensure all the assessments had been obtained. The DON stated she was unaware staff continued to fail to conduct weekly wound assessments until she started the investigation into the deterioration of Resident #1's wound on 10/18/12. According to the DON, she "knew it was missed at times but didn't realize it was such a big systems failure until the investigation was done." The interview confirmed the DON was unaware no one was responsible/assigned to conducted QA activities on wounds on the Secure Unit. An interview on 11/01/12, at 1:10 PM with the Assistant Administrator revealed she had been the Assistant Administrator for approximately one year and also functioned as the facility's QA Coordinator. The interview revealed the ADON and RN #2 had been given the responsibility to audit wound development and obtain information related to what contributed to the development of the wound. According to the Assistant Administrator, the ADON and RN #2 were also to determine the stage of wounds, ensure the wound was addressed on the resident's care plan, what the treatment was, if the treatment was effective, if there were nutritional interventions, physician/representative notification, changes in the wounds, or if there had been an increase in number of wounds. The Assistant Administrator stated she was not aware staff had not always conducted the weekly assessment of wounds in accordance to facility policy, or that staff had failed to report the information to the QAAC. The interview confirmed the Assistant Administrator was unaware no one was responsible/assigned to conducted QA activities on wounds on the Secure Unit. An interview on 10/25/12, at 5:45 PM with the Administrator revealed facility staff were to obtain information related to wounds and provide the information to the facility's Continuous Quality Improvement (CQI) program. The interview revealed nurses were to assess wounds once a week and record the assessment on the Wound Flow Sheet and the wound logbook in accordance with facility policy. According to the Administrator, she was unaware nurses had failed to conduct the weekly wound assessments until the facility initiated the investigation into the deterioration of Resident #1's wound. The Administrator acknowledged in interview conducted at 3:45 PM on 11/01/12, at 3:45 PM QA staff had not looked at the complete QA process to ensure the facility's QA program was completely effective. The interview confirmed the Administrator was unaware no one was responsible/assigned to conducted QA activities on wounds on the Secure Unit. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy (IJ) was submitted by the facility on 12/13/12, which alleged removal of IJ effective 10/25/12. An Extended Survey was conducted on 12/11-13/12, which determined the IJ was removed on 10/25/12 as alleged. --A review of the AOC revealed the following: On 10/19/12, the DON reviewed Resident #1's medical record and continued to investigate. Initiated on 10/19/12 and completed on 10/21/12, the DON in-serviced all licensed staff regarding the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, 7) the revisions to the transportation policy/procedures. As part of the facility's CQI for monitoring skin assessments upon admission, the DON has 1) Reviewed all skin assessments on new admissions and readmissions and compared the skin assessment with her own skin assessment of the resident to ensure all areas have been identified, staged and measured accurately. 2) Reviewed the new admissions and readmissions chart to ensure the physician and family were notified of any skin areas, that appropriate treatment is being utilized to all skin areas and all skin areas were appropriately documented on the wound monitoring flow sheet for the resident. As part of the facility's CQI for monitoring the transportation arrangement, the Assistant Administrator or the Activity Director will review the transportation logs on each unit to ensure all transportation arrangements have been made and any problems identified will be reported to the nursing administration immediately for correction. The DON and RN #2 will review all residents' weekly nurses summary (which include a skin assessment) and assess each resident to ensure the skin assessment matches and ensure the physician was notified of any new alterations in skin integrity or changes in condition. The nurse completing the weekly skin assessments will notify the physician of any changes, obtain new orders and update the resident's plan of care with the new orders. The Administrator formed a QA subcommittee which consists of each department head/manager that will meet weekly to review the monitoring tools recently developed to improve the facility's QA program. The Assistant Administrator/QA Coordinator will report all monitoring results in the quarterly CQI meetings. A decision was made to hire a full time QA nurse with [AGE] years' experience, who will start employment on 11/19/12. --The surveyors validated the corrective actions taken by the facility as follows: Interview on 12/12/12, at 4:40 PM with the DON and review notes dated 10/19/12, revealed the DON reviewed Resident #1's medical record investigating the resident's wound and appointment issues. Interview on 12/12/12, at 4:40 PM with the DON and review in-service records dated 10/19/12, through 10/21/12, revealed the DON in-serviced all licensed staff regarding the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, and 7) the revisions to the transportation policy/procedures. Interviews on 12/12/12, at 11:00 AM with RN #2, at 2:15 PM with LPN #4, at 5:00 PM with LPN #12, on 12/13/12, at 2:00 PM with LPN #9, at 11:00 AM with RN #4, at 11:10 AM with LPN #2, at 1:15 PM with RN #6 and at 1:20 PM with LPN #13 confirmed the licensed staff were in-serviced on the following: 1) assessment, measuring, treatments and documentation of wounds, 2) maintaining accurate medical records, 3) physician and responsible party notification of change in condition, 4) scheduling appointments, 5) making transportation arrangements, 6) utilizing the transportation log, and 7) the revisions to the transportation policy/procedures. Interview on 12/12/12, at 4:40 PM with the DON and review of documentation of the only resident that had been admitted since 10/25/12, revealed as part of the facility's CQI for monitoring skin assessments upon admission, the DON reviewed the resident's skin assessments and compared the skin assessment with her own skin assessment of the resident to ensure all areas have been identified, staged and measured accurately. The DON further reviewed the resident's chart to ensure the physician and family were notified of any skin areas, that appropriate treatment was being utilized to all skin areas and all skin areas were appropriately documented on the wound monitoring flow sheet for the resident. Interviews on 12/13/12, at 3:10 PM with the Assistant Administrator, on 12/12/12, at 4:25 PM and on 12/13/12, at 1:40 PM with the Activity Director and review of the Activity Director's audit book revealed as part of the facility's CQI for monitoring the transportation arrangement, the Activity Director had been reviewing the transportation logs on each unit to ensure all transportation arrangements have been made and no problems have been identified; however, if a problem is identified it will be reported to the nursing administration immediately for correction. Interview on 12/12/12, at 4:40 PM with the DON, at 11:00 AM with RN #2 and review of their personal hand written notes revealed the DON and RN #2 will review all weekly nurses summaries of each resident, including skin assessment and assess each resident to ensure the skin assessment matches and ensure the physician was notified of any new alterations in skin integrity or changes in condition. The nurse completing the weekly skin assessments will notify the physician of any changes, obtain new orders and update the resident's plan of care with the new orders. Interviews on 12/12/12, at 4:40 PM with the DON, on 12/13/12, at 2:55 PM with the Administrator, at 3:10 PM with the Assistant Administrator, at 1:40 PM with the Activity Director and review of the QA subcommittee meeting minutes for 10/23/12, revealed the Administrator formed a QA subcommittee which consists of each department head/manager that meet weekly to review the monitoring tools recently developed to improve the facility's QA program. Interviews on 12/13/12, at 2:55 PM with the Administrator, and at 3:10 PM with the Assistant Administrator revealed the Assistant Administrator/QA Coordinator will report all monitoring results in the quarterly CQI meetings. Interview on 12/13/12, at 11:45 AM with the newly hired QA nurse and review of her employee file revealed she started employment on 11/19/12, and will be working full time.

Based on observation, interview, record review and a review of facility policies/procedures, it was determined there were fifteen (15) residents in the facility with pressure sores and nine (9) of the fifteen residents were selected for review. A review of the nine (9) residents with pressure sores revealed the facility failed to ensure necessary treatment/services to promote healing or prevent the development of new pressure sores was provided for seven (7) of the residents (Resident #2, #3, #5, #6, #7, #8 and #9). The facility failed to perform weekly wound assessments as per facility policy for Residents #2, #3, #5, #8 and #9. In addition, the facility failed to follow physician orders related to wound care for Resident #3, #6 and #7 and also failed to turn/reposition Resident #7 in accordance with the resident's care plan. (Refer to F282 and F514.) The findings include: Review of the facility policy entitled "Skin Care" revised September 2001, revealed wounds were required to be measured and recorded weekly. Review of the facility policy entitled "Wound Documentation" (undated) revealed pressure ulcers, diabetic ulcers and other wounds deemed necessary to measure should be measured weekly by licensed staff. The policy revealed documentation should include wound location, stage, size, tunneling, undermining, necrotic tissue, sloughing tissue, eschar, drainage, granulation, description of surrounding tissue, pain, and support surface. Review further revealed if the wound did not show improvement or there were changes (such as warmth, redness of surrounding tissue, necrotic tissue or odor) the physician should be notified. 1. Review of Resident #3's medical record revealed the facility admitted the resident on 10/04/12 with multiple Pressure Ulcers and [DIAGNOSES REDACTED]. Review of Resident #3's Wound Evaluation Flow Sheet revealed on 10/04/12, the resident had an area to a bunion on the left foot that measured 0.6 centimeters (cm) x 0.4 cm x unable to determine (UTD); an area to the left outer ankle with measurements of 0.4 cm x 0.4 cm x UTD; an area to the left heel that measured 1.7 cm x 2.3 cm x UTD; a Stage II to the coccyx with measurements of 3 cm x 3 cm x 0.2 cm; and an area to the right heel with no measurements. A review of the monthly Physician's orders for October 2012, revealed an order for [REDACTED]. The orders revealed staff was to cleanse the coccyx with normal saline, apply [MEDICATION NAME] AG Extra [MEDICATION NAME] dressing cover with Transparent dressing every three (3) days. Review of Resident #3's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was at risk for pressure ulcers and was admitted with several pressure ulcers at various stages. Review of Resident #3's plan of care dated 10/24/12, revealed the facility addressed the resident's risk for impaired skin integrity related to stage II pressure ulcer to the coccyx, unstageable ulcers to bilateral heels, and stage II pressure areas to the resident's lower ankle. A review of interventions revealed nursing staff was 1) to complete a skin assessment every week and report any alterations to the physician and 2) to provide treatments as ordered by the physician. Further review of Resident #3's Wound Evaluation Flow Sheet revealed no other assessments of the wounds had been conducted until 10/20/12 (a timeframe of sixteen days after the last assessment). The flow sheet revealed on 10/20/12, the bunion to the resident's left foot measured slightly larger at 0.6 cm x 0.5 cm x UTD; the area to the left outer ankle measured slightly larger at 0.4 cm x 0.5 cm x UTD; the area to the left heel measured the same; the Stage II to the coccyx measured larger at 7 cm x 3.5 cm x UTD; and the area to the right heel measured 3.4 cm x 4.1 cm x UTD and the area to the resident's left third toe measuring 0.6 cm x 0.8 cm x UTD. There was no documented evidence the resident's physician was notified for the increase in size of the resident's wounds to the left foot, left outer ankle, and coccyx. Review of Resident #3's Treatment Administration Record (TAR) for October 2012, revealed Licensed Practical Nurse (LPN) #7 documented the treatment had been provided to the resident's feet on 10/27/12 and 10/28/12. In addition, documentation revealed LPN #6 provided the treatment on 10/29/12. Observation on 10/30/12, at 3:00 PM of Resident #3's wound care performed by LPN #3 revealed the area to the resident's coccyx had red tissue surrounding the open wound which, based on measurements obtained by the LPN, measured 8.3 cm x 6.2 cm, and the open wound measured 5.4 cm x 4.7 cm x 0.5 cm. The coccyx wound was pink with yellow/white sloughing noted. The observation revealed the "Kling" dressings to both heels had a date of 10/26/12, written in black marker on both dressings. LPN #3 acknowledged the initials on the dressings were hers and stated although she had not worked for the last three (3) days, the wound care to the resident's feet was ordered to be completed every day. The resident's right inner ankle was slightly red with no open wounds, the right heel was boggy and dark measuring 2.2 cm x 3.4 cm, and the left outer ankle was yellow, with a slight amount of yellow drainage noted on the old dressing, and measured 1.2 cm x 1 cm x 0.1 cm. The left heel had a dark area that measured 1.5 cm x 1.2 cm. The bunion to the outer side of the resident's left foot was dark and measured 0.4 cm x 0.4 cm and the third toe on the left foot had black edge on a dark area that measured 0.4 cm x 0.8 cm. Interview on 10/30/12, at 6:17 PM with LPN #7 revealed she had signed that the treatments to Resident #3's heels on 10/27/12 and 10/28/12 had been provided; however, the LPN acknowledged she had not completed the treatments. LPN #7 stated she ran out of time, but had reported the treatments had not been provided to the night nurse (LPN #8) who was supposed to provide the treatments. During an interview on 10/30/12, at 6:40 PM with LPN #8, the LPN stated she had not provided treatments to Resident #3's heels on 10/27/12 and 10/28/12. LPN #8 also stated she had not been notified that Resident #3's treatments needed to be provided. Interview on 10/30/12, at 5:20 PM with LPN #6 confirmed the LPN signed off the treatment to Resident #3's heels on 10/29/12, but did not complete the treatment. LPN #6 stated she provided wound care to the resident's coccyx, but was called out of the room before providing wound care to the resident's heels. The interview revealed the LPN "forgot" to go back and provide the wound care to the resident's heels. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 10/31/11, with [DIAGNOSES REDACTED]. Resident #2's medical record revealed the resident was readmitted from an acute care facility on 08/06/12 with a pressure ulcer to the left buttock and blisters to both heels. The Wound Evaluation Flow Sheet revealed the wounds were assessed on 08/07/12 (one day after re-admission) and the wound to the left buttock measured 3 cm x 3.5 cm x 4 cm; the left heel wound measured 5 cm x 5 cm; and the right heel wound measured 5 cm x 5 cm. Review of Resident #2's Significant Change MDS assessment dated [DATE], revealed a decline in the resident's cognition, Activities of Daily Living (ADL) status, continence, and new development of pressure ulcers following a hospitalization . Review of Resident #2's plan of care dated 11/20/11, revealed the facility addressed the resident's risk for alteration in skin integrity and at risk for development of pressure ulcers was revised on 08/06/12, when the resident was readmitted with unstageable pressure ulcers to both heels and a Stage IV to the left buttocks, with interventions to provide treatments as ordered by the physician. Continuous review of Resident #2's Wound Evaluation Flow Sheet dated 08/19/12, revealed documentation that the left heel wound measured 6.1 cm x 8.6 cm x UTD; there were no documented measurements of the wound to the resident's right heel and the wound on the resident's left buttocks measured 3 cm x 3.4 cm x 5 cm. There was no documented evidence the physician was notified of the increase in size of the left heel wound. The Wound Evaluation Flow Sheet revealed the next documented assessment of the Resident #2's wound to the left buttock was on 09/07/12 (4 weeks after the previous assessment on 08/07/12) and the wound measured 3 cm x 3 cm x UTD. There was no documentation of an assessment and/or measurement of the wounds on Resident #2's heels. Further review of the Wound Evaluation Flow Sheets revealed on 09/14/12 (5 weeks after the previous assessment on 08/19/12) the wound to the resident's left heel measured 2 cm x 2 cm and the right heel wound measured 2.5 cm x 1 cm. Review of the Wound Evaluation Flow Sheet revealed the next measurement of the resident's left heel was on 10/21/12 (four weeks after the previous assessment) and revealed the wound measured 3 cm x 1.8 cm. Observation on 10/23/12, at 3:40 PM, of Resident #2's wound care with LPN #2 revealed a dark, dry, scabbed area with redness of the wound on the left heel and a small amount of swelling around the wound. The wound measured 3 cm x 1.5 cm with no drainage or odor. The observation revealed the right heel had no wound and the resident's buttocks had a [DEVICE] with an occlusive dressing. Interview on 10/23/12, at 7:30 PM, with Registered Nurse (RN) #2, revealed she was unsure why nurses had failed to document weekly wounds assessments for Resident #2. 3. A review of Resident #5's medical record revealed the facility admitted the resident on 01/14/12, with [DIAGNOSES REDACTED]. Continued review of Resident #5's medical record revealed nurse's notes dated 08/27/12, that the resident's physician was notified the resident had a Stage II pressure ulcer to the coccyx. Treatment orders were obtained to cleanse the resident's coccyx area with normal saline, pat the area dry, apply [MEDICATION NAME] ointment (an antibacterial used to treat skin infections), and to cover the area with a "[MEDICATION NAME]" pad (non-adherent absorbent cotton dressing) and [MEDICATION NAME] (self-adhesive, non-woven fabric for dressing retention) every day. However, there was no documentation of the appearance or size of the pressure wound. Review of Resident #5's plan of care revealed a revision date of 09/05/12, with additional interventions for staff to cleanse area to the coccyx with normal saline, pat dry and apply [MEDICATION NAME] AG (a silver impregnated antimicrobial dressing which reduces the number of bacteria in the wound) and a 4 x 4 gauze and cover with [MEDICATION NAME] every seventy-two (72) hours. Review of a Wound Evaluation Flow Sheet revealed facility staff failed to document the status of Resident #5's pressure ulcer until 09/14/12, (eighteen days after first identified), and at that time, the ulcer measured 1.4 cm x 1.0 cm x 0.2 cm. Review of the Wound Evaluation Flow Sheet revealed the form was to be completed by a nurse upon identification of a wound and at least weekly from the date of identification. However, a review of the Wound Evaluation Flow Sheet revealed staff failed to conduct an assessment of Resident #5's wound during the weeks of 08/26/12, and 09/02/12. A review of instructions on a Treatment Administration Record (TAR) for September and October 2012, revealed staff was to cleanse Resident #5's coccyx pressure ulcer with normal saline, pat dry, cover with [MEDICATION NAME] AG and a 4 x 4 gauze, and then secure with [MEDICATION NAME] Kling. The treatment was to be performed every seventy-two (72) hours. The TAR revealed wound care was performed as ordered by the physician. 4. A review of Resident #6's medical record revealed the facility admitted the resident on 08/17/12. A review of Resident #6's Wound Evaluation Flow Sheet revealed on 10/21/12, the facility identified a new Stage II pressure sore to the right buttock area on Resident #6. The facility assessed the wound to measure 1.0 cm x 1.5 cm x 0.1 cm. The facility further assessed the wound to be red with no drainage and a small amount of brown crust. A review of physician's orders dated 10/21/12, revealed an order to clean the Stage II on Resident #6's right buttock with normal saline, pat the area dry, apply "[MEDICATION NAME]" (a topical treatment for [REDACTED]. Observation of a skin assessment of Resident #6 on 10/25/12, at 4:08 PM revealed a dressing in place on the right buttock. Observation revealed a Stage II wound was approximately three (3) inches from the dressing. Interview with LPN #5 during the skin assessment at 4:08 PM on 10/25/12, revealed Resident #6 had previously received wound care on 10/25/12, by Certified Medication Aide (CMA) #1, so the dressing was not removed for this observation. LPN #5 stated she was not aware Resident #6 had developed a second Stage II wound and stated the wound did not "look new." Interview on 10/25/12, at 4:40 PM with Certified Medication Assistant (CMA) #1 revealed the CMA had performed wound care on Resident #6 at approximately 10:00 AM on the morning of 10/25/12. The CMA stated during wound care to Resident #6 the resident only had one wound on the right buttock and that wound was treated as per physician order. The CMA further stated she had not identified another wound on Resident #6's buttocks during wound care. Review of facility's "Job Description" for "Certified Medication Technician" undated revealed CMTs can observe, monitor, and report symptoms of potential skin breakdown and/or decubitus ulcers to the Charge Nurse and provide treatment as directed. A review of a physician note dated 10/26/12, revealed Resident #6 had a Stage II pressure sore to the right buttock and a tape abrasion to the right buttock in the same vicinity. The note further revealed a nursing aide had inadequately covered the abrasion with the treatment that was ordered for the Stage II pressure sore, and as a result, facility staff failed to provide the treatment as ordered by the physician to the Stage II pressure sore on the resident's right buttock. 5. Review of Resident #7's medical record revealed the facility admitted the resident on 08/23/12. A review of Resident #7's Minimum Data Set (MDS) Assessment completed after admission, dated 08/30/12, revealed the facility assessed Resident #7 to be cognitively intact. Further review revealed the facility assessed Resident #7 to require extensive assistance from two (2) staff with bed mobility. A review of Resident #7's comprehensive plan of care dated 09/12/12 revealed the resident was at risk for alteration in skin integrity due to the resident's dependency on two (2) staff to provide the resident "weight-bearing" assistance, position changes, and bed mobility every two (2) hours and as needed. A review of the October 2012, Certified Nursing Assistant (CNA) care plan revealed staff was required to reposition Resident #7 every two (2) hours. Observations were conducted of Resident #7 on 10/30/12, at 8:57 AM, 9:38 AM, 11:18 AM, 12:27 PM, 3:20 PM, 4:50 PM and 6:30 PM. During each observation Resident #7 was positioned in bed on his/her right side. Interview with Resident #7 on 10/25/12, at 11:55 AM revealed staff did not assist the resident with turning and repositioning every two (2) hours. Resident #7 stated, "They (staff) don't offer" to assist the resident with turns and reposition. Resident #7 further stated staff encouraged the resident to stay off his/her right side, but stated, "Sometimes I forget." A second interview with Resident #7 on 10/30/12, at 7:50 PM revealed, it "would be nice if staff helped (her/him) turn." Interview with CNA #5 on 10/30/12, at 12:42 PM, and CNA #13 at 12:00 PM revealed they were not aware Resident #7 required assistance with turning and repositioning every two (2) hours. Both CNA #5 and CNA #13 stated Resident #7 turned her/himself in bed and were not aware Resident #7's care plan stated the resident required assistance with turning and repositioning every two (2) hours. However, the CNA care plan for Resident #7 revealed staff was required to reposition the resident every two (2) hours. Interview with Registered Nurse (RN) #2 on 10/30/12, at 3:15 PM revealed CNAs were required to review care plans daily for each resident and provide the care that the care plan required. In addition, a review of Resident #7's nurse's notes dated 10/28/12 revealed the resident had complained of pain to the right hip. Upon assessment by facility staff, an "abrasion" was observed on the resident's right hip. A review of physician orders, not dated, revealed an order to clean the abrasion to the right hip with normal saline, pat the area dry, apply "[MEDICATION NAME]," cover with "[MEDICATION NAME]," and secure with "[MEDICATION NAME]" daily, for ten days. Observation during a wound care assessment, on 10/30/12, at 10:30 AM of Resident #7's right hip revealed a Stage II pressure sore that measured 1.6 cm x 1.8 cm, with no dressing in place. A review of Resident #7's October 2012 Treatment Administration Record (TAR) revealed the physician ordered treatment was documented on the TAR to be provided daily; however, no treatment was documented on 10/29/12. Interview with LPN #2 on 10/31/12, at 9:15 PM revealed she did not provide treatment to Resident #7's wound on 10/29/12. The LPN stated, "It was a crazy day" on 10/29/12, and she must have forgotten to perform the wound care. 6. A review of Resident #8's medical record revealed the facility admitted the resident on 09/21/10, with [DIAGNOSES REDACTED]. Continued review of Resident #8's medical record revealed nurse's notes dated 08/31/12, which revealed staff notified the resident physician the resident had a Stage II pressure ulcer to the right buttock. Treatment orders were obtained to cleanse the resident's right buttock with normal saline, pat dry, apply [MEDICATION NAME] ointment (an antibacterial used to treat skin infections), cover with a "[MEDICATION NAME]" (a non-adherent absorbent cotton dressing pad), and to secure the "[MEDICATION NAME]" with a [MEDICATION NAME] (a self-adhesive, non-woven fabric for dressing retention). The treatment was to be performed every day. However, facility staff failed to document the appearance or size of the pressure wound until 09/16/12. Review of Resident #8's care plan revealed the care plan was revised on 09/04/12, and on 09/16/12, to include the treatment as directed by the physician. Based on documentation, interventions had been added to the plan of care for staff to cleanse area to the resident's right buttocks with normal saline, apply [MEDICATION NAME] ointment, cover with a "[MEDICATION NAME]" pad, and secure with "[MEDICATION NAME]," on a daily basis. The care plan required nursing to complete a skin assessment every week and to notify the physician of any alterations. Review of a Wound Evaluation Flow Sheet revealed facility staff had failed to document the status of and/or treatment to Resident #8's pressure ulcer from 09/16/12 until 10/06/12 (twenty days later), when the ulcer measured "0.4 cm x 0.2 cm x 0.1 cm" on both dates. However, documentation revealed staff assessed the resident's wound on 10/19/12, (thirteen days after the previous assessment) and noted the ulcer measured "4.0 cm x 0.8 cm x 0.1 cm." Review of the Wound Evaluation Flow Sheet revealed the sheet was to be completed by a nurse upon identification of a wound and at least weekly from the date of identification. However, based on documentation, the staff failed to conduct a wound assessment for several weeks. A review of Resident #8's Treatment Administration Record (TAR) for September and October 2012, revealed staff was to cleanse the resident's right buttock with normal saline, pat dry, apply [MEDICATION NAME] ointment (an antibacterial used to treat skin infections), cover with a "[MEDICATION NAME]" (a non-adherent absorbent cotton dressing pad), and to secure the "[MEDICATION NAME]" with a [MEDICATION NAME] (a self-adhesive, non-woven fabric for dressing retention). The TAR revealed wound care was performed as ordered by the physician. 7. A review of Resident #9's medical record revealed the facility admitted the resident on 03/29/11, with [DIAGNOSES REDACTED]. Review of Resident #9's care plan revealed the care plan was revised on 10/04/12, to include the Stage II pressure ulcer to the resident's right outer hip; however, at the time of the revision, there were no additional interventions added to the care plan to address the pressure area. Based on documentation on the care plan, staff was to complete a skin assessment every week and to notify the physician of any alterations in the resident's skin integrity. Review of a Wound Evaluation Flow Sheet revealed facility staff documented on 10/06/12 that the pressure area to Resident #9's right outer hip measured "3.2 cm x 2.0 cm x 0.1 cm." The next assessment was conducted on 10/20/12 (fourteen days after the previous assessment) and revealed the ulcer measured "2.5 cm x 2.5 cm x 0.1 cm." A review of Resident #9's Treatment Administration Record (TAR) for September and October 2012, revealed staff was to cleanse the resident's right buttock with normal saline, pat dry, apply [MEDICATION NAME] ointment (an antibacterial used to treat skin infections), cover with a "[MEDICATION NAME]" (a non-adherent absorbent cotton dressing pad), and to secure the "[MEDICATION NAME]" with a [MEDICATION NAME] (a self-adhesive, non-woven fabric for dressing retention) daily. The TAR revealed wound care was performed as ordered by the physician. Interviews on 10/23/12, at 6:15 PM with the Administrator and the Director of Nursing (DON) revealed the nurse assigned to the resident on Friday of each week was required to assess wounds unless the resident's dressing was not scheduled to be changed on Friday. In that case, the resident's wound was required to be assessed on the day the dressing was changed, either Wednesday or Thursday. The interview revealed staff was required to assess the wound, including measurements, and document the assessment on the Wound Evaluation Flow Sheet. The interview revealed the Quality Assurance (QA) nurses were to ensure wounds were assessed per facility policy and report any issues to the QA Committee. (Refer to F520.) Further interview on 11/01/12, at 2:30 PM with the Director of Nursing (DON) revealed staff should review physician's orders prior to treatments to ensure treatments were performed in accordance with physician's orders. Further interview with the Administrator on 11/01/12, at 3:45 PM revealed nurse are to follow physician's orders this is a nursing "standard of practice."

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure one of twenty-four sampled residents (Resident #14) received adequate supervision and assistive devices to prevent accidents. (Refer to F282.) The facility assessed Resident #14 to require the assistance of a minimum of two staff persons for transfers. However, on 04/09/12, one staff person transferred the resident from the bed to a wheelchair, and the resident sustained [REDACTED]. As a result of the injury, Resident #14 required evaluation at an Emergency Department on two separate occasions. On 04/09/12, Resident #14 was transferred to the emergency room for evaluation due to swelling, pain, and redness of the left ankle. On 04/18/12, Resident #14 experienced increased pain, (refused for staff to touch the ankle), swelling and developed a necrotic area at the injured site. On 04/18/12, Resident #14 was transferred to the emergency room for evaluation, was diagnosed with [REDACTED]. In addition, on 04/26/12, a hematoma formed at the injured site and wound care was required for the left ankle. The facility also failed to ensure the resident's environment remained as free of accident hazards as possible. A review of the facility policy titled Safety of Water Temperatures Dated 10/20/08, revealed water heaters that service common areas shall be set to temperatures of no more than 110 degrees Fahrenheit. During environmental tour on 10/31/12 at 11:04 AM water temperatures at a sink in the secured unit was observed to be 138 degrees Fahrenheit. In addition, a switch that controlled and disabled the cooking stove was located in an unlocked cabinet near the stove. The findings include: Review of the facility's policy titled, Safety and Supervision of Residents (revised 10/20/09) revealed the resident's environment would be as free from accident hazards as possible. The policy indicated resident safety, supervision and assistance to prevent accidents was a facility wide priority. A review of the facility's policy titled, Care Plans-Comprehensive (revised 10/20/08) revealed the Certified Nursing Assistant (CNA) care plans would be developed from the comprehensive care plan and would identify specific care area needs and approaches necessary for the CNAs to provide daily care to individual residents. Review of an in-service conducted 01/31/12, revealed CNAs were instructed to review the CNA care plan/assignment sheet and carry it at all times. The in-service informed staff the care plan listed all the care needs of residents. The in-service stressed failure to follow the CNA assignment sheet could result in resident and employee injury and staff would be subject to written warnings or termination for not following the care plan/assignment sheet. Further review revealed resident safety was a priority and every effort should be made to avoid resident/staff injury during transfers. 1. Review of the record revealed the facility admitted Resident #14 on 01/07/11, with [DIAGNOSES REDACTED]. The Comprehensive Annual assessment dated [DATE] and a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was at risk for falls. Facility staff assessed Resident #14's risk for falls was related to environmental factors; impaired balance and coordination during transfers; the resident's unsteady gait and his/her decreased awareness for safety; impaired cognition, hearing problems, limited range of motion of the left upper extremity secondary to a previous CVA, incontinence, generalized weakness and the use of a wheelchair for mobility. The Quarterly MDS Assessment revealed the facility had assessed the resident to require extensive physical assistance of a minimum of two staff persons with transfers; the resident was to wear non-skid footwear for safety; and CNAs were to assist the resident with all transfers. Review of Resident #14's Comprehensive Care Plan developed on 01/27/11 and last reviewed/revised on 10/22/12, revealed the facility developed a plan of care for Resident #14's risk for falls with injury, his/her impaired mobility, generalized weakness with interventions which included staff assistance for transfers. In addition, a review of the CNA Care Record dated April 2012, and the most recent CNA Care Record dated October 2012, revealed the CNAs were instructed Resident #14 was at risk for falls, required the assistance of two staff for transfers, had weakness of the left hand and arm, and required the use of a gait belt with transfers. The CNA Care Record also directed staff to report any sign of injury to the nurse. A review of an Incident Report Tracking log, on 04/09/12 at approximately 9:30 AM, CNA #15 transferred Resident #14 from the bed to a wheelchair without assistance and Resident #14 sustained an injury to the left ankle. According to the nurse's note dated 04/09/12 at 1:50 PM, Resident #14 experienced "severe" pain of the left foot/ankle and refused for staff to touch the foot. Further review of the nurses' notes, Incident Report Tracking log, and a review of the Treatment Administration Record (TAR) revealed on 04/09/12, Resident #14 was transferred to the emergency room for evaluation due to the complaint of pain, redness, and swelling of the left foot. According to the Patient Transfer Form, Resident #14 was transferred as the result of hitting his/her left foot on the wheelchair and resident complained of "a lot of pain." The transfer form revealed the resident's left ankle was swollen. Continued review of the Incident Report Tracking log revealed Resident #14 was transferred from the facility to an Emergency Department on 04/09/12 at 2:00 PM and returned to the facility that evening. A review of the Emergency Department's discharge instructions dated 04/09/12 revealed Resident #14 had a foot contusion with soft tissue injury and was to apply an ace bandage and keep the left foot elevated five days. Review of the Medication Administration Record (MAR) for April 2012, revealed following Resident #14's return to the facility from the Emergency Department, Resident #14 complained of pain on 04/11/12 at 9:00 AM, related to the injury to the left foot and required 5/500 milligrams of Lortab (analgesic/narcotic) and 500 milligrams of Extra Strength Tylenol for pain. On 04/18/12, nine days following the incident on 04/09/12, nurse's notes, and Patient Transfer Form dated 04/18/12, revealed Resident #14 experienced increased pain, (resident refused for staff to touch the ankle), swelling, and a necrotic area had developed at the previously injured site. The nurses' notes revealed the left ankle was "deep, dark red with a necrotic looking area on the outer ankle." Review of the Comprehensive Care Plan revealed a 1 centimeter by 5 centimeter blood blister was observed to have formed on the left outer foot on 04/18/12. Documentation revealed Resident #14 was again transferred to the Emergency Department on 04/18/12 for evaluation and was diagnosed with [REDACTED]. Continued review of nurses notes revealed on 04/24/12 facility staff observed a change in condition of Resident #14's left foot and contacted Resident #14's physician to obtain wound care orders. A skin assessment was conducted of Resident #14 on 10/29/12, at 7:35 PM. A black eschar (dead tissue) area was observed on Resident #14's left outer ankle and the tissue surrounding the eschar area was deep red in color. LPN #2 cleansed the eschar/wound area with normal saline, applied Bactroban antibacterial ointment, covered the wound with a non-adherent pad, and secured the dressing with gauze wrap and tape. As the LPN cleansed the resident's wound, the black eschar detached from the wound onto the normal saline moistened gauze. Resident #14 was observed on 10/29/12, at 5:25 PM to be lying in bed with a dressing intact to the left foot. Resident #14 made no effort to respond to verbal prompts and an attempt to interview the resident was unsuccessful. In addition, a review of a quarterly assessment, dated 10/09/12, of Resident #14 revealed the resident was cognitively impaired. CNA #15 stated in interview conducted on 10/31/12, at 2:15 PM that she had been trained to review CNA Care Records to determine the resident's needs prior to providing assistance with care, and was aware Resident #14 required the assistance of two staff for transfers. CNA #15 confirmed she failed to obtain assistance with transferring Resident #14 from the bed to a wheelchair on 04/09/12, and stated during the transfer Resident #14 was unable to pivot to the wheelchair as well as he/she had done in the past. CNA #15 stated she was not aware of any injury to Resident #14 until the afternoon of 04/09/12, when the CNAs were asked about the resident's ankle swelling. CNA #15 stated Resident #14 must have hit the leg rest of the wheelchair and acknowledged she should not have transferred Resident #14 without assistance. Interview on 10/31/12, at 2:45 PM with CNA #13 revealed Resident #14 had been transported to the shower room by CNA #15 and she had assisted CNA #15 with the resident's shower. CNA #13 stated she and CNA #15 assisted the resident to stand after the shower was complete and stated the resident did not complain of any pain or discomfort. In addition, CNA #13 stated she did not observe an injury to the resident's leg when she assisted the resident to dress. Licensed Practical Nurse (LPN) #4 revealed in an interview conducted on 11/01/12 at 4:00 PM, that she had been responsible for directing the care of Resident #14 on 04/09/12. LPN #4 stated CNAs were provided a CNA plan of care at the beginning of each shift of resident care needs and were expected to follow the plan of care. LPN #4 stated she had requested the assistance of the Assistant Director of Nursing (ADON) on 04/09/12 and stated the ADON had asked her to assess Resident #14's foot and ankle. LPN #4 stated Resident #14 complained of left foot and ankle pain, the ankle was swollen and "a little red," and the resident complained of pain when the ankle was touched. LPN #4 stated she was not aware at the time of the resident's complaints on 04/09/12, that CNA #15 had failed to follow the plan of care for Resident #14 and had transferred the resident without assistance. The Director of Nursing (DON) stated in an interview on 11/01/12, at 2:30 PM, that staff members were required to follow the resident plan of care. The DON confirmed CNA #15 failed to follow the plan of care and transferred Resident #14 from the bed to a wheelchair without assistance and Resident #14 sustained an injury to the left ankle. 2. A review of the facility's policy titled Safety of Water Temperatures Dated 10/20/08, revealed water heaters that service common areas shall be set to temperatures of no more than 110 degrees Fahrenheit. Further review of the policy revealed maintenance staff was responsible for periodically monitoring tap water temperature and to record the water temperatures in a safety log. In addition, an interview conducted with the facility Maintenance Director revealed the facility did not have a policy regarding the maintenance/security of a control switch that disabled the cooking stove in the secured unit. Observations of water temperatures conducted during an environmental tour on 10/31/12, at 11:04 AM, revealed a hot water temperature of 138 degrees Fahrenheit in a sink in the common area of the secured unit where residents with dementia resided. Additional observation during the tour revealed a control switch that disabled the cooking stove located in the kitchen was located inside an unlocked cabinet next to the stove and as a result, residents in the unit had access to the switch. A review of the resident census for the secured unit revealed during the survey conducted 10/29-11/01/12, there were three (3) cognitively impaired residents who wandered through out the unit. An interview conducted with the Maintenance Director on 10/31/12, at 11:04 AM, revealed he periodically checked the water temperature in the secured unit but had not documented the water temperatures. The Maintenance Director stated he had never checked the water temperature at the sink in the common area and was not aware the hot water temperature was 138 degrees Fahrenheit. According to the Maintenance Director, the secured unit had been in use for approximately two (2) years and he had not considered checking the water temperature in the sink. Additional interview with the Maintenance Director revealed the control switch to the cook stove on the secured unit was placed in the cabinet to prevent unwanted resident use but was not aware the cabinet was not secured and could be accessed by residents. An interview conducted with the Facility Administrator on 10/31/12, at 4:30 PM, revealed the Administrator was not aware the Maintenance Director had failed to monitor or maintain a temperature log of the water temperatures in the Secure Unit. In addition, the Administrator stated she was not aware residents had access to the control switch that controlled the power to the cook stove.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure admission care planning was sufficient to meet the needs of newly admitted residents prior to completion of the resident's first comprehensive assessment and care plan for one of twenty-four sampled residents (Resident #21). Resident #21 sustained a fall on 12/30/11 and 12/31/11, and two falls on 01/01/12; however, the facility failed to review/revise the resident's admission care plan to prevent recurrence of the resident's falls. After the resident sustained [REDACTED]. The findings include: A review of the facility's fall prevention policy/procedure, dated 04/27/11, revealed any resident that experienced a pattern of falls (2 or more during a 30-day period) or an injury from a fall would be referred for a falls assessment to be completed by the nurse. Following completion of the falls risk assessment, the interdisciplinary team/nursing staff would inform the family and resident about the recommended fall prevention management approach and adjust the care plan. Review of the medical record of Resident #21 revealed the facility admitted the resident on 12/07/11, and readmitted the resident on 12/23/11, after a hospitalization for [MEDICAL CONDITION]. The facility had not completed a Minimum Data Set (MDS) assessment because the resident had not been in the facility long enough for the assessment to be completed. A review of Resident #21's admission care plan, dated 12/08/11 and updated on 12/27/11, revealed the resident was at risk for falls related to generalized weakness. The interventions in place for the prevention of falls included the following interventions: 1) "Fall precautions as needed" 2) "Orient to room including call light and bathroom" 3) "Call light within reach at all times" 4) "Place on Level 3 restorative program for active range of motion to extremities and ambulation training." A review of the nursing notes for Resident #21 dated 12/30/11, at 2:00 PM, revealed the resident was found on the floor after the resident had attempted to ambulate unassisted. Review of the resident's admission care plan revealed the care plan was updated again on 12/30/11, as a result of the resident's fall. The care plan revealed the resident had transferred and ambulated without calling for assistance and was unable to do so safely. At that time interventions were added for the resident to wear non-skid socks, to remind the resident to call for assistance, and noted the resident was at a high risk for a fall with injury. Further review of the nursing notes revealed on 12/31/11, at 5:40 PM, Resident #21 attempted to ambulate to the bathroom without assistance and fell on to the resident's roommate who lowered the resident to the floor. An interview with Registered Nurse (RN) #3 on 01/05/12, at 5:15 PM, revealed RN #3 was responsible for the care of Resident #21 on 12/31/11. According to RN #3, Resident #21 had attempted to ambulate to the bathroom, lost his/her balance and fell on to the roommate. The RN stated she reminded the resident to use the call light and to ask for assistance prior to ambulating. RN #3 stated she felt the resident needed a bed alarm to alert staff to the resident's attempts of unassisted transfers; however, she was unable to find a bed alarm. The RN informed the nurse on the next shift of the resident's falls and that there was no bed alarm available. Interview with CNA #6 on 01/05/12, at 5:35 PM, revealed she was assigned to Resident #21's hallway on 12/30/11 and 12/31/11, and stated she found Resident #21 on the floor on both dates. The CNA stated that after the first fall she reinforced the need for the resident to call for assistance with transfers and ambulation. CNA #6 stated she informed the nursing staff that the resident was not using the call light and she thought the nursing staff would obtain a bed alarm for the resident. The CNA stated an alarm would have alerted staff the resident was attempting to get up. During the interview CNA #6 stated nursing staff had to issue the bed alarms and after the fall on 12/31/11, the nurse responsible for Resident #21 (RN #3) had stated she would obtain a bed alarm for the resident. Review of the nursing notes revealed on 01/01/12, at 2:40 AM, Resident #21 was found on the floor in the resident's room and at 6:25 AM, the resident was again found on the floor and had sustained injury to the left leg. The resident was transported to the hospital and found to have a [MEDICAL CONDITION] hip that required surgical intervention. Further review of the resident's admission care plan revealed there was no evidence new interventions were put into place after the resident sustained [REDACTED]. Interview with unsampled Resident B on 01/04/12, at 2:50 PM, revealed on 12/31/11, Resident #21 had attempted to ambulate to the bathroom and fell on to Resident B. Resident B stated the resident attempted unassisted transfers on three separate occasions on the evening of 12/31/11 and in the early morning on 01/01/12, and had not requested staff to assist him/her. Interview on 01/05/12, at 7:10 PM, with Licensed Practical Nurse (LPN) #2 revealed she was responsible for the care of Resident #21 on 01/01/12, during the 7:00 PM to 7:00 AM shift. LPN #2 stated she was informed by nursing staff on the previous shift that Resident #21 had sustained a fall. LPN #2 stated earlier in the shift Resident #21 had sustained a fall while she was on her lunch break. According to LPN #2, she felt the resident needed a bed alarm but there was no bed alarm in the medication room, and other available staff did not know where to find an alarm. LPN #2 stated that if a bed alarm had been placed on the bed of Resident #21, staff would have been alerted the resident was trying to get up unassisted and a fall might have been prevented. Interview on 01/06/12, at 10:10 AM, with LPN #3 revealed he/she was on duty on 01/01/12, during the 7:00 PM to 7:00 AM shift. According to LPN #3, one of the Certified Nursing Assistants (CNAs) came to the nursing station and stated she needed the LPN's assistance. LPN #3 found Resident #21 on the floor outside the bathroom door lying on his/her left side. According to LPN #3, the resident informed the nurse that he/she had used the bathroom, felt tired, and had lain down on the floor. LPN #3 was not aware if LPN #2 had obtained a bed alarm for Resident #21. According to LPN #3, if there were no bed alarms on the floor staff could obtain one from the first floor nursing unit or the facility stock room. LPN #3 stated staff could always telephone the Director of Nursing (DON) to assist with finding a bed alarm. Interview with CNA #7 on 01/01/12, at 5:40 AM, revealed the CNA was responsible for the care of Resident #21 on the 11:00 PM to 7:00 AM shift on 01/01/12. CNA #7 stated she found Resident #21 lying on the floor, in front of the bathroom, asleep. According to CNA #7, at that time the nurse discussed a bed alarm for Resident #21 but there was no alarm available on the floor. The CNA stated later that morning at approximately 6:00 AM, staff heard a "thud" and a nurse and two CNAs ran to the resident's room. The CNA stated the resident appeared to be hurt and complained of pain in the left leg. The CNA stated only nursing staff had access to the bed alarm storage area and acknowledged the resident did not have a bed alarm on the bed. CNA #7 stated in her opinion the resident's second fall could have been prevented if a bed alarm had been in place because staff would have been alerted when the resident attempted to get out of bed and could have intervened/assisted. Interview with RN #4 on 01/05/12, at 5:45 PM, revealed RN #4 had updated Resident #21's care plan after the fall on 12/30/11, to include the addition of non-skid socks. RN #4 stated all nursing staff was responsible for revising/updating the care plan for residents. An interview was conducted with the Director of Nursing (DON) on 01/05/12, at 11:25 AM. The DON stated Resident #21 sustained the first fall on 12/30/11. At that time staff determined the resident's socks were "regular" and the socks were the reason the resident had fallen on the tiled floor. Staff implemented non-skid socks and documented the intervention to the resident's care plan. The DON stated she had not been informed by staff of the resident's falls from 12/31/11 to 01/01/12, until the resident sustained [REDACTED]. The DON stated staff should have added interventions after the fall on 12/31/11.

Based on observation, interview, record review, and review of facility policy/procedures it was determined the facility failed to ensure two of twenty-four sampled residents (Residents #16 and #21) received adequate supervision and assistive devices to prevent accidents. Resident #21 was assessed by the facility to be at high risk for falls. On 12/30/11, staff implemented the use of non-skid socks for Resident #21 after the resident sustained [REDACTED]. On 01/01/12, Resident #21 sustained a fall at 2:25 AM, and again staff failed to implement new interventions. At 6:25 AM on 01/01/12, Resident #21 sustained a second fall. The resident was transferred to the hospital and was diagnosed with [REDACTED]. The resident underwent [REDACTED]. The facility assessed Resident #16 to require the assistance of a minimum of two staff persons for transfers. However, on 10/02/11, one staff person attempted to transfer the resident from the bed to a shower chair, and the resident sustained [REDACTED]., and the left side of the resident's left breast area were bruised. The findings include: Review of the stock control policy/procedure (dated 12/06/10) revealed a personal alarm, bed pad alarm, and a chair pad alarm would be stored in the medication room for use after hours or on weekends. In the event staff should run out of supplies after hours a key to the main stock control room was located at each nurses' station in the drawer. Review of the facility's Fall Prevention Policy (dated 04/27/11) revealed any resident experiencing a pattern of falls (2 or more during a 30-day period) or an injury from a fall would be referred for a falls assessment to be completed by the nurse. 1. A review of the medical record of Resident #21 revealed the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #21's admission care plan dated 12/08/11, revealed interventions in place to prevent falls were as follows: 1) "Fall precautions as needed" 2) "Orient to room including call light and bathroom" 3) "Call light within reach at all times" and 4) "Place on Level 3 restorative program for active range of motion to extremities and ambulation training." A review of the re-admission nursing notes dated 12/23/11, revealed Resident #21 was alert and oriented to person, place, and time. The facility assessed the resident to require assistance with activities of daily living and to be at risk for falls due to generalized weakness. The admission Minimum Data Set (MDS) assessment had not been completed at the time of the survey. Review of the nursing notes dated 12/30/11, at 2:00 PM, revealed staff found Resident #21 lying on the floor of the bedroom on his/her back, between both beds. According to the nursing notes, the resident had regular socks on and had been sitting in a geri-chair. The resident had attempted to get out of the chair without assistance and fell . A review of the updated admission care plan, dated 12/30/11, revealed the resident had sustained a fall in the facility due to ambulating without calling for assistance and an intervention had been implemented for the resident to wear non-skid socks. Additionally, the care plan update documented the resident was a high risk for a fall with injury. Further review of the nursing notes dated 12/31/11, at 5:40 PM, revealed Resident #21 got out of bed without calling for assistance and fell on to his/her roommate on the way to the bathroom. The resident's roommate reportedly eased the resident to the floor and called staff for assistance. Interview on 01/04/12, at 2:50 PM, with the roommate (Resident B) of Resident #21 confirmed the resident had fallen onto the roommate's lap while ambulating to the bathroom. According to Resident B, Resident #21 had not used the call light to inform staff the resident needed assistance. Resident B stated that on 12/31/11, Resident #21 had attempted to ambulate to the bathroom and fell on to Resident B. Resident B stated the resident attempted to transfer unassisted on three separate occasions on the evening of 12/31/11 and the early morning of 01/01/12. Interview with CNA #6 on 01/05/12, at 5:35 PM, revealed she was assigned to Resident #21's hallway on 12/30/11 and 12/31/11. According to CNA #6, she found Resident #21 on the floor on 12/30/11 and 12/31/11, and informed the resident's assigned nurse on both occasions. The CNA stated that after the first fall she reinforced the need for the resident to call for assistance with transfers and ambulation. CNA #6 stated she informed the nursing staff that the resident was not using the call light and she assumed the nursing staff would obtain a bed alarm for the resident. The CNA stated an alarm would have alerted staff the resident was attempting to transfer without assistance. During the interview CNA #6 stated nursing staff had to issue the bed alarms and after the fall on 12/31/11, the nurse responsible for Resident #21 (RN #3) had stated she would obtain a bed alarm for the resident. CNA #6 was unaware whether the nurse had obtained a bed alarm for Resident #21. Registered Nurse (RN) #3 stated in an interview on 01/05/12, at 5:15 PM, that she provided care to Resident #21 on 12/31/11, and on that date the resident attempted to ambulate to the bathroom unassisted but lost his/her balance and fell on to the roommate, and was on the floor when she entered the room. The RN stated she assessed Resident #21, found no injuries, and reminded the resident to use the call light and call for assistance prior to getting out of bed and walking in the room. In addition, RN #3 stated due to the resident's prior attempts to get out of bed and walk unassisted she planned to place a bed alarm on the resident's bed to alert staff when the resident attempted to get out of bed unassisted. However, according to the RN, there were no bed alarms available on the nursing unit and she had informed the nurse on the next shift of the resident's falls and that there were no bed alarms available. Further review of Resident #21's admission care plan revealed no additional interventions were added after the resident sustained [REDACTED]. Further review of the nursing notes revealed on 01/01/12, at 2:25 AM, Resident #21 was found on the floor. The resident was assessed and no injuries were found. At 6:25 AM on 01/01/12, Resident #21 again sustained a fall in the room, and at that time, the resident complained of pain to the left leg. The resident was transported to the hospital for evaluation and was found to have a fracture of the left hip that required surgical intervention. Interview on 01/05/12, at 7:10 PM, with Licensed Practical Nurse (LPN) #2 revealed she was responsible for the care of Resident #21 on 01/01/12, during the 7:00 PM to 7:00 AM shift. LPN #2 stated she was informed by nursing staff on the previous shift that Resident #21 had sustained another fall. According to LPN #2, when she returned to the unit from break she was informed Resident #21 had sustained a fall. LPN #2 felt the resident needed a bed alarm but a bed alarm was not available in the medication room. LPN #2 stated she asked other staff on duty where she could obtain a bed alarm and no one knew. The LPN stated she was unaware she could obtain a bed alarm from the stock room or the first floor nursing unit. LPN #2 stated that if Resident #21 had received a bed alarm staff would have been alerted to the resident's attempt at unassisted transfers and the fall could have been prevented. During an interview on 01/06/12, at 10:10 AM, with LPN #3, it was revealed she was on duty on 01/01/12, during the 7:00 PM to 7:00 AM shift. LPN #3 stated she provided nursing coverage to patients while LPN #2 was on lunch break. According to LPN #3, one of the Certified Nursing Assistants (CNAs) came to the nursing station and stated she needed the LPN's assistance. LPN #3 found Resident #21 on the floor outside the bathroom door lying on his/her left side. According to LPN #3, the resident informed the nurse that he/she had used the bathroom, felt tired, and had lain down on the floor. LPN #3 stated she assessed the resident's vital signs and assessed for injuries. At that time, according to LPN #3, LPN #2 returned to the nursing unit and was informed the resident had been found on the floor and that she had completed the required incident report. LPN #3 was not aware if LPN #2 had obtained a bed alarm for Resident #21. According to LPN #3, if there were no bed alarms on the floor staff could have obtained one from the first floor nursing unit or the facility stock room. LPN #3 stated staff could always telephone the Director of Nursing (DON) to assist with finding a bed alarm. An interview was conducted with CNA #7 on 01/01/12, at 5:40 AM. The CNA stated she was responsible for the care of Resident #21 on the 11:00 PM to 7:00 AM shift on 01/01/12. CNA #7 had started to enter a room adjacent to Resident #21's when she observed the bathroom door in Resident #21's room was open. CNA #7 stated she found Resident #21 lying on the floor in front of the bathroom, asleep. According to CNA #7, at that time LPN #2 discussed a bed alarm for Resident #21 but LPN #2 informed the CNA a bed alarm was not available. The CNA stated the same morning at approximately 6:00 AM, staff heard a "thud" and LPN #2 and two CNAs ran to the resident's room. The CNA stated the resident appeared to be hurt and complained of pain in the left leg. The CNA stated only nursing staff had access to the bed alarm storage area and was to obtain the alarms and the CNAs would apply the alarms to the bed. CNA #7 acknowledged the resident did not have a bed alarm on the bed. CNA #7 stated, in her opinion the resident's second fall could have been prevented if a bed alarm had been in place because staff would have been alerted when the resident attempted to get out of bed and could have intervened/assisted. Further review of Resident #21's admission care plan revealed no additional interventions were added after the resident sustained [REDACTED]. A visit was conducted to the hospital on [DATE], and revealed Resident #21 was in the Intensive Care Unit of the local hospital. The resident was in bed with an oxygen mask in place. The resident responded to questions with a shake of the head. An interview with the resident could not be obtained due to the resident's use of an oxygen mask and pain. Review of the facility's safety alarm checklist revealed staff was to check to ensure a pad alarm, a personal alarm, and a chair alarm were available on each floor during the change of shift medication count. The form stated that if an alarm was missing staff was to contact Stock Control or the Director of Nursing (DON). A review of the safety alarm checklist for the second floor alarms revealed staff had documented on 12/31/11, that no pad alarm was available. However, there was no evidence the DON was notified of the need for a pad alarm. Review of the safety alarm checklist for the pad alarm for the first floor revealed an alarm was available. Interview on 01/06/12, at 10:00 AM, with the Social Services Director (SSD) revealed RN #3 had called her on 12/31/11, and informed the SSD that staff was having trouble with Resident #21 attempting unassisted transfers and ambulation. The SSD stated RN #3 asked her why the resident did not have a bed alarm and asked what she should do. According to the SSD, she informed RN #3 to notify the Charge Nurse. The SSD stated she was informed on 01/02/12, that RN #3 had not notified the Charge Nurse. The SSD stated staff was aware that alarms were stored in the medication rooms on each floor and also in the stock room and that all nursing staff had access to the stock room. Interview with the Director of Nursing (DON) on 01/05/12, at 11:25 AM, revealed Resident #21 sustained the first fall on 12/30/11. At that time staff determined the resident's socks were "regular" and the socks were the reason the resident had fallen on the tiled floor. Staff implemented non-skid socks and documented the intervention to the resident's care plan. The DON stated she had not been informed by staff of the resident's falls from 12/31/11 to 01/01/12, until the resident had sustained the fall with injury on 01/01/12. The DON stated the facility had a system in place to aid in the prevention of falls and staff had received education related to falls during the past year. The DON stated all staff had been trained related to accessing bed alarms when needed and, according to the DON, a bed alarm was always available to staff, if not on the unit then in the stock room. 2. On 06/01/11, the facility admitted Resident #16 with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE], and the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to require extensive assistance of a minimum of two staff persons to assist with transfers. A review of the Nursing Care Plan dated 06/21/11, revealed Resident #16 was at risk for falls, had impaired mobility, and required assistance with transfers and mobility. Furthermore, a review of the Nursing Care Plan revealed Resident #16 was to wear non-skid footwear if available. A review of the Certified Nursing Assistant (CNA) Care Record dated October 2011 revealed Resident #16 required the assistance of two staff persons along with the use of a gait belt during transfers. A review of documentation on the "Fall Chronological" (no date) revealed on 10/02/11, at 12:00 AM, Certified Nursing Assistant (CNA) #3 attempted to transfer Resident #16 from the bed to a shower chair unassisted. Documentation in the report revealed as the CNA assisted Resident #16 from bed the bed began to "scoot" back and, as a result, the resident sustained [REDACTED]. In addition, documentation revealed the resident did not have socks on and was barefooted. A review of the Post Fall Investigation dated 10/11/11, revealed Resident #16 also sustained bruises to the right side of the underarm and to the left side of the left breast as a result of the fall. An interview conducted on 01/06/12, at 9:10 AM, with CNA #3 revealed she was assigned to provide Resident #16's care for the night shift on 10/02/11. CNA #3 reported it was the responsibility of the CNAs to obtain a new CNA Care Record at the start of each shift. The CNA stated she was trained to review the Care Record at the beginning of the shift and prior to the provision of care to the residents. Further interview revealed CNA #3 was trained that a resident should not be transferred by the assistance of one person if the resident's CNA Care Record indicated the resident required the assistance of two to transfer the resident. CNA #3 reported she had not reviewed Resident #16's Care Record before she attempted to assist the resident from the bed to the shower chair, had not used a gait belt, checked the resident's bed to ensure it was locked, and had not applied non-skid socks to the resident's feet prior to attempting the transfer. According to CNA #3 Resident #16 had previously been assigned to a room on the second floor, and had been moved to a room on the first floor. CNA #3 stated when she had provided care to the resident on the second floor, the resident only required the assistance of one staff person and the CNA assumed the resident's plan of care had not changed. An interview conducted on 01/06/12, at 9:25 AM, with the Director of Nursing (DON) revealed staff was trained upon hire to obtain a new CNA Care Record at the beginning of a new shift, and to review the Care Record before providing care to the resident. Further interview with the DON revealed staff was trained if the Care Record indicated a resident required the assistance of two people to transfer, they should not attempt to transfer the resident alone. The DON reported staff was also trained to check beds and wheelchairs to ensure they were locked prior to transferring a resident.

Based on observation, interview, and record review, it was determined the facility failed to notify the physician and responsible party when the resident had a significant change in status and a need to alter treatment for one of seven residents (resident #1). On admission, resident #1 required assistance to get out of bed, but on [DATE] and 17, 2010, resident #1 began attempting to get out of bed unassisted. There was no evidence the resident's physician was notified, and no evidence the facility intervened. On [DATE], at 12:35 a.m., resident #1 was found on the floor beside the resident's bed. The resident sustained [REDACTED]. The resident expired on [DATE], as a result of complications from the fall. (Refer to F281, F323, F490, and F520.) The facility's failure to notify the resident's physician placed residents at risk for serious injury, harm, impairment, or death. The findings include: A review of resident #1's medical record revealed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the nursing notes dated [DATE], at 2:00 p.m., signed by nurse #1, revealed staff found resident #1 "wedged between bedrail and mattress." The nursing note revealed the resident had a slight red "mark" on the upper left thigh. According to the nursing note, resident #1's physician and the resident's family were notified. A review of physician's orders [REDACTED].#1's bed. The physician's telephone order stated the resident "continuously attempting to get out of bed by (his/her) self." According to the order, resident #1's family was notified. A review of the Mood & Behavior Summary form for resident #1 revealed on [DATE], on the 11 p.m. to 7 a.m. shift, "Resident tried to climb out of bed;" [DATE], on the 7 a.m. to 3 p.m. shift, "Resident was trying to get out of bed today;" [DATE], (no time/shift documented) "Resident had tried 3 or 4 times to get out of the bed;" [DATE], 11 p.m. to 7 a.m. shift, "I discovered resident laying on bed rail facing the window with (his/her) gown completely off." Interviews with CNA #1 on [DATE], at 4:00 p.m., CNA #2 on [DATE], at 4:20 p.m., nurse #1 on [DATE], at 5:25 p.m., CMA #1 on [DATE], at 10:05 a.m., CNA #4 on [DATE], at 3:53 p.m., CNA #5 on [DATE], at 5:30 p.m., and CNA #7 on [DATE], at 2:20 p.m., revealed resident #1 attempted to get out of bed numerous times on [DATE] and 17, 2010. In addition an interview with a family member of unsampled resident #1 on [DATE], at 6:45 p.m., revealed he/she observed resident #1 sitting on the bedside on [DATE]. Interviews with unsampled residents #2 and #3 on [DATE], at 6:35 p.m., revealed they observed resident #1 attempting to get out of bed. The residents rang the call light and yelled for staff to assist the resident at least three times after the evening meal on [DATE]. According to the facility's investigation, on [DATE], at approximately 5:00 a.m., CNA #8 observed resident #1 attempting to get out of bed. CNA #8's statement revealed, "(Resident #1) was almost out in the floor. (Resident #1) had (his/her) leg stuck in the rail." A review of the facility's policy, Notification of Rights and Services, revised on [DATE], revealed the facility would immediately consult with the resident's physician and notify the resident's legal representative or interested family member when there was an accident which resulted in injury, a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly, or a decision had been made to transfer or discharge the resident from the facility. According to the facility's policy, if staff was unable to contact the resident's physician, and treatment was urgent, staff should contact the Medical Director. The policy stated if treatment was not urgent, the facility should continue to contact the resident's physician. An interview with nurse #1 on [DATE], at 5:25 p.m., revealed nurse #1 was the nurse responsible for resident #1's care on [DATE] and 17, 2010, on the 7 a.m. to 7 p.m. shift. According to nurse #1, resident #1 required assistance with transferring to/from bed. Nurse #1 stated on Saturday, [DATE], that nursing assistants reported resident #1 was "wedged" between the side rail and the mattress. According to the nurse, he/she assessed resident #1 and the resident had a red area on the resident's left thigh. The nurse stated that after speaking with the nurse aides the nurse believed the resident was not "wedged" but was "too close to the side rail." The nurse continued that the resident's "arm may have been wedged." In addition, on at least two occasions on [DATE] and 17, 2010, resident #1 was observed with the resident's feet off the side of the bed and sitting on the bedside. The nurse stated the resident across the hall from resident #1 summoned the nurse to assist resident #1. According to nurse #1, resident #1's physician and responsible party were notified that the resident was wedged between the side rail and the bed, and a physician's orders [REDACTED]. However, a bed alarm was not available and was not implemented for resident #1. The nurse stated he/she did not notify the resident's physician of the resident's continued attempts to get out of bed or the non-availability of the bed alarm. An interview with resident #1's physician on [DATE], at 3:15 p.m., revealed the resident's physician did not recall being notified that resident #1 was attempting to get out of bed or that the resident was caught/wedged in a side rail. However, the physician stated he/she should have been notified. The physician stated he/she did not give an order to implement a bed alarm, but the intervention was appropriate. According to the physician, he/she was not notified by the facility that a bed alarm was not available for resident #1, or that the resident continued to attempt to exit the bed unassisted. A subsequent interview with nurse #1 on [DATE], at 4:10 p.m., revealed a different nurse wrote the physician's orders [REDACTED].#1 signed the order. Nurse #1 stated he/she did not recall if the resident's physician was actually notified. The nurse stated he/she should have notified the resident's physician but "honestly didn't know what to do with (the resident's) situation." According to resident #1's medical record and interviews with staff, on [DATE], at 12:35 a.m., resident #1 was found on the floor by the resident's bed with a large open area on the right forearm and above the resident's right eye. The resident was transferred to the hospital. According to resident #1's hospital record, the resident sustained [REDACTED]. Further interview with resident #1's physician on [DATE], at 3:15 p.m., revealed resident #1 expired on [DATE], as a result of complications from the fall. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy effective [DATE]. A partial extended survey was conducted on [DATE], which determined the Immediate Jeopardy was removed on [DATE]. A review of documentation revealed on [DATE], the facility notified the physicians of all residents who had fallen in the last 15 months with the number of falls and the interventions that were in place to prevent falls. A review of sign-in sheets and interviews with staff on [DATE], revealed the facility conducted in-services with nursing staff on [DATE], related to notifying the resident's physician and legal representative or interested family member when there was a change in a resident's condition, particularly if a resident was trying to get out of bed, or a need to alter treatment and that physician orders [REDACTED]. In addition, according to the in-service sign in sheets dated [DATE], and interviews with staff on [DATE], a log was being kept to further document when physicians were notified and if there were any new orders as a result of the notification. According to the AOC, the in-service information would also be provided to new employees during the orientation process. A review of a call log audit form revealed four resident records were being audited daily to ensure physicians were being notified, and that the facility's policy/procedure for physician notification was being followed. An interview with the Administrator, Assistant Administrator, and Director of Nursing on [DATE], at 4:45 p.m. and 6:40 p.m., revealed all resident physicians were notified in writing with the name of each resident who had fallen, the number of falls, and the interventions the residents had in place. The administrative staff stated four residents' charts were audited daily (two from each floor) for changes in condition and/or a need to alter treatment to ensure the physician was notified in accordance with the facility's policy/procedure for physician notification. Based on the above findings, it was determined on [DATE], the Immediate Jeopardy was removed effective [DATE]. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the implementation of systematic changes and quality assurance activities.

Based on observation, interview, and record review, it was determined the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure physician's orders were implemented for one of seven sampled residents (resident #1). On [DATE], a physician's order was written for a bed alarm for resident #1; however, there was no evidence the bed alarm was implemented. On [DATE] and 17, 2010, resident #1 made attempts to get out of bed unassisted. On [DATE], at 12:35 a.m., resident #1 was found on the floor beside the resident's bed. The resident sustained [REDACTED]. The resident expired on [DATE], as a result of complications from the fall. (Refer to F157, F323, F490, and F520.) The facility's failure to ensure services met professional standards of quality by failing to implement physician's orders placed residents at risk for serious injury, harm, impairment, or death. The findings include: A review of resident #1's medical record revealed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the nursing notes dated [DATE], at 2:00 p.m., signed by nurse #1, revealed staff found resident #1 "wedged between bedrail and mattress" and the resident's physician and family were notified. A review of physician's orders dated [DATE], (no time documented) revealed nurse #1 documented a physician's telephone order for a bed alarm for resident #1's bed. The physician's telephone order stated the resident "continuously attempting to get out of bed by (his/her) self." An interview with nurse #1 on [DATE], at 5:25 p.m., revealed on [DATE], resident #1's physician and responsible party were notified that the resident was wedged between the side rail and the bed, and a physician's order was obtained for a bed alarm. The nurse stated a bed alarm was not available and was not implemented for resident #1, as per the physician's orders. According to nurse #1, a bed alarm was not available on Saturday, [DATE], because bed alarms not being used by residents were locked in the facility's stock room and staff did not have access to the stock room. According to resident #1's medical record and interviews with staff, on [DATE], at 12:35 a.m., resident #1 was found on the floor by the resident's bed with a large open area on the right forearm and above the resident's right eye. The resident was transferred to the hospital. According to resident #1's hospital record, the resident sustained [REDACTED]. An interview conducted with resident #1's physician on [DATE], at 3:15 p.m., revealed resident #1 expired on [DATE], as a result of complications from the fall. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy effective [DATE]. A partial extended survey was conducted on [DATE], which determined the Immediate Jeopardy was removed on [DATE]. A review of documentation revealed the facility completed an audit on [DATE], to ensure all physician ordered safety devices, including bed alarms, were being implemented and the devices were documented on the Medication Administration Record (MAR). Interviews with staff on [DATE], and a review of sign-in sheets revealed the facility conducted an in-service on [DATE], related to following physician's orders and the facility's policy for obtaining equipment. According to the facility's Stock Control Policy (updated [DATE]), and interviews with staff, a personal alarm and a bed pad alarm were placed in the medication room for use after hours or on the weekends. In addition, staff stated alarms in the medication rooms were being audited at the end of each shift to ensure the alarms were available. The interviews revealed staff was completing a form when an alarm was removed so stock room staff was aware that a replacement alarm was needed. Staff stated they monitored to ensure alarms were being implemented and functional with each contact with the resident. Nursing staff stated devices were documented on residents' Medication Administration Records (MAR) and nurses initialed the MAR once per shift to indicate the devices were present and functioning. Staff explained that a key to the stock room was available and staff would notify the stock control clerk or the Director of Nursing after hours if supplies/equipment were unavailable. Observation revealed one bed alarm and one personal alarm were kept in the medication room on each unit of the facility. Further review of a log revealed staff was monitoring the presence of the alarms once per shift since [DATE]. A review of a safety device audit form revealed the facility audited 12 residents daily (three per shift, per floor) to ensure safety devices/alarms were in place, the device was operational, the device was documented on the MAR, and the MAR was initialed. An interview with the Administrator, Assistant Administrator, and Director of Nursing on [DATE], at 4:45 p.m. and 6:40 p.m., revealed 12 charts were being audited daily to ensure that physician ordered safety devices were being implemented. The administrative staff stated any concerns identified were being addressed/corrected immediately. Based on the above findings, it was determined the Immediate Jeopardy was removed effective [DATE]. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the implementation of systematic changes and quality assurance activities.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of three sampled residents (resident #1) and failed to ensure one of seven residents (resident #1) received adequate supervision and assistance devices to prevent accidents. On [DATE], staff implemented the use of two three-quarter-length raised side rails for resident #1, who was assessed by the facility to be at high risk for falls. On [DATE], resident #1 began attempting to get out of bed unassisted, exiting the bed around the side rails. The resident was observed by staff to be wedged/caught in the side rail. Subsequently a physician's orders [REDACTED]. However, there was no evidence the bed alarm was implemented. In addition, the facility failed to reassess the safety risks of the raised side rails for resident #1 after the resident was observed wedged/caught in the side rail. Resident #1 continued to attempt to get out of bed on [DATE], without evidence the safety of the side rails was reassessed, nor any interventions implemented to prevent the resident from falling. On [DATE], at 12:35 a.m., resident #1 was found on the floor by the resident's bed with a large open area on the right forearm and above the resident's right eye. The resident was transferred to the hospital. The resident sustained [REDACTED]. The resident expired on [DATE], as a result of complications from the fall. The facility's failure to ensure the resident environment remained as free of accident hazards as is possible and the facility's failure to ensure residents received adequate supervision and assistive devices to prevent accidents placed residents at risk for serious injury, harm, impairment, or death. The findings include: A review of resident #1's medical record revealed the resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the admission nursing assessment dated [DATE], revealed resident #1 was alert and oriented to person and place, with periods of confusion. According to the Hospice care face sheet, dated [DATE], resident #1 was "bedbound" and "required total care." A review of the facility's policy titled "Management of Falls" revised in [DATE] revealed the facility would provide a safe environment for residents and would identify residents who were at risk for increased falls. According to the policy, all residents would have a "Fall at Risk" assessment completed upon admission and quarterly thereafter. The policy further addressed procedures for residents who experienced a fall. The policy did not address preventing falls for resident who were at risk. A review of a fall risk assessment dated [DATE], revealed resident #1 was at high risk for falls. A side rail assessment dated [DATE], revealed the resident used two side rails to "help with bed mobility." According to the assessment, there was evidence the resident had or may have a desire to get out of bed, there was no possibility the resident would climb over the side rails, there was no risk to the resident if side rails were used, and side rail alternatives/interventions did not create more risks than side rail usage. A review of the care plan dated [DATE], revealed resident #1 was at risk for falls and fall precautions should be implemented as needed. A review of the CNA care record for [DATE] revealed resident #1 required the assistance of two staff for transferring from/to bed/chair. According to the CNA care record, the resident had "other side rails," was a "fall risk." An interview with the Assistant Director of Nursing (ADON) on [DATE], at 10:35 a.m. and 3:50 p.m., revealed the ADON completed the fall risk assessment and the side rail assessment for resident #1 on [DATE]. The ADON stated resident #1 required assistance to get in and out of bed and there was no indication the resident would attempt to exit the bed over the side rails, or would get out of bed without assistance. According to the ADON, when the side rail assessment was completed the side rails did not pose any risks to resident #1. In addition, the ADON stated resident #1 was at high risk for falls; however, there were no interventions in place to prevent falls. The ADON stated because the resident had not had any previous falls, staff would "just monitor to see what interventions are needed." A review of the nursing notes dated [DATE], at 2:00 p.m., signed by nurse #1, revealed staff found resident #1 "wedged between bedrail and mattress." The nursing note revealed the resident had a slight red "mark" on the upper left thigh. According to the nursing note, resident #1's physician and the resident's family were notified. A review of an incident report dated [DATE], at 2:00 p.m., revealed nurse #1 documented that an aide entered resident #1's room and the resident was "caught" between the mattress and the side rail. According to the incident investigation, the resident was "at the end of the bed at the opening in the side rail. (The resident) was sitting with (his/her) leg out of the bed against the side rail." A review of physician's orders [REDACTED].#1's bed. The physician's telephone order stated the resident "continuously attempting to get out of bed by (his/her) self." An interview with nurse #1 on [DATE], at 5:25 p.m., revealed nurse #1 was the nurse responsible for resident #1's care on [DATE] and 17, 2010, on the 7 a.m. to 7 p.m. shifts. According to nurse #1, resident #1 required assistance with transferring to/from bed, but on Saturday, [DATE], nursing assistants reported resident #1 was "wedged" between the side rail on the resident's bed and the mattress. Nurse #1 stated he/she assessed resident #1 and the resident had a red area on the resident's left thigh. The nurse explained the nursing assistants had already assisted resident #1 to bed when the nurse assessed the resident. However, after speaking with the nurse aides, the nurse believed the resident was not "wedged," but was "too close to the side rail." Nurse #1 revealed the resident's "arm may have been wedged." In addition, nurse #1 stated that on at least two occasions on [DATE] and 17, 2010, the resident across the hall from resident #1 summoned the nurse to assist resident #1. The nurse stated resident #1 was observed with the resident's feet off the side of the bed and sitting up on the bedside. According to nurse #1 no reassessment was conducted related to the safety of the continued use of side rails for resident #1. Further interview with nurse #1 on [DATE], at 5:25 p.m., revealed on [DATE], resident #1's physician and responsible party were notified that the resident was wedged between the side rail and the bed, and a physician's orders [REDACTED]. However, a bed alarm was not available and was not implemented for resident #1 because the alarms were not available on weekends. The nurse stated bed alarms that were not being used by residents were locked in the facility's stock room and staff did not have access to the stock room. Nurse #1 stated he/she consulted with the other nurses regarding the unavailability of a bed alarm and the staff believed a bed alarm would not be available until the following Monday ([DATE]). A review of the Mood & Behavior Summary form revealed staff documented on [DATE], on the 11 p.m. to 7 a.m. shift, " Resident tried to climb out of bed;" [DATE], on the 7 a.m. to 3 p.m. shift, "Resident was trying to get out of bed today;" [DATE], (no time/shift documented) "Resident had tried 3 or 4 times to get out of the bed;" [DATE], 11 p.m. to 7 a.m. shift, "I discovered resident laying on bed rail facing the window with (his/her) gown completely off." Interviews with CNA #1 on [DATE], at 4:00 p.m., CNA #2 on [DATE], at 4:20 p.m., nurse #1 on [DATE], at 5:25 p.m., CMA #1 on [DATE], at 10:05 a.m., CNA #4 on [DATE], at 3:53 p.m., CNA #5 on [DATE], at 5:30 p.m., and CNA #7 on [DATE], at 2:20 p.m., revealed resident #1 attempted to get out of bed numerous times on [DATE] and 17, 2010. In addition an interview with a family member of unsampled resident #1 on [DATE], at 6:45 p.m., revealed he/she observed resident #1 sitting on the bedside on [DATE]. Interviews with unsampled residents #2 and #3 on [DATE], at 6:35 p.m., revealed they observed resident #1 attempting to get out of bed. The residents rang the call light and yelled for staff to assist the resident at least three times after the evening meal on [DATE]. According to the facility's investigation, on [DATE], at approximately 5:00 a.m., CNA #8 observed resident #1 attempting to get out of bed. CNA #8's statement revealed, "(Resident #1) was almost out in the floor. (Resident #1) had (his/her) leg stuck in the rail." According to resident #1's medical record and interviews with staff, on [DATE], at 12:35 a.m., resident #1 was found on the floor by the resident's bed with a large open area on the right forearm and above the resident's right eye. The resident was transferred to the hospital. According to resident #1's hospital record, the resident sustained [REDACTED]. Further review of the facility's investigation dated [DATE], revealed an alarm did not sound and resident #1's alarm was not in the resident's room when the resident fell , even though the resident had an order for [REDACTED].#5. Nurse #5 stated resident #1's three-quarter-length side rails were raised when the resident fell . Observation of resident #1 on [DATE], at 3:00 p.m., at the hospital, revealed the resident was unresponsive and was having periods of apnea (no breathing). The resident's right eye was observed to be swollen and purple. In addition, the resident's right arm/hand was swollen. An interview with the resident's daughter during the observation revealed the resident was going "to die." An interview with resident #1's physician on [DATE], at 3:15 p.m., revealed the resident's physician did not recall being notified that resident #1 was attempting to get out of bed or that the resident was caught/wedged in a side rail, however, stated he/she should have been notified. The physician stated he/she did not give an order to implement a bed alarm, however, the intervention was appropriate and the resident needed a bed alarm. The physician further stated he/she was not notified by the facility that a bed alarm was not available for resident #1 or that the resident continued to attempt to get out of bed. The physician stated he/she should have been notified so that other interventions could have been implemented to prevent resident #1 from falling. According to resident #1's physician, resident #1 developed mucus plugs and increased secretions in the lungs due to being unable to clear secretions as a result of the rib fractures. According to the physician, rUse zygomatic arch in a Sentence <http://ask.reference.com/web?q=Use+zygomatic%20arch+in+a+Sentence&qsrc=2892&o= 3> See images of zygomatic arch <http://ask.reference.com/pictures?q=zygomatic%20arch&o= 5> Search zygomatic arch on the Web <http://ask.reference.com/web?q=zygomatic%20arch&o= 4> esident #1 expired on [DATE], at the hospital due to complications as a result of the fall. A subsequent interview with nurse #1 on [DATE], at 4:10 p.m., revealed he/she was unable to recall if the resident's physician was actually notified related to resident #1's continued attempts to exit the bed unassisted. The nurse stated he/she should have notified the resident's physician but "honestly didn't know what to do with (resident #1's) situation." **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy effective [DATE]. A partial extended survey was conducted on [DATE], which determined the Immediate Jeopardy was removed on [DATE]. According to documentation on [DATE], the facility completed Fall Risk Assessments and Side Rail Assessments for all residents who had fallen in the last 15 months. On [DATE], the facility also completed reviews of residents' Minimum Data Set (MDS), comprehensive care plan, and nurse aide care plan to ensure that falls or fall risk factors were identified and appropriate prevention measures were being implemented. Further review of documentation revealed the facility conducted an audit on [DATE], to ensure all physician ordered safety devices, including bed alarms, were being implemented and the devices were documented on the Medication Administration Record (MAR). According to documentation, the facility notified the physician of all residents who had fallen in the last 15 months and the interventions that were in place. Interviews with staff on [DATE], and a review of sign-in sheets confirmed the facility had in-serviced staff on [DATE] and [DATE], related to notifying the resident's physician and legal representative or interested family member when there was a change in a resident's condition or a need to alter treatment and that physician's orders [REDACTED]. According to the in-service sign-in sheets and interviews with nurses, nursing staff was educated on assessing residents and completing a fall risk and/or side rail assessment when there were changes in residents, or as needed. Staff stated they would stay with a resident who was trying to get out of bed or that they felt was not safe to be left alone. According to the facility's Stock Control Policy (updated [DATE]) in-service and interviews with staff, a personal alarm and a bed pad alarm were available in the medication room for use after hours or on the weekends. In addition, staff stated alarms in the medication rooms were being audited at the end of each shift to ensure the alarms were available. The interviews revealed staff was completing a form when an alarm was removed so stock room staff was aware a replacement alarm was needed. Further staff stated they monitored to ensure alarms were being implemented and functional with each contact with the resident. Nursing staff revealed devices were documented on residents' Medication Administration Records (MAR) and nurses initialed the MAR once per shift to indicate the devices were present and functioning properly. In addition, staff stated in interview that a key to the stock room was available and staff would notify the stock control clerk or the Director of Nursing after hours if supplies/equipment was unavailable. According to the AOC, the information will be provided to new employees during their orientation process. A review of a call log audit form revealed four resident records were being audited daily to ensure the facility's policy/procedure for physician notification was being followed and appropriate documentation was in the resident's medical record. A review of a safety device audit form revealed the facility audited 12 residents daily (three per shift per floor) to ensure safety devices/alarms were in place, the device was operational, the device was documented on the MAR, and the MAR was initialed. An interview with the Administrator, Assistant Administrator, and Director of Nursing on [DATE], at 4:45 p.m. and 6:40 p.m., revealed the Interdisciplinary Team (IDT) would meet with residents and families on the day of admission to determine the history of falls/injury and identify other potential risk factors for injury and an individualized care plan would be implemented to better meet the resident's needs. In addition, the Fall Risk Assessment Policy was reviewed and updated and two charts would be audited every week to ensure the fall risk assessment and side rail assessment was accurate. Based on the above findings, it was determined the Immediate Jeopardy was removed effective [DATE]. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the implementation of systematic changes and quality assurance activities.

Based on observation, interview, and record review, it was determined the facility failed to be administered in a manner that enabled the facility to use its resources effectively and efficiently to provide the required care and services to the residents. The facility Administration failed to ensure resident #1's environment remained as free of accident hazards as is possible and failed to ensure resident #1 received adequate supervision and assistance devices to prevent accidents. (Refer to F157, F281, F323, and F490.) Resident #1, who was assessed by the facility to be at risk for falling, fell at the facility on [DATE]. The facility failed to implement interventions to prevent the resident from falling. In addition, the resident was assessed to need two three-quarter-length side rails on the bed. However, the facility failed to reassess the risks of side rail usage when the resident began attempting to get out of bed around the side rails, and was observed with body parts caught/wedged in the side rails. The facility Administration's failure to ensure adequate supervision and assistive devices were provided and the failure to ensure the environment remained as free of accident hazards as is possible placed residents in the facility at risk for serious injury, harm, impairment, or death. The findings include: Observation of resident #1 on [DATE], at 3:00 p.m., at the hospital revealed the resident was unresponsive and was having periods of apnea (no breathing). The resident's right eye was observed to be swollen and purple, and the right arm/hand was swollen. An interview with the resident's daughter during the observation revealed the resident was going "to die." According to resident #1's medical record and a review of an incident report, on [DATE], at 12:35 a.m., resident #1 was found on the floor by the resident's bed with a large open area on the right forearm and above the resident's right eye. The resident was transferred to the hospital. The resident sustained [REDACTED]. According to an interview with the resident's physician on [DATE], at 3:15 p.m., resident #1 expired on [DATE], as a result of complications from the fall. review of the resident's medical record revealed [REDACTED]. A review of the medical record revealed the facility completed a fall risk assessment on [DATE], and determined the resident was at high risk for falling. However, further review of the medical record revealed no interventions were implemented to prevent the resident from falling. In addition, on [DATE], the facility conducted a side rail assessment and determined side rail usage was needed to assist the resident with bed mobility. According to the nursing notes, Mood and Behavior form, and the facility's investigation, on [DATE], resident #1 began attempting to exit the bed or was observed to be sitting on the side of the bed between the bottom of the side rail and the end of the bed. In addition, the resident was observed to be wedged/caught in the side rail on two occasions. There was no evidence the facility notified the resident's physician or reassessed the resident's fall risk or the risks the side rails posed for resident #1. A physician's orders [REDACTED]. However, according to an interview with nurse #1 on [DATE], at 5:25 p.m., the bed alarm was not implemented because bed alarms were locked in the stock room and were not available to staff. An interview with the Administrator on [DATE], at 8:35 p.m., revealed staff should have notified the Director of Nursing (DON) when they did not have a bed alarm available for resident #1. The Administrator stated the facility had always kept alarms in the stock room because he/she did not want staff to put alarms on everyone without all staff being aware of the intervention. According to the Administrator, the nurse should have called the resident's physician to get medical interventions for resident #1, and should have called the resident's family to possibly visit the resident when the resident was trying to get out of bed. According to the Administrator, a nurse assessed residents' fall risk and side rail usage on admission. In addition, all residents newly admitted to the facility were discussed in a morning meeting with administrative staff and department heads. According to the Administrator, if resident #1 had a history of [REDACTED]. However, according to the Administrator, the resident did not have a history of falls or a history of attempting to get out of bed unassisted. The Administrator stated staff nurses should then assess residents and use nursing judgment to provide care for residents. According to the Administrator, the nurse for resident #1 should have used nursing judgment to provide care for resident #1 and the "senior" nurses on the floor should have given the nurse guidance. An interview with the Assistant Administrator on [DATE], at 4:40 p.m., revealed administrative staff monitored care when they were on the living units of the facility. In addition, the nursing supervisors were responsible for monitoring to ensure care was being provided appropriately; however, the supervisor was on sick leave. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy effective [DATE]. A partial extended survey was conducted on [DATE], which determined the Immediate Jeopardy was removed on [DATE]. A review of documentation and an interview with the Administrator revealed the Medical Director met with the facility Administrator on [DATE], to discuss the facility's plan of action necessary to remedy the Immediate Jeopardy. The Medical Director reviewed all resident falls and interventions that were in place for each resident. According to the AOC, the Medical Director will provide oversight and supervision during the compliance process and during the Quality Assurance process to remove jeopardy. A review of a list of residents who had fallen at the facility and the interventions that were in place for each resident revealed they were signed by the Medical Director. According to documentation and an interview with the facility Administrator, Assistant Administrator, Director of Nursing, and Assistant Director of Nursing on [DATE], Health Care Excel had in-serviced the staff members on fall prevention measures. Based on the above findings it was determined the Immediate Jeopardy was removed effective [DATE]. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the implementation of systematic changes and quality assurance activities.

Based on record review and interview, the facility failed to ensure the quality assessment and assurance committee identified issues to which quality assessment and assurance activities were necessary. There was no evidence the facility Quality Assurance Committee identified fall interventions or side rail assessment as quality concerns in the facility. Resident #1 was admitted to the facility on [DATE], and the facility assessed the resident to be at high risk for falls, and to require the use of two three-quarter-length side rails for bed mobility. On [DATE] and 17, 2010, resident #1 experienced a change in status and began to exit the bed unassisted. Even though a bed alarm was ordered, the alarm was not implemented. In addition, there was no evidence the side rail usage was reassessed to ensure resident safety. On [DATE], resident #1 sustained a fall at the facility, was transported to the hospital, and expired on [DATE], due to complications from the fall. The facility's failure to ensure a Quality Assurance Committee was in place which identified quality concerns in the facility, and implemented action plans to correct the concerns placed residents at risk for serious injury, harm, impairment, or death. The findings include: A review of the facility's "Quality Control" policy (not dated) revealed the facility had developed a quality control program that identified specific deficiencies, measured the level of the quality of services provided by facility departments, and continually furnished information that would aid the facility in taking corrective action. The Quality Control policy further stated items requiring corrective action would be discussed with the Administrator "as they arise." A review of the facility's Resident Accident and Incident Review form revealed the facility reviewed resident falls after they occurred. According to the form, the facility reviewed to ensure care after the accident/incident was appropriate, whether or not the accident/incident was avoidable, if measures were taken beforehand to prevent the occurrence, and if there was evidence a plan was implemented to prevent further occurrences. In addition, the facility's Physical Restraint Use Review form revealed the facility monitored restraint use in the facility's CQI program. An interview with the Assistant Administrator, the staff member in charge of Quality Assurance, on [DATE], at 4:40 p.m., revealed the facility monitored resident falls in Quality Assurance. According to the Administrator, the facility monitored side rails that were used as restraints, and if a resident who utilized side rails experienced a fall, the facility would review the side rail usage as a possible causative factor of the fall. According to the interview with the Assistant Administrator, the facility's Quality Assurance program had not identified a concern with interventions not being implemented to prevent falls. In addition, the facility Quality Assurance program had not identified side rails as accident hazards. According to the Assistant Administrator, the facility monitored residents' medical records to ensure physician's orders [REDACTED]. Further, the facility's Quality Assurance program had not identified that staff was unaware how to obtain equipment when administrative/stock room staff was not at the facility. Review of resident #1's medical record revealed the resident was admitted on [DATE]. Review of the fall risk assessment, dated [DATE], revealed the resident was assessed by the facility to be a high risk for falls. In addition, the facility conducted a side rail assessment, and determined side rail usage was needed to assist the resident with bed mobility. Review of nursing notes, the Mood and Behavior form, and the facility's investigation revealed on [DATE] and 17, 2010, resident #1 began to exit the bed unassisted, was observed by staff to be sitting on the edge of the bed between the bottom of the side rail and end of the bed, and had become wedged/caught in the side rail on two separate occasions. review of the resident's medical record revealed [REDACTED]. According to the medical record, resident #1 was found on the floor by the resident's bed on [DATE], at 12:35 a.m. The resident was observed to have a large open area on the right forearm and above the resident's right eye. According to hospital records, resident #1 sustained a right orbital fracture, [MEDICAL CONDITION] zygomatic arch (bones which surround the eye), right supra and periorbital hematoma (around the eye), and six rib fractures. Interview with the resident's physician, on [DATE], at 3:15 p.m., revealed resident #1 expired on [DATE], as a result of complications from the fall. **An acceptable Allegation of Compliance (AOC) related to the Immediate Jeopardy was submitted by the facility on [DATE], which alleged removal of Immediate Jeopardy effective [DATE]. A partial extended survey was conducted on [DATE], which determined the Immediate Jeopardy was removed on [DATE]. According to documentation and interviews with the Administrator, the facility had a Continuous Quality Improvement (CQI) meeting on [DATE], with the Medical Director and developed the facility's Allegation of Removal of Immediate Jeopardy. According to the "CQI Problem Follow-Up Forms," the facility obtained a new fall risk and side rail assessment and conducted the assessments for every resident who had fallen in the past 15 months. According to the AOC, the Fall Risk Assessment Policy was reviewed and updated, and two charts would be audited every week to ensure the fall risk assessment and side rail assessment was accurate, and physician notification and documentation was in the nursing notes. According to the CQI, the audits would begin on [DATE]. In addition, a review of audits revealed four resident records were audited daily to ensure the facility's policy/procedure for physician notification was being followed and appropriate documentation was in the resident's medical record. Further, a safety device audit was conducted for 12 residents daily (three per shift per floor) to ensure safety devices/alarms were in place, the device was operational, the device was documented on the MAR, and the MAR was initialed A review of the audits and interviews with the Administrator, Director of Nursing, and the Assistant Administrator on [DATE], revealed the audits were being conducted and any concerns that were identified were being corrected immediately and the results of the audits would be discussed in the facility's next CQI meeting scheduled for the last week in [DATE]. Based on the above findings, it was determined on [DATE], the Immediate Jeopardy was removed effective [DATE]. Noncompliance continued with the scope and severity lowered to "D" based on the facility's need to evaluate the implementation of systematic changes and quality assurance activities.