Every finding on record at Oakview Nursing & Rehabilitation Center

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for one (1) of five (5) sampled residents (Resident #66 (R66)). The facility admitted R66 from the hospital post-treatment for an ankle fracture. On 04/26/2024, R66 underwent an open reduction internal fixation trimalleolar to repair the left ankle. The facility failed to implement the physician's orders or provide wound care to R66's incisional cites as ordered. On 05/15/2024, R66 was seen by the Podiatric surgeon for complaints of left ankle pain and was transferred to the emergency room (ER) to be evaluated. The ER assessed R66 for diffuse redness, swelling, purulent and foul smelling drainage of the left ankle surgical incisions. Further review revealed R66 met sepsis criteria. (Sepsis is a life threatening condition that may occur when the body's immune response to an infection causes injury to its own tissues and organs). R66 was admitted to the hospital on 05/15/2024 with a diagnosis of Cellulitis (a deep infection of the skin caused by bacteria). R66 was treated with intravenous (IV) antibiotics (vancomycin and cefepime). R66 was discharged on [DATE]. The facility's failure to have an effective system to ensure each resident received care and treatment in accordance with professional standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/30/2024 and was determined to exist on 05/03/2024 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; and Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care, F684. The facility was notified of the Immediate Jeopardy on 06/06/2024. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 06/08/2024, alleging removal of the IJ on 06/08/2024. An Extended Survey was initiated on 06/12/2024, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 06/13/2024. The SSA validated the immediacy of the IJ had been removed on 06/08/2024, as alleged. The findings include: Review of the facility's policy titled, Skin Integrity, dated 06/09/2022 and revised 09/15/2023, revealed the facility would ensure a resident received care, consistent with professional standards of practice, to prevent avoidable skin integrity issues unless the individual's clinical condition demonstrated that they were unavoidable and a resident with impaired skin integrity would receive necessary treatment and services, to promote healing, and prevent infection. The Nurse Leader/Wound nurse would document all impaired skin integrity areas such as pressure, stasis, surgical incision, or diabetic ulcers in the Electronic Medical Record on an ongoing basis or until closed or the resident had been discharged . Review of a facility policy titled, Admission and Readmission to the Facility, dated 07/30/2018 and reviewed 04/02/2024, revealed the facility would admit and readmit residents whose needs could be met. The Objectives of the policy were to assure that the facility received appropriate medical and financial records prior to or upon the resident ' s admission. Closed record review of a face sheet revealed the facility admitted R66 on 04/22/2024 and discharged on [DATE] with diagnoses of: Unspecified fracture of left lower leg; subsequent encounter for closed fracture with routine healing, Personal history of Transient Ischemic Attack (TIA), and cerebral infarction without residual deficits, and difficulty in walking, not elsewhere classified. Review of an Admission Minimum Data Set (MDS) Assessment, dated 04/25/2024, revealed R66 was assessed to have a Brief Interview for Mental Status (BIMS) of a twelve out of fifteen, indicating the resident was cognitively intact. Review of R66 ' s hospital records dated 04/26/2024, revealed she underwent an open reduction internal fixation trimalleolar due to multiple fractures of the left ankle and returned to the facility the same day. Record review revealed no documented evidence the facility developed a Comprehensive Care Plan for R66 related to skin integrity or incisional care until 05/07/2024. Review of an office visit with R66 ' s Podiatric surgeon, dated 04/29/2024, revealed a well-padded below-the-knee splint with plaster cast material was placed on the left lower extremity, R66 was to remain non-weight bearing, use rest, ice, compression, and elevation to the left lower extremity and return to the clinic in one week for a follow up and x-ray evaluation. Review of an office visit with R66 ' s Podiatric surgeon, dated 05/03/2024, revealed R66 was to remain non-weight-bearing. An order was given for Medi-Honey to be applied to the anterior wound daily after a sterile saline cleanse was performed. A sterile below the knee pneumatic boot was fitted and dispensed. New orders were given to cleanse the wound with saline and change the dressing once a day. Review of an emergency room visit note, dated 05/15/2024, revealed R66 had been seen at her Podiatric Surgeon ' s office earlier that day and presented with diffuse redness, swelling of the left ankle, purulent and foul-smelling drainage from her wounds. Further review revealed R66 met sepsis criteria and a sepsis workup was ordered. R66 was admitted with Cellulitis and treated with Intravenous Antibiotics (Vancomycin and Cefepime). Review of a consult note from the Infectious Disease physician, dated 05/20/2024, revealed R66 remained on Intravenous Antibiotics (Vancomycin and Cefepime), some serous drainage with minimal cloudiness to the incision sites as well as an open portion of the incision on the left ankle being open. Further review revealed a result of positive blood cultures for Staphylococcus hominis and Staphylococcus epidermidis which resulted in Vancomycin and Cefepime being discontinued and R66 was ordered Clindamycin 600 mg orally every eight hours for fourteen days. Review of R66 ' s hospital discharge summary revealed she was discharged on [DATE] to a Skilled Nursing Facility for continuation of wound care and rehabilitation. Review of a physician ' s order to apply Medi-Honey to the wound, clean with saline solution and change dressing every day. The order was dated 05/03/2024 however, the order was not scanned into R66 ' s medical record until 05/16/2024, which was after the resident discharged from the facility. During an interview with Family Member #4 (FM4) on 05/30/2024 at 3:09 PM, he stated R66 had a fall at home on 04/07/2022 and remained in the hospital until 04/22/2024. He stated R66 had surgery to repair the fractures to her ankle on 04/26/2024 and returned to the facility the same day. He further stated after a follow up appointment with her podiatric surgeon on 05/03/2024, he brought R66 back to the facility with orders for R66's dressing to be changed once a day. He stated he handed the orders to the front desk staff. He stated the bandages were not changed for seven-eight days. He stated the nurse told the family that R66 ' s incisions were not infected on 05/14/2024. However, the family took photographs of the incision and forwarded to the Podiatric surgeon which wanted to see R66 in his office and then sent her to the hospital to be admitted . He stated the nurses just did not take care of her ankle like they should have. During an interview with Family Member #5 (FM5) on 05/30/2024 at 3:19 PM, she stated on two separate occasions, the family had brought orders to the facility after returning R66 from follow up surgeon appointments and handed the orders to the lady at the front desk. FM5 stated staff would tell the family that they were doing dressing changes on R66 but the family did not believe it was getting done. FM5 stated on 05/14/2024 during a visit, she had asked Licensed Practical Nurse #8 (LPN8) to look at R66 ' s dressing. FM5 stated the dressing was saturated, had an odor, yellow/green drainage, the skin was red and the ankle was swollen. FM5 stated LPN8 informed her the incision was not infected or swollen and if it were infected, the drainage would have been bright green in color. FM5 stated she took pictures of the dressing and incisions and forwarded to R66 ' s Podiatric surgeon. She stated the surgeon requested to see R66 in his office as soon as possible. She stated the family transported R66 to the Podiatric office on 05/15/2024, the surgeon was very upset and knew immediately the incisions were infected so he recommended R66 go to the hospital to be admitted for intravenous antibiotics. FM5 stated R66 was currently in the hospital and continued to receive intravenous antibiotics at the time of the interview. During an interview with Registered Nurse #1 (RN1) on 05/31/2024 at 10:41 AM, she stated she was an agency nurse and had worked at the facility for two (2) months. She stated she could not recall receiving orders from R66 ' s family when she returned to the facility after her follow up appointments. RN1 stated when a resident returned to the facility, they should have orders either brought by family or the nurse should call the physician ' s office or hospital for orders. RN1 stated the nurse should then enter and scan the orders into the Electronic Medical Record (EMR). RN1 further stated the Minimum Data Set (MDS) nurse was responsible for all care plans. She stated the floor nurses do not create or revise care plans but are asked for input. RN1 stated she was told during report that R66 ' s wounds were not to be touched right after she had surgery. RN1 further stated if a resident ' s wounds were not assessed in a seven (7) day timeframe, the wound could become infected. During an interview with the Assistant Director of Nursing (ADON) on 05/31/2024, she stated she was also the wound care nurse but was not certified. The ADON stated she was responsible for tracking wounds and did monitor surgical incisions. She stated after R66 ' s ankle surgery on 04/26/2024, her wounds were assessed but was not sure if she had documented the assessments. She stated she was notified on 05/14/2024 that R66 ' s wound dressing was saturated with drainage. The ADON stated the surgeon was notified at that time, the R was seen in the surgeon ' s office the following day and admitted due to the surgical incisions being infected. She stated R66 ' s care plan should have ben implemented when she returned to the facility after her surgery to reflect the need for monitoring of the surgical incisions. She stated the MDS nurse was responsible to implement or revise a care plan. However, if she was providing care or monitoring a wound then she would be the one responsible to implement the care plan. The ADON stated she did not implement a care plan for R66. The ADON stated she would expect the nurse to call the physician for orders if they did not receive them and for care plans to be implemented and revised as needed. During an interview with Licensed Practical Nurse #8 (LPN8) on 05/31/2024 at 2:01 PM, she stated she had not assessed R66 ' s wound until 05/14/2024 when the daughter asked her to. She stated she had been told in report that the wounds were not to be touched and was under the impression R66 ' s surgical wounds had actually healed. However, LPN8 stated she had not seen any orders for R66 related to the care of her surgical wounds. LPN8 stated R66 should have had orders to monitor the surgical wounds. LPN8 stated she assessed R66 ' s surgical wounds on 05/14/2024 and the incisions had a scant amount of drainage that had no color, no odor, was not red but was pink and was not swollen. She described the skin around the incisions as moist appearing. LPN8 stated she notified the wound care nurse which assessed and measured R66 ' s wounds on 05/14/2024. LPN8 stated she relied solely on the report given to her by the offgoing shifts. She stated she did notify the surgeon ' s office and R66 was taken into his office the following day. She stated she only called the surgeon because R66 ' s family was concerned. LPN8 stated she assumed R66 ' s wound needed orders or at least more than a gauze wrap but she did not call to obtain orders. During an interview with LPN9 on 05/31/2024 at 2:32 PM, she stated she was an agency nurse and worked primarily the weekend shift. She stated she did not recall seeing any orders for wound care or monitoring for R66 but it would be normal protocol to monitor surgical incisions. During an interview with the Podiatric Surgeon on 05/31/2024 at 3:00 PM, he stated he saw R66 for a follow up appointment on 05/03/2024 and wrote orders for Medi-Honey to be applied to a fracture blister, clean surgical incisions with saline solution and do dressing changes daily. He stated the family took orders back to the facility. He stated he had no further contact until 05/14/2024 when R66 ' s family had e-mailed photographs of R66 ' s surgical incisions that appeared to be very concerning. He stated he saw R66 in his office on 05/15/2024 and she had developed Cellulitis and no one from the facility had notified his office. He stated if the ordered dressing changes had not been done, that was the problem. He stated R66 was transferred to the hospital and admitted for intravenous antibiotics due to Cellulitis and sepsis. The Podiatric Surgeon stated R66 continued to be followed by Infectious Disease and remained on intravenous antibiotics. During an interview with the Signature Care Consultant on 06/04/2024 at 1:00 PM, she stated the wound care nurse had not received any formal wound care certification. She stated she had received some wound training with her leadership training and online through Relias which was the same training the floor nurses received. During an interview with LPN3 on 06/05/2024 at 8:02 PM, she stated she works night shift and did not provide any surgical wound care for R66. LPN3 stated she was responsible for the daily skilled charting note and on 05/02/2024 under special treatments checked incisional care was done, on 05/03/2024. 05/08/2024 and 05/09/2024, marked incision was clean, well approximated with signs of healing, then on 05/10/2024 and 05/14/2024 that incision care was provided per order. However, she further stated she never assessed R66 ' s wounds at all and she was apparently completing the daily skilled charting note incorrectly. LPN3 stated she thought if a resident was admitted with that skill then she should be charting it on the skilled charting note. LPN3 further stated the facility dropped the ball on R66 and that was why the facility was unable to provide any documentation related to her wound care. LPN3 stated R66 should have had orders to monitor her surgical wound and provide any care the physician ordered. LPN3 stated R66 returned to the facility prior to her shift beginning on 05/03/2024 and she was given report by RN1 that all orders were completed and R66 had been assessed. LPN3 stated there should not have been a reason she would have had to double check what was told to her. During an interview with the MDS coordinator on 06/06/2024 a 11:12 AM, she stated when R66 returned to the facility with a surgical wound on 04/26/2024, she should have had a care plan developed. The MDS coordinator stated she did do an admission observation assessment and developed an enhanced barrier precaution care plan related to R66 ' s surgical wound on 05/07/2024. During an interview with the Medical Director on 06/06/2024 at 11:00 AM, he stated he expected staff to follow orders and if there was any deviation from the physician orders, he would expect a telephone call to clarify. He stated the orders are there for a purpose and should be followed. He stated he was not familiar with R66 care and was not her attending but was aware of the situation. He stated there were times when a dressing should be left in place, however, if you don ' t now what is going on, you must find out because you should not work autonomously or above your scope of practice. During an interview with the Director of Nursing (DON) on 06/06/2024 at 10:06 AM, she stated R66 should have had orders in place to at least monitor her surgical wounds. The DON stated the facility had attempted to look for orders from 05/03/2024 but were unable to find them. She further stated the facility had called the surgeon ' s office on four (4) occasions, did not receive a return call, and had some communication issues. However, the DON stated she failed to document the failed attempts to contact R66 ' s surgeon. The DON stated she personally did not provide wound care for R66 and did not know what happened. The DON stated the facility should have called the physician ' s office and obtained orders and implemented a care plan within forty-eight hours after she returned from surgery. The DON stated she expected nurses to obtain and follow physician orders, assess the resident ' s, do the ordered treatments, complete an event and care plan and notify the resident ' s family. The DON stated she was not sure why R66 did not have a care plan but should have had one when she returned from surgery. She stated the MDS coordinator was responsible for Comprehensive Care plans and she expected each resident to have person centered Comprehensive Care plans implemented and revised as needed. During an interview with the Administrator on 06/07/2024 at 10:41 AM, he stated he expected all residents to have the necessary orders for staff to provide the care the resident may need. He stated if orders were not received, he expected staff to call the physician or hospital to obtain them. He further stated he expected each resident to have a Comprehensive Care Plan in place to ensure the staff would know how to provide care to the residents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a care plan was developed and implemented for one of five (5) sampled residents (Resident #66 (R66)). R66 was post-op from a surgical procedure performed on 04/26/2024. However, record review revealed the facility failed to develop a Comprehensive Person-Centered Care Plan to monitor the surgical incisions until 05/07/2024. On 05/15/2024, R66 was seen by the Podiatric Surgeon for complaints of left ankle pain and was transferred to the emergency room (ER) to be evaluated. The ER assessed and diagnosed R66 with diffuse redness, swelling, purulent and foul smelling drainage of the left ankle surgical incisions. R66 was admitted to the hospital for intravenous antibiotic therapy on 05/15/2024 and discharged on [DATE]. The facility's failure to have an effective system to ensure each resident received care and treatment in accordance with professional standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/30/2024 and was determined to exist on 05/03/2024 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; and Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care, F684. The facility was notified of the Immediate Jeopardy on 06/06/2024. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 06/08/2024, alleging removal of the IJ on 06/08/2024. An Extended Survey was initiated on 06/12/2024, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 06/13/2024. The SSA validated the immediacy of the IJ had been removed on 06/08/2024, as alleged. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 04/06/2015 and revised 02/09/2024, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Closed record review of R66's face sheet revealed the facility admitted the resident on 04/22/2024. R66's readmission on 05/15/2024 included diagnoses of: unspecified fracture of the left lower leg; subsequent encounter for closed fracture with routine healing; personal history of Transient Ischemic Attack (TIA/stroke); and cerebral infarction without residual deficits, and difficulty in walking, not elsewhere classified. Review of the Admission Minimum Data Set (MDS) Assessment, dated 04/25/2024, revealed the facility assessed R66 to have a Brief Interview for Mental Status (BIMS) score of twelve out of fifteen. This score indicated the resident was cognitively intact. Review of R66's hospital records dated 04/26/2024, revealed she underwent an open reduction internal fixation trimalleolar due to multiple fractures of the left ankle. R66 returned to the facility the same day. Review of an office visit report from R66's Podiatric Surgeon, dated 05/03/2024, revealed new orders were given to cleanse R66's surgical incisions with saline and to change the dressing once a day. Review of an emergency room visit note, dated 05/15/2024, revealed R66 presented with diffuse redness, swelling of the left ankle, purulent and foul-smelling drainage from the surgical incisions. Further review revealed R66 met sepsis criteria (sepsis is a life threatening condition that may occur when the body's immune response to an infection causes injury to its own tissues and organs). R66 was admitted to the hospital with a diagnosis of Cellulitis (a deep infection of the skin caused by bacteria). R66 was treated with intravenous (IV) antibiotics (vancomycin and cefepime). Review of the Infectious Disease Physician's consultation note, dated 05/20/2024, revealed R66 remained on IV antibiotics (vancomycin and cefepime); some serous drainage was noted, and a portion of the incision on the left ankle remained open. Further review revealed positive blood cultures for Staphylococcus hominis and Staphylococcus epidermidis. The vancomycin and cefepime were discontinued. R66's antibiotic was changed to clindamycin 600 mg (milligrams) orally every eight hours for fourteen days. Review of R66's hospital discharge summary revealed a discharge date of [DATE] to a skilled nursing facility for continuation of wound care and rehabilitation. Review of a Physician's Order to apply Medi-Honey to the wound, clean with saline solution and change dressing every day. The order was dated 05/03/2024. However, the order was not scanned into R66's medical record until 05/16/2024, which was after the resident discharged from the facility. Record review revealed no documented evidence the facility developed a Comprehensive Care Plan for R66 related to skin integrity or for incisional wound care until 05/07/2024. During an interview with the Minimum Data Set (MDS) Coordinator on 06/06/2024 at 11:12 AM, she stated R66 should have had a Comprehensive Care Plan implemented when she returned from her surgical procedure on 04/26/2024. During an interview with the Assistant Director of Nursing (ADON) on 05/31/2024, she stated she was also responsible for wound care but was not certified. The ADON stated she also tracked wounds and monitored surgical incisions. She stated after R66's ankle surgery on 04/26/2024, she did assess her wounds but was not sure if she had documented those assessments. She stated she was notified on 05/14/2024 that R66's wound dressing was saturated with drainage. The ADON stated the surgeon was notified at that time. She stated R66 was seen in the surgeon's office the following day. The surgeon had R66 admitted to the hospital due to the surgical incisions being infected. She stated R66's care plan should have ben implemented when she returned to the facility after her surgery to reflect the need for monitoring of the surgical incisions. She stated the MDS Nurse was responsible to implement or revise a care plan. However, if she was providing care or monitoring a wound then she would be the one responsible to implement the care plan. The ADON stated she did not implement a care plan for R66. She stated she would expect the nurse to call the physician for orders if orders were not received and for care plans to be implemented and revised as needed. During an interview with the Director of Nursing (DON) on 06/06/2024 at 10:06 AM, she stated each resident should have a person-centered Comprehensive Care Plan and the MDS Coordinator was responsible for implementing the care plans. The DON stated her expectations were for each resident to have the appropriate care plan implemented. During an interview with the Administrator on 06/06/2024 at 10:41 AM, he stated he expected all residents to have a comprehensive care plan and for staff to follow the facility's policies.

Based on observation and interview it was determined the facility failed to have an effective pest control program to ensure the facility was free of pest. All 76 residents had the potential to be affected. Observation during the initial tour on 06/03/2024 at 11:15 AM, revealed rodent and bird droppings in the emergency food storage supply room. The findings include: The facility was unable to provide a specific policy related to pest control. The Administrator stated the facility followed the guidance from the State Operations Manual which defined an effective pest control program as a measure to eradicate and contain common household pest. Observation during the initial tour on 06/03/2024 at 11:15 AM, revealed the storage area for the facility's emergency food supply was housed in a detached building occupied by the maintenance department. Observation revealed the floor of the room was covered with white droppings. Further observation revealed rodent droppings on the boxes of food stored on the shelves. During an interview with the Dietary Manager on 06/05/2024 at 12:50 PM, she stated the white droppings on the storage room floor appeared to be bird droppings. She further stated she was not aware of any rodent droppings. During an interview with the Administrator on 06/13/2024 at 3:28 PM, he stated he expected the storage room to stay within the appropriate temperatures and to be kept clean and free of rodents.

Based on observation, interview and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Observations revealed containers filled with a dark liquid that were opened, not dated, and/or labeled. This had the potential to affect 76 of 76 residents. Observation during the initial kitchen tour on [DATE] at 11:15 AM, revealed five drink containers that were not labeled, dated, or had expired in the walk-in cooler. The findings include: Review of the facility's policy titled, Food Storage, Cold Foods, dated ,d+[DATE] and revised ,d+[DATE], revealed all time/temperature control for safety, foods frozen and refrigerated, would be appropriately stored in accordance with guidelines of the FDA's (US Food and Drug Administration's) food code. All foods should be stored, wrapped, or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. Observation of a walk-in cooler on [DATE] at 11:15 AM, revealed two (2) containers of a dark liquid that were labeled with a created date of [DATE] and discard date of [DATE]. Further observation revealed three (3) containers of a dark liquid that were not labeled or dated. During an interview with Dietary Worker #1 on [DATE] at 11:15 AM, she stated the containers should always have a label and date. She further stated the containers should have been discarded. During an interview with the Dietary Manager on [DATE] at 11:30 AM, she stated she expected all food to be labeled and dated and staff should not use food or liquids after the discard by date. During an interview with the Administrator on [DATE] at 3:28 PM, he stated the dietary department was contracted and responsible to control the food brought into the facility. He stated he expected food to be dated, labeled, and covered. He further stated the use by date should be marked and the food should not be used past that date.

Based on observation, interview and facility policy review, the facility failed to develop and implement an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible related to clean supplies stored with Biohazard Waste in an outside storage building. The findings include: Review of the facility's policy, Infection Control, effective 01/23/2024, noted the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the facility's infection control policies and practices included: a. Prevent, detect, investigate, and control infections in the facility; and b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. After an observation of Resident #74's (R74) wound care on 06/05/2024 at 10:22 AM with the Special Projects Director of Nursing, the nurse and the charge nurse went out of the facility to a small storage building. This building had a sign which stated it was the Biohazard room. Further observation revealed there were Biohazard Containers which held Biohazard Waste in the room. Observation revealed to the left of the waste containers, there were multiple boxes of clean examination gloves, COVID testing supplies, and clean trash bags. During an interview with the DON and the Regional DON, they stated clean supplies and Biohazard Materials should never be stored together. They further stated everything in the Biohazard Room would be considered contaminated. During an interview with the Administrator on 06/07/2024 at 10:49 AM, he stated he expected staff to follow the facility's policies as written regarding Biohazard Materials. He stated Biohazard Materials should not be stored in the same area as clean supplies.

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure residents were assisted with/encouraged to perform hand washing before meals and the facility staff failed to avoid touching ready-to-eat foods with their bare hands during meals. This affected two (2) of three (3) halls observed. In addition, the facility did not maintain proper clean to dirty techniques in the laundry room, for one (1) of one (1) laundry room. Also staff failed to ensure proper dirty linen placement while providing incontinent care for Resident #43. Further observations revealed personal protective equipment (PPE) was not properly disposed of after use or before exiting residents' rooms who were on isolation for two (2) of two (2) residents observed on isolation. (Resident #10 and Resident #13) This deficient practice occurred during the COVID-19 pandemic, and had the potential to affect all residents. Findings included: 1. Review of the facility's policy titled, Hand Washing/Hand Hygiene, revised 08/2019, revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Review of the Centers for Disease Control (CDC) Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/23/2021, revealed Educate patients, visitors, and healthcare personnel (HCP) about the important of performing hand hygiene . Review of the 2017 Food Code by the U.S. Food and Drug Administration, page 69, revealed food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. Observations on 08/12/2021 at 8:36 AM through 9:30 AM, revealed staff were passing the breakfast meals to residents on the 100 Hall with no encouragement of handwashing prior to the meal. An observation of the meal trays revealed no additional sanitizer or handwashing wipes present on the resident trays or available for easy access to the residents prior to the start of the meal. Staff passed a tray to room [ROOM NUMBER] with no encouragement for sanitizer or hand washing prior to the meal. Observations on 08/12/2021 at 8:53 AM, revealed Certified Nurse Aide (CNA) #2 sprayed some sanitizer onto her hands and rubbed her hands together for approximately two seconds. Observations on 08/12/2021 at 12:04 PM, revealed Resident #32 walking down the hallway touching the handrails along one side of the hall with one hand and then the other side of the hall with the other hand. No cleaning of the handrails was observed during the lunch meal from 12:00 PM through 1:00 PM. An observation of the lunch meal at 12:31 PM revealed no encouragement for resident hand washing before the meal. At 12:34 PM, Resident #32 helped set up their roommate's tray. Resident #32 walked over to the beverage cart and touched the top of one of the beverage containers. No cleaning of the beverage container was observed prior to meal service. Observations on 08/12/2021 at 12:38 PM, revealed Registered Nurse (RN) #1 scooped ice out of the ice bin using a cup instead of the ice scoop, leading to potential contamination. At 12:40 PM, RN #1 set up a tray for Resident #68 and touched the resident's sandwich with bare hands. The RN picked up the sandwich and tore the sandwich in half with bare hands. Resident #68 was observed to eat the sandwich. Resident #68 was observed with brown matter underneath the right- and left-hand fingernails. No sanitizing or handwashing was observed or encouraged prior to the meal. Additional hand washing or encouragement was not observed for room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] throughout meal service. At 12:55 PM, CNA #1 was observed to sanitize their hands for approximately three seconds. At 1:07 PM, RN #2 was observed to sanitize their hands for a few seconds. Interview with Certified Nursing Assistant (CNA) #1, on 08/12/2021 at 1:21 PM, revealed they were supposed to encourage handwashing for the residents, but things were just hectic. Interview with Registered Nurse (RN) #2, on 08/12/2021 at 1:24 PM, revealed they probably needed to wash the residents' hands. The RN said they had seen resident hand washing, but it was not consistent. Interview with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON), on 08/13/2021 at 9:08 AM, revealed they needed to ensure a washcloth was provided for handwashing. They said the CNA and manager made rounds to help the residents who were not able to wash hands on their own. They said the staff needed to rub their hands together with sanitizer until dry. The DON acknowledged sanitizing the hands for two seconds was not long enough. They said the staff had been previously educated on not touching food with bare hands. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), on 08/13/2021 at 12:14 PM, revealed they had recently educated the staff on ensuring the resident's hand were washed before meals and as needed. Interview with the Nursing Home Administrator, on 08/13/2021 at 12:14 PM, revealed the facility had thirteen (13) COVID-19 positive residents in the building. The Administrator further revealed both the DON and ADON were both also infection control nurses. He/she stated they had recently educated the staff on ensuring the resident's hand were washed before meals and as needed. 2. Review of a facility policy, Laundry Operations, dated 06/2016, indicated, As soiled linens are sorted into the proper wash classifications, employees must wear the proper personal protective equipment (PPE), which includes gloves and a protective apron. The policy did not give guidance on removing the apron or wearing an apron when handling linen that has been through the wash cycle. Review of the Centers for Disease Control (CDC) Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/23/2021, revealed, Management of laundry should be performed in accordance with routine procedures. Observation of the laundry room, on 8/12/2021 at 2:10 PM, revealed the Laundry Attendant (LA) was placing soiled clothing into the washing machine. The LA was wearing a gown, gloves, mask, and eye protection. After the washing machine was started, LA removed the gown and hung it behind the drier. Observation revealed there was only one gown available in the laundry room. Interview with the LA, on 08/12/2021 at 2:12 PM, revealed he/she used the same gown to put dirty linens and resident clothing, including clothing that came from the COVID-19 positive unit, into the washing machine. LA said that the same gown was also worn when removing clothing from the washing machine and putting clothing into the drier. The gown was not sanitized after use. The housekeeping supervisor (HS) was present for the interview. The HS said that at the end of each day, he would sanitize the gown, so it was ready to be used the next day. Interview with the Director of Nursing (DON), on 08/13/2021 at 12:14 PM, revealed he/she had not observed the process in the laundry. Interview with the Nursing Home Administrator, on 08/13/2021 at 12:14 PM, revealed he/she had not observed the process in the laundry. 3. Review of the facility policy, titled, Linen Handling, with a last reviewed date of 06/12/2018, indicated under Guideline steps, Bullet 3, to deposit soiled linen directly into the covered linen receptacle or plastic bag. Do not place soiled linen on the floor, or over bed, table, bedside stand, and/or chair. Keep the soiled linen container covered. Observation of Resident #43, on 08/10/2021 at 3:30 PM, revealed upon entering Resident #43's room, the Certified Nursing Assistant (CNA #6) had placed a gown and linen on the floor. CNA #6 stated she had not seen a place to put the dirty gown and linen. CNA #7 who was in the room directed CNA #6 to place the dirty items in the dirty linen bin at the foot of the resident's bed. The two CNA's completed the resident's care. CNA #7 then placed the rolled pads that had been under the resident on the floor. Interview with CNA #6, on 08/10/2021 at 3:40 PM, revealed she was aware the dirty gown and linen should not have been placed on the floor, and she could give no reason why she had. CNA #7 stated she knew she should not have placed the pads on the floor. The CNA added the germs on the pads were on the floor and her shoes and would be transported over the entire unit as well as her home. 4. Observation of Resident #10, revealed the resident was on isolation due to having close contact with a COVID-19 positive resident. Further observation revealed an isolation cart with personal protective equipment (PPE) was on the door, with directions on donning and doffing PPE and instructions on disposal. The instructions, provided by the Centers for Disease Control (CDC), indicated that all PPE should be removed before exiting the room and placed in a waste container. Observation of Resident #10, on 08/10/2021 at 11:00 AM, revealed when the surveyor completed the observation and interview with Resident #10, the PPE was removed prior to leaving the room. One small trash can was observed in the room that was located under the sink, approximately half-way inside the resident's room, which required walking across the room to dispose of the PPE. Observation of Licensed Practical Nurse (LPN) #3, revealed LPN #3 was observed placing red bags in the PPE holders on the door. The LPN stated she was placing the red bags in the door to use for discarded PPE due to not having enough trash receptacles in rooms to place discarded PPE. Interview with the Director of Nursing (DON), on 08/13/2021 at 8:45 AM, revealed PPE should be removed before leaving the room and placed in isolation bins located by the door. The DON stated she was unsure why there were no bins in the rooms and added that the responsibility for placing the waste receptacle in the room was the responsibility of whoever was in the building when a resident was placed on isolation. 5. Interview with Resident #13, on 08/12/2021 at 4:00 PM, revealed the resident had been placed on isolation due to close contact with a COVID-19 positive resident. An isolation cart with personal protective equipment (PPE) was on the door with directions on donning and doffing PPE and instructions on disposal. The instructions, provided by the Centers for Disease Control (CDC), indicated that all PPE should be removed before exiting the room and placed in a waste container. Observation of Resident #13's room, on 08/12/0201 at 4:00 PM, revealed there was no waste receptacle in Resident #13's room. The Minimum Data Set Nurse offered the Surveyor a plastic bag at the doorway for the disposal of the PPE. She stated there should have been a trash receptacle in the room. Interview with the DON on 08/13/2021 at 8:45 AM, revealed Resident #13 was placed on isolation on 08/12/2021 at 6:00 AM. The DON further stated someone should have placed a waste bin in the resident's room before the time of the interview at 4:00 PM on 08/12/2021.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat a resident with dignity by failing to close the privacy curtain during care and failed to address the resident in a dignified manner by calling the resident a feeder. This affected one (1) of three (3) sampled residents reviewed for dignity (Resident #43). Findings included: Review of the facility policy for, Resident Rights, with a last revision date of 08/16/2018, revealed under the Policy Statement, all residents had the right to be treated with dignity and respect. The policy also indicated the facility would promote and protect the residents' rights. 1. Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/17/2021, revealed the resident had short- and long-term memory impairment and was totally dependent on staff for activities of daily living. Review of the Comprehensive Care Plan, dated 06/22/2021, revealed Resident #43 was totally dependent on staff for all aspects of daily care and personal hygiene. The care plan further revealed Resident #43 as unable to make their needs known, which required staff to anticipate the resident's needs. The goal was established that all care needs would be met through staff interventions daily, maintaining the resident's dignity, and keeping the resident clean, dry, and odor-free. Observation on 08/10/2021 at 3:36 PM, revealed after knocking on the door and hearing an invitation to enter, the door was opened. Certified Nursing Assistant (CNA) #6 was observed bathing Resident #43. The privacy curtain had not been pulled, and Resident #43 was exposed to anyone who may have passed in the hall. CNA #6 was interviewed and acknowledged the curtain should have been pulled to maintain privacy and dignity. The CNA could offer no reason why she had not pulled the curtain. Interview with the Director of Nursing (DON) on 08/13/2021 at 8:26 AM, revealed she expected any staff member to shut doors and pull curtains during care to provide personal privacy and maintain dignity during care. 2. Observation on 08/10/2021 at 1:00 PM, of a meal observation, revealed Certified Nursing Assistant (CNA) #6 was asked to explain the process for delivering trays to the residents on the unit. The CNA responded trays were delivered to those who could feed themselves first and then to those who required assistance. She pointed to Resident #43, who was lying in their bed, and further explained that Resident #43 was a feeder and therefore would get the meal tray near the end of the meal service when staff were available to assist. Further observation revealed CNA #6 realized what she had said and commented she should not have called Resident #43 a feeder. Interview with the Director of Nursing (DON), on 08/12/2021 at 8:14 AM, revealed if a staff member called a resident a feeder in front of the resident, she would implement a teachable moment because that was not how staff should refer to residents.

Based on interview, record review, and facility policy review, it was determined that the facility failed to notify the physician of a change in condition for one (1) of three (3) sampled residents reviewed for notification of changes in condition (Resident #41). Findings included: Review of the facility policy, titled, Change of Condition, dated 11/06/2019, was completed. The policy indicated that a significant change in the resident's physical, mental or psychosocial status would be relayed to the physician. Record review revealed Resident #41 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/16/2021, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of the Nursing Admission Skin Assessment, dated 07/05/2021, revealed that Resident #41 had no open areas. Review of the Wound Management Observation History dated 07/08/2021, revealed a pressure ulcer to the left hip measuring 2.5 cm (centimeters) x 1.5 cm. The next measurement recorded was dated 08/09/2021. The wound measured 4.6 cm x 4 cm. Review of Resident #41's Comprehensive Care Plan, dated 07/15/2021, revealed Resident #41 would refuse care including wound treatments and wound measurements. Further review of the care plan staff were directed to reapproach the resident at a later time and were to assign consistent staff to Resident #41 when possible. Review of a Nurse Progress Note, dated 07/30/2021 at 4:07 PM, by Licensed Practical Nurse (LPN #2) indicated that Resident #41 refused dressing changes on 07/17/2021, 07/19/2021, 07/22/2021, 07/24/2021, 07/26/2021, and 07/30/2021. Resident #41 was also noted to have refused wound measurements. Review of the Progress Notes for Resident #41, from 07/05/2021 through 08/11/2021, revealed no indication that the physician was notified of the change in the size of the wound or Resident #41's refusal of wound treatments and measurements. Interview with Licensed Practical Nurse (LPN) #2, on 08/11/2021 at 5:31 PM, revealed she was identified as the facility wound nurse. LPN #2 stated Resident #41 refused wound measurements and would not let her measure the wound. She stated the wound was measured about once a month, as Resident #41 allowed the floor nurse to complete the measurement. LPN #2 further stated Resident #41's wound had gotten worse, and she had not spoken to Resident #41's physician about the refusals or the worsening of the wound. Interview with the Director of Nursing (DON), on 08/12/2021 at 9:30 AM, revealed she had spoke with Resident #41's physician, on 08/11/2021 about the worsening wound, and Resident #41's refusal of care. The doctor should have been called when the wound reopened, when it was measured as worse, or that [Resident #41] was refusing [care]. The physician was called to request a wound treatment on 07/08/2021, but there was no further communication about the refusal of treatments or the wound worsening.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure an allegation of resident abuse was reported immediately to the Administrator for two (2) of two (2) residents reviewed for abuse and neglect (Resident #42 and Resident #65). Facility staff failed to report to the Administrator when Certified Nurse Aide #3 (CNA) alleged to have witnessed Licensed Practical Nurse #2 (LPN) slap Resident #42 and Resident #65 on the hand. Findings included: Review of the facility's policy, Abuse, Neglect and Misappropriation of Property, dated 05/08/2019, revealed an assurance that all alleged violations of Federal and State laws which involved resident abuse are investigated and reported immediately to the facility Administrator. It was the Administrator's responsibility to direct a reasonable investigation of each alleged violation. 1. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 07/28/2021, revealed Resident #42 had a Brief Interview of Mental Status (BIMS) score of three (3) which indicated cognitive impairment and Resident #42 was not interviewable. Review of Resident #42's Comprehensive Care Plan, dated 06/22/2021, revealed a problem of cognitive deficit. The resident was alert to self and room with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Record review revealed Resident #65 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MDS assessment, dated 07/23/2021, revealed a BIMS score of 99 indicating the resident was unable to complete the interview. Review of Resident #65's Comprehensive Care Plan, dated 05/11/2021, revealed a problem of impaired cognitive skills as evidenced by decision-making problems, short- and long-term memory problems, and problems understanding others related to dementia. Review of the facility's Self-Reported Incident Form dated 07/20/2021, revealed allegations of witnessed resident abuse by LPN #2 on Residents #42 and #65 that was brought to the attention of the Administrator at approximately 5:21 PM. LPN #2 was suspended pending investigation, skin audits were done on all residents in the MCU, interviews were conducted, and the investigation was ongoing. Review of the facility's Five (5) Day Summary of Investigation dated 07/20/2021 revealed the allegation of physical abuse was reported to the Administrator on 07/20/2021, and LPN #2 was immediately suspended pending investigation. There was an allegation from a Certified Nurse Aide (CNA) that LPN #2 had slapped at the hand of Resident #42 when the resident picked up silverware and was unwilling to let it go. The same CNA stated they also witnessed LPN #2 push Resident #65 away and slapped the hand when the resident attempted to take a medication cup off the medication cart. LPN #2 stated there were situations like this allegation in which she had to intervene for the resident's safety, but she did not slap either resident on the hand. LPN #2 stated that she held her own hands up like STOP to prevent Resident #65 from taking items. Due to Resident #65's impaired cognition and impaired safety awareness, firm limits were set but nothing was abusive in the redirection attempts. The only resident that she could recall having to interact with regarding silverware takes silverware to their room. The LPN stated she must intervene for safety. A thorough investigation was completed on 07/23/2021 and, based on the thorough investigation and review of the State Operations Manual (SOM) for abuse, the allegation of abuse was not substantiated. Interview with the Assistant Director of Nursing (ADON) on 08/12/2021 at 1:30 PM, revealed she did not witness the reported incident on the MCU; CNA #3 reported the incident to her. She then called the Administrator who was not in the building at the time. The alleged perpetrator was suspended pending the investigation. The facility notified the physician and family, did skin audits, and started the interview process to figure out what happened. Interview with Certified Nursing Assistant (CNA) #3, on 08/12/2021 at 2:02 PM, revealed she normally worked in the MCU and could not remember the exact date the incident occurred. It was around 7:30 AM - 8:00 AM when LPN #2 was passing medications. There were crushed medications mixed into a cup of Medpass (nutrition supplement) on top of the medication cart. When Resident #65 picked up the cup, LPN #2 then ran over to Resident #65 and slapped their hand and took the cup of Medpass. When asked what the resident's response was, she stated the resident just looked at the nurse and walked away. CNA #3 further stated there was another incident that same day around lunch time where Resident #42 had a knife in the resident's hand, LPN #2 slapped the hand, and the resident then dropped the knife. Resident #42 became visibly agitated and verbally responded to LPN #2. CNA #3 reported the allegations to administration a day or two after it occurred. She further stated she told Registered Nurse (RN) #2 that night. When asked why she did not report it after the first incident or even that same day, she stated it was very hectic on the MCU that day, and she did not have time. When asked what kind of training she had on abuse and neglect, CNA #3 stated she did abuse training at orientation which told her to report to her charge nurse, but her charge nurse was LPN #2, so she later told RN #2. Interview with Registered Nurse (RN) #2, 08/13/2021 at 9:08 AM, revealed CNA #3 was a new CNA working with LPN #2 on the MCU. CNA #3 reported to her that LPN #2 raised her voice and yelled at the residents to get away from the medication carts or the desk, and CNA #3 did not think that behavior was appropriate. The first time it was reported to her, RN #2 reported it to the Director of Nursing (DON) who did not say anything. CNA #3 was not comfortable with this ongoing behavior. One of the days, CNA #3 reported to her that there were crushed medications mixed in a cup with liquid on a medication cart. Resident #65 picked up the cup and LPN #2 grabbed the cup and slapped the resident's hand. When asked what the DON said after the allegation was reported, RN #2 stated she just responded saying OK. She reported it to the DON because there was no full time Administrator at the time. RN #2 further stated the Administrator pulled her into her office on 07/20/2021 and asked why she did not report any of these allegations to her. RN #2 stated she told her that she reported the allegations to the DON and ADON on multiple occasions. RN #2 was suspended because she knew about the abuse and LPN #2 was terminated. Interview with the Director of Nursing (DON), on 08/13/2021 at 9:37 AM, revealed she was on vacation during the physical abuse investigation, and that it was found to be unsubstantiated. LPN #2 was the alleged perpetrator and was terminated for various nursing concerns. The DON further stated she was suspended pending investigation because it was alleged that she knew of the concerns with LPN #2, but no previous allegations had been brought to her attention. She did not know who or what was supposedly reported to her. Interview with the Facility Administrator, on 08/13/2021 at 9:48 AM, revealed she first learned of CNA #3 making the physical abuse allegation against LPN #2 on 07/20/2021. She had other concerns with LPN #2 as a nurse in the facility, so she had the ADON ask the CNAs and nurses who worked with her on the MCU if they had any concerns. This was when CNA #3 stated to the ADON the allegations of physical abuse against LPN #2. The ADON immediately notified the Administrator with the allegation. The Administrator further stated the incidents happened on 07/15/2021 but she first learned of it on 07/20/2021. They started getting witness statements and did a full skin audit of all the residents in the MCU that evening. LPN #2 was suspended, but they found the allegation to be unsubstantiated because nothing was found from the investigation. The Administrator further stated they re-educated CNA #3 on timeliness of reporting. CNA #3 was not suspended because she did report it to RN #2 who did not report it. They suspended certain staff because the reporting did not properly go up the chain of command.

Based on interview, record review, and facility policy review, it was determined that the facility failed to ensure an allegation of resident abuse was thoroughly investigated for two (2) of 2 residents reviewed for abuse and neglect (Residents #42 and #65). Facility staff failed to thoroughly investigate a physical abuse allegation when Certified Nurse Aide #3 (CNA) alleged to have witnessed Licensed Practical Nurse #2 (LPN) slap Resident #42 and Resident #65 on the hand. Findings included: Review of the facility's policy, Abuse, Neglect and Misappropriation of Property, dated 05/08/2019, revealed an assurance that all alleged violations of Federal and State laws which involved resident abuse are investigated and reported immediately to the facility Administrator. It was the Administrator's responsibility to direct a reasonable investigation of each alleged violation. 1. Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 07/28/2021, revealed Resident #42 had a Brief Interview of Mental Status (BIMS) score of three (3) which indicated cognitive impairment and Resident #42 was not interviewable. Review of Resident #42's Comprehensive Care Plan, dated 06/22/2021, revealed a problem of cognitive deficit. The resident was alert to self and room with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Record review revealed Resident #65 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MDS assessment, dated 07/23/2021, revealed a BIMS score of 99 indicating the resident was unable to complete the interview. Review of Resident #65's Comprehensive Care Plan, dated 05/11/2021, revealed a problem of impaired cognitive skills as evidenced by decision-making problems, short- and long-term memory problems, and problems understanding others related to dementia. Further review of the care plan revealed Resident #65 had impaired communication as evidenced by an expressive problem (difficulty finding words) and a receptive problem (difficulty understanding others) related to cognitive deficits due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #65 was in the memory care unit (MCU) and walked around the unit many times a day, went into others' rooms, rummaged through trash, drawers, items in the dining room and at the nurse's station. The resident required frequent redirection. Review of the facility's Self-Reported Incident Form dated 07/20/2021 revealed allegations of witnessed resident abuse by LPN #2 on Resident #42 and Resident #65 that was brought to the attention of the Administrator at approximately 5:21 PM on 07/20/2021. LPN #2 was suspended pending investigation, skin audits were conducted on all residents in the MCU, interviews were conducted, and the investigation was ongoing. Review of the facility's Five (5) Day Summary of Investigation dated 07/20/2021, revealed the allegation of physical abuse was reported to the Administrator on 07/20/2021, at approximately 5:21 PM, and LPN #2 was immediately suspended pending investigation. There was an allegation from a CNA that LPN #2 had slapped at the hand of Resident #42 when the resident picked up silverware and was unwilling to let it go. The same CNA stated they also witnessed LPN #2 push Resident #65 away and slapped the resident's hand when the resident attempted to take a medication cup off the medication cart. LPN #2 stated there were situations like this allegation in which she had to intervene for the residents' safety, but she did not slap either resident on the hand. LPN #2 stated that she held her own hands up like STOP to prevent Resident #65 from taking items. Due to Resident #65's impaired cognition and impaired safety awareness, firm limits were set but nothing was abusive in the redirection attempts. The only resident that she could recall having to interact with regarding silverware took silverware to their room and the LPN needed to intervene for safety. A thorough investigation was completed on 07/23/2021 and, based on the thorough investigation and review of the State Operations Manual (SOM) for abuse, the allegation of abuse was not substantiated. Review of the facility's investigation revealed the investigation did not include interviews with all staff who had worked with LPN #2. Review of Resident #42's skin audit, dated 07/20/2021, revealed a new bruise on the right wrist. Review of Resident #65's skin audit, dated 07/20/2021, revealed a new bruise on top of the left hand. Review of LPN #2's Termination Notice, dated 07/26/2021, revealed the reason for termination was performance. The company had determined separation of employment was necessary, as the employee had not met performance expectations. Interview with the Assistant Director of Nursing (ADON), on 08/12/2021 at 1:30 PM, the Assistant Director of Nursing (ADON) stated she did not witness the reported incident on the MCU; CNA #3 reported the incident to her. She then called the Administrator who was not in the building at the time. The alleged perpetrator was suspended pending investigation. The facility notified the physician and family, did skin audits, and started the interview process to figure out what happened. Interview with Certified Nursing Assistant (CNA) #3, on 08/12/2021 at 2:02 PM, revealed she normally worked on the MCU and could not remember the exact date the incident occurred. She stated it was around 7:30 AM - 8:00 AM when LPN #2 was passing medications. There were crushed medications mixed into a cup of Medpass (nutrition supplement) on top of the medication cart. When Resident #65 picked up the cup, LPN #2 then ran over to Resident #65, slapped the resident's hand and took the cup of Medpass. When asked what the resident's response was, she stated the resident just looked at the nurse and walked away. CNA #3 further stated there was another incident that same day around lunch time where Resident #42 had a knife in his/her hand. LPN #2 slapped the resident's hand, and the resident then dropped the knife. Resident #42 became visibly agitated and verbally responded to LPN #2. CNA #3 reported the allegations to administration a day or two after it occurred. She further stated she told Registered Nurse (RN) #2 that night. When asked why she did not report after the first incident or even that same day, she stated it was very hectic on the MCU that day, and she didn't have time. When asked what kind of training she had on abuse and neglect, CNA #3 stated she did abuse training at orientation which told her to report to her charge nurse, but her charge nurse was the one who did it, so she later told RN #2. Interview with Registered Nurse (RN) #2, on 08/13/2021 at 9:08 AM, revealed CNA #3 was a new CNA working with LPN #2 on the MCU. CNA #3 reported to her that LPN #2 raised her voice and yelled at the residents to get away from the medication cart or the desk, and CNA #3 did not think that behavior was appropriate. The first time it was reported to her, RN #2 reported it to the Director of Nursing (DON) who did not say anything. CNA #3 was not comfortable with this ongoing behavior. On another day, CNA #3 reported to her that there were crushed medications mixed in a cup with liquid on a medication cart. Resident #65 picked up the cup and LPN #2 grabbed the cup and slapped the resident's hand. When asked what the DON said after the allegation was reported, RN #2 stated she just responded saying OK. She reported it to the DON because there was no full time Administrator at the time. RN #2 further stated the Administrator pulled her into her office on 07/20/2021 and asked why she did not report any of these allegations to her. RN #2 told her that she reported the allegations to the DON and ADON on multiple occasions. RN #2 was suspended because she knew about the abuse and LPN #2 was terminated. Interview with Licensed Practical Nurse (LPN) #2, on 08/13/2021 at 10:48 AM, revealed she did not slap a resident's hand. She further stated that one time a resident was reaching for a book on the medication cart, and she slapped the book and redirected the resident but never made contact with the resident. Interview with the Director of Nursing (DON), on 08/13/2021 at 9:37 AM, revealed she was on vacation during the physical abuse investigation and that it was found to be unsubstantiated. LPN #2 was the alleged perpetrator and was terminated for various nursing concerns. The DON further stated she was suspended pending investigation because it was alleged that she knew of the concerns with LPN #2, but no previous allegations had been brought to her attention. She did not know who or what was supposedly reported to her. Interview with the Facility Administrator, on 08/13/2021 at 9:48 AM, revealed she first learned of CNA #3 making the physical abuse allegation against LPN #2 was on 07/20/2021. She had other concerns with LPN #2 as a nurse in the facility, so she had the ADON to ask the CNAs and nurses who worked with her on the MCU if they had any concerns. This was when CNA #3 stated to the ADON the allegations of physical abuse against LPN #2. The ADON immediately notified the Administrator of the allegation. The Administrator further stated the incidents happened on 07/15/2021, but she first learned of it on 07/20/2021. They started getting witness statements and did a full skin audit of the residents in the MCU that evening. LPN #2 was suspended, but they found the allegation to be unsubstantiated because nothing was found from the investigation. The Administrator further stated they re-educated CNA #3 on timeliness of reporting. CNA #3 was not suspended because she did report it to RN #2 who did not report it. They suspended certain staff because the reporting did not properly go up the chain of command. When asked about the bruising to Resident #42's wrist, the Administrator stated that it was from a bracelet the resident was wearing, so they removed it. When asked about the bruising to Resident #65's hand, the Administrator stated they determined the resident hit their hand on the corner of a dining room table. LPN #2 was terminated.

Based on interview, record review, and facility policy review, it was determined that the facility failed to develop a care plan for one (1) of twenty-four (24) sampled residents reviewed for care plans (Resident #24). Resident #24 did not have a care plan developed for activities. Findings included: Review of the facility policy, Comprehensive Care Plans, with a revision date of 07/19/2018, revealed the nurse/Interdisciplinary Team was responsible for the review and updating of care plans. Further review of the policy revealed the care plan should reflect the current status of the resident and be updated with changes in the resident's status. Record review revealed Resident #24 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, dated 06/04/2021, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), indicating the resident was interviewable. Review of Resident #24's Comprehensive Care Plan, revealed no entries related to preferences for activities. Interview with Resident #24, on 08/10/2021 at 3:00 PM, revealed he/she, I would like to go outside to the patio. They won't let me. I'm not sure why, but I'd like to go outside. Interview with the acting Activity Director (AD), on 8/12/2021 at 9:51 AM, revealed activities staff should complete the care plans for activities, and resident preferences on activities and ways to get the residents to participate should be included. Interview with the Director of Nursing (DON), on 08/12/2021 at 3:40 PM, revealed an activities care plan was developed by the AD on 08/12/2021, but there had not been one prior to 08/12/2021.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure a resident had scheduled care conferences with involvement from the resident representative. This affected one (1) of two (2) residents reviewed for participation in care planning. (Resident #48). Findings included: Review of the facility's policy, Comprehensive Care Plan, last reviewed 04/14/2021, revealed the comprehensive care plan will be developed with participation from the resident, resident's family, or resident representative. The nurse/interdisciplinary team was responsible for the review and updating of care plans. The care plan should reflect the status of the resident and be updated with changes with resident's status .at least quarterly. Record review revealed the facility admitted Resident #48 on 04/28/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/22/2021, revealed the facility assessed Resident #48's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident was not interviewable. Record review further revealed a care conference was completed on 05/25/2020, 06/16/2020, 08/25/2020, 12/08/2020, and 05/25/2021. There was no mention of the resident representative attendance for the care conferences on 06/16/2020, and 05/25/2021. The care conferences dated 05/25/2020 and 06/16/2020 had one staff member in attendance and lacked a multidisciplinary approach. The care conference dated 05/25/2021 had two staff members in attendance and lacked a multidisciplinary approach. There were no care conferences conducted between 12/08/2020 and 05/25/2021. Interview with Resident #48's Family Member, on 08/10/2021 at 2:44 PM, revealed the facility called them for updates, but there had not been any care conferences conducted in months. Interview with the Social Services Director (SSD), on 08/11/2021 at 12:30 PM, revealed that MDS staff completed the scheduled care conferences with the residents and resident representatives. Interview with the MDS Registered Nurse (MDSRN), on 08/11/2021 at 1:21 PM, revealed MDSRN was the person responsible for scheduling and completing the care conferences for the residents and representatives. The MDSRN said they tried to complete the care conferences quarterly. She further stated there were times that care conferences may have gotten missed. Interview with the MDSRN, on 08/12/2021 at 3:03 PM, revealed there were missing care conferences for Resident #48. She further stated she was unable to recall why the care conferences were missed. Interview with the MDSRN, on 08/13/2021 at 9:06 AM, revealed there was no documentation as to whether the resident representative attended some of the care conferences. The MDSRN said they sometimes forgot to document that information. Interview with the Director of Nursing (DON), 08/13/2021 at 9:08 AM, revealed they should have had care conferences with some frequency, usually in line with the MDS schedule. She further stated the care conferences included review of the care plan with the resident and family. Interview with the Assistant Director of Nursing (ADON), 08/13/2021 at 9:08 AM, revealed they should have had care conferences with some frequency, usually in line with the MDS schedule. She further stated the care conferences included review of the care plan with the resident and family.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to provide supervision and verbal cueing to complete oral hygiene for one (1) of three (3) sampled residents reviewed for activities of daily living (Resident #13). Findings included: Review of the facility policy, Oral Care, with a revision date of 07/08/2018, indicated under Section 3, Paragraph E, that a resident that appeared to be able to care for self may forget to care for teeth. Section 7 indicated staff should make sure the resident brushed their teeth. Record review revealed Resident #13 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment, dated 05/12/2021, revealed Resident #13 had adequate hearing, but impaired vision with no glasses. The resident was identified as moderately cognitively impaired. Limited assistance was required for personal care. Review of an Occupational Therapy (OT) Discharge Summary, dated 08/04/2020, revealed Resident #13 could complete tasks with stand-by assistance. The OT also documented Resident #13 required cues to initiate tasks and locate items to complete tasks. Review of Resident #13's Comprehensive Care Plan, last reviewed on 07/21/2021, indicated assistance and cues were needed to perform personal hygiene due to dementia and cognitive deficits. Observation and interview with Resident #13, on 08/10/2021 at 11:40 AM, revealed the resident's teeth were observed to be a dark color at the gum line with obvious plaque buildup on a lower tooth. Resident #13 denied having received oral care that day. Interview with Resident #13, on 08/11/2021 at 10:30 AM, revealed he/she had not been provided a reminder and assistance for oral care had not been received. Interview with the Rehabilitation Manager (RM), on 08/12/2021 at 2:53 PM, revealed Resident #13 had special cognitive considerations, some that were lifelong and some newer. She added for Resident #13 to complete oral care, staff would need to lay out the toothbrush and toothpaste and provide verbal cues for the task to be completed. The RM added that when assisting Resident #13, one had to think like you were helping a child and remind the resident and encourage the resident more than once. Interview with Certified Nursing Assistant (CNA) #4, on 08/12/2021 at 3:20 PM, revealed the CNA acknowledged Resident #13 required supervision and cueing to complete activities of daily living, including brushing teeth. She added her tasks included getting clothing out and setting the resident up to complete morning care. CNA #4 stated that did not include items for oral care, since that was completed on night shift. CNA #4 stated she was unaware if Resident #13 received oral care after lunch, since she did no set up for oral care. The CNA acknowledged without supervision and cueing Resident #13 would not participate in completion of oral care. Interview with the Minimum Data Set (MDS) Nurse on 08/12/2021 at 3:30 PM, revealed she had observed Resident #13's oral cavity on 08/12/2021 at 3:30 PM and stated it looked as if the resident needed dental/oral care. Interview with the Director of Nursing (DON), on 08/13/2021 at 8:21 AM, revealed Resident #13 was trustworthy in what was said. The DON stated she expected staff to cue/help Resident #13 with oral care after each meal. The DON acknowledged if the resident was not set up and cued, oral care would not be completed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of two sampled residents received nail care and foot care (Resident #43 and Resident #68). Staff failed to provide Resident #68 with adequate nail care and Resident #43 with adequate nail and foot care. Findings included: 1. Review of the facility's policy, Nail Grooming, last reviewed 07/24/2018, revealed Regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and as needed. Record review revealed the facility admitted Resident #68 on 10/29/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/13/2021, revealed the facility was unable to assess Resident #68's cognition, and a staff assessment of mental status was completed. The staff assessment of mental status revealed the resident had severe cognitive decline. The resident required extensive assistance for personal hygiene. Observation on 08/10/2021 at 2:21 PM, revealed Resident #68 had brown matter underneath the right- and left-hand fingernails. The resident was observed feeding themselves a banana with their bare left hand. An observation on 08/12/2021 at 9:06 AM revealed the resident had brown matter underneath the right- and left-hand fingernails. An observation on 08/12/2021 at 1:04 PM revealed the resident had brown matter underneath the right- and left-hand fingernails. The resident was observed feeding themselves two sandwiches with their bare hands. Record review revealed Certified Nurse Aide (CNA) skin care alerts were completed for the resident to include nails trimmed during bathing or showers provided to the resident. There was no documentation between 08/07/2021 and 08/12/2021 (during survey) for the completion of nail care for Resident #68. Interview with CNA #1, on 08/12/2021 at 1:21 PM, revealed they had not noticed this resident's nails. CNA #1 said Resident #68 put anything in their mouth. This CNA said this resident had their fingernails cleaned the past Sunday and the CNA had not noticed the current dirty nails. Interview with Registered Nurse (RN) #2, on 08/12/2021 at 1:24 PM, revealed everyone was responsible for ensuring the residents' nails were cleaned. RN #2 said a list was provided to the CNA today on who needed their nails cleaned. RN #2 said nail care needed to be provided daily or as needed. The RN said Resident #68 needed nail care three (3) to four (4) times a day. Interview with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) on 08/13/2021 at 9:08 AM, revealed nail care was part of the shower/bathing routine and as needed. They said some documentation was located on the bath sheets for nail care. They said it was the responsibility of the CNA's and the charge nurse to ensure nail care was completed. 2. Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/17/2021, revealed Resident #43 had short-term and long-term memory impairment and was totally dependent on staff for all activities of daily living. Review of Resident #43's Comprehensive Care Plan, last revised on 08/01/2021, indicated Resident #43 was totally dependent on staff fir activities of daily living and was unable to make needs known, which required staff to anticipate the resident's needs. The goal was that all care needs would be met through staff interventions daily. Observations on 08/10/2021 at 3:43 PM and 08/11/2021 at 3:29 PM, revealed Resident #43's toenails were long, thick, and jagged, with a large amount of loose, dry skin on the soles of the feet that was seen flaking onto the bed linens. Interviews with the Hospitality Aide and Certified Nursing Assistant (CNA) #7, on 08/11/2021 at 3:15 PM, revealed hospice was responsible for providing care to Resident #43. She then added the hospice aide was there twice weekly, and facility staff were responsible for care the other days. Both staff members acknowledged Resident #43's feet were dry and flaky and did not look as if they had been washed. The staff members acknowledged the resident's toenails were long and needed to be cut. Interview with Registered Nurse (RN) #4, on 08/11/2021 at 3:30 PM, revealed she could tell by the dry, flaky feet that Resident #43's feet had not been washed or had lotion applied. She stated the resident's toenails needed to be trimmed. The RN added she would not be able to cut the resident's nails due to how thick they were, and the resident would wait until the podiatrist came to the building. Interview with the Director of Nursing (DON) on 08/12/2021 at 10:14 AM, revealed podiatry services were available in the facility, and the services would send the facility a list of residents to be seen on the next visit. If a resident was not on the list to be seen, a referral could be sent to the service. If a resident was not a diabetic, the CNA could file the nails, but not trim. Nurses were able to trim the toenails, but if the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated she expected the CNA to wash residents' feet daily and apply lotion for dry skin.

Based on an observation, interview, record review, and facility policy review, it was determined the facility failed to provide activities per resident's preferences for one (1) of three (3) sampled residents reviewed for activities (Resident #24). Findings included: Review of the facility policy, Activity Program, dated 07/25/2017, indicated the facility would provide an on-going Activities program designed to support residents in their choice of activities. 5. Individualized and group activities are provided that - a. Reflect the schedules choices and rights of the residents. Record review revealed Resident #24 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, dated 06/04/2021, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), indicating mild cognitive impairment. Review of Resident #24's Comprehensive Care Plan, revealed no entries related to preferences for activities. Review of the Progress Notes for Resident #24, revealed no entries from activities staff regarding Resident #24's preferences. Interview with Resident #24, on 08/10/2021 at 3:00 PM, revealed he/she would like to go outside to the patio. He/she further stated, They won't let me, I'm not sure why, but I'd like to go outside. Review of the Activity Log, dated 06/01/2021 through 08/11/2021, revealed that Resident #24 went outside only on 06/18/2021. Interview with the Activity Director (AD), on 08/11/2021 at 11:26 AM, revealed that they fill out a form called Simply Me was filled out and placed in each resident's room, listing things they like. The AD indicated there was no assessment form to list preferences for activities. The AD stated that the locked memory unit had a fenced courtyard that activity and nursing staff could utilize to take residents outdoors in a secure area. The AD said that Resident #24 went outside for an activity on 08/08/2021 with the Administrator (ADM) and would go outside to visit with a spouse. The AD said the visit with the spouse would be counted as an activity and that outside activities were recorded by activities staff. The AD was not sure when Resident #24 went outside before 08/08/2021. AD was aware that R#24 enjoyed being outside. Observation of Resident #24's room, with AD on 08/11/2021 at 11:32 AM, revealed a sign titled, Simply Me posted on Resident #24's closet door. Under, My Favorite Place, was written, Outside. Under, Hobbies/Interests, was written, Four wheeling, and People watching. Interview with the AD, on 08/11/2021 at 11:42 AM, revealed she had taken a group of residents outside to the courtyard on 08/08/2021, but Resident #24 did not go. Additional interview with the AD on 08/11/2021 at 2:49 PM, revealed I noticed that [Resident #24] went out just one time when I gathered the forms you asked for. The AD stated Resident #24 did go outside to visit when the spouse visited, but the visitation logs were not kept.

Based on observations, interviews, and record review, it was determined the facility failed to obtain orders for an indwelling urinary catheter, failed to obtain orders for catheter care, and failed to secure an indwelling urinary catheter for one (1) of one (1) sampled residents reviewed who had an indwelling urinary catheter (Resident #3). Findings included: Interview with the Corporate Clinical Consultant, on 08/13/2021 at 12:56 PM, revealed the facility used the Lippincott Nursing Manual as their policy and procedure manual. Per the 10th edition of the Clinical Nursing and Skills Technique, an indwelling urinary catheter should be secured to reduce the risk of urethral trauma, urethral erosion, or accidental removal. Record review revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, dated 05/03/2021, revealed Resident #3 was cognitively intact with no behaviors exhibited during the lookback period. Further review of the MDS assessment revealed the resident was occasionally incontinent of urine. Review of an Emergency Department After Visit Summary, dated 07/28/2021, revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of indwelling urinary catheter placement or orders for the catheter. Review of Resident #3's Comprehensive Care Plan, dated 07/31/2021, revealed the resident had an indwelling urinary catheter related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Care Plan revealed approaches to prevent infection included changing the catheter as ordered and as needed, documenting output each shift, keeping the drainage system below the level of the bladder, monitoring the characteristics of the urine, observing for pain or retention, and providing catheter care as ordered. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Resident #3, on 08/11/2021 at 11:38 AM, revealed the catheter was placed during the last hospitalization due to difficulty passing urine. At this time, Resident #3 stated there was no leg strap securing the catheter and added the catheter had not been secured since returning to the facility. Resident #3 further stated staff had not performed catheter care. Interview with Certified Nursing Assistant (CNA) #2, on 08/12/2021 at 1:55 PM, revealed she emptied the urinary drainage bag at least twice during her twelve (12) hour shift. She further stated the indwelling catheter was something Resident #3 recently acquired. The CNA stated last week Resident #3 had a leg strap securing the catheter, and there had been one today securing the catheter to the resident's leg. Interview with Registered Nurse (RN) #2, on 08/12/2021 at 2:15 PM, revealed if a resident had an indwelling urinary catheter there also had to be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated the facility also had to obtain orders for changing the catheter and for catheter care. RN #3 stated Resident #3 obtained the indwelling urinary catheter during a recent emergency department visit due to urinary retention, adding a urology appointment had been scheduled. She reviewed the resident's orders and verified there were no orders for the catheter or for catheter care. RN #3 went in and spoke with Resident #3 and verified the resident's catheter was not secured. Interview with the Director of Nursing (DON), on 08/13/2021 at 8:34 AM, revealed there had been orders for Resident #3's indwelling urinary catheter, but the orders had not been transcribed. She added she needed to read the facility's urinary catheter policy to see if securing the catheter was part of the policy. The DON further added she had read on discharge papers for Resident #3 that the indwelling urinary catheter had been placed due to a [CONDITION(S)]. The DON stated she knew Resident #3 had received catheter care because she had completed catheter care a few times for the resident.

Based on observation, interview, and record review, it was determined the facility failed to maintain a medication error rate of less than five (5%) percent. Two (2) errors were made in twenty-five (25) opportunities, for a medication error rate of eight (8%) percent. Findings included: Review of the facility policy, The facility's Medication Administration General Guidelines, with a review date of 09/2018, indicated under Procedures, Paragraph 5b, that long-acting, extended-release, or [MEDICATION(S)]-coated dosage forms should generally not be crushed, and an alternative should be sought. 1. Record review revealed Resident #29 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's Physician Orders, included [MEDICATION(S)] DR (a delayed release medication used as a mood stabilizer for this resident) 250 milligrams, one (1) tablet to be given by mouth during the morning medication pass. Observation of medication administration on 08/12/2021 at 8:15 AM, revealed Registered Nurse (RN) #3 preparing medications for Resident #29. RN #3 had completed retrieving the medications, she crushed all the medications and mixed the medications with applesauce for Resident #29. The label for the [MEDICATION(S)] or the Medication Administration Record (MAR) did not warn the nurse the medication should not be crushed. Interview the RN #3, on 08/12/2021 at 9:51 AM, revealed the medications that were not crushed included extended-release medications. The nurse added sometimes on the MAR, medications that were not safe to crush would be identified. At other times, the information not to crush could be found on the medication label. RN #3 reviewed the medication label, saw the DR after the medication name, and stated she had no clue what the DR stood for. She further stated she typically crushed all medications for Resident #29. Interview with the Director of Nursing (DON), on 08/12/2021 at 10:09 AM, revealed she had identified [MEDICATION(S)] as a delayed release medication used as a mood stabilizer for Resident #29, adding any delayed release medication should not be crushed. The DON added the information should be located on the medication card or the MAR. The DON added crushing a delayed release medication meant the resident would receive the medication quicker than intended. 2. Record review revealed Resident #15 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of medication administration on 08/12/2021 at 8:53 AM, revealed Registered Nurse (RN) #7, was preparing medications for Resident #15, which included a [MEDICATION(S)] EC (a [MEDICATION(S)] identified as [MEDICATION(S)] coated) 5 milligrams. In addition, to the other medications received by the resident, RN #7 crushed the [MEDICATION(S)] coated medication. The medication label or the Medication Administration Record (MAR) had not identified the medication as one that should not be crushed. Interview with Registered Nurse (RN) #7, on 08/12/2021 at 8:53 AM, revealed the medications that were extended-release or [MEDICATION(S)]-coated should not be crushed. The nurse stated she did not have a list on her cart of medications that should not be crushed and verified the MAR and the medication label had not listed the [MEDICATION(S)] EC as a medication not to be crushed. RN #7 stated she was unaware [MEDICATION(S)] was [MEDICATION(S)]-coated and had always crushed this medication for this resident. Interview with the Director of Nursing (DON), on 08/12/2021 at 10:09 AM, revealed she had identified [MEDICATION(S)] EC as an [MEDICATION(S)]-coated [MEDICATION(S)] used for Resident #15. She added the information identifying the medication as one that should not be crushed should be located on the medication card or the MAR. The DON added crushing an [MEDICATION(S)]-coated medication meant the resident would receive the medication quicker than intended.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide pneumococcal vaccines for two (2) of five (5) sampled residents reviewed for pneumococcal vaccinations (Resident #54 and Resident #15). Findings included: Review of the facility policy, Vaccination of Residents, revised 2019, revealed all residents would be offered vaccines that aid in preventing infectious diseases unless the vaccine were medically contraindicated, or the resident has already been vaccinated. 1. Record review revealed Resident #54 was admitted to the facility on [DATE]. Further review of Resident #54's record revealed immunization consents indicated Resident #54 had requested the pneumococcal vaccine on 06/11/2021. There was no documented evidence Resident #54 received the vaccination. Interview with the Director of Nursing (DON), on 08/13/2021 at 1:12 PM, revealed pneumonia shots were given whenever the request was made. If a consent was signed, an order was sent to the pharmacy. The pharmacy would send the vaccine and place the administration order on the Medication Administration Record. After researching the medical record, the DON stated Resident #15's order was never sent to the pharmacy. The DON also stated the pneumococcal vaccine was ordered for Resident #54 on 05/17/2021 but was never signed out as given, and it did not continue to display on the Medication Administration Record. 2. Record review revealed Resident #15 was admitted to the facility on [DATE]. Further review of the record revealed Resident #15 had a signed consent for the pneumococcal vaccine dated 05/25/2021. There was no documented evidence Resident #15 received the vaccination. Interview with the DON, on 08/13/2021 at 1:12 PM, revealed pneumonia shots were given whenever the request was made. If a consent was signed, an order was sent to the pharmacy. The pharmacy would send the vaccine and place the administration order on the Medication Administration Record. After researching the medical record, the DON said that Resident #15's order was never sent to the pharmacy.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the physician of the need to alter treatment when newly developed pressure ulcers were identified to (1) of two (2) sampled residents (Resident #1). On 10/03/19, licensed staff identified Resident #1 had a Stage III pressure ulcer to right upper buttock; and on 10/15/19, identified pressure ulcers to the left buttock, a suspected deep tissue injury (DTI) to left heel, a darkened purple area to the right great toe, and pencil eraser sized wound to the left lateral aspect of the left pinky toe. Licensed staff failed to notify the physician when the wounds were identified per facility policy, until 10/21/19. The findings include: Review of the facility's policy, titled Change of Condition dated revised 07/10/18, revealed the facility would evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner, to relay evaluation information to physician and to document actions to include but not limited to the following: A significant change in the resident's physical, mental or psychosocial status A need to alter treatment A decision to transfer or discharge the resident from the facility Refusal of compliance with prescribed plan of care Accident which results in injury and/or has the potential for requiring physician intervention Record review revealed the facility admitted Resident #1 on 08/09/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 08/16/19, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident #1's Intermittent Payment Assessment (IPA) Minimum Data Set (MDS) assessment, Section M, dated 10/03/19 revealed Resident #1 was assessed to have a Stage II and a Stage III pressure ulcer. Review of a Weekly Skin Observation Report completed by Licensed Practical nurse (LPN) #3, dated 10/08/19 revealed Resident #1's Stage III pressure ulcer to the right upper buttock measured one.five (1.5) cm with white slough. Review of a Wound Observation Detail Report completed by LPN #1, dated 10/15/19, revealed Resident #1 had a pressure ulcer on the left buttock area, and a suspected deep tissue injury to the right heel. Further review revealed there was a darkened purpled pressure area to the right great toe and a pencil eraser sized reddened area to the left lateral aspect of the left pinky toe. There were no measurements or descriptions of the wounds. Review of the Nursing Notes, dated 10/08/19 through 10/21/19 revealed there was no documented evidence the Physician was notified of the wound to the right upper buttock, identified on 10/03/19; and the wounds to the right heel, left buttock, right great toe, and left pinky toe, identified on 10/15/19. In addition, review of Resident #1's Physician Orders, dated 10/01/19 through 10/21/19, and the October 2019 Treatment Administration Record (TAR) revealed there was no documented evidence of orders from the physician for treatment of [REDACTED]. Review of a head to toe skin assessment completed on 10/21/19 by the Director of Nursing (DON) and the physician orders, dated 10/21/19, revealed Resident #1 had the following wounds and the physician was notified with treatment orders provided for each wound: 1. Blackened areas to bilateral buttocks 2. Right heel wound 3. Left hip wound 4. Big toe, and wound between 4th and 5th toes (no measurements or description noted) Interview (Post Survey) attempts with LPN #3 who completed skin assessment on 10/08/19, on 01/16/20 at 3:28 PM and on 01/17/20 at 8:29 AM were unsuccessful. A voice mail was left on 01/16/20; however, when attempted to leave a voicemail on 01/17/20, the phone kept cutting off before a message could be left. Interview (Post Survey) with LPN #1, on 01/16/20 at 3:30 PM, revealed she reviewed the skin assessment she completed on 10/15/19 and her nursing documentation and stated she failed to document on the wounds and did not measure the wounds. She stated she also did not contact the physician regarding the worsened wounds or the new wounds identified and it was her responsibility to do so. She revealed she reported the wounds had declined and the identification of the new wounds to the ADON on 10/15/19, because she was the wound nurse at that time. Inteview with Resident #1's Primary Care Physician, on 01/15/20 at 3:47 PM, revealed he expected the nurse to notify him of any new wound issues Resident #1 had acquired. He stated he was not surprised by the new wound development related to the residents' clinical condition. He stated he thought the staff had gone off of previous orders and used them instead of requesting new orders and it probably wound not have made a difference in the outcome. Interview with the Director of Nursing (DON) and the Administrator, on 12/11/19 at 8:35 AM, revealed the physician should have been notified when the wounds were identified to ensure treatments were obtained. **The facility implemented the following actions to correct the deficient practice: 1. Resident #1 no longer resided in the facility. 2. On 10/30/19 through 10/31/19, the DON, Staff Development Coordinator (SDC), MDS Coordinator, Nurse Scheduler, Regional Nurse, or Medical Record's Nurse reviewed progress notes for the last thirty (30) days for residents who were residing in the building for any potential condition changes that occurred that were not reported to the physician. The physician was notified of any concerns identified. 3. On 10/29/19 through 10/31/19, the Wound Care Nurse performed a full skin assessment on residents residing in the facility to ensure there were no new pressure sores which had not been identified, had not had physician notification or did not have a current treatment in place. The physician and DON were notified of any new concerns identified, if applicable. 4. On 10/29/19 through 10/31/19, the Wound Care Nurse ensured residents, who resided in the facility, who had a pressure sore were assessed to determine if the pressure ulcer was new, non-healing or improving and physician notification was made for new or non-healing pressure sores or for any treatment changes that were needed. 5. On 10/30/19 through 10/31/19, the MDS Coordinator reviewed residents, who resided in the facility, pressure sore care plans to ensure they were revised and updated with the most current information. 6. Education was provided on 10/30/19 through 11/01/19 by the DON or Unit Manager for Licensed Nursing staff regarding: A. Condition changes B. Physician and Responsible Party Notifications C. SBAR use of and completion of D. Documentation of wounds and physician notification and Responsible Party related to worsening or non-healing E. Weekly Skin Assessments and Weekly Wound Assessments requirement and documentation of F. Training to be provided to new licensed nursing staff. Any Licensed Nurses that had not had the education by 11/01/19 were sent a certified letter to inform them they would not be able to work their scheduled shift until they had the above stated education. 7. Audits of residents' progress notes will be conducted daily by the DON, MDS Coordinator, or Nurse Scheduler/Unit Manager for resident's, residing in the facility for four (4) weeks. The audit/ review of Nurse's Notes/Progress Notes encompassed all shifts for documented condition changes or concerns for residents to determine if there was a condition change, if the physician was notified as well as the responsible party and if any new orders/interventions were needed and implemented. These audits were implemented on 11/01/19 and were ongoing for four (4) weeks to ensure professional standards were being met. The findings of the daily audits were being reviewed by the DON daily during the clinical white board meetings, Monday through Friday and discussed with the QAPI team during weekly QAPI meetings for eight (8) weeks, then monthly. 8. Audits of residents' weekly skin assessments will be completed by the DON, MDS Coordinator, or Nurse Scheduler/Unit Manager the day before they were due and this began on 11/01/19 and will be ongoing daily for four (4) weeks to ensure completeness, then a random sample of five (5) residents weekly for four (4) weeks. The daily audit findings were being reviewed by the DON daily during the daily clinical white board meetings and discussed with the QAPI team during weekly QAPI meetings for eight (8) weeks, then monthly. 9. Audits of residents' weekly wound assessments by the DON, MDS Coordinator, or Nurse Scheduler/Unit Manager will be completed on the assessments that were scheduled to be done that week and this was to be completed for eight (8) weeks starting 11/05/19 to ensure completeness, physician notification and implementation of new treatments, orders and interventions. The findings of the weekly audits would be reviewed by the DON daily during the daily clinical white board meetings and discussed with the QAPI team during weekly QAPI meetings for eight (8) weeks, then monthly. 10. A nurse from the regional team or corporate office has been onsite since 10/29/19 and was available by phone daily since 10/28/19 and will continue weekly visits and would be available daily by telephone until immediacy had been lifted, then every other week for four (4) weeks, then monthly. The nurses from the regional team or home office were assisting as needed, providing oversight and consultation, performing review of QAPI committee meeting minutes and ensuring additional education was being provided as needed. **The State Survey Agency validated correction of the deficient practice as follows: 1. Record review revealed Resident #1 no longer resided in the facility. 2. Review of the audits completed on 10/30/19 through 10/31/19, revealed the DON, Staff Development Coordinator (SDC), MDS Coordinator, Nurse Scheduler, Regional Nurse, or Medical Record's Nurse reviewed progress notes for the last thirty (30) days for residents who were residing in the building for any potential condition changes that occurred that were not reported to the physician. The physician was notified of any concerns identified with none noted. 3. Review of the skin assessments completed on 10/29/19 through 10/31/19, revealed the Wound Care Nurse performed a full skin assessment on residents residing in the facility to ensure there were no new pressure sores which had not been identified, had not had physician notification or did not have a current treatment in place. The physician and DON were notified of any new concerns identified, with no issues identified. 4. Review of audits completed on 10/29/19 through 10/31/19, revealed the Wound Care Nurse ensured residents, who resided in the facility, who had a pressure sore were assessed to determine if the pressure ulcer was new, non-healing or improving and physician notification was made for new or non-healing pressure sores or for any treatment changes that were needed. 5. Review of audits completed on 10/30/19 through 10/31/19, revealed the MDS Coordinator reviewed residents', who resided in the facility, pressure sore care plans to ensure they were revised and updated with the most current information. 6. Review of education provided on 10/30/19 through 11/01/19 by the DON or Unit Manager for Licensed Nursing staff, revealed the following education was provided regarding the following was conducted: 1. Condition changes 2. Physician and Responsible Party Notifications 3. SBAR use of and completion of 4. Documentation of wounds and physician notification and Responsible Party related to worsening or non-healing 5. Weekly Skin Assessments and Weekly Wound Assessments requirement and documentation of 6. Training to be provided to new licensed nursing staff Any Licensed Nurses that had not had the education by 11/01/19 were sent a certified letter to inform them they would not be able to work their scheduled shift until they had the above stated education. Interview with RN #1, on 12/11/19 at 9:06 AM, revealed she was educated on the procedure of doing weekly skin assessments and what to do if there were any changes and on notifying the physician and responsible party of change of condition. (Day shift nurse 7a-7p) Interview with LPN #1, on 01/16/20 at 3:30 PM, revealed she was educated regarding anytime there was a change in skin condition of any kind, she was supposed to notify the DON and physician and receive treatments orders anytime a wound worsens. (Day shift nurse 7a-7p) Interview with RN #2, on 01/17/20 at 12:15 PM, revealed she was educated regarding if a wound was identified during assessment or anytime, she would report it to the DON and contact the physician and responsible party. She stated she would notify the DON and try to get a treatment plan in progress and update the care plan with new treatments. She stated she would monitor the wounds and do dressing changes as ordered and document any wound changes of decline or improvement. (Night shift nurse 7p- 7a) 7. Review of audits of residents' progress notes, revealed the DON, MDS Coordinator, or Nurse Scheduler/Unit Manager reviewed progress notes daily since 10/29/19 for resident's, residing in the facility for four (4) weeks. The audit/ review of Nurse's Notes/Progress Notes encompassed all shifts for documented condition changes or concerns for residents to determine if there was a condition change, if the physician was notified as well as the responsible party and if any new orders/interventions were needed and implemented. These audits were implemented on 11/01/19 and were ongoing for four (4) weeks to ensure professional standards were being met. The findings of the daily audits were reviewed by the DON daily during the clinical white board meetings, Monday through Friday and discussed with the QAPI team during weekly QAPI meetings for eight (8) weeks, then monthly. 8. Review of the audits of residents' weekly skin assessments, revealed the DON, MDS Coordinator, or Nurse Scheduler/Unit Manager reviewed/audited the weekly skin assessments, the day before the skin assessments were due to ensure completeness and this began on 11/01/19 and was conducted daily for four (4) weeks to ensure completeness. Further review revealed a random sample of five (5) residents was completed for four (4) weeks. Review of the daily audit findings revealed they were being reviewed by the DON daily during the daily clinical white board meetings and discussed with the QAPI team during weekly QAPI meetings for eight (8) weeks, then monthly. 9. Review of audits of residents' weekly wound assessments revealed assessments that were scheduled each week were being completed for eight (8) weeks by the DON, MDS Coordinator, or Nurse Scheduler/Unit Manager. This started on 11/05/19 and ensured completeness, physician notification and implementation of new treatments, orders and interventions. Review of the findings of the weekly audits were being reviewed by the DON daily during the daily clinical white board meetings and discussed with the QAPI team during weekly QAPI meetings for eight (8) weeks, then monthly. Interviews with the DON and the Administrator, on 12/11/19 at 8:35 AM, revealed the DON reviewed the audits daily during the daily clinical white board meetings and discussed with the QAPI team during weekly QAPI meetings for eight (8) weeks, then monthly. 10. Interviews with the Special Projects Manager, on 12/11/19 at 9:00 AM, revealed a nurse from the regional team or corporate office had been onsite since 10/29/19 and was available by phone daily since 10/28/19 and would continue weekly visits and would be available daily by telephone until immediacy had been lifted, then every other week for four (4) weeks, then monthly. The nurses from the regional team or home office were assisting as needed, providing oversight and consultation, performing review of QAPI committee meeting minutes and ensuring additional education was being provided as needed.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to revise the care plan for one (1) of two (2) sampled residents (Resident #1). Resident #1 was assessed by licensed staff to have a Stage III pressure ulcer to the right upper buttock on 10/03/19, and pressure ulcer to the left buttock, a suspected deep tissue injury to the right heel, a darkened purple area to right great toe and a reddened area to the left lateral aspect of the left pinky toe on 10/15/19. Staff failed to revise the Comprehensive Care Plan to address the care of the newly identified wounds per facility policy. The findings include: Review of the facility's policy, titled Comprehensive Care Plans, revised 07/19/18 revealed care plan interventions would be implemented after consideration of the resident's problem areas and their causes. The nurse/Interdisciplinary Team would be responsible for the review and updating of care plans. Record review revealed the facility admitted Resident #1 on 08/09/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 08/16/19, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Further review of the admission MDS assessment revealed the resident had one (1) Stage II (2) pressure sore to the left heel. Review of the Comprehensive Care Plan for risk for pressure ulcer development and actual pressure sore (stage II left heel), dated 08/23/19 and last revised on 09/30/19, revealed interventions to observe effectiveness of /response to treatment as ordered, and apply a low air loss mattress to the bed. Review of an Intermittent Payment MDS Assessment (IPA), dated 10/03/19, and Weekly Skin Observation Report completed by Licensed Practical Nurse (LPN) #3, dated 10/08/19, revealed Resident #1 had a Stage III pressure ulcer to the right upper buttock that measured one.five (1.5) cm with white slough. In addition, review of a Wound Observation Detail Report, dated 10/15/19, revealed Resident #1 had a pressure ulcer on the left buttock area, a suspected deep tissue injury to the right heel, a darkened purpled pressure area to the right great toe, and a pencil eraser sized reddened area to the left lateral aspect of the left pinky toe. However, further review of the Comprehensive Care Plan for Risk for pressure sores, dated 08/23/19 revealed there was no documented evidence the care plan was revised to address the newly identified pressure sores and DTI to include treatment. Interview (Post Survey) with LPN #1, on 01/16/20 at 3:30 PM, revealed she reviewed the skin assessment she completed on 10/15/19 and her nursing documentation and stated she failed updated the care plan when she identified the new wounds and it was her responsibility to do so. Interview with the Director of Nursing (DON), on 12/11/19 at 8:35 AM, revealed any new issues identified to include new wounds were discussed in the morning clinical white board meeting and anyone could update the care plan. Interview with the Administrator and Director of Nursing (DON) on 12/11/19 at 08:35 AM, revealed the care plan should have been revised when the new pressure sores were identified.

Based on interview, record review and facility policy review, it was determined the facility failed to have an effective system in place to ensure staff provided Basic Life Support (BLS), including Cardiopulmonary Resuscitation (CPR), as per physician's orders [REDACTED].#1). On [DATE], the facility admitted Resident #1 with an Advance Directive, which stated, Full Code (wanted to have CPR performed). On [DATE], at approximately 11:20 PM-11:25 PM, Licensed Practical Nurse (LPN) #1 observed Resident #1 to be unresponsive with no pulse or respirations about ten (10) minutes after she had given the resident some water. LPN #1 did not call a Code Blue (announcement made when a resident is in need of immediate medical attention which alerts a rapid response team to rush to a specific location), perform CPR to include respirations, call the ambulance, obtain the crash cart, or call the physician according to the facility's policy. LPN #1 stopped compressions and called the resident's death at 11:25 PM; however, according to the facility's policy, only a Licensed Physician or Registered Nurse (RN) may call a death. In addition, the facility failed to ensure three (3) licensed nurses (MDS Coordinator, LPN #8 and LPN #14) had CPR certification for health care providers validated upon employment or maintained a current CPR certification during employment, which is required per facility policy. Also the facility failed to ensure the crash cart was checked fifteen (15) of thirty (30) days in (MONTH) (YEAR) and two (2) of twelve (12) days in (MONTH) (YEAR), to ensure all items were maintained on the crash cart, per facility policy; and, failed to notify central supply immediately when it was identified there was no suction tubing on the cart from ,[DATE]-,[DATE], per facility policy. The facility's failure to ensure CPR was performed on a resident who had an Advanced Directive to be a Full Code has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency (SSA) validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy, last revised [DATE], revealed CPR will be attempted for any resident who is found to have no palpable pulse and/or no discernible respirations, unless there is a written physician's orders [REDACTED]. Continued review revealed upon identifying a resident with a change in condition which presents as an unresponsive condition, the facility's emergency response process will be initiated which includes to announce Code Blue and retrieve the resident's medical record to check for advance directive status. Emergency Management System (EMS)/911 will be contacted immediately when the code blue is called. The facility will contact the resident's legal representative and the resident's physician as soon as possible after contacting 911. Retrieve the emergency cart and if the record indicates CPR, then initiate Basic Life Support if a pulse and/or respirations are undetectable. Basic Life support sequence is referred to as C-A-B (chest compressions, airway, and breathing). If a resident is found unresponsive and without respirations, a licensed staff member, who is certified in CPR/BLS, shall promptly initiate CPR for the resident, who has requested CPR in their advance directive. CPR includes high-quality chest compressions which are a depth of at least two (2) inches at a rate of at least 100 to 120 compressions per minute and ventilation with a compression-ventilation ratio of 30:2. CPR will be continued by facility staff until EMS arrives to assume responsibility for providing CPR. Facility staff should utilize the emergency code documentation form to document the event and place it in the resident's medical record. Review of the facility's Death of Resident, Documenting Policy, last reviewed [DATE], revealed appropriate documentation shall be made in the clinical record concerning the death of a resident. Continued review revealed a resident may be declared dead by a Licensed Physician or, Registered Nurse with physician authorization. Information pertaining to a resident's death which includes date and time of death, the name and title of the individual pronouncing the resident death shall be recorded in the Nurse's Notes. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable and able to make decisions. Review of Resident #1's Advance Directive/Informed Consent Form, signed by the Guardian on [DATE] revealed Full Code, indicating in the event the resident experienced a cardiopulmonary arrest, the resident/guardian wanted CPR performed. Review of Resident #1's physician's orders [REDACTED]. Review of the Comprehensive Care Plan for Advanced Directive, dated [DATE] revealed an intervention for staff to follow Advanced Directives for Full Code. Review of a Nursing Progress Note dated [DATE] at 1:53 AM, revealed the resident expired quietly at 11:25 PM ([DATE]); and the supervisor, family, physician, and funeral home were notified. A Provisional Report of Death was completed for date of death , on [DATE] at 11:25 PM. Review of the facility's Investigation Report completed by the Administrator, dated [DATE], revealed LPN #1 entered Resident #1's room at 11:30 PM and found the resident with no pulse, respirations, or blood pressure. LPN #1 had been in the room ten (10) minutes prior and gave the resident water with no issues noted. LPN #1 stated she started chest compressions due to the resident being a full code but the resident was not able to be resuscitated. LPN #1 notified the facility, physician, and funeral home. The facility determined LPN #1 did not follow the facility's CPR policy. Interview with LPN #1 on [DATE] at 2:13 PM revealed a little after 11:00 PM on [DATE], Resident #1 asked for water and she got the resident a water pitcher with water and ice and sat him/her up on the side of the bed. She stated when she came back five (5) to ten (10) minutes later the resident was lying on the bed and was gone with no pulse or respirations. LPN #1 stated she went to the chart and saw that the resident was a Full Code, so she then went back to the room and started chest compressions. The LPN stated she did not call Code Blue, obtain the crash cart or call 911, per facility policy. LPN #1 also stated she could not remember if she checked the chart first or started chest compressions first because she thought the resident was a Do Not Resuscitate (DNR). LPN #1 stated, I just did not know. She stated she saw the resident and started chest compressions after checking for a pulse and for breathing, but she did not initiate breaths. However, LPN #1 stated she knew breaths were a part of CPR. She then stated after performing compressions she checked the chart. LPN #1 stated 911 should have been called, but she did not call 911. Continued interview with LPN #1 on [DATE] at 2:13 PM revealed she emailed (electronic messaged) the doctor that the resident had passed and called the family. LPN #1 stated she knew CPR was not to be stopped until the doctor told the nurse to stop, or until EMS arrived and took over the CPR. She stated she did not have any help as the Certified Nurse Aide (CNA) on her unit was outside on break and, she would have to go through the resident's chart and look under Advance Directives to determine the resident's code status. LPN #1 further stated she started to call for help and call a Code Blue, but she knew by that time the resident would be brain dead. She stated she started to get help but she just did not have time as she had never been in a code situation before. LPN #1 stated she knew the steps to take, but she failed to perform the steps. Further interview revealed she was not aware of the Emergency Documentation Form, she was supposed to complete, according to the facility's policy to document a code. She further stated she did not document anything for the code and she should have documented what she did to the resident, but she was not sure what to document. Interview on [DATE] at 12:34 PM, revealed she emailed the doctor of the resident's passing and called the time of death as she did not have a telephone number to call the physician. She stated the resident was gone so she called it. However, review of the facility's policy revealed a resident may be declared dead only by a Licensed Physician or Registered Nurse with physician authorization. LPN #1 further stated she never had a resident pass on her in the facility. Interview with CNA #1 on [DATE] at 10:08 PM, revealed she placed a gown on the resident around 10:30 PM on [DATE] and noticed the resident was pale. CNA #1 stated the resident was breathing heavy, but this was not different for the resident. The CNA stated LPN #1 performed a blood sugar check on Resident #1 around 11:13 PM as she was with LPN #1 and then she went on break. CNA #1 revealed she heard no Code Blue called while she was on break. She stated she came inside around 11:25 PM and LPN #1 looked upset and motioned her to Resident #1's room and told her she thought the resident was a Full Code. CNA #1 stated LPN #1 left the room and returned about two (2) minutes later and asked me if I had it, referring to cleaning up the resident. CNA #1 stated she called LPN #2 and told her they had one to pass and LPN #2 told her she would be there soon. She stated LPN #2 told her (CNA #1) that LPN #1 had said the resident was a DNR and then CNA #1 told LPN #2 that LPN #1 told her (CNA #1) that the resident was a Full Code. She further stated at 11:35 PM, LPN #1 stated she was going to call it (meaning the time of death) at 11:25 PM. Interview with LPN #2 on [DATE] at 8:55 PM, revealed she was working as House Supervisor at the time of the incident with Resident #1. She stated she gave Resident #1 his/her medications at 8:00 PM and a med-pass supplement due to a poor appetite. She stated she raised the resident's head up to thirty-five (35) degrees due to the [MEDICAL CONDITION] as she still noticed puffiness in the resident's periorbital area. LPN #2 stated around 11:15 PM on [DATE] she left the building to take another employee home. She stated when she was on her way back to the facility, she received a call from CNA #1, who asked if she could assist with cleaning up Resident #1. LPN #2 stated she then spoke with LPN #1 via phone and LPN #1 stated everything was okay as Resident #1 was a DNR. Further interview revealed LPN #2 stated she then called the Director of Nursing (DON) and told her that Resident #1 had passed and he/she was a DNR. LPN #1 called the family. She stated when she got back to the facility which was about 11:30 PM-11:35 PM, LPN #1 waved (her) off which is something she does when she does not want to be bothered. LPN #2 stated the family came to the facility and condolences were offered and she explained to LPN #1 what to do with the Provisional Death Report. LPN #2 revealed at this time, LPN #1 stated to her she had done a little CPR. LPN #2 stated when she asked LPN #1 about what kind of CPR, LPN #1 stated the resident was a DNR and that she (LPN #1) did a sternal rub to see if she could get him/her back. LPN #2 stated she never looked in the chart to verify code status and she did not review the Advance Directive as she took the word of LPN #1 that the resident was a DNR. She stated the next morning around 8:30 AM-9:00 AM on [DATE], she received a call from the DON stating the resident was a Full Code. LPN #2 further stated there was no Registered Nurse (RN) in the building so LPN #1 could not call the time of death. She stated the ambulance should have taken over CPR, and transported the resident to the hospital where the time of death would have been called by a physician. LPN #2 stated if the resident was a DNR (as previously thought) the physician should have been notified of the absence of vital signs and the time of death would have been called at that time. However the physician was emailed. Interview on [DATE] at 8:06 PM, revealed she checked and the resident was a Full Code on the SBAR dated [DATE], but code status could change daily so when LPN #1 told her the resident was a DNR she had no reason to doubt her. Interview with LPN #5 on [DATE] at 10:08 PM, revealed she was working another hall when Resident #1 passed on [DATE] and a Code Blue was never called, nor did the ambulance ever come. She stated LPN #1 came over to her about 11:00 PM and stated a resident had passed, and she needed a Provisional Death Form. LPN #5 revealed LPN #1 told her that she went into Resident #1's room and the resident did not respond, he/she was dead with no blood pressure, respirations, or pulse. She stated LPN #1 stated the resident had not been doing good the last couple of days. Interview with Resident #1's Physician and Medical Director on [DATE] at 1:35 PM revealed if a resident was a Full Code then he expected staff to perform CPR. He stated the nurse should have called 911 and initiated CPR; and when EMS arrived they would pick up the CPR. He further stated if there was an emergent situation the nurse should call him by utilizing the telephone answering service, if it was on weekends and through the week after 4:00 PM. He stated emergent questions would be a resident not breathing and a fall with major injury. He further stated it was not healthcare standards to not administer CPR on a Full Code resident. Interview with the Director of Nursing (DON) [DATE] at 10:06 AM, revealed if a resident was a Full Code, she expected the licensed nurse to perform CPR and honor the Advance Directive. She stated the nurse should have initiated CPR, called a Code Blue, called 911, obtained the crash cart, and called the physician. The DON stated she received a call from the House Supervisor (LPN #2) before midnight and after 11:00 PM on [DATE] and was told Resident #1 had passed away. She stated she asked LPN #2 if the family had been called and did they have to code the resident. She stated LPN #2 told her the family was fine and the resident was a DNR. The DON further stated she reviewed the chart the next morning on [DATE], due to the death and realized the resident was a Full Code. She stated she called LPN #1 and LPN #2 to come back to the facility. The DON stated LPN #2 again stated LPN #1 told her Resident #1 was a DNR. Continued interview revealed LPN #1 told her she initiated chest compressions. The DON stated she expected LPN #1 to call 911 if the resident was a Full Code and follow the facility's policy. Further interview on [DATE] at 2:16 PM, with the DON revealed when a resident died in the facility the doctor was to be notified with the findings, no pulse and no respirations, and the physician would call the time of death. The DON stated since the doctor was notified via email and was not aware until the next morning she assumed the death was called at 7:30 AM at [DATE]. She was not sure if an LPN could call a death as she did not ask that question while investigating this incident as this was the first time she was hearing this information. She was not aware of what the policy stated and would need to check on who could call death. The DON stated she assumed the doctor was notified as nothing different was reported to her and she was not aware of any issue with notifying the physician. 2. Review of facility's CPR Certification Policy, reviewed [DATE], revealed all licensed nurses will have CPR certification for health care providers validated upon employment and will maintain current CPR certification during employment. The CPR card will be copied and placed in the employee's personnel file. The Staff Development Coordinator (SDC) or designee will coordinate and will maintain an updated list of personnel for re-certification purposes, and will notify the licensed staff when recertification is warranted. Review of facility provided licensed nurses with CPR certification revealed there were three (3) staff members who did not have validated CPR when the event occurred on [DATE]. Two (2) licensed nurse's (LPN #14 and the MDS Coordinator) CPR had expired and (1) licensed nurse's (LPN #8) CPR had not been validated on date of hire ([DATE]). However review of the facility's policy revealed all licensed nurses will have CPR certification validated upon employment and maintain current CPR certification during employment. Interview with the SDC (Staff Development Coordinator) on [DATE] at 1:06 PM, revealed she had been in the position of SDC since [DATE]. She stated it was her responsibility to monitor the licensed nurses' (who work the floor) certification and report to them when their CPR would expire. The SDC stated she knew LPN #14's certification was expiring [DATE]; however, since he worked midnights it was hard to get ahold of him. She stated he was signed up for CPR but the CPR class was canceled; and, he was unable to make it to the make-up class. She stated she did not keep up with licensed nurses' certification that did not work the floor which included administrative staff such as the MDS Coordinator. She further stated LPN #8 was a new nurse that started in (MONTH) (YEAR) and was hired while she was on leave. The SDC stated that this week, she was going to have new staff bring their CPR certification card to her so she could ensure the card was obtained and certification was renewed appropriately. However, according to the facility's policy, all licensed nurses will have CPR certification for health care providers validated upon employment and will maintain current CPR certification during employment. Further review revealed the employee's CPR card will be copied and placed in the employee's personnel file. The Staff Development Coordinator (SDC) or designee will coordinate and maintain an updated list of personnel for re-certification purposes, and will notify the licensed staff when recertification is warranted. Interview with the Administrator on [DATE] at 10:20 AM, revealed the SDC was responsible for CPR certifications and ensuring they were up to date. Further interview on [DATE] at 1:45 PM revealed the SDC would gather information for new employees to send to the home office. She stated she (Administrator) checks the file before it is sent to the home office, but not that good, to see if everything was in the file, as she depends on the SDC. Interview on [DATE] at 2:40 PM revealed the employee was hired when the SDC was on leave and the ADON performed the paperwork. She stated the ADON took the licensed nurse's word that her CPR certification was up to date without asking for proof and placing a copy in her personnel file. 3. Review of the facility's Emergency Cart Check List revealed to notify central supply immediately if any items are missing. If after business office hours, leave a voicemail at extension 207. Review of the form revealed daily check off of each item in the cart. Review of the crash cart checklist on the 200 Hall on [DATE] at 11:25 AM revealed fifteen (15) blanks for thirty (30) days in (MONTH) (YEAR) that the cart was not checked and the staff was unable to locate the (MONTH) (YEAR) crash cart checklist. Furthermore, review of the crash cart located behind locked doors with LPN #3 revealed there was no suction tubing on the crash cart. Interview with LPN #3 on [DATE] at 10:47 AM, revealed she was not sure where the (MONTH) (YEAR) crash cart checklist was, but the midnight shift checked the cart to ensure all items were on the cart. LPN #3 stated she then asked the Director of Nursing (DON), where the (MONTH) list was stored/filed. She stated the DON told her, she would get back with her on where the (MONTH) crash cart checklist was located. Review of the Emergency Cart Checklist for (MONTH) (YEAR) revealed it was not checked for two (2) days out of twelve days in (MONTH) (YEAR). Further review revealed a slash on the 8th-12th on [MEDICAL CONDITION] for the ambu bag, which indicated the bag was not available for use. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 11:30 AM revealed LPN #2, who is the midnight supervisor checked the crash cart when she was working and when she was off no one checked the cart. She stated she did not realize this until today. Further interview revealed LPN #2, the Midnight Supervisor had been keeping the crash cart checklist with her since she was checking the cart, therefore the nurse had to come back to the facility to bring the checklist. Observation of the crash cart was made with the ADON. The observation revealed the cart did not contain suction tubing, although the crash cart checklist was marked as containing suction tubing. Continued interview revealed that when the Midnight Supervisor came in with the checklist it was noted the cart needed suction tubing and it had been out for several days. The ADON stated the Midnight Supervisor told her she made a mistake and the suction tubing was missing, not [MEDICAL CONDITION] for the ambu bag as she had indicated. She stated if a piece of equipment was missing after hours, a note was to be left for any administrative staff to replace. Interview with LPN #2 on [DATE] at 8:55 PM revealed the suction tubing had been missing off the crash cart for several days. She stated she marked the wrong piece of equipment as missing and instead of marking a slash on [MEDICAL CONDITION] for the ambu bag she should have put slashes on the suction tubing. LPN #2 stated another resident needed suctioning and it was pulled off the crash cart and the staff member did not replace it. She stated there was none in the building, but central supply told her where the tubing was located. She stated she was responsible to check the crash cart every night, but if she was not at the facility no one would check it. LPN #2 stated she had to come back to work on [DATE] and bring the crash cart checklist for (MONTH) (YEAR) as she would take it home. She stated someone had used the suction tubing about a week ago and central supply replaced it then someone used it again and she told central supply on [DATE] when she brought the checklist to the facility. Interview on [DATE] at 9:25 AM, with the Administrator revealed she expected the crash cart to be checked daily and the supplies on the cart that were listed on the list were to be checked to ensure the items were on the cart. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], all residents advance directives/code status/Physician order [REDACTED]. 2. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed to ensure there had been no violation of resident's rights. Interviews were completed by the Social Services Director or Administrator. 3. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of seven (7) or below were physically assessed by the Director of Nursing, Assistant Director of Nursing or Charge Nurse for any signs and symptoms of quality of life or resident' rights violations. No concerns were identified. 4. On [DATE], the Regional Nurse Consultant and Administrator reviewed the records of residents who expired in the facility in the past thirty (30) days for issues or concerns related to the following of advance directives/code status. No concerns were identified. 5. On [DATE], the Regional Nurse Consultant audited the CPR certification status of all licensed nurses. By [DATE], all licensed nurses had current CPR certification. 6. On [DATE], the Director of Nursing, Assistant Director of Nursing, and the Staff Development Coordinator received education from the Administrator regarding monitoring CPR Certification status for licensed nurses. Including the Director of Nursing will be responsible for ensuring the CPR status for licensed nurses. In the absence of the Director of Nursing, the Assistant Director of Nursing will assume this responsibility. 7. On [DATE], a mock code blue drill was conducted by the Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator to ensure understanding and compliance with the Cardiopulmonary Resuscitation policy and procedure. 8. On [DATE], a review of the emergency cart and emergency code documentation form was completed for the licensed nurses present in the facility. 9. On [DATE], the Regional Nurse Consultant provided education to the Administrator, Director of Nursing and the Staff Development Coordinator regarding the policies for Cardiopulmonary [MEDICAL CONDITION] Resuscitation, Change of Condition, Comprehensive Care Plan and following the care plan, Resident' Rights, and following physician's orders [REDACTED]. 10. On [DATE], a pre-test was completed by the Staff Development Coordinator for all licensed nurses to test knowledge of their above stated policies. 11. On [DATE], all licensed nursing staff were educated by the Staff Development Coordinator, Director of Nursing, or Assistant Director of Nursing on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. 12. Education will be provided by the Staff Development Coordinator during orientation, prior to working on the floor, for newly hired licensed nurses on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. A post-test will be administered and a score of 100% will be required. Should a score of 100% not be obtained, re-education will occur and a post-test will be re-administered. This will be continued until a score of 100% on the post-test is obtained. 13. Starting on [DATE], post-tests were completed with four (4) licensed nurses by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, regarding the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. Four (4) post-tests with licensed nurses will be completed by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, daily for one (1) week (thru [DATE]), then three (3) post-tests with licensed nurses, daily for one (1) week ([DATE] - [DATE]), then two (2) post-tests with licensed nurses for two (2) weeks ([DATE] - [DATE]). If a nurse does not obtain a score of 100% on the post-test, re-education will be completed, and the post-test re-administered. This process will continue until a score of 100% is obtained on the post-test. Licensed Nurses will not be allowed to work until the score of 100% on the post-test is obtained. 14. Beginning [DATE], resident interviews are being completed for five (5) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or above, daily to ensure there are no violations of resident's rights. Interviews will be completed by the Social Services Director, Administrator, Director of Nursing, Assistant Director of Nursing, or Staff Development Coordinator, for five (5) residents daily for one (1) week (thru [DATE]), then for two (2) residents three (3) times weekly for two (2) weeks ([DATE] - [DATE]), one (1) two (2) times weekly for one (1) week ([DATE] - [DATE]). 15. Mock code drills will be conducted by the Director of Nursing, Assistant Director of Nursing, or the Staff Development Coordinator every shift for seventy-two (72) hours ([DATE], [DATE], [DATE]). Mock code drills will be completed twice weekly for two (2) weeks ([DATE] - [DATE]). Mock code drills will be completed once monthly for three (3) months ([DATE] - [DATE]). Mock code drills will be completed quarterly thereafter. 16. CPR certification for licensed nurses will be audited by the Administrator monthly. 17. Admission records will be reviewed on the day of admission by the Charge Nurse, Director of Nursing, Assistant Director of Nursing, Social Services Director, or the MDS Coordinator to ensure accurate documentation of Advance Directives, physician's orders [REDACTED]. 18. The emergency cart checklist will be reviewed daily by Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator or Medical Records, Monday thru Friday, for two (2) weeks, then three (3) times weekly for two (2) weeks, then weekly thereafter. The weekend manager/manager on duty for holidays will complete the review of the emergency cart checklist on weekends and holidays. 19. On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, the Administrator, the Director of Nursing, the Assistant Director of Nursing, and the Staff Development Coordinator to discuss the occurrence of CPR not being continued as per policy for a resident with a full code status. Also discussed was the education completed with licensed nurses, as well as audits and monitoring that has been initiated as a corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 20. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Nursing, Social Services Director, Business Office Manager, and Regional Nurse Consultant to review findings of audits that were completed on [DATE], and continuance of the corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 21. On [DATE], an ad hoc QAPI meeting was held with Medical Director, Administrator, Director of Nursing, MDS Coordinator, Medical Records Clerk, Admissions and Marketing Director, Staff Development Coordinator, Rehab Services Manager, Business Office Manager, Plant Operations Director, Dietary Manager, Assistant Director of Nursing, Social Services Director, and the Staffing Coordinator to review the corrective action plan with all department managers. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 22. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator to review findings and continuation of the corrective action plan. The Medical Director agreed with the continuance of the corrective action plan, and had no further recommendations at this time. 23. A QAPI meeting will be held weekly for four (4) weeks ([DATE] - [DATE]), then monthly to review the corrective action plan and d

Based on interview, record review and facility policy review, it was determined the facility failed to have an effective system in place to provide for the provision of physician services for one (1) of three (3) sampled residents (Resident #1). On [DATE] at approximately 11:,[DATE]:25 PM, Resident #1 was found with no respirations or pulse and Licensed Practical Nurse (LPN) #1 notified the Physician by e-mail (electronic message) as there was no telephone number available to call the Physician in an emergency. The Physician did not respond until 7:30 AM on [DATE] {(eight) 8 hours later}. The physician was not available to be contacted to call the death of Resident #1. The facility's failure to have an effective system in place to provide for the provision of physician services has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency (SSA) validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Death of Resident, Documenting Policy, last reviewed [DATE], revealed a resident may be declared dead by a Licensed Physician or, Registered Nurse with physician authorization. Review of the facility's Change in Condition Policy, reviewed [DATE], revealed for life threatening events call 911 and notify the physician. If unable to contact the physician, depending on the significance of the change, contact the Medical Director. If the condition does not appear to be life threatening perform a Situation, Background, Assessment, Recommendations (SBAR) form to provide the physician with necessary evaluation findings and verbally communicate the information to the physician. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Advance Directive/Informed Consent Form, signed by the Guardian on [DATE] revealed Full Code, indicating the resident wanted Cardiopulmonary Resuscitation (CPR). Review of a Nursing Progress Note, dated [DATE] at 1:53 AM revealed Resident #1 expired quietly at 11:25 PM ([DATE]); and the supervisor, family, physician, and funeral home were notified. However, interview with LPN #1 on [DATE] at 2:13 PM revealed she found Resident #1 lying on the bed and the resident was gone with no pulse or respirations. She stated she emailed the Physician that the resident had passed because email was the only way of communicating with the Physician as there was no on call Physician that she was aware of to notify. Interview with LPN #1 on [DATE] at 12:34 PM, revealed she called the time of death as she did not have a number to call the physician. She stated the resident was gone so she called it (declared the resident dead). Interview with LPN #5 on [DATE] at 10:08 PM, revealed the only way to get ahold of the physician was to email him as there was no telephone number to contact the physician for emergencies. She stated she spoke with the Director of Nursing (DON) and ADON (Assistant Director of Nursing) last week after the incident occurred on [DATE]; and, again on [DATE] expressing concerns regarding no telephone number to call the physician for emergencies, only email. LPN #5 stated, The Nurse Practitioner will get back with you, but you will have to wait a while. She stated she was told by the DON on [DATE], that she had not figured it out yet but she was working on it and would get back with her. Interview on [DATE] at 8:47 PM revealed she was inserviced yesterday ([DATE]) regarding a phone number for an on call physician for emergencies. Interview on [DATE] with LPN #6 at 8:22 PM revealed a while back she had called the physician's office for a change in condition on a resident during office hours and was told by the physician's staff to email as that was protocol and not to call the office under no circumstances. She stated she received an inservice by the DON on [DATE] and was given a telephone number for an on call physician. Interview with LPN #7 on [DATE] at 8:36 PM revealed the only way to contact the physician was through email even for emergency situations as he was not aware of an on-call physician. He stated he received an inservice via phone on [DATE] by the DON that the physician now had an answering service number the nurses could contact in an emergency Interview with Resident #1's Physician/Medical Director on [DATE] at 1:35 PM revealed if there was an emergent situation the nurse should call him by utilizing the telephone answering service, if it was after hours on weekends and through the week after 4:00 PM. He stated this was in place before as nurses have utilized the answering service in the past. The Physician revealed during office hours the physician could be contacted at the office or via email. The physician stated in non-emergent situations the facility could contact him via email. The Physician stated emails were reviewed in less than twenty-four (24) hours and email questions (non-emergent) would be routine labs and pharmacy questions. The Physician stated emergent questions would be a resident not breathing and a fall with major injury. He stated the email came through for him regarding Resident #1's death in the early AM on [DATE] and he responded ok at 7:30 AM on [DATE] via email (eight {8} hours after the resident passed). Interview on [DATE] at 2:16 PM, with the DON revealed when a resident died in the facility the Physician was to be notified with the findings, no pulse and no respirations, and the physician would call the time of death. She stated since the Physician was notified via email and was not aware until the next morning she assumed the death was called at 7:30 AM at [DATE]. The DON stated she assumed the Physician was notified as nothing different was reported to her and she was not aware of any issue with notifying the physician. She stated there was a phone number the staff could use to call the on call Physician after hours if needed for emergency situations. She stated this number was in the communication book for the nurses at the desk. However, interview with licensed staff revealed they were unaware of the emergency after hours number. Interview with the DON on [DATE] at 10:06 AM, revealed she inserviced staff on [DATE] in regards to the physician's answering service telephone number and to call the number for a change in condition, not email. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], all residents advance directives/code status/Physician order [REDACTED]. 2. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed to ensure there had been no violation of resident's rights. Interviews were completed by the Social Services Director or Administrator. 3. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of seven (7) or below were physically assessed by the Director of Nursing, Assistant Director of Nursing or Charge Nurse for any signs and symptoms of quality of life or resident' rights violations. No concerns were identified. 4. On [DATE], the Regional Nurse Consultant and Administrator reviewed the records of residents who expired in the facility in the past thirty (30) days for issues or concerns related to the following of advance directives/code status. No concerns were identified. 5. On [DATE], the Regional Nurse Consultant audited the CPR certification status of all licensed nurses. By [DATE], all licensed nurses had current CPR certification. 6. On [DATE], the Director of Nursing, Assistant Director of Nursing, and the Staff Development Coordinator received education from the Administrator regarding monitoring CPR Certification status for licensed nurses. Including the Director of Nursing will be responsible for ensuring the CPR status for licensed nurses. In the absence of the Director of Nursing, the Assistant Director of Nursing will assume this responsibility. 7. On [DATE], a mock code blue drill was conducted by the Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator to ensure understanding and compliance with the Cardiopulmonary Resuscitation policy and procedure. 8. On [DATE], a review of the emergency cart and emergency code documentation form was completed for the licensed nurses present in the facility. 9. On [DATE], the Regional Nurse Consultant provided education to the Administrator, Director of Nursing and the Staff Development Coordinator regarding the policies for Cardiopulmonary [MEDICAL CONDITION] Resuscitation, Change of Condition, Comprehensive Care Plan and following the care plan, Resident' Rights, and following physician's orders [REDACTED]. 10. On [DATE], a pre-test was completed by the Staff Development Coordinator for all licensed nurses to test knowledge of their above stated policies. 11. On [DATE], all licensed nursing staff were educated by the Staff Development Coordinator, Director of Nursing, or Assistant Director of Nursing on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. 12. Education will be provided by the Staff Development Coordinator during orientation, prior to working on the floor, for newly hired licensed nurses on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. A post-test will be administered and a score of 100% will be required. Should a score of 100% not be obtained, re-education will occur and a post-test will be re-administered. This will be continued until a score of 100% on the post-test is obtained. 13. Starting on [DATE], post-tests were completed with four (4) licensed nurses by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, regarding the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. Four (4) post-tests with licensed nurses will be completed by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, daily for one (1) week (thru [DATE]), then three (3) post-tests with licensed nurses, daily for one (1) week ([DATE] - [DATE]), then two (2) post-tests with licensed nurses for two (2) weeks ([DATE] - [DATE]). If a nurse does not obtain a score of 100% on the post-test, re-education will be completed, and the post-test re-administered. This process will continue until a score of 100% is obtained on the post-test. Licensed Nurses will not be allowed to work until the score of 100% on the post-test is obtained. 14. Beginning [DATE], resident interviews are being completed for five (5) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or above, daily to ensure there are no violations of resident's rights. Interviews will be completed by the Social Services Director, Administrator, Director of Nursing, Assistant Director of Nursing, or Staff Development Coordinator, for five (5) residents daily for one (1) week (thru [DATE]), then for two (2) residents three (3) times weekly for two (2) weeks ([DATE] - [DATE]), one (1) two (2) times weekly for one (1) week ([DATE] - [DATE]). 15. Mock code drills will be conducted by the Director of Nursing, Assistant Director of Nursing, or the Staff Development Coordinator every shift for seventy-two (72) hours ([DATE], [DATE], [DATE]). Mock code drills will be completed twice weekly for two (2) weeks ([DATE] - [DATE]). Mock code drills will be completed once monthly for three (3) months ([DATE] - [DATE]). Mock code drills will be completed quarterly thereafter. 16. CPR certification for licensed nurses will be audited by the Administrator monthly. 17. Admission records will be reviewed on the day of admission by the Charge Nurse, Director of Nursing, Assistant Director of Nursing, Social Services Director, or the MDS Coordinator to ensure accurate documentation of Advance Directives, physician's orders [REDACTED]. 18. The emergency cart checklist will be reviewed daily by Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator or Medical Records, Monday thru Friday, for two (2) weeks, then three (3) times weekly for two (2) weeks, then weekly thereafter. The weekend manager/manager on duty for holidays will complete the review of the emergency cart checklist on weekends and holidays. 19. On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, the Administrator, the Director of Nursing, the Assistant Director of Nursing, and the Staff Development Coordinator to discuss the occurrence of CPR not being continued as per policy for a resident with a full code status. Also discussed was the education completed with licensed nurses, as well as audits and monitoring that has been initiated as a corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 20. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Nursing, Social Services Director, Business Office Manager, and Regional Nurse Consultant to review findings of audits that were completed on [DATE], and continuance of the corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 21. On [DATE], an ad hoc QAPI meeting was held with Medical Director, Administrator, Director of Nursing, MDS Coordinator, Medical Records Clerk, Admissions and Marketing Director, Staff Development Coordinator, Rehab Services Manager, Business Office Manager, Plant Operations Director, Dietary Manager, Assistant Director of Nursing, Social Services Director, and the Staffing Coordinator to review the corrective action plan with all department managers. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 22. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator to review findings and continuation of the corrective action plan. The Medical Director agreed with the continuance of the corrective action plan, and had no further recommendations at this time. 23. A QAPI meeting will be held weekly for four (4) weeks ([DATE] - [DATE]), then monthly to review the corrective action plan and discuss findings of audits and monitoring, and for further recommendations as indicated. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of facility provided flowsheet dated [DATE] revealed all residents advanced directives/code status/physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM, Assistant Director of Nursing at 2:15 PM, Social Service Director at 3:21 PM, and Regional Nurse Consultant at 3:42 PM; and on [DATE] at 11:10 AM with the Director of Nursing, revealed they were part of the audit process on [DATE] which reviewed the physician's orders [REDACTED]. They further stated there were no noted concerns with the audits. 2. Review of facility provided Census Report dated [DATE] revealed all residents with a BIMS eight (8) and greater were reviewed with a star beside each resident. Furthermore, each resident with a BIMS of eight (8) and greater had a questionnaire with questions of Do you have any concerns? Do you feel safe? Do you feel safe from abuse? filled out by the Administrator and Social Service Director on [DATE]. Interviews on [DATE] with the Administrator at 11:20 AM and the Social Service Director at 3:21 PM revealed they interviewed all residents with a BIMS eight (8) and greater to assess for any signs and symptoms of abuse or violation of resident's rights by asking the above questions. 3. Review of skin assessments of residents with a BIMS of less than eight (8) dated [DATE] revealed those residents were assessed by the DON and ADON for signs and symptoms of quality of life or resident's rights violation with no concerns identified. Interview with the ADON on [DATE] at 2:15 PM and the DON on [DATE] at 11:10 AM revealed they performed skin assessments on residents with a BIMS of seven (7) and below on [DATE] to assess for any rights violations. 4. Review of a facility provided list dated [DATE] revealed residents who had expired in the past ninety (90) days with a review of the physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM and the Regional Nurse Consultant at 3:42 PM revealed they reviewed residents that had expired in the last ninety (90) days on [DATE] to ensure code status, nurses notes, advance directive, and care plans all matched with no concerns identified. 5. Review of a facility provided list dated [DATE] revealed all licensed nursing staff CPR certification was audited by the Regional Nurse Consultant and all licensed nurses had current CPR certification. Interview with the Regional Nurse Consultant on [DATE] at 3:42 PM revealed on [DATE] she reviewed all licensed nurse's CPR certification on [DATE]. She stated there were two (2) nurses who had expired CPR certifications and one (1) nurse who had not provided proof of certification upon hired. She further stated by the afternoon on [DATE] all licensed nurses had proof of certification. 6. Review of CPR Certification Verification Education dated [DATE] revealed the Administrator provided education to the Staff Development Coordinator (SDC), DON, and ADON. Interviews on [DATE] with the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they received education from the Administrator on [DATE] if a new licensed nurse employee is hired the SDC is responsible to ensure the CPR certification is obtained before starting work. Furthermore, if the SDC is off the DON and ADON is responsible for obtaining the information. In addition, the SDC is responsible to ensure the licensed nurses certification is checked monthly for expiration and are up to date. Interview with the Administrator on [DATE] at 11:20 AM revealed she provided education to the SDC, ADON, and DON on [DATE] ensuring employees on hire had proof of CPR certification and CPR certification was renewed before expiring or the employee was not allowed to work. In addition, the SDC is responsible to monitor monthly for CPR certification expiration as well as to obtain the certification on hire. Furthermore, the DON and ADON is responsible in the absence of the SDC. 7. Review of the Mock Code Checklist dated [DATE] at 6:00 PM revealed a drill was conducted by the DON. Review of the Mock Code Checklist dated [DATE] at 8:00 PM revealed a drill was conducted by the SDC. Interview with the SDC on [DATE] at 2:34 PM and the DON on [DATE] at 11:10 AM revealed they performed Mock Code Blue Drills with staff on [DATE]. Interviews on [DATE] with Licensed Practical Nurse (LPN) #8 at 4:15 PM and LPN #9 at 4:41 PM revealed they were part of a Code Blue Drill on [DATE] presented by the SDC, DON, and ADON. 8. Review of facility provided calendar titled charts and crash cart reviewed for (MONTH) (YEAR) revealed the Administrator's initials for [DATE] on review of the crash cart. Furthermore, review of inservice form titled Crash cart should be checked by night shift nurse on wing two (2) dated [DATE] revealed education was provided by the SDC. Interviews on [DATE] with LPN #11 at 1:50 PM, LPN #3 at 2:03 PM, and LPN #9 at 2:08 PM revealed they received inservicing from the SDC on [DATE] regarding the night nurse's responsibility to check the crash cart at night. If an item was missing it was the nurses responsibility to replace the item who removed the item from the cart. Interview with the SDC on [DATE] at 1:05 PM revealed she began education with staff on [DATE] regarding the crash cart and educated the nurses present in the facility on [DATE]. 9. Review of Inservice Sign In sheet dated [DATE] with education topics of Advance Directives, Resident Rights, CPR, Location of DNR form in resident's medical record, following physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON, revealed they were educated by the Regional Nurse Consultant on when to perform an SBAR with change in condition in a resident, notification of family and physician for a change, following the physician's orders [REDACTED]. 10. Review of a pre-test administered to licensed nurses on Full Code Status and CPR revealed all licensed nurses completed from [DATE]-[DATE] and received 100 percent (%). Furthermore, the pre-tests were signed by the SDC for verification and signed by the staff member performing the test. Interview with the SDC on [DATE] at 2:34 PM revealed she gave pre-test to all licensed nurses on [DATE] and [DATE] with 100% of nurses completed at a score of 100%. Interviews on [DATE] with LPN #8 at 4:15 PM, Registered Nurse (RN) #1 at 4:25 PM, and LPN #9 at 4:41 PM revealed they received a pre-test on Full Code and CPR prior to education on [DATE] and [DATE] and made a 100%. 11. Review of Inservice Form dated [DATE] revealed the licensed nurses were inserviced on initiating CPR on a resident when found unresponsive if they have a code status of Full Code. In addition, the CPR is to continue unless an order is received to stop or until EMS arrives. Furthermore, the education included following physician's orders [REDACTED]. Interview with the SDC on [DATE] at 2:34 PM revealed she provided education to the licensed nurses on [DATE] regarding resident's rights in choosing a code status, following through with the code status as ordered and per the resident's wishes, where to find the code status in the chart, location of the crash cart, notification to the family and physician, following the care plan/Advanced Directive. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, and LPN #9 at 4:41 PM revealed they were inserviced on [DATE] on where to locate the code status in the resident's chart, location of the crash cart, a full code resident requires CPR if found unresponsive, call 911, call a code blue, notification of change to the physician and family, following the care plan and Advance Directive, and performing an SBAR. 12. Review of new hire orientation for LPN #10 on [DATE] revealed education on CPR policy, resident rights, advance directives, change in condition, location of the code status and advance directives, emergency documentation form, following the care plans, and a pre and post test by the SDC. Interview with LPN #10 on [DATE] at 4:57 PM revealed before she was able to work the floor she was provided a pre and post test, education about the facility policy on CPR, instructions on the crash cart, how to review the contents on the crash cart, who was responsible to check the crash cart which was the night nurse, if an item was missing off the crash cart to replace it, how to find the advance directive and code status in the chart, call 911 is resident found unresponsive and was a full code, initiate CPR, call a Code Blue, continue CPR until EMS arrives, follow physician orders, physician notification, and emergency documentation form. 13. Review of post-tests on [DATE] revealed four (4) licensed nurses completed the test which included education on CPR, following physician's orders [REDACTED]. In addition, review of post test revealed test completed by licensed nurses daily for one (1) week through [DATE], then three (3) post test daily for one week through [DATE]. All nurses obtained 100% on the post test. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, LPN #9 at 4:41 PM, and LPN #10 at 4:57 PM revealed they have performed post test after the initial pre test regarding questions of notification to the physician, when to end CPR, where the Advance Directive is located, and change in condition. 14. Review of Resident interviews for residents with a BIMS of eight (8) or above revealed questions of any resident concerns, feeling safe, and safe from abuse was completed on five (5) residents daily starting [DATE]; then two (2) residents three (3) times a week for two (2) weeks starting [DATE] by the Administrator and Social Services. Interviews on [DATE] with the Administrator at 11:20 AM and Social Services Director at 3:26 PM revealed they interview residents with a BIMS of eight (8) and greater to assess for signs and symptoms of abuse or violation of resident rights. 15. Review of Mock Code Blue Drills dated [DATE], [DATE], and [DATE] revealed the drills were conducted for seventy-two (72) hours; then the drills were completed twice weekly for two (2) weeks starting [DATE] until [DATE] by the DON, ADON, or SDC. Interviews on [DATE] with the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they have performed Mock Code Blue Drills everyday on [DATE], [DATE], and [DATE] and continue to perform the mock drills twice a week at the present time. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, LPN #9 at 4:41 PM, and LPN #10 at 4:57 PM revealed they have been involved with several mock code blue drills so far since [DATE]. 16. Review of facility provided list of all licensed nurses with date of CPR expiration for month of (MONTH) (YEAR) with Administrators initials for (MONTH) (YEAR)'s review. Interview with the Administrator on [DATE] at 11:20 AM revealed she had already audited the CPR certifications for the month of (MONTH) and initialed on the CPR expiration form. She stated the calendar will be initialed when she performs each month. 17. Review of (MONTH) (YEAR) calendar titled Chart review and crash cart review revealed initials by Administrative staff every day from [DATE]-[DATE]. Interviews on [DATE] with the ADON at 2:15 PM and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they review new admissions for code status, Advance Directives, care plan, and physician's orders [REDACTED]. 18. Review of the Emergency Cart Check List revealed the cart has been reviewed daily by Administrative Staff since [DATE]. Interviews on [DATE] with the Administrator at 11:20 AM and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they have taken part in checking the crash cart daily since identified on [DATE] to ensure all the equipment was on the crash cart. In addition, they ensured the staff had signed off on the checklist daily. 19. Review of the facility provided Quality Performance Improvement (QAPI) sign in sheet dated [DATE] revealed the Administrator, DON, ADON, and SDC was in attendance along with the Medical Director via phone. Review of the typed up minutes revealed the incident with Resident #1 was discussed and a plan was discussed which included audits. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they attended an Ad Hoc Quality Assurance (QA) meeting in which they discussed with the Medical Director via phone the plan, concerns, audits, and education to begin and what had already been started. 20. Review of the facility provided QAPI sign in sheet dated [DATE] revealed the Administrator, DON, Social Service Director, Business Office Manager, and SDC including the Medical Director via phone was in attendance. Review of the typed up minutes revealed no concerns noted from audits and no new suggestions. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, the SDC at 2:34 PM, and the Business Office Manager at 3:06 PM; and, on [DATE] at 11:10 AM with the DON revealed they attended a QA meeting on [DATE] and discussed the progress with education, audits, and the ongoing plan. 21. Review of the facility provided QAPI sign in sheet dated [DATE] revealed the Administrator, DON, MDS, Medical Records, SDC, Business Office Manager, Plant Operations Manager, ADON, Dietary Manager, and Social Service Director including the Medical Director via phone was in attendance. Review of the typed up minutes revealed no concerns with audits and no new suggestions. Interviews on [DATE] with the Administrator at 11:20 AM, Plant Operations at 1:57 PM, the ADON at 2:15 PM, the SDC at 2:34 PM, the Business Office Manager at 3:06 PM, the Dietary Manager at 3:15 PM, and the Social Services Director at 3:42 PM; and, on [DATE] at 11:10 AM with the DON revealed they were part of QA on [DATE]. Furthermore, they stated the audits that had been performed were reviewed, review of the plan again, and reviewed education that had been provided. 22. Review of facility provided QAPI sign in sheet dated [DATE] revealed the Administrator, DON, ADON, and SDC including the Medical Director via phone was in attendance. Review of the summary of discussion revealed no concerns noted from audits and reviews. Interviews on [DATE] with the Administrator at 11:20 AM, ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed the audits from the days prior were reviewed for any concerns, the plan was reviewed again for any changes, and continued education was reviewed. 23. A QAPI meeting was planned on [DATE] to discuss the outcome of audits via phone with the Medical Director. Interview with the Administrator on [DATE] at 11:20 AM revealed a QAPI meeting was planned on [DATE] to discuss the progress of the plan and to review for any changes. She stated the Medical Director wi

Based on interview, record review, and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1) which was consistent with the resident's rights according to their Advance Directive. The facility created care plans for Resident #1 to follow Advanced Directives for a Full Code (wanted to have Cardiopulmonary Resuscitation {CPR} performed). However, Licensed Practical Nurse (LPN) #1 failed to provide Resident #1 CPR on [DATE], when she found the resident unresponsive with no pulse and respirations. LPN #1 called the time of death at 11:25 PM. The facility's failure to implement the care plan related to the resident's Advance Directive to be a Full Code has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of Immediate Jeopardy on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Care Plan-Comprehensive Policy, dated [DATE], revealed care plan interventions are implemented after consideration of the resident's problem areas and their causes. Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy, last revised [DATE], revealed CPR will be attempted for any resident who is found to have no palpable pulse and/or no discernible respirations, unless there is a written physician order [REDACTED]. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable and able to make decisions. Review of Resident #1's Advance Directive/Informed Consent Form, signed by the Guardian on [DATE] revealed Full Code, indicating in the event the resident experienced a cardiopulmonary arrest, the resident/guardian wanted CPR performed. Review of the resident's Advanced Directive Care Plan, dated [DATE] revealed an intervention to follow Advanced Directives for Full Code. However, interview with LPN #1 on [DATE] at 2:13 PM revealed she found Resident #1 lying on the bed with no pulse or respirations, five (5) to ten (10) minutes after she had checked on the resident. LPN #1 stated when she went to the chart she saw the resident was a Full Code. She then went back to the room and started chest compressions. LPN #1 further stated she could not remember if she checked the chart first or started chest compressions first because she thought the resident was a Do Not Resuscitate (DNR). She stated when she saw the resident she started chest compressions after checking for a pulse and for breathing, but she did not initiate breaths. LPN #1 stated she knew giving breaths was part of CPR. During further interview, LPN #1 stated she did not obtain the crash cart, call a Code Blue, or call Emergency Medical Services (EMS). She stated she knew CPR was not to be stopped until the physician told the nurse to stop or until EMS arrived and took over the CPR. LPN #1 stated she did not have any help as her Certified Nurse Aide (CNA) was outside on break. Review of the Nursing Progress Notes, dated [DATE] at 1:53 AM revealed LPN #1 documented Resident #1 expired quietly at 11:25 PM ([DATE]) with supervisor, family, physician, and funeral home notified. A Provisional Report of Death was completed for date of death as [DATE] at 11:25 PM. Interview with LPN #12 on [DATE] at 7:04 PM, LPN #2 on [DATE] at 8:55 PM, LPN #4 on [DATE] at 9:50 PM, and LPN #5 on [DATE] at 10:08 PM revealed nurses were expected to follow the care plan for code status. Interview with the Director of Nursing on [DATE] at 10:06 AM revealed she expected the nurses to honor the resident's Advance Directive and care plan and perform CPR as the resident requested and was care planned. The DON stated she monitors physician's orders [REDACTED]. Interview with the Administrator on [DATE] at 9:25 AM revealed they had identified LPN #1 did not follow the CPR policy and did not follow Resident #1's care plan/Advance Directive. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], all residents advance directives/code status/Physician order [REDACTED]. 2. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed to ensure there had been no violation of resident's rights. Interviews were completed by the Social Services Director or Administrator. 3. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of seven (7) or below were physically assessed by the Director of Nursing, Assistant Director of Nursing or Charge Nurse for any signs and symptoms of quality of life or resident' rights violations. No concerns were identified. 4. On [DATE], the Regional Nurse Consultant and Administrator reviewed the records of residents who expired in the facility in the past thirty (30) days for issues or concerns related to the following of advance directives/code status. No concerns were identified. 5. On [DATE], the Regional Nurse Consultant audited the CPR certification status of all licensed nurses. By [DATE], all licensed nurses had current CPR certification. 6. On [DATE], the Director of Nursing, Assistant Director of Nursing, and the Staff Development Coordinator received education from the Administrator regarding monitoring CPR Certification status for licensed nurses. Including the Director of Nursing will be responsible for ensuring the CPR status for licensed nurses. In the absence of the Director of Nursing, the Assistant Director of Nursing will assume this responsibility. 7. On [DATE], a mock code blue drill was conducted by the Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator to ensure understanding and compliance with the Cardiopulmonary Resuscitation policy and procedure. 8. On [DATE], a review of the emergency cart and emergency code documentation form was completed for the licensed nurses present in the facility. 9. On [DATE], the Regional Nurse Consultant provided education to the Administrator, Director of Nursing and the Staff Development Coordinator regarding the policies for Cardiopulmonary [MEDICAL CONDITION] Resuscitation, Change of Condition, Comprehensive Care Plan and following the care plan, Resident' Rights, and following physician's orders [REDACTED]. 10. On [DATE], a pre-test was completed by the Staff Development Coordinator for all licensed nurses to test knowledge of their above stated policies. 11. On [DATE], all licensed nursing staff were educated by the Staff Development Coordinator, Director of Nursing, or Assistant Director of Nursing on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. 12. Education will be provided by the Staff Development Coordinator during orientation, prior to working on the floor, for newly hired licensed nurses on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. A post-test will be administered and a score of 100% will be required. Should a score of 100% not be obtained, re-education will occur and a post-test will be re-administered. This will be continued until a score of 100% on the post-test is obtained. 13. Starting on [DATE], post-tests were completed with four (4) licensed nurses by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, regarding the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. Four (4) post-tests with licensed nurses will be completed by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, daily for one (1) week (thru [DATE]), then three (3) post-tests with licensed nurses, daily for one (1) week ([DATE] - [DATE]), then two (2) post-tests with licensed nurses for two (2) weeks ([DATE] - [DATE]). If a nurse does not obtain a score of 100% on the post-test, re-education will be completed, and the post-test re-administered. This process will continue until a score of 100% is obtained on the post-test. Licensed Nurses will not be allowed to work until the score of 100% on the post-test is obtained. 14. Beginning [DATE], resident interviews are being completed for five (5) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or above, daily to ensure there are no violations of resident's rights. Interviews will be completed by the Social Services Director, Administrator, Director of Nursing, Assistant Director of Nursing, or Staff Development Coordinator, for five (5) residents daily for one (1) week (thru [DATE]), then for two (2) residents three (3) times weekly for two (2) weeks ([DATE] - [DATE]), one (1) two (2) times weekly for one (1) week ([DATE] - [DATE]). 15. Mock code drills will be conducted by the Director of Nursing, Assistant Director of Nursing, or the Staff Development Coordinator every shift for seventy-two (72) hours ([DATE], [DATE], [DATE]). Mock code drills will be completed twice weekly for two (2) weeks ([DATE] - [DATE]). Mock code drills will be completed once monthly for three (3) months ([DATE] - [DATE]). Mock code drills will be completed quarterly thereafter. 16. CPR certification for licensed nurses will be audited by the Administrator monthly. 17. Admission records will be reviewed on the day of admission by the Charge Nurse, Director of Nursing, Assistant Director of Nursing, Social Services Director, or the MDS Coordinator to ensure accurate documentation of Advance Directives, physician's orders [REDACTED]. 18. The emergency cart checklist will be reviewed daily by Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator or Medical Records, Monday thru Friday, for two (2) weeks, then three (3) times weekly for two (2) weeks, then weekly thereafter. The weekend manager/manager on duty for holidays will complete the review of the emergency cart checklist on weekends and holidays. 19. On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, the Administrator, the Director of Nursing, the Assistant Director of Nursing, and the Staff Development Coordinator to discuss the occurrence of CPR not being continued as per policy for a resident with a full code status. Also discussed was the education completed with licensed nurses, as well as audits and monitoring that has been initiated as a corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 20. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Nursing, Social Services Director, Business Office Manager, and Regional Nurse Consultant to review findings of audits that were completed on [DATE], and continuance of the corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 21. On [DATE], an ad hoc QAPI meeting was held with Medical Director, Administrator, Director of Nursing, MDS Coordinator, Medical Records Clerk, Admissions and Marketing Director, Staff Development Coordinator, Rehab Services Manager, Business Office Manager, Plant Operations Director, Dietary Manager, Assistant Director of Nursing, Social Services Director, and the Staffing Coordinator to review the corrective action plan with all department managers. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 22. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator to review findings and continuation of the corrective action plan. The Medical Director agreed with the continuance of the corrective action plan, and had no further recommendations at this time. 23. A QAPI meeting will be held weekly for four (4) weeks ([DATE] - [DATE]), then monthly to review the corrective action plan and discuss findings of audits and monitoring, and for further recommendations as indicated. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of facility provided flowsheet dated [DATE] revealed all residents advanced directives/code status/physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM, Assistant Director of Nursing at 2:15 PM, Social Service Director at 3:21 PM, and Regional Nurse Consultant at 3:42 PM; and on [DATE] at 11:10 AM with the Director of Nursing, revealed they were part of the audit process on [DATE] which reviewed the physician's orders [REDACTED]. They further stated there were no noted concerns with the audits. 2. Review of facility provided Census Report dated [DATE] revealed all residents with a BIMS eight (8) and greater were reviewed with a star beside each resident. Furthermore, each resident with a BIMS of eight (8) and greater had a questionnaire with questions of Do you have any concerns? Do you feel safe? Do you feel safe from abuse? filled out by the Administrator and Social Service Director on [DATE]. Interviews on [DATE] with the Administrator at 11:20 AM and the Social Service Director at 3:21 PM revealed they interviewed all residents with a BIMS eight (8) and greater to assess for any signs and symptoms of abuse or violation of resident's rights by asking the above questions. 3. Review of skin assessments of residents with a BIMS of less than eight (8) dated [DATE] revealed those residents were assessed by the DON and ADON for signs and symptoms of quality of life or resident's rights violation with no concerns identified. Interview with the ADON on [DATE] at 2:15 PM and the DON on [DATE] at 11:10 AM revealed they performed skin assessments on residents with a BIMS of seven (7) and below on [DATE] to assess for any rights violations. 4. Review of a facility provided list dated [DATE] revealed residents who had expired in the past ninety (90) days with a review of the physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM and the Regional Nurse Consultant at 3:42 PM revealed they reviewed residents that had expired in the last ninety (90) days on [DATE] to ensure code status, nurses notes, advance directive, and care plans all matched with no concerns identified. 5. Review of a facility provided list dated [DATE] revealed all licensed nursing staff CPR certification was audited by the Regional Nurse Consultant and all licensed nurses had current CPR certification. Interview with the Regional Nurse Consultant on [DATE] at 3:42 PM revealed on [DATE] she reviewed all licensed nurse's CPR certification on [DATE]. She stated there were two (2) nurses who had expired CPR certifications and one (1) nurse who had not provided proof of certification upon hired. She further stated by the afternoon on [DATE] all licensed nurses had proof of certification. 6. Review of CPR Certification Verification Education dated [DATE] revealed the Administrator provided education to the Staff Development Coordinator (SDC), DON, and ADON. Interviews on [DATE] with the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they received education from the Administrator on [DATE] if a new licensed nurse employee is hired the SDC is responsible to ensure the CPR certification is obtained before starting work. Furthermore, if the SDC is off the DON and ADON is responsible for obtaining the information. In addition, the SDC is responsible to ensure the licensed nurses certification is checked monthly for expiration and are up to date. Interview with the Administrator on [DATE] at 11:20 AM revealed she provided education to the SDC, ADON, and DON on [DATE] ensuring employees on hire had proof of CPR certification and CPR certification was renewed before expiring or the employee was not allowed to work. In addition, the SDC is responsible to monitor monthly for CPR certification expiration as well as to obtain the certification on hire. Furthermore, the DON and ADON is responsible in the absence of the SDC. 7. Review of the Mock Code Checklist dated [DATE] at 6:00 PM revealed a drill was conducted by the DON. Review of the Mock Code Checklist dated [DATE] at 8:00 PM revealed a drill was conducted by the SDC. Interview with the SDC on [DATE] at 2:34 PM and the DON on [DATE] at 11:10 AM revealed they performed Mock Code Blue Drills with staff on [DATE]. Interviews on [DATE] with Licensed Practical Nurse (LPN) #8 at 4:15 PM and LPN #9 at 4:41 PM revealed they were part of a Code Blue Drill on [DATE] presented by the SDC, DON, and ADON. 8. Review of facility provided calendar titled charts and crash cart reviewed for (MONTH) (YEAR) revealed the Administrator's initials for [DATE] on review of the crash cart. Furthermore, review of inservice form titled Crash cart should be checked by night shift nurse on wing two (2) dated [DATE] revealed education was provided by the SDC. Interviews on [DATE] with LPN #11 at 1:50 PM, LPN #3 at 2:03 PM, and LPN #9 at 2:08 PM revealed they received inservicing from the SDC on [DATE] regarding the night nurse's responsibility to check the crash cart at night. If an item was missing it was the nurses responsibility to replace the item who removed the item from the cart. Interview with the SDC on [DATE] at 1:05 PM revealed she began education with staff on [DATE] regarding the crash cart and educated the nurses present in the facility on [DATE]. 9. Review of Inservice Sign In sheet dated [DATE] with education topics of Advance Directives, Resident Rights, CPR, Location of DNR form in resident's medical record, following physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON, revealed they were educated by the Regional Nurse Consultant on when to perform an SBAR with change in condition in a resident, notification of family and physician for a change, following the physician's orders [REDACTED]. 10. Review of a pre-test administered to licensed nurses on Full Code Status and CPR revealed all licensed nurses completed from [DATE]-[DATE] and received 100 percent (%). Furthermore, the pre-tests were signed by the SDC for verification and signed by the staff member performing the test. Interview with the SDC on [DATE] at 2:34 PM revealed she gave pre-test to all licensed nurses on [DATE] and [DATE] with 100% of nurses completed at a score of 100%. Interviews on [DATE] with LPN #8 at 4:15 PM, Registered Nurse (RN) #1 at 4:25 PM, and LPN #9 at 4:41 PM revealed they received a pre-test on Full Code and CPR prior to education on [DATE] and [DATE] and made a 100%. 11. Review of Inservice Form dated [DATE] revealed the licensed nurses were inserviced on initiating CPR on a resident when found unresponsive if they have a code status of Full Code. In addition, the CPR is to continue unless an order is received to stop or until EMS arrives. Furthermore, the education included following physician's orders [REDACTED]. Interview with the SDC on [DATE] at 2:34 PM revealed she provided education to the licensed nurses on [DATE] regarding resident's rights in choosing a code status, following through with the code status as ordered and per the resident's wishes, where to find the code status in the chart, location of the crash cart, notification to the family and physician, following the care plan/Advanced Directive. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, and LPN #9 at 4:41 PM revealed they were inserviced on [DATE] on where to locate the code status in the resident's chart, location of the crash cart, a full code resident requires CPR if found unresponsive, call 911, call a code blue, notification of change to the physician and family, following the care plan and Advance Directive, and performing an SBAR. 12. Review of new hire orientation for LPN #10 on [DATE] revealed education on CPR policy, resident rights, advance directives, change in condition, location of the code status and advance directives, emergency documentation form, following the care plans, and a pre and post test by the SDC. Interview with LPN #10 on [DATE] at 4:57 PM revealed before she was able to work the floor she was provided a pre and post test, education about the facility policy on CPR, instructions on the crash cart, how to review the contents on the crash cart, who was responsible to check the crash cart which was the night nurse, if an item was missing off the crash cart to replace it, how to find the advance directive and code status in the chart, call 911 is resident found unresponsive and was a full code, initiate CPR, call a Code Blue, continue CPR until EMS arrives, follow physician orders, physician notification, and emergency documentation form. 13. Review of post-tests on [DATE] revealed four (4) licensed nurses completed the test which included education on CPR, following physician's orders [REDACTED]. In addition, review of post test revealed test completed by licensed nurses daily for one (1) week through [DATE], then three (3) post test daily for one week through [DATE]. All nurses obtained 100% on the post test. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, LPN #9 at 4:41 PM, and LPN #10 at 4:57 PM revealed they have performed post test after the initial pre test regarding questions of notification to the physician, when to end CPR, where the Advance Directive is located, and change in condition. 14. Review of Resident interviews for residents with a BIMS of eight (8) or above revealed questions of any resident concerns, feeling safe, and safe from abuse was completed on five (5) residents daily starting [DATE]; then two (2) residents three (3) times a week for two (2) weeks starting [DATE] by the Administrator and Social Services. Interviews on [DATE] with the Administrator at 11:20 AM and Social Services Director at 3:26 PM revealed they interview residents with a BIMS of eight (8) and greater to assess for signs and symptoms of abuse or violation of resident rights. 15. Review of Mock Code Blue Drills dated [DATE], [DATE], and [DATE] revealed the drills were conducted for seventy-two (72) hours; then the drills were completed twice weekly for two (2) weeks starting [DATE] until [DATE] by the DON, ADON, or SDC. Interviews on [DATE] with the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they have performed Mock Code Blue Drills everyday on [DATE], [DATE], and [DATE] and continue to perform the mock drills twice a week at the present time. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, LPN #9 at 4:41 PM, and LPN #10 at 4:57 PM revealed they have been involved with several mock code blue drills so far since [DATE]. 16. Review of facility provided list of all licensed nurses with date of CPR expiration for month of (MONTH) (YEAR) with Administrators initials for (MONTH) (YEAR)'s review. Interview with the Administrator on [DATE] at 11:20 AM revealed she had already audited the CPR certifications for the month of (MONTH) and initialed on the CPR expiration form. She stated the calendar will be initialed when she performs each month. 17. Review of (MONTH) (YEAR) calendar titled Chart review and crash cart review revealed initials by Administrative staff every day from [DATE]-[DATE]. Interviews on [DATE] with the ADON at 2:15 PM and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they review new admissions for code status, Advance Directives, care plan, and physician's orders [REDACTED]. 18. Review of the Emergency Cart Check List revealed the cart has been reviewed daily by Administrative Staff since [DATE]. Interviews on [DATE] with the Administrator at 11:20 AM and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they have taken part in checking the crash cart daily since identified on [DATE] to ensure all the equipment was on the crash cart. In addition, they ensured the staff had signed off on the checklist daily. 19. Review of the facility provided Quality Performance Improvement (QAPI) sign in sheet dated [DATE] revealed the Administrator, DON, ADON, and SDC was in attendance along with the Medical Director via phone. Review of the typed up minutes revealed the incident with Resident #1 was discussed and a plan was discussed which included audits. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they attended an Ad Hoc Quality Assurance (QA) meeting in which they discussed with the Medical Director via phone the plan, concerns, audits, and education to begin and what had already been started. 20. Review of the facility provided QAPI sign in sheet dated [DATE] revealed the Administrator, DON, Social Service Director, Business Office Manager, and SDC including the Medical Director via phone was in attendance. Review of the typed up minutes revealed no concerns noted from audits and no new suggestions. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, the SDC at 2:34 PM, and the Business Office Manager at 3:06 PM; and, on [DATE] at 11:10 AM with the DON revealed they attended a QA meeting on [DATE] and discussed the progress with education, audits, and the ongoing plan. 21. Review of the facility provided QAPI sign in sheet dated [DATE] revealed the Administrator, DON, MDS, Medical Records, SDC, Business Office Manager, Plant Operations Manager, ADON, Dietary Manager, and Social Service Director including the Medical Director via phone was in attendance. Review of the typed up minutes revealed no concerns with audits and no new suggestions. Interviews on [DATE] with the Administrator at 11:20 AM, Plant Operations at 1:57 PM, the ADON at 2:15 PM, the SDC at 2:34 PM, the Business Office Manager at 3:06 PM, the Dietary Manager at 3:15 PM, and the Social Services Director at 3:42 PM; and, on [DATE] at 11:10 AM with the DON revealed they were part of QA on [DATE]. Furthermore, they stated the audits that had been performed were reviewed, review of the plan again, and reviewed education that had been provided. 22. Review of facility provided QAPI sign in sheet dated [DATE] revealed the Administrator, DON, ADON, and SDC including the Medical Director via phone was in attendance. Review of the summary of discussion revealed no concerns noted from audits and reviews. Interviews on [DATE] with the Administrator at 11:20 AM, ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed the audits from the days prior were reviewed for any concerns, the plan was reviewed again for any changes, and continued education was reviewed. 23. A QAPI meeting was planned on [DATE] to discuss the outcome of audits via phone with the Medical Director. Interview with the Administrator on [DATE] at 11:20 AM revealed a QAPI meeting was planned on [DATE] to discuss the progress of the plan and to review for any changes. She stated the Medical Director will be via phone.

Based on interview, record review, review of the facility's policy, review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statements (AOS), and review of the American Heart Association Journal, Ethical Issues Around Out of Hospital Resuscitation, Withholding CPR at the Start versus Withdrawing CPR at the End, it was determined the facility failed to meet professional standards of quality for one (1) of three (3) sampled residents (Resident #1) related to providing Cardiopulmonary Resuscitation (CPR). Resident #1 was admitted to the facility with an Advance Directive, which stated, Full Code (wanted to have Cardiopulmonary Resuscitation {CPR} performed) if found with no pulse and/or respirations and a physician's orders [REDACTED]. On [DATE], at approximately 11:20 PM, Licensed Practical Nurse (LPN) #1 observed Resident #1 to be unresponsive with no pulse or respirations. However, LPN #1 failed to provide CPR according to Resident #1's Advanced Directive and Physician order [REDACTED]. LPN #1 went to the chart and identified the resident was a Full Code and initiated chest compressions but did not perform rescue breaths. LPN #1 stopped compressions and called the time of death at 11:25 PM. The facility's failure to perform CPR on a resident ordered and requested per their Advanced Directive to be a Full Code according to accepted standard of clinical practice has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of Immediate Jeopardy on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE] as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the KBN, AOS #36, Resuscitation, approved (MONTH) 2008, revealed nurses's were required to honor the Advanced Directives of patients who had the Advanced Directive documented in the medical record, unless a physician or healthcare facility refused to comply and the patient and surrogate were informed of the refusal. Review of KBN, AOS #14, revised (MONTH) (YEAR), Roles of Nurses in the implementation of Patient Care Orders, revealed in accordance with Kentucky Revised Statues (KRS) 314.021 (2), nurses were responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing and requires licensees to provide proactive nursing with reasonable skill and safety. Further review revealed licensed nurses should administer medication and treatment as prescribed by the Physician, Physician Assistant, Dentist, or Advanced Practice Registered Nurse (ARNP). Review of the American Heart Association Journal, Ethical Issues Around Out of Hospital Resuscitation , Withholding CPR at the Start versus Withdrawing CPR at the End, dated [DATE], revealed Basic Life Support (BLS) Training urges the average citizen responding first to a [MEDICAL CONDITION] to perform CPR. Healthcare professionals are expected to provide BLS and Advanced Cardiac Life Support (ACLS) as part of their professional duty to respond. The exceptions included: when a person lies dead, with no obvious clinical signs of irreversible death; when attempts to perform CPR would place the rescuer at risk of physical injury; and when the patient or surrogate has indicated that resuscitation is not desired. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Advance Directive/Informed Consent Form, signed by the Guardian on [DATE] and Physician order [REDACTED]. However, interview with LPN #1 on [DATE] at 2:13 PM revealed on [DATE] she gave the resident some water and when she came back five (5) to ten (1) minutes later the resident was lying on the bed and was gone with no pulse or respirations. She stated she did not start CPR per the Advanced Directive and physician's orders [REDACTED]. LPN #1 stated she went to the chart and saw the resident was a Full Code, then she went back to the room and started chest compressions, but she did not initiate any breaths, or call a code blue (for help). She further stated she knew that CPR was not to be stopped until the doctor told the nurse to stop, or until EMS arrived and took over the CPR. LPN #1 stated she did not have any help as the Certified Nurse Aide (CNA) on her unit was outside on break. Review of a Nurse's Progress Note, dated [DATE] at 1:53 AM, revealed LPN #1 documented the resident expired quietly at 11:25 PM ([DATE]), supervisor, family, physician, and funeral home notified. A Provisional Report of Death was completed for date of death as [DATE] at 11:25 PM. Interview with LPN #2 on [DATE] at 8:55 PM revealed she was working as House Supervisor at the time of the incident with Resident #1. She stated around 11:15 PM on [DATE], she left the building to take another employee home and when she was on her way back to the facility she received a call from CNA #1, who asked her if she could assist with cleaning up Resident #1. LPN #2 stated she then spoke with LPN #1 via phone and LPN #1 stated everything was okay as Resident #1 was a DNR. Further interview with LPN #2 revealed she then called the DON (Director of Nursing) and the family. LPN #2 stated LPN #1 informed her that she had done a little CPR, and when she asked LPN #1 as to what kind of CPR, LPN #1 stated the resident was a DNR, but she did a sternal rub to see if she could get him/her back. LPN #2 stated she never looked in the chart to verify the resident's code status or reviewed the Advanced Directive as she took the word of LPN #1 that the resident was a DNR. Interview with Resident #1's Physician/Medical Director on [DATE] at 1:35 PM revealed if a resident was a Full Code then he expected staff to perform CPR. He stated the nurse should have called 911 and initiated CPR and when EMS arrived they would pick up the CPR. Further interview revealed he also expected the nurses to follow physician's orders [REDACTED]. The Physician stated the nurse did not follow healthcare standards when she did not administer CPR on a Full Code resident. Interview with the Director of Nursing (DON), on [DATE] at 10:06 AM revealed she expected the licensed nurse to perform CPR and honor the Advance Directive if a resident was a Full Code. The DON stated she received a call from the House Supervisor (LPN #2) before midnight and after 11:00 PM on [DATE] and was told Resident #1 had passed away and the resident was a DNR. The DON stated she reviewed the chart the next morning on [DATE] due to the death and realized the resident was a Full Code. Further interview with the DON revealed she expected LPN #1 to initiate CPR on Resident #1, call 911 and the physician. She stated she expected the nurse to follow the care plan and facility policy for CPR. Interview with the Administrator on [DATE] at 10:20 AM revealed LPN #1 should have provided CPR to Resident #1, who had a documented Advanced Directive and physician's orders [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], all residents advance directives/code status/Physician order [REDACTED]. 2. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed to ensure there had been no violation of resident's rights. Interviews were completed by the Social Services Director or Administrator. 3. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of seven (7) or below were physically assessed by the Director of Nursing, Assistant Director of Nursing or Charge Nurse for any signs and symptoms of quality of life or resident' rights violations. No concerns were identified. 4. On [DATE], the Regional Nurse Consultant and Administrator reviewed the records of residents who expired in the facility in the past thirty (30) days for issues or concerns related to the following of advance directives/code status. No concerns were identified. 5. On [DATE], the Regional Nurse Consultant audited the CPR certification status of all licensed nurses. By [DATE], all licensed nurses had current CPR certification. 6. On [DATE], the Director of Nursing, Assistant Director of Nursing, and the Staff Development Coordinator received education from the Administrator regarding monitoring CPR Certification status for licensed nurses. Including the Director of Nursing will be responsible for ensuring the CPR status for licensed nurses. In the absence of the Director of Nursing, the Assistant Director of Nursing will assume this responsibility. 7. On [DATE], a mock code blue drill was conducted by the Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator to ensure understanding and compliance with the Cardiopulmonary Resuscitation policy and procedure. 8. On [DATE], a review of the emergency cart and emergency code documentation form was completed for the licensed nurses present in the facility. 9. On [DATE], the Regional Nurse Consultant provided education to the Administrator, Director of Nursing and the Staff Development Coordinator regarding the policies for Cardiopulmonary [MEDICAL CONDITION] Resuscitation, Change of Condition, Comprehensive Care Plan and following the care plan, Resident' Rights, and following physician's orders [REDACTED]. 10. On [DATE], a pre-test was completed by the Staff Development Coordinator for all licensed nurses to test knowledge of their above stated policies. 11. On [DATE], all licensed nursing staff were educated by the Staff Development Coordinator, Director of Nursing, or Assistant Director of Nursing on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. 12. Education will be provided by the Staff Development Coordinator during orientation, prior to working on the floor, for newly hired licensed nurses on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. A post-test will be administered and a score of 100% will be required. Should a score of 100% not be obtained, re-education will occur and a post-test will be re-administered. This will be continued until a score of 100% on the post-test is obtained. 13. Starting on [DATE], post-tests were completed with four (4) licensed nurses by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, regarding the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. Four (4) post-tests with licensed nurses will be completed by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, daily for one (1) week (thru [DATE]), then three (3) post-tests with licensed nurses, daily for one (1) week ([DATE] - [DATE]), then two (2) post-tests with licensed nurses for two (2) weeks ([DATE] - [DATE]). If a nurse does not obtain a score of 100% on the post-test, re-education will be completed, and the post-test re-administered. This process will continue until a score of 100% is obtained on the post-test. Licensed Nurses will not be allowed to work until the score of 100% on the post-test is obtained. 14. Beginning [DATE], resident interviews are being completed for five (5) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or above, daily to ensure there are no violations of resident's rights. Interviews will be completed by the Social Services Director, Administrator, Director of Nursing, Assistant Director of Nursing, or Staff Development Coordinator, for five (5) residents daily for one (1) week (thru [DATE]), then for two (2) residents three (3) times weekly for two (2) weeks ([DATE] - [DATE]), one (1) two (2) times weekly for one (1) week ([DATE] - [DATE]). 15. Mock code drills will be conducted by the Director of Nursing, Assistant Director of Nursing, or the Staff Development Coordinator every shift for seventy-two (72) hours ([DATE], [DATE], [DATE]). Mock code drills will be completed twice weekly for two (2) weeks ([DATE] - [DATE]). Mock code drills will be completed once monthly for three (3) months ([DATE] - [DATE]). Mock code drills will be completed quarterly thereafter. 16. CPR certification for licensed nurses will be audited by the Administrator monthly. 17. Admission records will be reviewed on the day of admission by the Charge Nurse, Director of Nursing, Assistant Director of Nursing, Social Services Director, or the MDS Coordinator to ensure accurate documentation of Advance Directives, physician's orders [REDACTED]. 18. The emergency cart checklist will be reviewed daily by Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator or Medical Records, Monday thru Friday, for two (2) weeks, then three (3) times weekly for two (2) weeks, then weekly thereafter. The weekend manager/manager on duty for holidays will complete the review of the emergency cart checklist on weekends and holidays. 19. On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, the Administrator, the Director of Nursing, the Assistant Director of Nursing, and the Staff Development Coordinator to discuss the occurrence of CPR not being continued as per policy for a resident with a full code status. Also discussed was the education completed with licensed nurses, as well as audits and monitoring that has been initiated as a corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 20. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Nursing, Social Services Director, Business Office Manager, and Regional Nurse Consultant to review findings of audits that were completed on [DATE], and continuance of the corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 21. On [DATE], an ad hoc QAPI meeting was held with Medical Director, Administrator, Director of Nursing, MDS Coordinator, Medical Records Clerk, Admissions and Marketing Director, Staff Development Coordinator, Rehab Services Manager, Business Office Manager, Plant Operations Director, Dietary Manager, Assistant Director of Nursing, Social Services Director, and the Staffing Coordinator to review the corrective action plan with all department managers. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 22. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator to review findings and continuation of the corrective action plan. The Medical Director agreed with the continuance of the corrective action plan, and had no further recommendations at this time. 23. A QAPI meeting will be held weekly for four (4) weeks ([DATE] - [DATE]), then monthly to review the corrective action plan and discuss findings of audits and monitoring, and for further recommendations as indicated. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of facility provided flowsheet dated [DATE] revealed all residents advanced directives/code status/physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM, Assistant Director of Nursing at 2:15 PM, Social Service Director at 3:21 PM, and Regional Nurse Consultant at 3:42 PM; and on [DATE] at 11:10 AM with the Director of Nursing, revealed they were part of the audit process on [DATE] which reviewed the physician's orders [REDACTED]. They further stated there were no noted concerns with the audits. 2. Review of facility provided Census Report dated [DATE] revealed all residents with a BIMS eight (8) and greater were reviewed with a star beside each resident. Furthermore, each resident with a BIMS of eight (8) and greater had a questionnaire with questions of Do you have any concerns? Do you feel safe? Do you feel safe from abuse? filled out by the Administrator and Social Service Director on [DATE]. Interviews on [DATE] with the Administrator at 11:20 AM and the Social Service Director at 3:21 PM revealed they interviewed all residents with a BIMS eight (8) and greater to assess for any signs and symptoms of abuse or violation of resident's rights by asking the above questions. 3. Review of skin assessments of residents with a BIMS of less than eight (8) dated [DATE] revealed those residents were assessed by the DON and ADON for signs and symptoms of quality of life or resident's rights violation with no concerns identified. Interview with the ADON on [DATE] at 2:15 PM and the DON on [DATE] at 11:10 AM revealed they performed skin assessments on residents with a BIMS of seven (7) and below on [DATE] to assess for any rights violations. 4. Review of a facility provided list dated [DATE] revealed residents who had expired in the past ninety (90) days with a review of the physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM and the Regional Nurse Consultant at 3:42 PM revealed they reviewed residents that had expired in the last ninety (90) days on [DATE] to ensure code status, nurses notes, advance directive, and care plans all matched with no concerns identified. 5. Review of a facility provided list dated [DATE] revealed all licensed nursing staff CPR certification was audited by the Regional Nurse Consultant and all licensed nurses had current CPR certification. Interview with the Regional Nurse Consultant on [DATE] at 3:42 PM revealed on [DATE] she reviewed all licensed nurse's CPR certification on [DATE]. She stated there were two (2) nurses who had expired CPR certifications and one (1) nurse who had not provided proof of certification upon hired. She further stated by the afternoon on [DATE] all licensed nurses had proof of certification. 6. Review of CPR Certification Verification Education dated [DATE] revealed the Administrator provided education to the Staff Development Coordinator (SDC), DON, and ADON. Interviews on [DATE] with the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they received education from the Administrator on [DATE] if a new licensed nurse employee is hired the SDC is responsible to ensure the CPR certification is obtained before starting work. Furthermore, if the SDC is off the DON and ADON is responsible for obtaining the information. In addition, the SDC is responsible to ensure the licensed nurses certification is checked monthly for expiration and are up to date. Interview with the Administrator on [DATE] at 11:20 AM revealed she provided education to the SDC, ADON, and DON on [DATE] ensuring employees on hire had proof of CPR certification and CPR certification was renewed before expiring or the employee was not allowed to work. In addition, the SDC is responsible to monitor monthly for CPR certification expiration as well as to obtain the certification on hire. Furthermore, the DON and ADON is responsible in the absence of the SDC. 7. Review of the Mock Code Checklist dated [DATE] at 6:00 PM revealed a drill was conducted by the DON. Review of the Mock Code Checklist dated [DATE] at 8:00 PM revealed a drill was conducted by the SDC. Interview with the SDC on [DATE] at 2:34 PM and the DON on [DATE] at 11:10 AM revealed they performed Mock Code Blue Drills with staff on [DATE]. Interviews on [DATE] with Licensed Practical Nurse (LPN) #8 at 4:15 PM and LPN #9 at 4:41 PM revealed they were part of a Code Blue Drill on [DATE] presented by the SDC, DON, and ADON. 8. Review of facility provided calendar titled charts and crash cart reviewed for (MONTH) (YEAR) revealed the Administrator's initials for [DATE] on review of the crash cart. Furthermore, review of inservice form titled Crash cart should be checked by night shift nurse on wing two (2) dated [DATE] revealed education was provided by the SDC. Interviews on [DATE] with LPN #11 at 1:50 PM, LPN #3 at 2:03 PM, and LPN #9 at 2:08 PM revealed they received inservicing from the SDC on [DATE] regarding the night nurse's responsibility to check the crash cart at night. If an item was missing it was the nurses responsibility to replace the item who removed the item from the cart. Interview with the SDC on [DATE] at 1:05 PM revealed she began education with staff on [DATE] regarding the crash cart and educated the nurses present in the facility on [DATE]. 9. Review of Inservice Sign In sheet dated [DATE] with education topics of Advance Directives, Resident Rights, CPR, Location of DNR form in resident's medical record, following physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON, revealed they were educated by the Regional Nurse Consultant on when to perform an SBAR with change in condition in a resident, notification of family and physician for a change, following the physician's orders [REDACTED]. 10. Review of a pre-test administered to licensed nurses on Full Code Status and CPR revealed all licensed nurses completed from [DATE]-[DATE] and received 100 percent (%). Furthermore, the pre-tests were signed by the SDC for verification and signed by the staff member performing the test. Interview with the SDC on [DATE] at 2:34 PM revealed she gave pre-test to all licensed nurses on [DATE] and [DATE] with 100% of nurses completed at a score of 100%. Interviews on [DATE] with LPN #8 at 4:15 PM, Registered Nurse (RN) #1 at 4:25 PM, and LPN #9 at 4:41 PM revealed they received a pre-test on Full Code and CPR prior to education on [DATE] and [DATE] and made a 100%. 11. Review of Inservice Form dated [DATE] revealed the licensed nurses were inserviced on initiating CPR on a resident when found unresponsive if they have a code status of Full Code. In addition, the CPR is to continue unless an order is received to stop or until EMS arrives. Furthermore, the education included following physician's orders [REDACTED]. Interview with the SDC on [DATE] at 2:34 PM revealed she provided education to the licensed nurses on [DATE] regarding resident's rights in choosing a code status, following through with the code status as ordered and per the resident's wishes, where to find the code status in the chart, location of the crash cart, notification to the family and physician, following the care plan/Advanced Directive. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, and LPN #9 at 4:41 PM revealed they were inserviced on [DATE] on where to locate the code status in the resident's chart, location of the crash cart, a full code resident requires CPR if found unresponsive, call 911, call a code blue, notification of change to the physician and family, following the care plan and Advance Directive, and performing an SBAR. 12. Review of new hire orientation for LPN #10 on [DATE] revealed education on CPR policy, resident rights, advance directives, change in condition, location of the code status and advance directives, emergency documentation form, following the care plans, and a pre and post test by the SDC. Interview with LPN #10 on [DATE] at 4:57 PM revealed before she was able to work the floor she was provided a pre and post test, education about the facility policy on CPR, instructions on the crash cart, how to review the contents on the crash cart, who was responsible to check the crash cart which was the night nurse, if an item was missing off the crash cart to replace it, how to find the advance directive and code status in the chart, call 911 is resident found unresponsive and was a full code, initiate CPR, call a Code Blue, continue CPR until EMS arrives, follow physician orders, physician notification, and emergency documentation form. 13. Review of post-tests on [DATE] revealed four (4) licensed nurses completed the test which included education on CPR, following physician's orders [REDACTED]. In addition, review of post test revealed test completed by licensed nurses daily for one (1) week through [DATE], then three (3) post test daily for one week through [DATE]. All nurses obtained 100% on the post test. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, LPN #9 at 4:41 PM, and LPN #10 at 4:57 PM revealed they have performed post test after the initial pre test regarding questions of notification to the physician, when to end CPR, where the Advance Directive is located, and change in condition. 14. Review of Resident interviews for residents with a BIMS of eight (8) or above revealed questions of any resident concerns, feeling safe, and safe from abuse was completed on five (5) residents daily starting [DATE]; then two (2) residents three (3) times a week for two (2) weeks starting [DATE] by the Administrator and Social Services. Interviews on [DATE] with the Administrator at 11:20 AM and Social Services Director at 3:26 PM revealed they interview residents with a BIMS of eight (8) and greater to assess for signs and symptoms of abuse or violation of resident rights. 15. Review of Mock Code Blue Drills dated [DATE], [DATE], and [DATE] revealed the drills were conducted for seventy-two (72) hours; then the drills were completed twice weekly for two (2) weeks starting [DATE] until [DATE] by the DON, ADON, or SDC. Interviews on [DATE] with the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they have performed Mock Code Blue Drills everyday on [DATE], [DATE], and [DATE] and continue to perform the mock drills twice a week at the present time. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, LPN #9 at 4:41 PM, and LPN #10 at 4:57 PM revealed they have been involved with several mock code blue drills so far since [DATE]. 16. Review of facility provided list of all licensed nurses with date of CPR expiration for month of (MONTH) (YEAR) with Administrators initials for (MONTH) (YEAR)'s review. Interview with the Administrator on [DATE] at 11:20 AM revealed she had already audited the CPR certifications for the month of (MONTH) and initialed on the CPR expiration form. She stated the calendar will be initialed when she performs each month. 17. Review of (MONTH) (YEAR) calendar titled Chart review and crash cart review revealed initials by Administrative staff every day from [DATE]-[DATE]. Interviews on [DATE] with the ADON at 2:15 PM and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they review new admissions for code status, Advance Directives, care plan, and physician's orders [REDACTED]. 18. Review of the Emergency Cart Check List revealed the cart has been reviewed daily by Administrative Staff since [DATE]. Interviews on [DATE] with the Administrator at 11:20 AM and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they have taken part in checking the crash cart daily since identified on [DATE] to ensure all the equipment was on the crash cart. In addition, they ensured the staff had signed off on the checklist daily. 19. Review of the facility provided Quality Performance Improvement (QAPI) sign in sheet dated [DATE] revealed the Administrator, DON, ADON, and SDC was in attendance along with the Medical Director via phone. Review of the typed up minutes revealed the incident with Resident #1 was discussed and a plan was discussed which included audits. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they attended an Ad Hoc Quality Assurance (QA) meeting in which they discussed with the Medical Director via phone the plan, concerns, audits, and education to begin and what had already been started. 20. Review of the facility provided QAPI sign in sheet dated [DATE] revealed the Administrator, DON, Social Service Director, Business Office Manager, and SDC including the Medical Director via phone was in attendance. Review of the typed up minutes revealed no concerns noted from audits and no new suggestions. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, the SDC at 2:34 PM, and the Business Office Manager at 3:06 PM; and, on [DATE] at 11:10 AM with the DON revealed they attended a QA meeting on [DATE] and discussed the progress with education, audits, and the ongoing plan. 21. Review of the facility provided QAPI sign in sheet dated [DATE] revealed the Administrator, DON, MDS, Medical Records, SDC, Business Office Manager, Plant Operations Manager, ADON, Dietary Manager, and Social Service Director including the Medical Director via phone was in attendance. Review of the typed up minutes revealed no concerns with audits and no new suggestions. Interviews on [DATE] with the Administrator at 11:20 AM, Plant Operations at 1:57 PM, the ADON at 2:15 PM, the SDC at 2:34 PM, the Business Office Manager at 3:06 PM, the Dietary Manager at 3:15 PM, and the Social Services Director at 3:42 PM; and, on [DATE] at 11:10 AM with the DON reveale

Based on interview, record review and facility policy review, it was determined the facility failed to have an effective system in place to ensure one (1) of three (3) sampled residents (Resident #1) received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, related to a change in condition. On [DATE], Licensed Practical Nurse (LPN) #2 observed Resident #1 to have periorbital [MEDICAL CONDITION], decreased appetite, and lethargy with a history of [MEDICAL CONDITION]. She emailed (electronic message) the physician with a change in condition. However, the nurse failed to follow up with the physician regarding the resident's change. The physician ordered [MEDICATION NAME] (potent diuretic) 2 milligrams (mg) every day for three (3) days for [MEDICAL CONDITION] and gave an order, that if increase of Shortness of Air to send to the emergency room for evaluation and treatment on [DATE] via email (seven {7} minutes after LPN #2 sent the communication via email). However, review of the physician's orders [REDACTED]. In addition, review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]{36} hours after the order was received and three and a half hours before the resident's death). The facility's failure to ensure quality of care and treatment to Resident #1 according to professional standards of practice, and the care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency (SSA) validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Change in Condition Policy, last reviewed [DATE], revealed for life threatening events call 911 and notify the physician. If unable to contact the physician, depending on the significance of the change, contact the Medical Director. If the condition does not appear to be life threatening perform a Situation, Background, Assessment, Recommendations (SBAR) form to provide the physician with necessary evaluation findings and verbally communicate the information to the physician. Note any new orders on the bottom of the SBAR form. Execute the new orders including writing the telephone order and enter the orders received into the Easy Medication Administration Record [REDACTED] Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable and able to make decisions. Review of Resident #1's At Risk for Fluid Volume Deficit/Excess Care Plan, dated [DATE] revealed interventions to observe for signs and symptoms of [MEDICAL CONDITION]; and, administer and monitor effectiveness of diuretic use. Review of Resident #1's SBAR completed on [DATE] at 8:02 AM by LPN #2 revealed the resident had a [DIAGNOSES REDACTED]. The resident was noted to have a decreased level of consciousness (L[NAME]), was very lethargic, weak and looked very [MEDICAL CONDITION]. LPN #2 further documented the physician was notified of the resident's decreased appetite, decreased L[NAME], and periorbital [MEDICAL CONDITION] and she was awaiting orders. Interview with the Administrator on [DATE] at 2:40 PM revealed she was not allowed to give the State Survey Agency (SSA) the electronic mail (e-mail) communication between the physician and the nurse dated [DATE] regarding the resident's change in condition. She stated she would transcribe the information on paper. Review of the paper provided by the Administrator dated [DATE] revealed LPN #2 contacted Resident #1's Physician about the SBAR on [DATE] at 12:09 PM; and, the physician responded back around 12:16 PM (seven {7} minutes later) and gave a new order for [MEDICATION NAME] 2 milligrams (mg) every day for three (3) days for [MEDICAL CONDITION] and if increase of Shortness of Air to send to the emergency room for evaluation and treatment. However, review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of a Nursing Progress Note dated [DATE] at 1:53 AM, revealed Resident #1 expired quietly at 11:25 PM ([DATE]); and the supervisor, family, physician, and funeral home were notified. A Provisional Report of Death was completed for date of death as [DATE] at 11:25 PM. Interview with LPN #2 on [DATE] at 8:55 PM, revealed she had performed an SBAR assessment on [DATE] related to the resident's increased [MEDICAL CONDITION] and history of exacerbation of [MEDICAL CONDITION]. LPN #2 stated she emailed the physician around noon as that was the only way to contact the physician. She stated she did not look to see if the physician had responded back with any new orders during her shift which ended at 7:00 PM on [DATE]. During further interview with LPN #2, she stated it was the responsibility of the nurse to check the email to see if the Physician had responded. She stated she should have checked the email for a response. LPN #2 further stated she was not use to the Physician responding quickly because she normally worked midnights and the Physician usually responded the next morning. She stated the nurse should monitor the email system for new orders if the nurse sent the physician an email. LPN #2 stated when she returned to work on [DATE] at 6:00 PM she raised the resident's head to a thirty-five (35) degree angle due to the [MEDICAL CONDITION]. She stated since the resident still had [MEDICAL CONDITION], she checked to see if an order had been received and found that the physician had sent an email order for [MEDICATION NAME]. LPN #2 stated at that time she took the order off and put it in the computer and administered the medication at 8:00 PM on [DATE], Further interview with LPN #2 on [DATE] at 8:06 PM, revealed she performed the SBAR at the end of her shift on [DATE] at approximately 7:00 PM, but she forgot to change the time in the computer on the SBAR from 8:02 AM to 7:00 PM. Interview with Resident #1's Physician/Medical Director on [DATE] at 1:35 PM revealed if he ordered a medication at noon he would expect the medication to be started that night or at least by the next morning, definitely not thirty-six (36) hours later. The Physician stated that the [MEDICATION NAME] would have helped the resident with his/her [MEDICAL CONDITION] exacerbation. He stated he expected the nurses to follow physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 10:06 AM, revealed she was not aware Resident #1 was ordered [MEDICATION NAME] on [DATE] until the State Survey Agency (SSA) brought it to the Administrator's attention on [DATE]. She stated she saw the order once it was written the next day on [DATE] after the resident had passed. The DON stated she reviews orders to monitor for situations. She stated she relies on the nurses to treat an email like a phone call to the physician and follow up considering the urgency of the situation. During the interview, the DON further stated she did not have a system in place to monitor email orders. The DON stated she expected the nurse to contact the physician for a change in condition and follow up with the physician. She stated the physician had an answering service number that could be used. Interview with the Administrator on [DATE] at 9:15 AM revealed a SBAR should be created prior to contacting the physician. She stated the SBAR LPN #2 performed on [DATE] was created according to the computer at 6:57 PM after the doctor was contacted. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], all residents advance directives/code status/Physician order [REDACTED]. 2. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or greater were interviewed to ensure there had been no violation of resident's rights. Interviews were completed by the Social Services Director or Administrator. 3. On [DATE], residents with a Brief Interview of Mental Status (BIMS) score of seven (7) or below were physically assessed by the Director of Nursing, Assistant Director of Nursing or Charge Nurse for any signs and symptoms of quality of life or resident' rights violations. No concerns were identified. 4. On [DATE], the Regional Nurse Consultant and Administrator reviewed the records of residents who expired in the facility in the past thirty (30) days for issues or concerns related to the following of advance directives/code status. No concerns were identified. 5. On [DATE], the Regional Nurse Consultant audited the CPR certification status of all licensed nurses. By [DATE], all licensed nurses had current CPR certification. 6. On [DATE], the Director of Nursing, Assistant Director of Nursing, and the Staff Development Coordinator received education from the Administrator regarding monitoring CPR Certification status for licensed nurses. Including the Director of Nursing will be responsible for ensuring the CPR status for licensed nurses. In the absence of the Director of Nursing, the Assistant Director of Nursing will assume this responsibility. 7. On [DATE], a mock code blue drill was conducted by the Director of Nursing, Assistant Director of Nursing and Staff Development Coordinator to ensure understanding and compliance with the Cardiopulmonary Resuscitation policy and procedure. 8. On [DATE], a review of the emergency cart and emergency code documentation form was completed for the licensed nurses present in the facility. 9. On [DATE], the Regional Nurse Consultant provided education to the Administrator, Director of Nursing and the Staff Development Coordinator regarding the policies for Cardiopulmonary [MEDICAL CONDITION] Resuscitation, Change of Condition, Comprehensive Care Plan and following the care plan, Resident' Rights, and following physician's orders [REDACTED]. 10. On [DATE], a pre-test was completed by the Staff Development Coordinator for all licensed nurses to test knowledge of their above stated policies. 11. On [DATE], all licensed nursing staff were educated by the Staff Development Coordinator, Director of Nursing, or Assistant Director of Nursing on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. 12. Education will be provided by the Staff Development Coordinator during orientation, prior to working on the floor, for newly hired licensed nurses on the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. A post-test will be administered and a score of 100% will be required. Should a score of 100% not be obtained, re-education will occur and a post-test will be re-administered. This will be continued until a score of 100% on the post-test is obtained. 13. Starting on [DATE], post-tests were completed with four (4) licensed nurses by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, regarding the Cardiopulmonary Resuscitation policy, following physician's orders [REDACTED]. Four (4) post-tests with licensed nurses will be completed by the Staff Development Coordinator, Director of Nursing, or the Assistant Director or Nursing, daily for one (1) week (thru [DATE]), then three (3) post-tests with licensed nurses, daily for one (1) week ([DATE] - [DATE]), then two (2) post-tests with licensed nurses for two (2) weeks ([DATE] - [DATE]). If a nurse does not obtain a score of 100% on the post-test, re-education will be completed, and the post-test re-administered. This process will continue until a score of 100% is obtained on the post-test. Licensed Nurses will not be allowed to work until the score of 100% on the post-test is obtained. 14. Beginning [DATE], resident interviews are being completed for five (5) residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or above, daily to ensure there are no violations of resident's rights. Interviews will be completed by the Social Services Director, Administrator, Director of Nursing, Assistant Director of Nursing, or Staff Development Coordinator, for five (5) residents daily for one (1) week (thru [DATE]), then for two (2) residents three (3) times weekly for two (2) weeks ([DATE] - [DATE]), one (1) two (2) times weekly for one (1) week ([DATE] - [DATE]). 15. Mock code drills will be conducted by the Director of Nursing, Assistant Director of Nursing, or the Staff Development Coordinator every shift for seventy-two (72) hours ([DATE], [DATE], [DATE]). Mock code drills will be completed twice weekly for two (2) weeks ([DATE] - [DATE]). Mock code drills will be completed once monthly for three (3) months ([DATE] - [DATE]). Mock code drills will be completed quarterly thereafter. 16. CPR certification for licensed nurses will be audited by the Administrator monthly. 17. Admission records will be reviewed on the day of admission by the Charge Nurse, Director of Nursing, Assistant Director of Nursing, Social Services Director, or the MDS Coordinator to ensure accurate documentation of Advance Directives, physician's orders [REDACTED]. 18. The emergency cart checklist will be reviewed daily by Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator or Medical Records, Monday thru Friday, for two (2) weeks, then three (3) times weekly for two (2) weeks, then weekly thereafter. The weekend manager/manager on duty for holidays will complete the review of the emergency cart checklist on weekends and holidays. 19. On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, the Administrator, the Director of Nursing, the Assistant Director of Nursing, and the Staff Development Coordinator to discuss the occurrence of CPR not being continued as per policy for a resident with a full code status. Also discussed was the education completed with licensed nurses, as well as audits and monitoring that has been initiated as a corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 20. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Nursing, Social Services Director, Business Office Manager, and Regional Nurse Consultant to review findings of audits that were completed on [DATE], and continuance of the corrective action plan. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 21. On [DATE], an ad hoc QAPI meeting was held with Medical Director, Administrator, Director of Nursing, MDS Coordinator, Medical Records Clerk, Admissions and Marketing Director, Staff Development Coordinator, Rehab Services Manager, Business Office Manager, Plant Operations Director, Dietary Manager, Assistant Director of Nursing, Social Services Director, and the Staffing Coordinator to review the corrective action plan with all department managers. The Medical Director had no further recommendations and agreed with the plan of action set forth by the Administrator. 22. On [DATE], an ad hoc QAPI meeting was held with the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, and Staff Development Coordinator to review findings and continuation of the corrective action plan. The Medical Director agreed with the continuance of the corrective action plan, and had no further recommendations at this time. 23. A QAPI meeting will be held weekly for four (4) weeks ([DATE] - [DATE]), then monthly to review the corrective action plan and discuss findings of audits and monitoring, and for further recommendations as indicated. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of facility provided flowsheet dated [DATE] revealed all residents advanced directives/code status/physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM, Assistant Director of Nursing at 2:15 PM, Social Service Director at 3:21 PM, and Regional Nurse Consultant at 3:42 PM; and on [DATE] at 11:10 AM with the Director of Nursing, revealed they were part of the audit process on [DATE] which reviewed the physician's orders [REDACTED]. They further stated there were no noted concerns with the audits. 2. Review of facility provided Census Report dated [DATE] revealed all residents with a BIMS eight (8) and greater were reviewed with a star beside each resident. Furthermore, each resident with a BIMS of eight (8) and greater had a questionnaire with questions of Do you have any concerns? Do you feel safe? Do you feel safe from abuse? filled out by the Administrator and Social Service Director on [DATE]. Interviews on [DATE] with the Administrator at 11:20 AM and the Social Service Director at 3:21 PM revealed they interviewed all residents with a BIMS eight (8) and greater to assess for any signs and symptoms of abuse or violation of resident's rights by asking the above questions. 3. Review of skin assessments of residents with a BIMS of less than eight (8) dated [DATE] revealed those residents were assessed by the DON and ADON for signs and symptoms of quality of life or resident's rights violation with no concerns identified. Interview with the ADON on [DATE] at 2:15 PM and the DON on [DATE] at 11:10 AM revealed they performed skin assessments on residents with a BIMS of seven (7) and below on [DATE] to assess for any rights violations. 4. Review of a facility provided list dated [DATE] revealed residents who had expired in the past ninety (90) days with a review of the physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM and the Regional Nurse Consultant at 3:42 PM revealed they reviewed residents that had expired in the last ninety (90) days on [DATE] to ensure code status, nurses notes, advance directive, and care plans all matched with no concerns identified. 5. Review of a facility provided list dated [DATE] revealed all licensed nursing staff CPR certification was audited by the Regional Nurse Consultant and all licensed nurses had current CPR certification. Interview with the Regional Nurse Consultant on [DATE] at 3:42 PM revealed on [DATE] she reviewed all licensed nurse's CPR certification on [DATE]. She stated there were two (2) nurses who had expired CPR certifications and one (1) nurse who had not provided proof of certification upon hired. She further stated by the afternoon on [DATE] all licensed nurses had proof of certification. 6. Review of CPR Certification Verification Education dated [DATE] revealed the Administrator provided education to the Staff Development Coordinator (SDC), DON, and ADON. Interviews on [DATE] with the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they received education from the Administrator on [DATE] if a new licensed nurse employee is hired the SDC is responsible to ensure the CPR certification is obtained before starting work. Furthermore, if the SDC is off the DON and ADON is responsible for obtaining the information. In addition, the SDC is responsible to ensure the licensed nurses certification is checked monthly for expiration and are up to date. Interview with the Administrator on [DATE] at 11:20 AM revealed she provided education to the SDC, ADON, and DON on [DATE] ensuring employees on hire had proof of CPR certification and CPR certification was renewed before expiring or the employee was not allowed to work. In addition, the SDC is responsible to monitor monthly for CPR certification expiration as well as to obtain the certification on hire. Furthermore, the DON and ADON is responsible in the absence of the SDC. 7. Review of the Mock Code Checklist dated [DATE] at 6:00 PM revealed a drill was conducted by the DON. Review of the Mock Code Checklist dated [DATE] at 8:00 PM revealed a drill was conducted by the SDC. Interview with the SDC on [DATE] at 2:34 PM and the DON on [DATE] at 11:10 AM revealed they performed Mock Code Blue Drills with staff on [DATE]. Interviews on [DATE] with Licensed Practical Nurse (LPN) #8 at 4:15 PM and LPN #9 at 4:41 PM revealed they were part of a Code Blue Drill on [DATE] presented by the SDC, DON, and ADON. 8. Review of facility provided calendar titled charts and crash cart reviewed for (MONTH) (YEAR) revealed the Administrator's initials for [DATE] on review of the crash cart. Furthermore, review of inservice form titled Crash cart should be checked by night shift nurse on wing two (2) dated [DATE] revealed education was provided by the SDC. Interviews on [DATE] with LPN #11 at 1:50 PM, LPN #3 at 2:03 PM, and LPN #9 at 2:08 PM revealed they received inservicing from the SDC on [DATE] regarding the night nurse's responsibility to check the crash cart at night. If an item was missing it was the nurses responsibility to replace the item who removed the item from the cart. Interview with the SDC on [DATE] at 1:05 PM revealed she began education with staff on [DATE] regarding the crash cart and educated the nurses present in the facility on [DATE]. 9. Review of Inservice Sign In sheet dated [DATE] with education topics of Advance Directives, Resident Rights, CPR, Location of DNR form in resident's medical record, following physician's orders [REDACTED]. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON, revealed they were educated by the Regional Nurse Consultant on when to perform an SBAR with change in condition in a resident, notification of family and physician for a change, following the physician's orders [REDACTED]. 10. Review of a pre-test administered to licensed nurses on Full Code Status and CPR revealed all licensed nurses completed from [DATE]-[DATE] and received 100 percent (%). Furthermore, the pre-tests were signed by the SDC for verification and signed by the staff member performing the test. Interview with the SDC on [DATE] at 2:34 PM revealed she gave pre-test to all licensed nurses on [DATE] and [DATE] with 100% of nurses completed at a score of 100%. Interviews on [DATE] with LPN #8 at 4:15 PM, Registered Nurse (RN) #1 at 4:25 PM, and LPN #9 at 4:41 PM revealed they received a pre-test on Full Code and CPR prior to education on [DATE] and [DATE] and made a 100%. 11. Review of Inservice Form dated [DATE] revealed the licensed nurses were inserviced on initiating CPR on a resident when found unresponsive if they have a code status of Full Code. In addition, the CPR is to continue unless an order is received to stop or until EMS arrives. Furthermore, the education included following physician's orders [REDACTED]. Interview with the SDC on [DATE] at 2:34 PM revealed she provided education to the licensed nurses on [DATE] regarding resident's rights in choosing a code status, following through with the code status as ordered and per the resident's wishes, where to find the code status in the chart, location of the crash cart, notification to the family and physician, following the care plan/Advanced Directive. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, and LPN #9 at 4:41 PM revealed they were inserviced on [DATE] on where to locate the code status in the resident's chart, location of the crash cart, a full code resident requires CPR if found unresponsive, call 911, call a code blue, notification of change to the physician and family, following the care plan and Advance Directive, and performing an SBAR. 12. Review of new hire orientation for LPN #10 on [DATE] revealed education on CPR policy, resident rights, advance directives, change in condition, location of the code status and advance directives, emergency documentation form, following the care plans, and a pre and post test by the SDC. Interview with LPN #10 on [DATE] at 4:57 PM revealed before she was able to work the floor she was provided a pre and post test, education about the facility policy on CPR, instructions on the crash cart, how to review the contents on the crash cart, who was responsible to check the crash cart which was the night nurse, if an item was missing off the crash cart to replace it, how to find the advance directive and code status in the chart, call 911 is resident found unresponsive and was a full code, initiate CPR, call a Code Blue, continue CPR until EMS arrives, follow physician orders, physician notification, and emergency documentation form. 13. Review of post-tests on [DATE] revealed four (4) licensed nurses completed the test which included education on CPR, following physician's orders [REDACTED]. In addition, review of post test revealed test completed by licensed nurses daily for one (1) week through [DATE], then three (3) post test daily for one week through [DATE]. All nurses obtained 100% on the post test. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, LPN #9 at 4:41 PM, and LPN #10 at 4:57 PM revealed they have performed post test after the initial pre test regarding questions of notification to the physician, when to end CPR, where the Advance Directive is located, and change in condition. 14. Review of Resident interviews for residents with a BIMS of eight (8) or above revealed questions of any resident concerns, feeling safe, and safe from abuse was completed on five (5) residents daily starting [DATE]; then two (2) residents three (3) times a week for two (2) weeks starting [DATE] by the Administrator and Social Services. Interviews on [DATE] with the Administrator at 11:20 AM and Social Services Director at 3:26 PM revealed they interview residents with a BIMS of eight (8) and greater to assess for signs and symptoms of abuse or violation of resident rights. 15. Review of Mock Code Blue Drills dated [DATE], [DATE], and [DATE] revealed the drills were conducted for seventy-two (72) hours; then the drills were completed twice weekly for two (2) weeks starting [DATE] until [DATE] by the DON, ADON, or SDC. Interviews on [DATE] with the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they have performed Mock Code Blue Drills everyday on [DATE], [DATE], and [DATE] and continue to perform the mock drills twice a week at the present time. Interviews on [DATE] with LPN #8 at 4:15 PM, RN #1 at 4:25 PM, LPN #9 at 4:41 PM, and LPN #10 at 4:57 PM revealed they have been involved with several mock code blue drills so far since [DATE]. 16. Review of facility provided list of all licensed nurses with date of CPR expiration for month of (MONTH) (YEAR) with Administrators initials for (MONTH) (YEAR)'s review. Interview with the Administrator on [DATE] at 11:20 AM revealed she had already audited the CPR certifications for the month of (MONTH) and initialed on the CPR expiration form. She stated the calendar will be initialed when she performs each month. 17. Review of (MONTH) (YEAR) calendar titled Chart review and crash cart review revealed initials by Administrative staff every day from [DATE]-[DATE]. Interviews on [DATE] with the ADON at 2:15 PM and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they review new admissions for code status, Advance Directives, care plan, and physician's orders [REDACTED]. 18. Review of the Emergency Cart Check List revealed the cart has been reviewed daily by Administrative Staff since [DATE]. Interviews on [DATE] with the Administrator at 11:20 AM and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they have taken part in checking the crash cart daily since identified on [DATE] to ensure all the equipment was on the crash cart. In addition, they ensured the staff had signed off on the checklist daily. 19. Review of the facility provided Quality Performance Improvement (QAPI) sign in sheet dated [DATE] revealed the Administrator, DON, ADON, and SDC was in attendance along with the Medical Director via phone. Review of the typed up minutes revealed the incident with Resident #1 was discussed and a plan was discussed which included audits. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, and the SDC at 2:34 PM; and, on [DATE] at 11:10 AM with the DON revealed they attended an Ad Hoc Quality Assurance (QA) meeting in which they discussed with the Medical Director via phone the plan, concerns, audits, and education to begin and what had already been started. 20. Review of the facility provided QAPI sign in sheet dated [DATE] revealed the Administrator, DON, Social Service Director, Business Office Manager, and SDC including the Medical Director via phone was in attendance. Review of the typed up minutes revealed no concerns noted from audits and no new suggestions. Interviews on [DATE] with the Administrator at 11:20 AM, the ADON at 2:15 PM, the SDC at 2:34 PM, and the Business Office Manager at 3:06 PM; and, on [DATE] at 11:10 AM with the DON revealed they attended a QA meeting on [DATE] and discussed the progress with education, audits, and

Based on interview, record review and review of witness statements and the facility's policy and procedure it was determined the facility failed to implement its "Abuse, Neglect and Misappropriation," policy and procedure for one (1) of fifteen (15) sampled residents (Resident #4). On 11/19/14, Resident #4 was seated in the hallway in a wheelchair. A blanket or sheet was observed by Certified Nurse Aide (CNA) #1 and CNA #3 wrapped across the resident's waist and secured to the back of the wheelchair. CNA #1 reported the incident to LPN #2 and LPN #4, who were in charge; however, the incident was not reported to the Administrator or the Director of Nursing immediately per the facility's policy and procedure. CNA #1 reported the incident to the Administrator at the end of her shift, approximately four (4) hours later. (Refer to F221 and F225) The facility's failure to ensure staff reported observed incidents of abuse, neglect, and mistreatment per the facility policy and procedure has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/21/14 and determined to exist on 11/19/14. The facility was notified of the Immediate Jeopardy on 11/21/14. An acceptable Allegation of Compliance (AoC) was received on 12/01/14 and the State Agency validated the Immediate Jeopardy was removed on 11/27/14, as alleged. The scope and Severity was lowered to a " D " while the facility develops and implements the Plan of Corrections (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Policy and Procedure titled, "Abuse, Neglect and Misappropriation," dated April 2013, revealed "All allegations of abuse are to be reported immediately to the Charge Nurse. If the person reporting the abuse believes there is a lack of response from the charge nurse, the person will then notify the DON and/or Administrator. If the DON and/ or Administrator are not in the facility, staff will notify them by phone. The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee, pending the outcome of the investigation." Interviews on 11/20/14 at 12:45 PM with CNA #1, on 11/19/14 at 9:27 AM with CNA #3, on 11/19/14 at 3:31 with LPN #2 and on 11/21/14 at 11:10 with LPN #4 and review of witness statements revealed on 11/19/14, CNA #1 and CNA #3 witnessed Resident #4 with a blanket/sheet wrapped around his/her waist. The blanket/sheet was secured to the back of the resident's wheelchair. CNA #1 reported what she had witnessed to LPN #2 and her Charge Nurse (LPN #4); however, the abuse was not reported to the Administrator and/or DON immediately per the facility's policy and procedure. CNA #1 reported the incident to the Administrator at the end of his/her shift, which was approximately four (4) hours after the resident was observed. Interview with CNA #2, on 11/19/14 at 9:15 AM, revealed Resident #4 was in his/her wheelchair and kept releasing the self-release seatbelt causing it to alarm so she took a blanket and tucked it over the self-releasing belt so Resident #4 would quit playing with the belt. CNA #2 stated this was not the first time she had hid the seat belt from Resident #4 to keep him/her from taking off the belt. She stated LPN #2 was aware she had to cover up Resident #4's belt. Interview with CNA #1, on 11/20/14 at 12:45 PM, revealed she told LPN #2 and LPN #4 about Resident #4 being tied to the wheelchair but no action was taken. CNA #1 stated the DON and the Administrator were not available during the night, so she went immediately to the Administrator before she left work that morning. She stated she was not aware she was supposed to call the Administrator or DON when they were not in the building. Interview with CNA #3, on 11/19/14 at 9:27 AM, revealed she witnessed a blanket wrapped around Resident #4's seatbelt. However, she did not immediately report this to her Charge Nurse, per the facility's policy because she did not consider it abuse. Interview with LPN #2, on 11/19/14 at 3:31 PM, revealed she was aware the blanket was tucked under the resident's seat belt. Further interview revealed she also did not immediately report the incident, as she should have per facility policy. LPN #2 stated she had been trained on the facility's abuse/neglect policy but did not report the incident because she did not consider it abuse. Review of LPN #4's witness statement, dated 11/19/14, revealed at approximately 4:35 AM on 11/19/14, CNA #1 stated she had a picture of a "resident tied up". There was no documented evidence LPN #4 reported the abuse to the Administrator and/or the DON immediately per the facility's policy and procedure. Unsuccessful attempts to interview LPN #4 were made on 11/20/14 at 9:50 AM and 11:00 AM; and, on 11/21/14 at 9:58 AM. Interview with the DON on 11/21/14 at 11:05 PM, revealed she would expect any staff, who witnessed or suspected any signs of abuse to report it immediately to their Charge Nurse on duty and to follow up through the chain of command, per the facility's policy. Interview with the Administrator on 11/21/14 at 11:30 AM, revealed he would have expected any staff that saw or suspected any signs of abuse to report immediately to their immediate supervisor per facility policy. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 11/19/14, the facility suspended five (5) staff members: CNA #1, CNA #2, CNA #3, LPN #2 and LPN #4; and, on 11/23/14, CNA #1, CNA #3 and LPN #4 were terminated. 2. On 11/19/14, the Unit Manager (UM) assessed Resident #4 for any signs of injury and none were observed. The family and the physician were notified of the allegation on 11/19/14 by the ADON and initial reports were filed with the (State Survey Agency) SSA on 11/19/14 by the Administrator. 3. The Interdisciplinary Team (IDT) reassessed Resident #4 for the self-releasing seat belt and this was deemed to have been a restraint for this resident, due to the resident not being able to release the restraint on command. The family and physician were notified on 11/19/14, a consent form and a physician's orders [REDACTED]. 4. On 11/26/14, the IDT met and discussed Resident #4's actions of un-securing the alarming seatbelt and attempts to self transfer. The care plan was reviewed and updated to include specific interventions for staff to utilize while providing care for the resident. 5. The Social Services Director (SSD) assessed the resident for psychosocial harm and none was identified on 11/20/14-11/25/14. 6. Walking rounds were made twice each eight (8) hour shift to visually assess each resident for any restraint or potential restraint not previously assessed, or ordered by the physician and no concerns were identified. 7. All department heads (Administrator, DON, ADON, Unit Manager, Staff Development Coordinator {SDC}, SSD, Chaplain, Business Office Manager {BOM}, Dietary Manager, Rehabilitation Manager, MDS Coordinator, Quality of Life Director, and Human Resource Director {HRD}were educated by the Regional Nurse Consultant on 11/19/14 regarding abuse, neglect, restraints, the cell phone policy and resident rights. A post-test was administered, with a required 100 percent (%) pass rate. 8. The HR Director was re-educated by the Chief Nurse Executive regarding back-ground checks and following the facility policy on 11/19/14. 9. On 11/19/14, the Regional HR Services performed 100% audit of criminal background results of all active employees from 04/2013 to present with no concerns noted. 10. All residents with any devices that could be categorized as a restraint were assessed by administrative nursing (DON, ADON, UM, MDS Coordinator, and SDC) to determine appropriateness, based on medical symptoms and correct applications and none were identified. Care plans were reviewed to reflect current status. Orders and consents were reviewed or obtained based upon the reassessment. No other devices were assessed as restraints. 11. During walking rounds and audits it was discovered on 11/25/14 that two (2) residents with electric wheelchairs with seatbelts had not been assessed. The residents were assessed by the IDT team on 11/25/14 and care plans, orders and consents have been reviewed or obtained. 12. On 11/26/14, education was provided to the Department Head Team by the Chief Nurse Executive regarding care plans, revision of the care plan and the role each nurse has in regard to updating and implementing appropriate interventions and a post test requiring 100% pass rate was required. 13. On 11/26/14, the IDT team made walking rounds on all residents and met to discuss interventions as it related to residents who required alarms, due to history of behaviors of self transfer attempts and seatbelts. Care plans were reviewed and/or updated on 11/26/14 to include the new interventions if applicable. 14. Residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater were interviewed on 11/19/14, by the Administrator, DON, ADON, Chaplain and SSD regarding concerns with care or possible restraint activity and all concerns, most of which were concerning missing items, were reported to the SA. 15. A Resident Council Meeting was held on 11/19/14, to discuss abuse, neglect and resident rights. This meeting was reviewed by the Administrator for any concerns. 16. Head-to-toe skin assessments were conducted 11/19-20/14 by the ADON and UM for residents with a BIMS' score less than eight (8) with no concerns identified. 17. Interviews were conducted with family members of residents with a BIMS' score of less than eight (8) on 11/20/14 by the BOM, with no concerns identified. 18. Incident/Accident Reports for 08/01/14 through 11/20/14 were reviewed by the Nurse Consultant related to abuse, neglect, inappropriate restraints or violation of resident rights and no concerns were identified. 19. The Staff Development Coordinator provided education on abuse and neglect, restraints, cell phones, and resident rights to all staff working 11/19/14 and a post test, with a required 100 percent (%) pass rate was administered. Education on restraints was provided again on 11/25/14 to the DON, ADON, UM, MDS Coordinator, SDC, and Rehabilitation Manager by the Regional Program Manager. Staff not working on 11/19/14 will receive education and testing prior to working. Signs were posted at the time clock. 20. All staff working 11/19/14 were interviewed by the Administrator, DON, HR Coordinator and SDC in regards to any resident having been restrained and the findings were negative. 21. A new policy for review of potential employees was put into place on 11/19/14, utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications would be reviewed by the HR Director for eligibility. The Administrator would complete the final review, before a potential employee would be allowed to work. 22. The HR Director received disciplinary action from the Administrator and the HR Regional Services on 11/22/14. 23. Orientation for all new staff will include education on abuse, resident rights, cell phone policy, restraints, care plan and revision of the care plan. A post test would be administered with a passing score of 100%. 24. Education was provided by the facility department heads to the nursing staff on 11/26/14, upon notification of the care plan deficiency. A post test was provided regarding care plans and revisions and interim care plans, interventions that should have been added that are specific to the resident's care and care plan policies prior to reporting to their assignments. A post test with a required passing grade of 100% was required. If 100% accuracy was not obtained, staff members were to be re-educated and re-tested until 100% was obtained. Staff not on duty 11/26/14 were to receive education, prior to working their next shift. Licensed staff was to update care plans during their shift for any resident changes, concerns with behaviors, removing their assistive devices, new orders, or any concerns with the resident's care, and to incorporate goals and objectives that would lead to the resident's highest obtainable level of independence. The Administrator would be responsible for checking all audits for any concerns. If concerns were identified, the Administrator was to act immediately. The Administrator or Department Heads or the RN Week-end Supervisor will be on site daily to review all audits and tests to identify any concerns to ensure all abuse, neglect, misappropriation, violation of resident rights, cell phone and restraint policies are being followed. A member of the regional staff or home office staff, Regional Nurse Special Projects, or Vice President of Operations were to have been on site daily until the immediacy was lifted and to ensure all audits and questionnaires were followed. If concerns were identified, the Administrator was to act immediately. 25. Walking rounds will be conducted two (2) times each eight (8) hour shift, for all residents, by the Department Managers to observe for abuse, neglect, misappropriation, violation of resident rights, cell phone and restraints, until the immediacy was lifted. During these rounds, two (2) staff members were to be tested regarding these issues and 100% accuracy was required or re-education was to have been administered. Also during the rounds, two (2) residents were to have been interviewed regarding any issues or concerns. Any violations of these policies was to have been addressed by ensuring the resident was safe, and reporting to the Charge Nurse, as well as the Administrator, per policy. Findings of all rounds and audits are to be reported to the DON and Administrator daily, who in turn are to report any concerns to the State Agencies and follow the abuse procedures and policies for reporting, protecting, etc. QA will review the results of all tests, interviews, and rounding observations to analyze results and determine if the frequency could have been reduced as well as any need for re-education. 26. The DON, ADON, or Staff Development Coordinator (SDC) will review the daily physician's orders [REDACTED]. 27. The IDT will hold daily meetings, beginning 11/26/14, in which a review of the twenty-four (24) hour nursing report for any changes of condition, any new admission, re-admission or concerns with the removal of assistive devices, as well as Physician Orders, for any changes or documentation requiring an interim care plan, a new care plan or a revision of the care plan. Care plans will be reviewed to ensure compliance, until the immediacy is lifted. Once the immediacy has been lifted, the IDT will continue to meet daily and ongoing for review of the care plans. 28. A QA meeting was conducted on 11/20/14, to discuss incidents as well as all education provided, assessments provided, assessments of all residents with devices, processes for restraints, employee files regarding any staff having been convicted of a felony and all reviewed with the Medical Director. 29. Weekly Quality Performance Improvement meetings with the Medical Director to be on-going. The meetings are to review the findings of on-going audits, tests, questions, education, new employee files and back ground checks and/or any new concerns identified. Findings were to reviewed, trended and the committee would determine the course of action. **The State Survey Agency validated the corrective action taken by the facility on 12/04/14 as follows: 1. On 12/02/14, five (5) staff members' personnel files were reviewed: CNA #1, CNA #2, CNA #3, LPN #2 and LPN #4, regarding their written disciplinary actions, the restraint of Resident #4 and the failure to report abuse. The review also revealed on 11/23/14, CNA #1, CNA #3 and LPN #4 were terminated. 2. Review of the Resident #4's skin assessments, family and physician notification, care plan revision, ITP reviews of the seat-belt alarm restraint assessment, documentation and the physician order [REDACTED]. 3. Review of the Resident #4's care plan revisions, to include the use of the seat-belt, as a restraint device and alternate coping strategies when the resident became agitated, dated 11/19-26/14; consent for the use of restraints, dated 11/19/14; physician's orders [REDACTED]. 4. Review of the IDT Notes and Comprehensive Care Plan for At Risk for Harm/Injury, related to the seat belt, dated 11/19/14 and the Resident At Risk for and/or Expressing Anxiety Care Plan, dated 11/19/14 and interventions, dated 11/26/14, revealed the IDT met and discussed Resident #4's actions of un-securing the alarming seatbelt and attempts to self transfer. The care plan was reviewed and updated to include specific interventions for staff to utilize while providing care for the resident. 5. Review of the Social Services Progress Notes, dated 11/20/14-11/25/14, revealed the Social Service Director (SSD) assessed the resident daily for psychosocial harm and no concerns were identified. 6. Review of the Instructions for Walking Rounds and Audit Sheets, dated 11/19/14 through 12/01/14 revealed walking rounds were completed twice each eight (8) hour shift to identify if there were any restraints or potential restraints. No concerns were identified. 7. Review of the POS [REDACTED]. Interviews conducted on 12/02/14 with the Administrator and Director of Nursing (DON) at 12:45 PM, the HR Director at 3:35 PM and LPN #6 at 3:50 PM revealed they had been inserviced and were educated by the Regional Nurse Consultant on 11/19/14 regarding abuse, neglect, restraints, the cell phone policy and resident rights, a post-test was administered, with a required 100 percent (%) pass rate and all stated they had been inserviced and passed the test, with a 100 % pass rate. 8. Interview with the HR Director, on 12/02/14 at 3:35 PM, revealed she had been educated on the new policy for review of potential employees, put into place on 11/19/14 and utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications that would be reviewed by the HR Director for eligibility. Further interview revealed the Administrator would complete the final review, before a potential employee would be allowed to work. 9. Review of the Audit Records, dated 11/19/14, revealed no concerns. Review of Personnel records revealed LPN #1 was terminated on 11/19/14, for falsification of the application for employment, regarding not having any felony on her records and review of the result of the audit for personnel records, back to 2003 and a review of the Policy for Criminal Background Checks, dated 11/19/14, revealed no other concerns were identified. 10. Review of the Instructions for Walking Rounds and the 100% Visual Audit Tool, dated 11/19-24/14, revealed all residents with any devices that could be categorized as a restraint, were assessed by administrative nursing (DON, ADON, UM, MDS Coordinator, and SDC) to determine appropriateness, based on medical symptoms and correct applications. No concerns were identified. 100% audits of all resident's care plans were reviewed to reflect current status. Orders and consents were reviewed or obtained based upon the reassessment. No other devices were assessed as restraints. 11. A review of the 100% audits, dated 11/19-24/14, completed during walking rounds, revealed on 11/25/14 that two (2) residents with electric wheelchairs with seatbelts, which were made and installed by the manufacturer of the electric wheel chair, had not been assessed. The residents were assessed by the IDT team on 11/25/14 and care plans, orders and consents were reviewed or obtained, as evidenced by review of Resident #1's and Resident B's records. It was determined, per the Pre-Restraining Evaluation, dated 11/25/14, these were not restraints for these residents. 12. Review of Post Testing, dated 11/20-25/14, The Healthcare-In-Service Sign-In Sheets for Department Heads, dated 11/19/14, and interviews on 12/02/14 with the HRD at 3:35 PM, the ADON at 3:50 PM, and the Administrator and DON at 12:45 PM, revealed the Department Heads were educated on care plans, revision of the care plan and each nurse's role in regard to updating and implementing appropriate interventions. A post test requiring 100% pass rate was required. 13. Review of the 11/25-26/14 Census Board Audit Sheets revealed the IDT team made walking rounds, and completed them on all residents. Review of the IDT meeting notes, dated 11/25-26/14 revealed they met to discuss interventions related to residents who required alarms, due to history of behaviors of self transfer attempts and seatbelts. Review of Care plans for Unsampled Residents B, C, D, E, and F, who required alarms, revealed they were reviewed and/or updated on 11/26/14 to include the new interventions. 14. Verified with the SSA Complaints Coordinator any concerns identified during the facility's resident interviews, were received on 12/01/14 and she was waiting on the final reports. Interviews conducted on 12/03/14 with Unsampled Resident B, at 9:25 AM; Resident C at 1:35 PM; Resident D, at 11:00 AM; Resident E, at 2:50 PM; and, Resident F, at 12:00 PM, revealed no concerns with resident care, abuse, neglect or any restraint activity. 15. Review of the Resident Council Minutes, dated 11/19/14, revealed the residents were educated on abuse, neglect, restraints and reporting these concern to staff and the DON and Administrator. 16. Review of five (5) residents with head-to-toe skin assessments, who were assessed to have a BIMS' score less than eight (8), revealed the assessments were completed by the ADON and UM, on 11/19/14. No concerns were identified. 17. Review of the family contacts for five (5) family members of residents, with a BIMS' score of less than eight (8) revealed they were completed on 11/20/14 by the BOM. No concerns were identified. Interview with a family member for Resident #4, on 11/21/14 at 2:30 PM, revealed no concerns. 18. Incident/Accident Reports dated 08/01/14 through 11/20/14 were reviewed related to abuse, neglect, inappropriate restraints or violation of resident rights. No concerns were identified. 19. Review of the POS [REDACTED]. Interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, and CNA #14 at 5:00 PM; and, on 12/04/14 with LPN #7 at 8:02 AM; CNA #15 at 7:45 AM and CNA #16, at 8:00 AM, revealed they were educated and tested on abuse and neglect, restraints, cell phones, and resident rights. 20. Review of the staff's written statements, dated 11/19/14 and interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, CNA #14 at 5:00 PM, the HRD at 3:35 PM, the ADON at 3:50 PM and the Administrator and DON at 12:45 PM; and, on 12/04/14 with LPN #7 at 8:02 AM, CNA #15 at 7:45 AM, and CNA #16, at 8:00 AM, revealed all were aware of the definition of restraints and abuse. 21. Review of the facility's general orientation policy utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications would be reviewed by the HR Director for eligibility. The Administrator would complete the final review, before a potential employee would be allowed to work, was reviewed with no concerns. Review of the facility's policy for "Pre-Hire Check List," dated 11/19/14, revealed it included a clause regarding the Administrator's final review before the potential employee is allowed to work. 22 Review of the written reprimand for the HRD on 11/22/14 and interview with the HRD, on 12/02/14 at 3:35 PM revealed she had training on the new policy and check list and the Administrator had to "sign-off" on this, prior to anyone being hired. Interview with the Administrator, on 12/02/14 at 8:35 AM revealed they had a double check system now and there should be no other problems with screening of employees, prior to hiring. 23. A review of the Orientation Packet on 12/03/14, with policies to include: "Abuse Prevention Policy and Procedure," dated April 2013; Health Insurance Portability and Accountability Act (HIPAA) Policy," undated; "Resident Rights," undated; "Restraint Reduction," dated 12/20/10; "Social Media," dated 03/01/13; "Care Planning," dated October 2013; "Change in a Resident's Condition," dated October 2013; "Goals and Objectives of the Care Plans," dated April 2011; "Resident/ Family Participation in the Care Plan," dated December 2006; and "Usage of the Care Plan," dated August 2006, revealed no concerns. 24. Review of auditing and testing records, dated 11/19/14 through 12/02/14, used to ensure all abuse, neglect, misappropriation, violation of resident rights, cell phone use and restraint policies were being followed, revealed no concerns. Care plan education and testing was provided to staff on 11/26/14 and interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, CNA #14 at 5:00 PM, the HRD at 3:35 PM, the ADON at 3:50 PM and the Administrator and the DON on at 12:45 PM; and, on 12/04/14 with LPN #7 at 8:02 AM, CNA #15 at 7:45 AM, and CNA #16 at 8:00 AM, revealed all were aware of the definition of restraints and abuse, when and to whom they were to report these things and all had education on the care plans. A review of pre-testing and post-tests administered 11/20-26/14, revealed no concerns. 25. Interview with the Administrator and DON on 12/04/14 at 10:35 AM, revealed all concerns were documented and the facility had three (3) QA Meetings with the Medical Director (11/19/14, 11/25/14 and 12/02/14) regarding the results of the testing, training, interviews, rounding and audits to analyze the results and determine any further training needs or further evaluation. 26. Review of the audit sheets for Residents With Assistive Devices, Daily Clinical Meetings; Walking Rounds and Testing of Staff, dated 11/19/14 through 12/01/14, revealed no concerns. 27. Review of the daily IDT records for 11/26/14-12/01/14, audits for residents with any assistive devices, 24 Hour Reports Reviews, physician's orders [REDACTED]. 28. Interview with the Administrator and DON on 12/04/14 at 10:35 AM, revealed all concerns were documented and the facility had three QA Meetings with the Medical Director (11/19/14, 11/25/14 and 12/02/14) regarding the results of the testing, training, interviews, rounding and audits to analyze the results and determine any further training needs or further evaluation. 29. Interviews with the Administrator on 12/02/14 at 8:35 AM and the DON on 12/04/14 at 10:35 AM, revealed the weekly Quality Performance Improvement meetings with the Medical Director would be on-going and the meetings were to review the findings of on-going audits, tests, questions, education, new employee files and back ground checks and/or any new concerns identified. Findings would be reviewed, trended and the committee would determine the course of action. Interviews with the DON on 12/02/14 at 8:35 AM; and, on 12/04/14 at 10:35 AM, revealed the IDT will continue an on-going weekly assessment to review all devices and restraints for the continued need, reduction attempt or elimination.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to revise the Interim Care Plan for one (1) of fifteen (15) sampled residents (Resident #4). Resident #4 had behaviors of releasing his/her self-releasing alarming seatbelt causing the alarm to repeatedly sound; however, review of the Interim Care Plan revealed there were no interventions to address what staff should do when the resident had this behavior. On 11/19/14, Certified Nursing Assistant (CNA) #1 and CNA #3 observed Resident #4 on the hallway in his/her wheelchair with a blanket/sheet over the seatbelt around the resident and secured to the back of the wheelchair. CNA #2 stated the resident was continuously causing the seatbelt to alarm so she placed the blanket around the resident. (Refer to F221) The facility's failure to revise the Interim Care Plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/21/14 and determined to exist on 11/19/14. The facility was notified of the Immediate Jeopardy on 11/21/14. An acceptable Allegation of Compliance (AoC) was received on 12/01/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 11/27/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedures titled, "Care Planning", last revised 08/2014, revealed "A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. Goals and objectives are reviewed and or/revised when the desired outcome has not been achieved and the Nurse Supervisor will use the care plan to complete the CNA's daily/weekly work assignment sheets and/or flow sheet. Record review revealed the facility admitted Resident #4 on 11/05/14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 11/12/14, revealed the facility assessed Resident #4's cognition as severely impaired, with a Brief Interview of Mental Status (BIMS) score of "2" indicating the resident was non-interviewable. Review of the Pre-Restraining Evaluation, dated 11/12/14, revealed the resident was assessed for the use of an alarming self-release seatbelt due to chair alarms not preventing falls. The resident was able to self-release the seatbelt. Review of the Interim Care Plan for Falls, dated 11/09/14, revealed the resident was at risk for falls related to a previous fall. Review of the Interim Care Plan for Activities, dated 11/12/14, revealed an intervention was put in place on 11/12/14 to use an alarming seatbelt for safety and to alert staff with self transfers; however, there were no interventions to address the resident's behavior of continuously removing the seatbelt. Review of Nursing Notes, dated 11/13/14 and 11/16/14 (no times), and interviews with CNA #11, CNA #3, CNA #9, and Licensed Practical Nurse (LPN) #5 revealed the resident would repeatedly release the seatbelt and cause the alarm to sound. However, further review of the Interim Care Plan revealed the care plan was not revised to include interventions to address the resident's behavior of repeatedly releasing the seatbelt and causing it to alarm. Interviews with and review of witness statements of CNA #1 and CNA #3, revealed on 11/19/14, CNA #1 and CNA #3 witnessed Resident #4 on the hall in his/her wheelchair with a self-releasing seat belt and clip alarm on his/her person. There was a blanket/sheet wrapped around the resident's waist and secured to the back of the resident's wheelchair. Interview with CNA #2, on 11/26/14 at 12:51 PM, revealed she did not try anything else before putting the blanket over the seat belt and she thought covering the belt was okay. She stated she just tried to cope with Resident #4 the best way she could and it was hard to come up with ideas to keep the resident distracted so the resident would leave the seatbelt alone so she could provide care for other residents. CNA #2 stated she was trying to keep Resident #4 from getting up out of his/her wheel chair and falling. Interview with CNA #11, on 11/20/14 at 6:30 PM, revealed she had to roll Resident #4 around as she provided care to other residents, so she could catch the resident before she/he tried to release the safety belt and get up out of his/her wheelchair. Interview with CNA #3, on 11/26/14 at 12:11 PM, revealed she tried to keep the resident occupied by giving him/her things to do during the night, but that was really hard to do when she were trying to provide care for other residents. She stated she just tried things that popped in her mind to distract the resident from the seatbelt, but there was nothing ever in writing for her to try to distract the resident. Interview with CNA #9, on 11/20/14 at 6:05 PM, revealed he just tried to keep Resident #4 in his view and was not really sure how to keep him/her occupied. Interview with LPN #5 on 11/26/14 at 11:26 AM, revealed she had attempted to redirect Resident #4 by having the resident fold wash cloths, offering him/her a snack, reading him/her the newspaper, keeping the resident in her view at all times and talking one on one with the resident. She further stated, these diversions were just something she had come up with over her years as a experienced nurse working with the elderly. She revealed these interventions were not added to Resident #4's care plan for the CNAs to try with Resident #4 but the interventions should have been added to the Interim Care Plan so the CNAs and any staff providing care to the resident would have known what interventions to try when the resident was removing his/her seatbelt. Interview with Minimum Data Set (MDS) Coordinator, on 11/26/14 at 11:30 AM, revealed the floor nurses were responsible for developing and updating the interim care plans until the Comprehensive Care Plan was developed. Interview with the DON on 11/26/14 at 2:10 PM, revealed she would have expected any and all licensed nursing staff to update and revise the Interim Care Plan as needed to reflect new interventions needed for Resident #4 until the Comprehensive Care Plan was developed. If this had been done, all staff providing care to the resident would have known interventions to keep Resident #4 from releasing his/her self-releasing seat belt. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 11/19/14, the facility suspended five (5) staff members: CNA #1, CNA #2, CNA #3, LPN #2 and LPN #4; and, on 11/23/14, CNA #1, CNA #3 and LPN #4 were terminated. 2. On 11/19/14, the Unit Manager (UM) assessed Resident #4 for any signs of injury and none were observed. The family and the physician were notified of the allegation on 11/19/14 by the ADON and initial reports were filed with the (State Survey Agency) SSA on 11/19/14 by the Administrator. 3. The Interdisciplinary Team (IDT) reassessed Resident #4 for the self-releasing seat belt and this was deemed to have been a restraint for this resident, due to the resident not being able to release the restraint on command. The family and physician were notified on 11/19/14, a consent form and a physician's orders [REDACTED]. 4. On 11/26/14, the IDT met and discussed Resident #4's actions of un-securing the alarming seatbelt and attempts to self transfer. The care plan was reviewed and updated to include specific interventions for staff to utilize while providing care for the resident. 5. The Social Services Director (SSD) assessed the resident for psychosocial harm and none was identified on 11/20/14-11/25/14. 6. Walking rounds were made twice each eight (8) hour shift to visually assess each resident for any restraint or potential restraint not previously assessed, or ordered by the physician and no concerns were identified. 7. All department heads (Administrator, DON, ADON, Unit Manager, Staff Development Coordinator {SDC}, SSD, Chaplain, Business Office Manager {BOM}, Dietary Manager, Rehabilitation Manager, MDS Coordinator, Quality of Life Director, and Human Resource Director {HRD}were educated by the Regional Nurse Consultant on 11/19/14 regarding abuse, neglect, restraints, the cell phone policy and resident rights. A post-test was administered, with a required 100 percent (%) pass rate. 8. The HR Director was re-educated by the Chief Nurse Executive regarding back-ground checks and following the facility policy on 11/19/14. 9. On 11/19/14, the Regional HR Services performed 100% audit of criminal background results of all active employees from 04/2013 to present with no concerns noted. 10. All residents with any devices that could be categorized as a restraint were assessed by administrative nursing (DON, ADON, UM, MDS Coordinator, and SDC) to determine appropriateness, based on medical symptoms and correct applications and none were identified. Care plans were reviewed to reflect current status. Orders and consents were reviewed or obtained based upon the reassessment. No other devices were assessed as restraints. 11. During walking rounds and audits it was discovered on 11/25/14 that two (2) residents with electric wheelchairs with seatbelts had not been assessed. The residents were assessed by the IDT team on 11/25/14 and care plans, orders and consents have been reviewed or obtained. 12. On 11/26/14, education was provided to the Department Head Team by the Chief Nurse Executive regarding care plans, revision of the care plan and the role each nurse has in regard to updating and implementing appropriate interventions and a post test requiring 100% pass rate was required. 13. On 11/26/14, the IDT team made walking rounds on all residents and met to discuss interventions as it related to residents who required alarms, due to history of behaviors of self transfer attempts and seatbelts. Care plans were reviewed and/or updated on 11/26/14 to include the new interventions if applicable. 14. Residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater were interviewed on 11/19/14, by the Administrator, DON, ADON, Chaplain and SSD regarding concerns with care or possible restraint activity and all concerns, most of which were concerning missing items, were reported to the SA. 15. A Resident Council Meeting was held on 11/19/14, to discuss abuse, neglect and resident rights. This meeting was reviewed by the Administrator for any concerns. 16. Head-to-toe skin assessments were conducted 11/19-20/14 by the ADON and UM for residents with a BIMS' score less than eight (8) with no concerns identified. 17. Interviews were conducted with family members of residents with a BIMS' score of less than eight (8) on 11/20/14 by the BOM, with no concerns identified. 18. Incident/Accident Reports for 08/01/14 through 11/20/14 were reviewed by the Nurse Consultant related to abuse, neglect, inappropriate restraints or violation of resident rights and no concerns were identified. 19. The Staff Development Coordinator provided education on abuse and neglect, restraints, cell phones, and resident rights to all staff working 11/19/14 and a post test, with a required 100 percent (%) pass rate was administered. Education on restraints was provided again on 11/25/14 to the DON, ADON, UM, MDS Coordinator, SDC, and Rehabilitation Manager by the Regional Program Manager. Staff not working on 11/19/14 will receive education and testing prior to working. Signs were posted at the time clock. 20. All staff working 11/19/14 were interviewed by the Administrator, DON, HR Coordinator and SDC in regards to any resident having been restrained and the findings were negative. 21. A new policy for review of potential employees was put into place on 11/19/14, utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications would be reviewed by the HR Director for eligibility. The Administrator would complete the final review, before a potential employee would be allowed to work. 22. The HR Director received disciplinary action from the Administrator and the HR Regional Services on 11/22/14. 23. Orientation for all new staff will include education on abuse, resident rights, cell phone policy, restraints, care plan and revision of the care plan. A post test would be administered with a passing score of 100%. 24. Education was provided by the facility department heads to the nursing staff on 11/26/14, upon notification of the care plan deficiency. A post test was provided regarding care plans and revisions and interim care plans, interventions that should have been added that are specific to the resident's care and care plan policies prior to reporting to their assignments. A post test with a required passing grade of 100% was required. If 100% accuracy was not obtained, staff members were to be re-educated and re-tested until 100% was obtained. Staff not on duty 11/26/14 were to receive education, prior to working their next shift. Licensed staff was to update care plans during their shift for any resident changes, concerns with behaviors, removing their assistive devices, new orders, or any concerns with the resident's care, and to incorporate goals and objectives that would lead to the resident's highest obtainable level of independence. The Administrator would be responsible for checking all audits for any concerns. If concerns were identified, the Administrator was to act immediately. The Administrator or Department Heads or the RN Week-end Supervisor will be on site daily to review all audits and tests to identify any concerns to ensure all abuse, neglect, misappropriation, violation of resident rights, cell phone and restraint policies are being followed. A member of the regional staff or home office staff, Regional Nurse Special Projects, or Vice President of Operations were to have been on site daily until the immediacy was lifted and to ensure all audits and questionnaires were followed. If concerns were identified, the Administrator was to act immediately. 25. Walking rounds will be conducted two (2) times each eight (8) hour shift, for all residents, by the Department Managers to observe for abuse, neglect, misappropriation, violation of resident rights, cell phone and restraints, until the immediacy was lifted. During these rounds, two (2) staff members were to be tested regarding these issues and 100% accuracy was required or re-education was to have been administered. Also during the rounds, two (2) residents were to have been interviewed regarding any issues or concerns. Any violations of these policies was to have been addressed by ensuring the resident was safe, and reporting to the Charge Nurse, as well as the Administrator, per policy. Findings of all rounds and audits are to be reported to the DON and Administrator daily, who in turn are to report any concerns to the State Agencies and follow the abuse procedures and policies for reporting, protecting, etc. QA will review the results of all tests, interviews, and rounding observations to analyze results and determine if the frequency could have been reduced as well as any need for re-education. 26. The DON, ADON, or Staff Development Coordinator (SDC) will review the daily physician's orders [REDACTED]. 27. The IDT will hold daily meetings, beginning 11/26/14, in which a review of the twenty-four (24) hour nursing report for any changes of condition, any new admission, re-admission or concerns with the removal of assistive devices, as well as Physician Orders, for any changes or documentation requiring an interim care plan, a new care plan or a revision of the care plan. Care plans will be reviewed to ensure compliance, until the immediacy is lifted. Once the immediacy has been lifted, the IDT will continue to meet daily and ongoing for review of the care plans. 28. A QA meeting was conducted on 11/20/14, to discuss incidents as well as all education provided, assessments provided, assessments of all residents with devices, processes for restraints, employee files regarding any staff having been convicted of a felony and all reviewed with the Medical Director. 29. Weekly Quality Performance Improvement meetings with the Medical Director to be on-going. The meetings are to review the findings of on-going audits, tests, questions, education, new employee files and back ground checks and/or any new concerns identified. Findings were to reviewed, trended and the committee would determine the course of action. **The State Survey Agency validated the corrective action taken by the facility on 12/04/14 as follows: 1. On 12/02/14, five (5) staff members' personnel files were reviewed: CNA #1, CNA #2, CNA #3, LPN #2 and LPN #4, regarding their written disciplinary actions, the restraint of Resident #4 and the failure to report abuse. The review also revealed on 11/23/14, CNA #1, CNA #3 and LPN #4 were terminated. 2. Review of the Resident #4's skin assessments, family and physician notification, care plan revision, ITP reviews of the seat-belt alarm restraint assessment, documentation and the physician order [REDACTED]. 3. Review of the Resident #4's care plan revisions, to include the use of the seat-belt, as a restraint device and alternate coping strategies when the resident became agitated, dated 11/19-26/14; consent for the use of restraints, dated 11/19/14; physician's orders [REDACTED]. 4. Review of the IDT Notes and Comprehensive Care Plan for At Risk for Harm/Injury, related to the seat belt, dated 11/19/14 and the Resident At Risk for and/or Expressing Anxiety Care Plan, dated 11/19/14 and interventions, dated 11/26/14, revealed the IDT met and discussed Resident #4's actions of un-securing the alarming seatbelt and attempts to self transfer. The care plan was reviewed and updated to include specific interventions for staff to utilize while providing care for the resident. 5. Review of the Social Services Progress Notes, dated 11/20/14-11/25/14, revealed the Social Service Director (SSD) assessed the resident daily for psychosocial harm and no concerns were identified. 6. Review of the Instructions for Walking Rounds and Audit Sheets, dated 11/19/14 through 12/01/14 revealed walking rounds were completed twice each eight (8) hour shift to identify if there were any restraints or potential restraints. No concerns were identified. 7. Review of the POS [REDACTED]. Interviews conducted on 12/02/14 with the Administrator and Director of Nursing (DON) at 12:45 PM, the HR Director at 3:35 PM and LPN #6 at 3:50 PM revealed they had been inserviced and were educated by the Regional Nurse Consultant on 11/19/14 regarding abuse, neglect, restraints, the cell phone policy and resident rights, a post-test was administered, with a required 100 percent (%) pass rate and all stated they had been inserviced and passed the test, with a 100 % pass rate. 8. Interview with the HR Director, on 12/02/14 at 3:35 PM, revealed she had been educated on the new policy for review of potential employees, put into place on 11/19/14 and utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications that would be reviewed by the HR Director for eligibility. Further interview revealed the Administrator would complete the final review, before a potential employee would be allowed to work. 9. Review of the Audit Records, dated 11/19/14, revealed no concerns. Review of Personnel records revealed LPN #1 was terminated on 11/19/14, for falsification of the application for employment, regarding not having any felony on her records and review of the result of the audit for personnel records, back to 2003 and a review of the Policy for Criminal Background Checks, dated 11/19/14, revealed no other concerns were identified. 10. Review of the Instructions for Walking Rounds and the 100% Visual Audit Tool, dated 11/19-24/14, revealed all residents with any devices that could be categorized as a restraint, were assessed by administrative nursing (DON, ADON, UM, MDS Coordinator, and SDC) to determine appropriateness, based on medical symptoms and correct applications. No concerns were identified. 100% audits of all resident's care plans were reviewed to reflect current status. Orders and consents were reviewed or obtained based upon the reassessment. No other devices were assessed as restraints. 11. A review of the 100% audits, dated 11/19-24/14, completed during walking rounds, revealed on 11/25/14 that two (2) residents with electric wheelchairs with seatbelts, which were made and installed by the manufacturer of the electric wheel chair, had not been assessed. The residents were assessed by the IDT team on 11/25/14 and care plans, orders and consents were reviewed or obtained, as evidenced by review of Resident #1's and Resident B's records. It was determined, per the Pre-Restraining Evaluation, dated 11/25/14, these were not restraints for these residents. 12. Review of Post Testing, dated 11/20-25/14, The Healthcare-In-Service Sign-In Sheets for Department Heads, dated 11/19/14, and interviews on 12/02/14 with the HRD at 3:35 PM, the ADON at 3:50 PM, and the Administrator and DON at 12:45 PM, revealed the Department Heads were educated on care plans, revision of the care plan and each nurse's role in regard to updating and implementing appropriate interventions. A post test requiring 100% pass rate was required. 13. Review of the 11/25-26/14 Census Board Audit Sheets revealed the IDT team made walking rounds, and completed them on all residents. Review of the IDT meeting notes, dated 11/25-26/14 revealed they met to discuss interventions related to residents who required alarms, due to history of behaviors of self transfer attempts and seatbelts. Review of Care plans for Unsampled Residents B, C, D, E, and F, who required alarms, revealed they were reviewed and/or updated on 11/26/14 to include the new interventions. 14. Verified with the SSA Complaints Coordinator any concerns identified during the facility's resident interviews, were received on 12/01/14 and she was waiting on the final reports. Interviews conducted on 12/03/14 with Unsampled Resident B, at 9:25 AM; Resident C at 1:35 PM; Resident D, at 11:00 AM; Resident E, at 2:50 PM; and, Resident F, at 12:00 PM, revealed no concerns with resident care, abuse, neglect or any restraint activity. 15. Review of the Resident Council Minutes, dated 11/19/14, revealed the residents were educated on abuse, neglect, restraints and reporting these concern to staff and the DON and Administrator. 16. Review of five (5) residents with head-to-toe skin assessments, who were assessed to have a BIMS' score less than eight (8), revealed the assessments were completed by the ADON and UM, on 11/19/14. No concerns were identified. 17. Review of the family contacts for five (5) family members of residents, with a BIMS' score of less than eight (8) revealed they were completed on 11/20/14 by the BOM. No concerns were identified. Interview with a family member for Resident #4, on 11/21/14 at 2:30 PM, revealed no concerns. 18. Incident/Accident Reports dated 08/01/14 through 11/20/14 were reviewed related to abuse, neglect, inappropriate restraints or violation of resident rights. No concerns were identified. 19. Review of the POS [REDACTED]. Interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, and CNA #14 at 5:00 PM; and, on 12/04/14 with LPN #7 at 8:02 AM; CNA #15 at 7:45 AM and CNA #16, at 8:00 AM, revealed they were educated and tested on abuse and neglect, restraints, cell phones, and resident rights. 20. Review of the staff's written statements, dated 11/19/14 and interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, CNA #14 at 5:00 PM, the HRD at 3:35 PM, the ADON at 3:50 PM and the Administrator and DON at 12:45 PM; and, on 12/04/14 with LPN #7 at 8:02 AM, CNA #15 at 7:45 AM, and CNA #16, at 8:00 AM, revealed all were aware of the definition of restraints and abuse. 21. Review of the facility's general orientation policy utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications would be reviewed by the HR Director for eligibility. The Administrator would complete the final review, before a potential employee would be allowed to work, was reviewed with no concerns. Review of the facility's policy for "Pre-Hire Check List," dated 11/19/14, revealed it included a clause regarding the Administrator's final review before the potential employee is allowed to work. 22 Review of the written reprimand for the HRD on 11/22/14 and interview with the HRD, on 12/02/14 at 3:35 PM revealed she had training on the new policy and check list and the Administrator had to "sign-off" on this, prior to anyone being hired. Interview with the Administrator, on 12/02/14 at 8:35 AM revealed they had a double check system now and there should be no other problems with screening of employees, prior to hiring. 23. A review of the Orientation Packet on 12/03/14, with policies to include: "Abuse Prevention Policy and Procedure," dated April 2013; Health Insurance Portability and Accountability Act (HIPAA) Policy," undated; "Resident Rights," undated; "Restraint Reduction," dated 12/20/10; "Social Media," dated 03/01/13; "Care Planning," dated October 2013; "Change in a Resident's Condition," dated October 2013; "Goals and Objectives of the Care Plans," dated April 2011; "Resident/ Family Participation in the Care Plan," dated December 2006; and "Usage of the Care Plan," dated August 2006, revealed no concerns. 24. Review of auditing and testing records, dated 11/19/14 through 12/02/14, used to ensure all abuse, neglect, misappropriation, violation of resident rights, cell phone use and restraint policies were being followed, revealed no concerns. Care plan education and testing was provided to staff on 11/26/14 and interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, CNA #14 at 5:00 PM, the HRD at 3:35 PM, the ADON at 3:50 PM and the Administrator and the DON on at 12:45 PM; and, on 12/04/14 with LPN #7 at 8:02 AM, CNA #15 at 7:45 AM, and CNA #16 at 8:00 AM, revealed all were aware of the definition of restraints and abuse, when and to whom they were to report these things and all had education on the care plans. A review of pre-testing and post-tests administered 11/20-26/14, revealed no concerns. 25. Interview with the Administrator and DON on 12/04/14 at 10:35 AM, revealed all concerns were documented and the facility had three (3) QA Meetings with the Medical Director (11/19/14, 11/25/14 and 12/02/14) regarding the results of the testing, training, interviews, rounding and audits to analyze the results and determine any further training needs or further evaluation. 26. Review of the audit sheets for Residents With Assistive Devices, Daily Clinical Meetings; Walking Rounds and Testing of Staff, dated 11/19/14 through 12/01/14, revealed no concerns. 27. Review of the daily IDT records for 11/26/14-12/01/14, audits for residents with any assistive devices, 24 Hour Reports Reviews, physician's orders [REDACTED]. 28. Interview with the Administrator and DON on 12/04/14 at 10:35 AM, revealed all concerns were documented and the facility had three QA Meetings with the Medical Director (11/19/14, 11/25/14 and 12/02/14) regarding the results of the testing, training, interviews, rounding and audits to analyze the results and determine any further training needs or further evaluation. 29. Interviews with the Administrator on 12/02/14 at 8:35 AM and the DON on 12/04/14 at 10:35 AM, revealed the weekly Quality Performance Improvement meetings with the Medical Director would be on-going and the meetings were to review the findings of on-going audits, tests, questions, education, new employee files and back ground checks and/or any new concerns identified. Findings would be reviewed, trended and the committee would determine the course of action. Interviews with the DON on 12/02/14 at 8:35 AM; and, on 12/04/14 at 10:35 AM, revealed the IDT will continue an on-going weekly assessment to review all devices and restraints for the continued need, reduction attempt or elimination.

Based on interview, record review, and review of witness statements and the facility's policy and procedure, it was determined the facility failed to ensure residents were free of physical restraints used for the purpose of discipline or staff's convenience for one (1) of fifteen (15) sampled residents (Resident #4). On 11/19/14, Certified Nursing Assistant (CNA) #2 restrained Resident #4 by wrapping a sheet/blanket across the resident's waist and securing it to the back of the wheelchair because the resident was trying to release the belt and the alarm kept sounding. This was observed by two (2) CNAs (CNAs #1 and #3); however no one intervened to address the use of this restraint. (Refer to F225 and F226) The facility's failure to ensure residents were free from physical restraints imposed for purposes of discipline or convenience has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/21/14 and determined to exist on 11/19/14. The facility was notified of the Immediate Jeopardy on 11/21/14. An acceptable Allegation of Compliance (AoC) was received on 12/01/14 and the State Agency validated the Immediate Jeopardy was removed on 11/27/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Corrections (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, "Physical Restraint Reduction Program", effective 12/2010, revealed this facility's definition of physical restrain is any manual method or mechanical device, material or equipment attached adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints include: Hand mitts, soft ties, or vest, lap cushions, lap trays that the resident cannot remove, a chair that prevents rising, tucking in or using velcro to hold a sheet, fabric or clothing tightly so that the resident's movement is restricted. Using devices in conjunction with a chair such as trays, table bars, belts, and/or side rails that the resident cannot remove easily that prevent resident from rising. Placing a chair or bed so close to the wall that the wall prevents a resident from rising out of the chair or voluntary getting out of the bed. Use of the physical restraint in this facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident or other residents and under the following conditions: As a last resort measure after a trail period where alternatives, less restrictive measures have been undertaken and proven to be unsuccessful; with a physician's orders [REDACTED]. Record review revealed the facility admitted Resident #4 on 11/05/14 with [DIAGNOSES REDACTED]. Review of admission Minimum Data Set (MDS) Assessment, dated 11/12/14, revealed the facility assessed Resident #4's cognition as severely impaired, with a Brief Interview of Mental Status (BIMS) score of "2" indicating the resident was non-interviewable Review of a physician's orders [REDACTED].#4 was to have an alarming seat belt for safety and to alert staff when the resident attempted to self transfer. The care plan goal for this resident was to be free from falls. Review of the facility's Initial Report, dated 11/19/14, revealed on 11/19/14 at 7:05 AM, Certified Nurse Aide (CNA) #1, who worked the 11:00 PM-7:00 AM shift, approached the Administrator to report Resident #4 had been observed secured to his/her wheelchair using a blanket. Review of CNA #1's written witness statement, dated 11/19/14, and interview with CNA #1, on 11/20/14 at 12:45 PM, revealed she was leaving for lunch at approximately 3:00 AM on 11/19/14, when she observed Resident #4 on Wing 2 "tied" in a wheelchair. When CNA #1 returned from lunch, at 3:30 AM, Resident #4 was still tied to the wheelchair in the hallway. Further interview with CNA #1 revealed Resident #4 was tied with a blanket which had 3 (three) knots which restricted the resident to the point he/she could barely lift his/her "bottom" up from his/her wheelchair. CNA #1 stated when she told Licensed Practical Nurse (LPN) #2, what she had observed, the LPN stated, it was against the law, " ... but what are we supposed to do". CNA #1 stated she also told LPN #4, the Charge Nurse, about what she had observed and he told her he knew she had taken a picture with her cell phone of Resident #4 being tied to the wheelchair. The Charge Nurse told her not to go back over on Wing 2 and ".. not get in the middle of the mess." CNA #1 stated the Director of Nursing (DON) and the Administrator were not available during the night, so she went immediately to the Administrator before she left work that morning. Interview with CNA #3, on 11/19/14 at 9:27 AM, revealed there was a blanket over the top of Resident #4's self-releasing seatbelt, almost all night long. She stated she did not consider it a restraint because it was not tied to the wheelchair, and the blanket kept the resident from pulling at the self-releasing belt all the time. CNA #3 revealed if she had seen it tied to the wheel chair she would have reported it to her Charge Nurse, but the blanket was not tied, it was just draped over the self-releasing seat belt. However, review of CNA #3's written witness statement, dated 11/19/14, revealed CNA #3 documented there was "a sheet tied" around Resident #4's waist, which was tied behind the wheel chair, rolled up like a belt. Further review of the statement revealed CNA #1 told CNA #3 that it was a restraint, and asked her did she know why it was a restraint and CNA #3 stated "No". Interview with CNA #2, on 11/19/14 at 9:15 AM, revealed Resident #4 was in his/her wheelchair with a self-releasing seat belt and clip alarm on his/her person. CNA #2 stated the resident kept trying to release the belt and the alarm kept sounding so she took a blanket and tucked it over the self-releasing belt so Resident #4 would quit playing with the belt. CNA #2 stated it was not the first time she had hid the seat belt from Resident #4 to keep him/her from taking off the belt. She stated LPN #2 was aware she had to cover up Resident #4's belt. She stated she did not consider this a restraint, because the resident could still reach the belt, just not as often as before the blanket was applied. Review of LPN #2's written witness statement, dated 11/19/14, and interview with LPN #2, on 11/19/14 at 3:31 PM, revealed Resident #4 had a self-releasing seatbelt on his/her wheel chair, which the resident took off frequently. LPN #2 revealed the belt was not effective, but anything else would be considered a restraint and the facility was "restraint-free". She stated the blanket was tucked under the resident's seat belt and it was not a restraint because it was not tied to the wheel chair. Review of LPN #4's witness statement, dated 11/19/14, revealed at approximately 4:35 AM on 11/19/14, CNA #1 stated she had a picture of a "resident tied up". The CNA left and came back and said "look at this." LPN #4 documented that he told CNA #1 to "Come on and let us just get busy, we are way behind". Attempts to interview LPN #4 on 11/20/14 at 9:50 AM and 11:00 AM; and, on 11/21/14 at 9:58 AM were unsuccessful. Interview with the DON, on 11/21/14 at 11:10 AM, revealed she became aware of the allegation on 11/19/14, when speaking with the Administrator and the Corporate Nurse and she immediately began her investigation. The DON stated she would have expected any staff that had observed a resident with a sheet or blanket tied to a wheelchair to have reported it immediately, as this would be considered a restraint. Interview with the Administrator, on 11/21/14 at 11:30 AM, revealed he became aware of the allegation on 11/19/14, when CNA #1 came into his office and showed him three (3) photographs of Resident #4. The pictures revealed Resident #4 had a blanket draped over his/her lap to the sides of the wheelchair. The Administrator stated he was not sure if the blanket was tied to the axle or not, but it was bunched up at the end of the blanket and he could not see the resident's safety belt. He stated when he observed the blanket it was across the resident, and he felt the resident was being restrained. A post survey interview with the Administrator, conducted on 12/12/2014 at 8:13 AM, revealed through the facility's investigation he was unable to determine if Resident #4 was tied to his/her wheel chair; however, he did determine the resident was restrained because the blanket was covering the self releasing seat belt causing Resident #4 not to be able to release his/her self releasing seat belt. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 11/19/14, the facility suspended five (5) staff members: CNA #1, CNA #2, CNA #3, LPN #2 and LPN #4; and, on 11/23/14, CNA #1, CNA #3 and LPN #4 were terminated. 2. On 11/19/14, the Unit Manager (UM) assessed Resident #4 for any signs of injury and none were observed. The family and the physician were notified of the allegation on 11/19/14 by the ADON and initial reports were filed with the (State Survey Agency) SSA on 11/19/14 by the Administrator. 3. The Interdisciplinary Team (IDT) reassessed Resident #4 for the self-releasing seat belt and this was deemed to have been a restraint for this resident, due to the resident not being able to release the restraint on command. The family and physician were notified on 11/19/14, a consent form and a physician's orders [REDACTED]. 4. On 11/26/14, the IDT met and discussed Resident #4's actions of un-securing the alarming seatbelt and attempts to self transfer. The care plan was reviewed and updated to include specific interventions for staff to utilize while providing care for the resident. 5. The Social Services Director (SSD) assessed the resident for psychosocial harm and none was identified on 11/20/14-11/25/14. 6. Walking rounds were made twice each eight (8) hour shift to visually assess each resident for any restraint or potential restraint not previously assessed, or ordered by the physician and no concerns were identified. 7. All department heads (Administrator, DON, ADON, Unit Manager, Staff Development Coordinator {SDC}, SSD, Chaplain, Business Office Manager {BOM}, Dietary Manager, Rehabilitation Manager, MDS Coordinator, Quality of Life Director, and Human Resource Director {HRD}were educated by the Regional Nurse Consultant on 11/19/14 regarding abuse, neglect, restraints, the cell phone policy and resident rights. A post-test was administered, with a required 100 percent (%) pass rate. 8. The HR Director was re-educated by the Chief Nurse Executive regarding back-ground checks and following the facility policy on 11/19/14. 9. On 11/19/14, the Regional HR Services performed 100% audit of criminal background results of all active employees from 04/2013 to present with no concerns noted. 10. All residents with any devices that could be categorized as a restraint were assessed by administrative nursing (DON, ADON, UM, MDS Coordinator, and SDC) to determine appropriateness, based on medical symptoms and correct applications and none were identified. Care plans were reviewed to reflect current status. Orders and consents were reviewed or obtained based upon the reassessment. No other devices were assessed as restraints. 11. During walking rounds and audits it was discovered on 11/25/14 that two (2) residents with electric wheelchairs with seatbelts had not been assessed. The residents were assessed by the IDT team on 11/25/14 and care plans, orders and consents have been reviewed or obtained. 12. On 11/26/14, education was provided to the Department Head Team by the Chief Nurse Executive regarding care plans, revision of the care plan and the role each nurse has in regard to updating and implementing appropriate interventions and a post test requiring 100% pass rate was required. 13. On 11/26/14, the IDT team made walking rounds on all residents and met to discuss interventions as it related to residents who required alarms, due to history of behaviors of self transfer attempts and seatbelts. Care plans were reviewed and/or updated on 11/26/14 to include the new interventions if applicable. 14. Residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater were interviewed on 11/19/14, by the Administrator, DON, ADON, Chaplain and SSD regarding concerns with care or possible restraint activity and all concerns, most of which were concerning missing items, were reported to the SA. 15. A Resident Council Meeting was held on 11/19/14, to discuss abuse, neglect and resident rights. This meeting was reviewed by the Administrator for any concerns. 16. Head-to-toe skin assessments were conducted 11/19-20/14 by the ADON and UM for residents with a BIMS' score less than eight (8) with no concerns identified. 17. Interviews were conducted with family members of residents with a BIMS' score of less than eight (8) on 11/20/14 by the BOM, with no concerns identified. 18. Incident/Accident Reports for 08/01/14 through 11/20/14 were reviewed by the Nurse Consultant related to abuse, neglect, inappropriate restraints or violation of resident rights and no concerns were identified. 19. The Staff Development Coordinator provided education on abuse and neglect, restraints, cell phones, and resident rights to all staff working 11/19/14 and a post test, with a required 100 percent (%) pass rate was administered. Education on restraints was provided again on 11/25/14 to the DON, ADON, UM, MDS Coordinator, SDC, and Rehabilitation Manager by the Regional Program Manager. Staff not working on 11/19/14 will receive education and testing prior to working. Signs were posted at the time clock. 20. All staff working 11/19/14 were interviewed by the Administrator, DON, HR Coordinator and SDC in regards to any resident having been restrained and the findings were negative. 21. A new policy for review of potential employees was put into place on 11/19/14, utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications would be reviewed by the HR Director for eligibility. The Administrator would complete the final review, before a potential employee would be allowed to work. 22. The HR Director received disciplinary action from the Administrator and the HR Regional Services on 11/22/14. 23. Orientation for all new staff will include education on abuse, resident rights, cell phone policy, restraints, care plan and revision of the care plan. A post test would be administered with a passing score of 100%. 24. Education was provided by the facility department heads to the nursing staff on 11/26/14, upon notification of the care plan deficiency. A post test was provided regarding care plans and revisions and interim care plans, interventions that should have been added that are specific to the resident's care and care plan policies prior to reporting to their assignments. A post test with a required passing grade of 100% was required. If 100% accuracy was not obtained, staff members were to be re-educated and re-tested until 100% was obtained. Staff not on duty 11/26/14 were to receive education, prior to working their next shift. Licensed staff was to update care plans during their shift for any resident changes, concerns with behaviors, removing their assistive devices, new orders, or any concerns with the resident's care, and to incorporate goals and objectives that would lead to the resident's highest obtainable level of independence. The Administrator would be responsible for checking all audits for any concerns. If concerns were identified, the Administrator was to act immediately. The Administrator or Department Heads or the RN Week-end Supervisor will be on site daily to review all audits and tests to identify any concerns to ensure all abuse, neglect, misappropriation, violation of resident rights, cell phone and restraint policies are being followed. A member of the regional staff or home office staff, Regional Nurse Special Projects, or Vice President of Operations were to have been on site daily until the immediacy was lifted and to ensure all audits and questionnaires were followed. If concerns were identified, the Administrator was to act immediately. 25. Walking rounds will be conducted two (2) times each eight (8) hour shift, for all residents, by the Department Managers to observe for abuse, neglect, misappropriation, violation of resident rights, cell phone and restraints, until the immediacy was lifted. During these rounds, two (2) staff members were to be tested regarding these issues and 100% accuracy was required or re-education was to have been administered. Also during the rounds, two (2) residents were to have been interviewed regarding any issues or concerns. Any violations of these policies was to have been addressed by ensuring the resident was safe, and reporting to the Charge Nurse, as well as the Administrator, per policy. Findings of all rounds and audits are to be reported to the DON and Administrator daily, who in turn are to report any concerns to the State Agencies and follow the abuse procedures and policies for reporting, protecting, etc. QA will review the results of all tests, interviews, and rounding observations to analyze results and determine if the frequency could have been reduced as well as any need for re-education. 26. The DON, ADON, or Staff Development Coordinator (SDC) will review the daily physician's orders [REDACTED]. 27. The IDT will hold daily meetings, beginning 11/26/14, in which a review of the twenty-four (24) hour nursing report for any changes of condition, any new admission, re-admission or concerns with the removal of assistive devices, as well as Physician Orders, for any changes or documentation requiring an interim care plan, a new care plan or a revision of the care plan. Care plans will be reviewed to ensure compliance, until the immediacy is lifted. Once the immediacy has been lifted, the IDT will continue to meet daily and ongoing for review of the care plans. 28. A QA meeting was conducted on 11/20/14, to discuss incidents as well as all education provided, assessments provided, assessments of all residents with devices, processes for restraints, employee files regarding any staff having been convicted of a felony and all reviewed with the Medical Director. 29. Weekly Quality Performance Improvement meetings with the Medical Director to be on-going. The meetings are to review the findings of on-going audits, tests, questions, education, new employee files and back ground checks and/or any new concerns identified. Findings were to reviewed, trended and the committee would determine the course of action. **The State Survey Agency validated the corrective action taken by the facility on 12/04/14 as follows: 1. On 12/02/14, five (5) staff members' personnel files were reviewed: CNA #1, CNA #2, CNA #3, LPN #2 and LPN #4, regarding their written disciplinary actions, the restraint of Resident #4 and the failure to report abuse. The review also revealed on 11/23/14, CNA #1, CNA #3 and LPN #4 were terminated. 2. Review of the Resident #4's skin assessments, family and physician notification, care plan revision, ITP reviews of the seat-belt alarm restraint assessment, documentation and the physician order [REDACTED]. 3. Review of the Resident #4's care plan revisions, to include the use of the seat-belt, as a restraint device and alternate coping strategies when the resident became agitated, dated 11/19-26/14; consent for the use of restraints, dated 11/19/14; physician's orders [REDACTED]. 4. Review of the IDT Notes and Comprehensive Care Plan for At Risk for Harm/Injury, related to the seat belt, dated 11/19/14 and the Resident At Risk for and/or Expressing Anxiety Care Plan, dated 11/19/14 and interventions, dated 11/26/14, revealed the IDT met and discussed Resident #4's actions of un-securing the alarming seatbelt and attempts to self transfer. The care plan was reviewed and updated to include specific interventions for staff to utilize while providing care for the resident. 5. Review of the Social Services Progress Notes, dated 11/20/14-11/25/14, revealed the Social Service Director (SSD) assessed the resident daily for psychosocial harm and no concerns were identified. 6. Review of the Instructions for Walking Rounds and Audit Sheets, dated 11/19/14 through 12/01/14 revealed walking rounds were completed twice each eight (8) hour shift to identify if there were any restraints or potential restraints. No concerns were identified. 7. Review of the POS [REDACTED]. Interviews conducted on 12/02/14 with the Administrator and Director of Nursing (DON) at 12:45 PM, the HR Director at 3:35 PM and LPN #6 at 3:50 PM revealed they had been inserviced and were educated by the Regional Nurse Consultant on 11/19/14 regarding abuse, neglect, restraints, the cell phone policy and resident rights, a post-test was administered, with a required 100 percent (%) pass rate and all stated they had been inserviced and passed the test, with a 100 % pass rate. 8. Interview with the HR Director, on 12/02/14 at 3:35 PM, revealed she had been educated on the new policy for review of potential employees, put into place on 11/19/14 and utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications that would be reviewed by the HR Director for eligibility. Further interview revealed the Administrator would complete the final review, before a potential employee would be allowed to work. 9. Review of the Audit Records, dated 11/19/14, revealed no concerns. Review of Personnel records revealed LPN #1 was terminated on 11/19/14, for falsification of the application for employment, regarding not having any felony on her records and review of the result of the audit for personnel records, back to 2003 and a review of the Policy for Criminal Background Checks, dated 11/19/14, revealed no other concerns were identified. 10. Review of the Instructions for Walking Rounds and the 100% Visual Audit Tool, dated 11/19-24/14, revealed all residents with any devices that could be categorized as a restraint, were assessed by administrative nursing (DON, ADON, UM, MDS Coordinator, and SDC) to determine appropriateness, based on medical symptoms and correct applications. No concerns were identified. 100% audits of all resident's care plans were reviewed to reflect current status. Orders and consents were reviewed or obtained based upon the reassessment. No other devices were assessed as restraints. 11. A review of the 100% audits, dated 11/19-24/14, completed during walking rounds, revealed on 11/25/14 that two (2) residents with electric wheelchairs with seatbelts, which were made and installed by the manufacturer of the electric wheel chair, had not been assessed. The residents were assessed by the IDT team on 11/25/14 and care plans, orders and consents were reviewed or obtained, as evidenced by review of Resident #1's and Resident B's records. It was determined, per the Pre-Restraining Evaluation, dated 11/25/14, these were not restraints for these residents. 12. Review of Post Testing, dated 11/20-25/14, The Healthcare-In-Service Sign-In Sheets for Department Heads, dated 11/19/14, and interviews on 12/02/14 with the HRD at 3:35 PM, the ADON at 3:50 PM, and the Administrator and DON at 12:45 PM, revealed the Department Heads were educated on care plans, revision of the care plan and each nurse's role in regard to updating and implementing appropriate interventions. A post test requiring 100% pass rate was required. 13. Review of the 11/25-26/14 Census Board Audit Sheets revealed the IDT team made walking rounds, and completed them on all residents. Review of the IDT meeting notes, dated 11/25-26/14 revealed they met to discuss interventions related to residents who required alarms, due to history of behaviors of self transfer attempts and seatbelts. Review of Care plans for Unsampled Residents B, C, D, E, and F, who required alarms, revealed they were reviewed and/or updated on 11/26/14 to include the new interventions. 14. Verified with the SSA Complaints Coordinator any concerns identified during the facility's resident interviews, were received on 12/01/14 and she was waiting on the final reports. Interviews conducted on 12/03/14 with Unsampled Resident B, at 9:25 AM; Resident C at 1:35 PM; Resident D, at 11:00 AM; Resident E, at 2:50 PM; and, Resident F, at 12:00 PM, revealed no concerns with resident care, abuse, neglect or any restraint activity. 15. Review of the Resident Council Minutes, dated 11/19/14, revealed the residents were educated on abuse, neglect, restraints and reporting these concern to staff and the DON and Administrator. 16. Review of five (5) residents with head-to-toe skin assessments, who were assessed to have a BIMS' score less than eight (8), revealed the assessments were completed by the ADON and UM, on 11/19/14. No concerns were identified. 17. Review of the family contacts for five (5) family members of residents, with a BIMS' score of less than eight (8) revealed they were completed on 11/20/14 by the BOM. No concerns were identified. Interview with a family member for Resident #4, on 11/21/14 at 2:30 PM, revealed no concerns. 18. Incident/Accident Reports dated 08/01/14 through 11/20/14 were reviewed related to abuse, neglect, inappropriate restraints or violation of resident rights. No concerns were identified. 19. Review of the POS [REDACTED]. Interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, and CNA #14 at 5:00 PM; and, on 12/04/14 with LPN #7 at 8:02 AM; CNA #15 at 7:45 AM and CNA #16, at 8:00 AM, revealed they were educated and tested on abuse and neglect, restraints, cell phones, and resident rights. 20. Review of the staff's written statements, dated 11/19/14 and interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, CNA #14 at 5:00 PM, the HRD at 3:35 PM, the ADON at 3:50 PM and the Administrator and DON at 12:45 PM; and, on 12/04/14 with LPN #7 at 8:02 AM, CNA #15 at 7:45 AM, and CNA #16, at 8:00 AM, revealed all were aware of the definition of restraints and abuse. 21. Review of the facility's general orientation policy utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications would be reviewed by the HR Director for eligibility. The Administrator would complete the final review, before a potential employee would be allowed to work, was reviewed with no concerns. Review of the facility's policy for "Pre-Hire Check List," dated 11/19/14, revealed it included a clause regarding the Administrator's final review before the potential employee is allowed to work. 22 Review of the written reprimand for the HRD on 11/22/14 and interview with the HRD, on 12/02/14 at 3:35 PM revealed she had training on the new policy and check list and the Administrator had to "sign-off" on this, prior to anyone being hired. Interview with the Administrator, on 12/02/14 at 8:35 AM revealed they had a double check system now and there should be no other problems with screening of employees, prior to hiring. 23. A review of the Orientation Packet on 12/03/14, with policies to include: "Abuse Prevention Policy and Procedure," dated April 2013; Health Insurance Portability and Accountability Act (HIPAA) Policy," undated; "Resident Rights," undated; "Restraint Reduction," dated 12/20/10; "Social Media," dated 03/01/13; "Care Planning," dated October 2013; "Change in a Resident's Condition," dated October 2013; "Goals and Objectives of the Care Plans," dated April 2011; "Resident/ Family Participation in the Care Plan," dated December 2006; and "Usage of the Care Plan," dated August 2006, revealed no concerns. 24. Review of auditing and testing records, dated 11/19/14 through 12/02/14, used to ensure all abuse, neglect, misappropriation, violation of resident rights, cell phone use and restraint policies were being followed, revealed no concerns. Care plan education and testing was provided to staff on 11/26/14 and interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, CNA #14 at 5:00 PM, the HRD at 3:35 PM, the ADON at 3:50 PM and the Administrator and the DON on at 12:45 PM; and, on 12/04/14 with LPN #7 at 8:02 AM, CNA #15 at 7:45 AM, and CNA #16 at 8:00 AM, revealed all were aware of the definition of restraints and abuse, when and to whom they were to report these things and all had education on the care plans. A review of pre-testing and post-tests administered 11/20-26/14, revealed no concerns. 25. Interview with the Administrator and DON on 12/04/14 at 10:35 AM, revealed all concerns were documented and the facility had three (3) QA Meetings with the Medical Director (11/19/14, 11/25/14 and 12/02/14) regarding the results of the testing, training, interviews, rounding and audits to analyze the results and determine any further training needs or further evaluation. 26. Review of the audit sheets for Residents With Assistive Devices, Daily Clinical Meetings; Walking Rounds and Testing of Staff, dated 11/19/14 through 12/01/14, revealed no concerns. 27. Review of the daily IDT records for 11/26/14-12/01/14, audits for residents with any assistive devices, 24 Hour Reports Reviews, physician's orders [REDACTED]. 28. Interview with the Administrator and DON on 12/04/14 at 10:35 AM, revealed all concerns were documented and the facility had three QA Meetings with the Medical Director (11/19/14, 11/25/14 and 12/02/14) regarding the results of the testing, training, interviews, rounding and audits to analyze the results and determine any further training needs or further evaluation. 29. Interviews with the Administrator on 12/02/14 at 8:35 AM and the DON on 12/04/14 at 10:35 AM, revealed the weekly Quality Performance Improvement meetings with the Medical Director would be on-going and the meetings were to review the findings of on-going audits, tests, questions, education, new employee files and back ground checks and/or any new concerns identified. Findings would be reviewed, trended and the committee would determine the course of action. Interviews with the DON on 12/02/14 at 8:35 AM; and, on 12/04/14 at 10:35 AM, revealed the IDT will continue an on-going weekly assessment to review all devices and restraints for the continued need, reduction attempt or elimination.

Based on interview, review of witness statements, personnel records, a Backgound Summary Report and the facility's policy and procedure, it was determined the facility failed to have an effective system to ensure staff reported observed incidents of abuse and/or mistreatment to the facility's Administrator for one (1) of fifteen (15) sampled residents (Resident #4). In addition, the facility failed to make reasonable efforts to uncover information about any past criminal prosecutions for one (1) staff member, LPN #1, related to felony charges. On 11/19/14, Certified Nurse Aide (CNA) #1 and CNA #3 observed Resident #4 in his/her wheelchair with a blanket or sheet, tied around the resident's waist and secured to the back of his/her wheel chair. CNA #1 reported what she had observed to Licensed Practical Nurse (LPN) #2 and LPN #4; however, no action was taken. The Administrator was not made aware of the situation until CNA #1 reported it to the Administrator at the end of her shift, approximately four (4) hours later. (Refer to F221) The facility's failure to ensure staff reported observed incidents of abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/21/14 and determined to exist on 11/19/14. The facility was notified of the Immediate Jeopardy on 11/21/14. An acceptable Allegation of Compliance (AoC) was received on 12/01/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 11/27/14, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: 1. Review of the facility's Policy and Procedure titled, "Abuse, Neglect and Misappropriation," dated April 2013, revealed "... all allegations of abuse are to be reported immediately to the Charge Nurse. If the person reporting the abuse believes there is a lack of response from the Charge Nurse, the person will then notify the Director of Nursing (DON) and/or Administrator. If the DON and/or Administrator are not in the facility, staff will notify them by phone. The Charge Nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee, pending the outcome of the investigation." Interviews on 11/20/14 at 12:45 PM with CNA #1, on 11/19/14 at 9:27 AM with CNA #3, on 11/19/14 at 3:31 with LPN #2 and on 11/21/14 at 11:10 with LPN #4 and review of their witness statements revealed on 11/19/14 CNA #1 and CNA #4 observed Resident #4 on the hall in his/her wheelchair with a self-releasing seat belt and clip alarm on his/her person. There was a blanket/sheet wrapped around the resident's waist and secured to the back of the resident's wheelchair. CNA #1 reported what she had witnessed to LPN #2 and LPN #4; however, the abuse was not reported to the Administrator and/or DON until CNA #1 reported it to the Administrator at the end of her shift, approximately four (4) hours after the resident was observed secured to his/her wheelchair. Interview with CNA #1, on 11/20/14 at 12:45 PM, revealed she told LPN #2, what she had observed and the LPN stated, "It was against the law. But what are we supposed to do". CNA #1 stated she also told LPN #4, the Charge Nurse about what she had observed and LPN #4 told her he knew she had taken a picture with her cell phone of Resident #4 being tied to the wheelchair. The CNA stated the Charge Nurse then told her not to go back over on Wing 2 and "... not get in the middle of the mess". CNA #1 stated the DON and the Administrator were not available during the night, so she went immediately to the Administrator before she left work that morning. Interview with CNA #3, on 11/19/14 at 9:27 AM, revealed she had been trained on abuse/neglect but she did not report this to her Charge Nurse immediately because she did not think this was abuse. Interview with LPN #2, on 11/19/14 at 3:31 PM, revealed she was aware the blanket was tucked under the resident's seat belt. LPN #2 stated she did not report it because she did not consider it abuse. LPN #2 revealed she had received training on the facility's policy on abuse/neglect. Review of LPN #4's witness statement, dated 11/19/14, revealed at approximately 4:35 AM on 11/19/14, CNA #1 stated she had a picture of a "resident tied up". The CNA left and came back and asked LPN #4 to look at the picture. Further review revealed LPN #4 documented that she told CNA #1 to "Come on and let us just get busy, we are way behind". There was no documented evidence LPN #4 reported the abuse to the Administrator or DON or took any actions to intervene. Attempts to interview LPN #4 on 11/20/14 at 9:50 AM and 11:00 AM; and, on 11/21/14 at 9:58 AM were unsuccessful. Interview with the DON, on 11/21/14 at 11:10 AM, revealed she became aware of the allegation on 11/19/14, when speaking with the Administrator and the Corporate Nurse and she immediately began her investigation regarding the allegation of abuse towards Resident #4. The DON stated she would have expected any staff that had observed a resident with a sheet or blanket tied to a wheelchair, would have reported this immediately, as this would be considered abuse. Interview with the Administrator, on 11/21/14 at 11:30 AM, revealed he became aware of the allegation on 11/19/14, when CNA #1 came into his office and showed him three (3) photographs of Resident #4. The pictures revealed Resident #4 had a blanket draped over his/her lap to the sides of the wheelchair. The Administrator stated he was not sure if the blanket was tied to the axle or not, but it was bunched up at the end of the blanket and he could not see the resident's safety belt. Further interview with the Administrator revealed he would expect that if anyone had seen this type of abuse it should have been reported immediately. 2. Review of the facility's policy for "Criminal Background Checks," dated 10/01/09, revealed, "A criminal background check will be completed for each state and or county of residence during the past seven (7) years. The check must be done post offer and cleared prior to the stakeholder (staff member) beginning work, no exceptions. HR (Human Resources) will access and review the findings of the Criminal Background Checks and stakeholders who have been convicted of, or entered a plea of no contest, or guilty to, any of the following crimes will not be eligible for initial or continued employment with the company." The crimes included "theft, robbery and related crimes, if the offense was a felony; sale, manufacture, delivery or possession with an intent to sell, manufacture, deliver or use of controlled substances or counterfeit controlled substances, if the offense was a felony; forgery or uttering forged instruments; and fraud in obtaining medicinal drugs." Review of LPN #1's Personnel Record revealed she was hired, by the facility, on 11/03/14. Review of the Statewide Criminal Background Report Summary, dated 10/21/14, revealed the staff member's results were ''decisional," and required "further review to determine the staff member's eligibility for hire, based on background check results." The facility was to have "reviewed the corresponding detailed component report section for additional information." Review of the Background Summary Report, dated 10/21/14, revealed the LPN was found guilty of a felony, on 05/08/09 and the charge was obtaining a controlled substance by fraud, making a false statement and a forgery attempt. The LPN was credited for two (2) days time served; a two year prison sentence was suspended; and, the LPN was on probation for two years. Review of the staff member's employment application, dated 09/03/14, revealed the question "have you ever been convicted of, pled guilty or nolo contendere or had adjudication withheld by the court, judge or jury for a crime that is a felony or a first degree misdemeanor?" to which the LPN's written response was "no." Interview with the Human Resources (HR) Director, on 11/20/14 at 12:50 PM, who stated she "was the only one responsible" to review the application and the background checks, prior to hiring any staff member, revealed she failed to fully review the Criminal Background Report Summary, prior to hiring LPN #1. She stated she was not aware LPN #1 had a prior felony charge. Interview with the Administrator, on 11/20/14 at 2:10 PM, revealed he was also unaware of the charges, as this part of the application process was left up to the HR Director. After review of the background checks and the application process, the Administrator terminated LPN #1 on 11/19/14, for making a false statement on her application for employment. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 11/19/14, the facility suspended five (5) staff members: CNA #1, CNA #2, CNA #3, LPN #2 and LPN #4; and, on 11/23/14, CNA #1, CNA #3 and LPN #4 were terminated. 2. On 11/19/14, the Unit Manager (UM) assessed Resident #4 for any signs of injury and none were observed. The family and the physician were notified of the allegation on 11/19/14 by the ADON and initial reports were filed with the (State Survey Agency) SSA on 11/19/14 by the Administrator. 3. The Interdisciplinary Team (IDT) reassessed Resident #4 for the self-releasing seat belt and this was deemed to have been a restraint for this resident, due to the resident not being able to release the restraint on command. The family and physician were notified on 11/19/14, a consent form and a physician's orders [REDACTED]. 4. On 11/26/14, the IDT met and discussed Resident #4's actions of un-securing the alarming seatbelt and attempts to self transfer. The care plan was reviewed and updated to include specific interventions for staff to utilize while providing care for the resident. 5. The Social Services Director (SSD) assessed the resident for psychosocial harm and none was identified on 11/20/14-11/25/14. 6. Walking rounds were made twice each eight (8) hour shift to visually assess each resident for any restraint or potential restraint not previously assessed, or ordered by the physician and no concerns were identified. 7. All department heads (Administrator, DON, ADON, Unit Manager, Staff Development Coordinator {SDC}, SSD, Chaplain, Business Office Manager {BOM}, Dietary Manager, Rehabilitation Manager, MDS Coordinator, Quality of Life Director, and Human Resource Director {HRD}were educated by the Regional Nurse Consultant on 11/19/14 regarding abuse, neglect, restraints, the cell phone policy and resident rights. A post-test was administered, with a required 100 percent (%) pass rate. 8. The HR Director was re-educated by the Chief Nurse Executive regarding back-ground checks and following the facility policy on 11/19/14. 9. On 11/19/14, the Regional HR Services performed 100% audit of criminal background results of all active employees from 04/2013 to present with no concerns noted. 10. All residents with any devices that could be categorized as a restraint were assessed by administrative nursing (DON, ADON, UM, MDS Coordinator, and SDC) to determine appropriateness, based on medical symptoms and correct applications and none were identified. Care plans were reviewed to reflect current status. Orders and consents were reviewed or obtained based upon the reassessment. No other devices were assessed as restraints. 11. During walking rounds and audits it was discovered on 11/25/14 that two (2) residents with electric wheelchairs with seatbelts had not been assessed. The residents were assessed by the IDT team on 11/25/14 and care plans, orders and consents have been reviewed or obtained. 12. On 11/26/14, education was provided to the Department Head Team by the Chief Nurse Executive regarding care plans, revision of the care plan and the role each nurse has in regard to updating and implementing appropriate interventions and a post test requiring 100% pass rate was required. 13. On 11/26/14, the IDT team made walking rounds on all residents and met to discuss interventions as it related to residents who required alarms, due to history of behaviors of self transfer attempts and seatbelts. Care plans were reviewed and/or updated on 11/26/14 to include the new interventions if applicable. 14. Residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater were interviewed on 11/19/14, by the Administrator, DON, ADON, Chaplain and SSD regarding concerns with care or possible restraint activity and all concerns, most of which were concerning missing items, were reported to the SA. 15. A Resident Council Meeting was held on 11/19/14, to discuss abuse, neglect and resident rights. This meeting was reviewed by the Administrator for any concerns. 16. Head-to-toe skin assessments were conducted 11/19-20/14 by the ADON and UM for residents with a BIMS' score less than eight (8) with no concerns identified. 17. Interviews were conducted with family members of residents with a BIMS' score of less than eight (8) on 11/20/14 by the BOM, with no concerns identified. 18. Incident/Accident Reports for 08/01/14 through 11/20/14 were reviewed by the Nurse Consultant related to abuse, neglect, inappropriate restraints or violation of resident rights and no concerns were identified. 19. The Staff Development Coordinator provided education on abuse and neglect, restraints, cell phones, and resident rights to all staff working 11/19/14 and a post test, with a required 100 percent (%) pass rate was administered. Education on restraints was provided again on 11/25/14 to the DON, ADON, UM, MDS Coordinator, SDC, and Rehabilitation Manager by the Regional Program Manager. Staff not working on 11/19/14 will receive education and testing prior to working. Signs were posted at the time clock. 20. All staff working 11/19/14 were interviewed by the Administrator, DON, HR Coordinator and SDC in regards to any resident having been restrained and the findings were negative. 21. A new policy for review of potential employees was put into place on 11/19/14, utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications would be reviewed by the HR Director for eligibility. The Administrator would complete the final review, before a potential employee would be allowed to work. 22. The HR Director received disciplinary action from the Administrator and the HR Regional Services on 11/22/14. 23. Orientation for all new staff will include education on abuse, resident rights, cell phone policy, restraints, care plan and revision of the care plan. A post test would be administered with a passing score of 100%. 24. Education was provided by the facility department heads to the nursing staff on 11/26/14, upon notification of the care plan deficiency. A post test was provided regarding care plans and revisions and interim care plans, interventions that should have been added that are specific to the resident's care and care plan policies prior to reporting to their assignments. A post test with a required passing grade of 100% was required. If 100% accuracy was not obtained, staff members were to be re-educated and re-tested until 100% was obtained. Staff not on duty 11/26/14 were to receive education, prior to working their next shift. Licensed staff was to update care plans during their shift for any resident changes, concerns with behaviors, removing their assistive devices, new orders, or any concerns with the resident's care, and to incorporate goals and objectives that would lead to the resident's highest obtainable level of independence. The Administrator would be responsible for checking all audits for any concerns. If concerns were identified, the Administrator was to act immediately. The Administrator or Department Heads or the RN Week-end Supervisor will be on site daily to review all audits and tests to identify any concerns to ensure all abuse, neglect, misappropriation, violation of resident rights, cell phone and restraint policies are being followed. A member of the regional staff or home office staff, Regional Nurse Special Projects, or Vice President of Operations were to have been on site daily until the immediacy was lifted and to ensure all audits and questionnaires were followed. If concerns were identified, the Administrator was to act immediately. 25. Walking rounds will be conducted two (2) times each eight (8) hour shift, for all residents, by the Department Managers to observe for abuse, neglect, misappropriation, violation of resident rights, cell phone and restraints, until the immediacy was lifted. During these rounds, two (2) staff members were to be tested regarding these issues and 100% accuracy was required or re-education was to have been administered. Also during the rounds, two (2) residents were to have been interviewed regarding any issues or concerns. Any violations of these policies was to have been addressed by ensuring the resident was safe, and reporting to the Charge Nurse, as well as the Administrator, per policy. Findings of all rounds and audits are to be reported to the DON and Administrator daily, who in turn are to report any concerns to the State Agencies and follow the abuse procedures and policies for reporting, protecting, etc. QA will review the results of all tests, interviews, and rounding observations to analyze results and determine if the frequency could have been reduced as well as any need for re-education. 26. The DON, ADON, or Staff Development Coordinator (SDC) will review the daily physician's orders [REDACTED]. 27. The IDT will hold daily meetings, beginning 11/26/14, in which a review of the twenty-four (24) hour nursing report for any changes of condition, any new admission, re-admission or concerns with the removal of assistive devices, as well as Physician Orders, for any changes or documentation requiring an interim care plan, a new care plan or a revision of the care plan. Care plans will be reviewed to ensure compliance, until the immediacy is lifted. Once the immediacy has been lifted, the IDT will continue to meet daily and ongoing for review of the care plans. 28. A QA meeting was conducted on 11/20/14, to discuss incidents as well as all education provided, assessments provided, assessments of all residents with devices, processes for restraints, employee files regarding any staff having been convicted of a felony and all reviewed with the Medical Director. 29. Weekly Quality Performance Improvement meetings with the Medical Director to be on-going. The meetings are to review the findings of on-going audits, tests, questions, education, new employee files and back ground checks and/or any new concerns identified. Findings were to reviewed, trended and the committee would determine the course of action. **The State Survey Agency validated the corrective action taken by the facility on 12/04/14 as follows: 1. On 12/02/14, five (5) staff members' personnel files were reviewed: CNA #1, CNA #2, CNA #3, LPN #2 and LPN #4, regarding their written disciplinary actions, the restraint of Resident #4 and the failure to report abuse. The review also revealed on 11/23/14, CNA #1, CNA #3 and LPN #4 were terminated. 2. Review of the Resident #4's skin assessments, family and physician notification, care plan revision, ITP reviews of the seat-belt alarm restraint assessment, documentation and the physician order [REDACTED]. 3. Review of the Resident #4's care plan revisions, to include the use of the seat-belt, as a restraint device and alternate coping strategies when the resident became agitated, dated 11/19-26/14; consent for the use of restraints, dated 11/19/14; physician's orders [REDACTED]. 4. Review of the IDT Notes and Comprehensive Care Plan for At Risk for Harm/Injury, related to the seat belt, dated 11/19/14 and the Resident At Risk for and/or Expressing Anxiety Care Plan, dated 11/19/14 and interventions, dated 11/26/14, revealed the IDT met and discussed Resident #4's actions of un-securing the alarming seatbelt and attempts to self transfer. The care plan was reviewed and updated to include specific interventions for staff to utilize while providing care for the resident. 5. Review of the Social Services Progress Notes, dated 11/20/14-11/25/14, revealed the Social Service Director (SSD) assessed the resident daily for psychosocial harm and no concerns were identified. 6. Review of the Instructions for Walking Rounds and Audit Sheets, dated 11/19/14 through 12/01/14 revealed walking rounds were completed twice each eight (8) hour shift to identify if there were any restraints or potential restraints. No concerns were identified. 7. Review of the POS [REDACTED]. Interviews conducted on 12/02/14 with the Administrator and Director of Nursing (DON) at 12:45 PM, the HR Director at 3:35 PM and LPN #6 at 3:50 PM revealed they had been inserviced and were educated by the Regional Nurse Consultant on 11/19/14 regarding abuse, neglect, restraints, the cell phone policy and resident rights, a post-test was administered, with a required 100 percent (%) pass rate and all stated they had been inserviced and passed the test, with a 100 % pass rate. 8. Interview with the HR Director, on 12/02/14 at 3:35 PM, revealed she had been educated on the new policy for review of potential employees, put into place on 11/19/14 and utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications that would be reviewed by the HR Director for eligibility. Further interview revealed the Administrator would complete the final review, before a potential employee would be allowed to work. 9. Review of the Audit Records, dated 11/19/14, revealed no concerns. Review of Personnel records revealed LPN #1 was terminated on 11/19/14, for falsification of the application for employment, regarding not having any felony on her records and review of the result of the audit for personnel records, back to 2003 and a review of the Policy for Criminal Background Checks, dated 11/19/14, revealed no other concerns were identified. 10. Review of the Instructions for Walking Rounds and the 100% Visual Audit Tool, dated 11/19-24/14, revealed all residents with any devices that could be categorized as a restraint, were assessed by administrative nursing (DON, ADON, UM, MDS Coordinator, and SDC) to determine appropriateness, based on medical symptoms and correct applications. No concerns were identified. 100% audits of all resident's care plans were reviewed to reflect current status. Orders and consents were reviewed or obtained based upon the reassessment. No other devices were assessed as restraints. 11. A review of the 100% audits, dated 11/19-24/14, completed during walking rounds, revealed on 11/25/14 that two (2) residents with electric wheelchairs with seatbelts, which were made and installed by the manufacturer of the electric wheel chair, had not been assessed. The residents were assessed by the IDT team on 11/25/14 and care plans, orders and consents were reviewed or obtained, as evidenced by review of Resident #1's and Resident B's records. It was determined, per the Pre-Restraining Evaluation, dated 11/25/14, these were not restraints for these residents. 12. Review of Post Testing, dated 11/20-25/14, The Healthcare-In-Service Sign-In Sheets for Department Heads, dated 11/19/14, and interviews on 12/02/14 with the HRD at 3:35 PM, the ADON at 3:50 PM, and the Administrator and DON at 12:45 PM, revealed the Department Heads were educated on care plans, revision of the care plan and each nurse's role in regard to updating and implementing appropriate interventions. A post test requiring 100% pass rate was required. 13. Review of the 11/25-26/14 Census Board Audit Sheets revealed the IDT team made walking rounds, and completed them on all residents. Review of the IDT meeting notes, dated 11/25-26/14 revealed they met to discuss interventions related to residents who required alarms, due to history of behaviors of self transfer attempts and seatbelts. Review of Care plans for Unsampled Residents B, C, D, E, and F, who required alarms, revealed they were reviewed and/or updated on 11/26/14 to include the new interventions. 14. Verified with the SSA Complaints Coordinator any concerns identified during the facility's resident interviews, were received on 12/01/14 and she was waiting on the final reports. Interviews conducted on 12/03/14 with Unsampled Resident B, at 9:25 AM; Resident C at 1:35 PM; Resident D, at 11:00 AM; Resident E, at 2:50 PM; and, Resident F, at 12:00 PM, revealed no concerns with resident care, abuse, neglect or any restraint activity. 15. Review of the Resident Council Minutes, dated 11/19/14, revealed the residents were educated on abuse, neglect, restraints and reporting these concern to staff and the DON and Administrator. 16. Review of five (5) residents with head-to-toe skin assessments, who were assessed to have a BIMS' score less than eight (8), revealed the assessments were completed by the ADON and UM, on 11/19/14. No concerns were identified. 17. Review of the family contacts for five (5) family members of residents, with a BIMS' score of less than eight (8) revealed they were completed on 11/20/14 by the BOM. No concerns were identified. Interview with a family member for Resident #4, on 11/21/14 at 2:30 PM, revealed no concerns. 18. Incident/Accident Reports dated 08/01/14 through 11/20/14 were reviewed related to abuse, neglect, inappropriate restraints or violation of resident rights. No concerns were identified. 19. Review of the POS [REDACTED]. Interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, and CNA #14 at 5:00 PM; and, on 12/04/14 with LPN #7 at 8:02 AM; CNA #15 at 7:45 AM and CNA #16, at 8:00 AM, revealed they were educated and tested on abuse and neglect, restraints, cell phones, and resident rights. 20. Review of the staff's written statements, dated 11/19/14 and interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, CNA #14 at 5:00 PM, the HRD at 3:35 PM, the ADON at 3:50 PM and the Administrator and DON at 12:45 PM; and, on 12/04/14 with LPN #7 at 8:02 AM, CNA #15 at 7:45 AM, and CNA #16, at 8:00 AM, revealed all were aware of the definition of restraints and abuse. 21. Review of the facility's general orientation policy utilizing a pre-hire check list, in which all employees' criminal background checks, abuse registry checks and license verifications would be reviewed by the HR Director for eligibility. The Administrator would complete the final review, before a potential employee would be allowed to work, was reviewed with no concerns. Review of the facility's policy for "Pre-Hire Check List," dated 11/19/14, revealed it included a clause regarding the Administrator's final review before the potential employee is allowed to work. 22 Review of the written reprimand for the HRD on 11/22/14 and interview with the HRD, on 12/02/14 at 3:35 PM revealed she had training on the new policy and check list and the Administrator had to "sign-off" on this, prior to anyone being hired. Interview with the Administrator, on 12/02/14 at 8:35 AM revealed they had a double check system now and there should be no other problems with screening of employees, prior to hiring. 23. A review of the Orientation Packet on 12/03/14, with policies to include: "Abuse Prevention Policy and Procedure," dated April 2013; Health Insurance Portability and Accountability Act (HIPAA) Policy," undated; "Resident Rights," undated; "Restraint Reduction," dated 12/20/10; "Social Media," dated 03/01/13; "Care Planning," dated October 2013; "Change in a Resident's Condition," dated October 2013; "Goals and Objectives of the Care Plans," dated April 2011; "Resident/ Family Participation in the Care Plan," dated December 2006; and "Usage of the Care Plan," dated August 2006, revealed no concerns. 24. Review of auditing and testing records, dated 11/19/14 through 12/02/14, used to ensure all abuse, neglect, misappropriation, violation of resident rights, cell phone use and restraint policies were being followed, revealed no concerns. Care plan education and testing was provided to staff on 11/26/14 and interviews conducted on 12/02/14 with RN #1 at 3:18 PM, RN #2 at 4:30 PM, LPN #6 at 3:50 PM, CNA #13 at 3:25 PM, CNA #14 at 5:00 PM, the HRD at 3:35 PM, the ADON at 3:50 PM and the Administrator and the DON on at 12:45 PM; and, on 12/04/14 with LPN #7 at 8:02 AM, CNA #15 at 7:45 AM, and CNA #16 at 8:00 AM, revealed all were aware of the definition of restraints and abuse, when and to whom they were to report these things and all had education on the care plans. A review of pre-testing and post-tests administered 11/20-26/14, revealed no concerns. 25. Interview with the Administrator and DON on 12/04/14 at 10:35 AM, revealed all concerns were documented and the facility had three (3) QA Meetings with the Medical Director (11/19/14, 11/25/14 and 12/02/14) regarding the results of the testing, training, interviews, rounding and audits to analyze the results and determine any further training needs or further evaluation. 26. Review of the audit sheets for Residents With Assistive Devices, Daily Clinical Meetings; Walking Rounds and Testing of Staff, dated 11/19/14 through 12/01/14, revealed no concerns. 27. Review of the daily IDT records for 11/26/14-12/01/14, audits for residents with any assistive devices, 24 Hour Reports Reviews, physician's orders [REDACTED]. 28. Interview with the Administrator and DON on 12/04/14 at 10:35 AM, revealed all concerns were documented and the facility had three QA Meetings with the Medical Director (11/19/14, 11/25/14 and 12/02/14) regarding the results of the testing, training, interviews, rounding and audits to analyze the results and determine any further training needs or further evaluation. 29. Interviews with the Administrator on 12/02/14 at 8:35 AM and the DON on 12/04/14 at 10:35 AM, revealed the weekly Quality Performance Improvement meetings with the Medical Director would be on-going and the meetings were to review the findings of on-going audits, tests, questions, education, new employee files and back ground checks and/or any new concerns identified. Findings would be reviewed, trended and the committee would determine the course of action. Interviews with the DON on 12/02/14 at 8:35 AM; and, on 12/04/14 at 10:35 AM, revealed the IDT will continue an on-going weekly assessment to review all devices and restraints for the continued need, reduction attempt or elimination.