Every finding on record at Orchard View Rehabilitation & Skilled Nursing CTR

Based on observations and staff interview, the facility failed to ensure perishable waste was disposed properly and free from a leak to prevent infestation or spread of infection for one of two garbage dumpsters. This failure had the potential to affect all 154 facility residents.Findings include:During an observation on 03/06/2026 at 8:04 AM and 03/07/2026 at 10:43 AM of the garbage disposal revealed a leak of brown liquid substance draining from an exposed hole on the side of the compact garbage dumpster. Continued tour of the garbage revealed blue gloves, plastic drink can, cardboard, plastic container tops, plastic bags, and cigarette butts around the dumpster grounds. During a walk-through observation and interview on 03/07/2026 at 12:55 PM with Maintenance Tech JJ and Director of Nursing (DON) revealed the garbage should be cleaned on a daily basis and it was deep cleaned once a month. During an interview on 03/08/2026 at 9:45 AM with the Maintenance Director confirmed the dumpster grounds should be cleaned out daily and checked by the end of the day to ensure the grounds were clean.

Based on observations, staff interviews, and review of the facility's policy titled, Food Service Policy and Procedure, the facility failed to ensure opened food items in the dry storage were properly stored, food items were properly labeled, dated, and discarded by expiration date, and failed to remove food items containing a gray thick fuzzy substance in the refrigerators for four of six kitchens (Main Kitchen, Rehabilitation Kitchen, Meadows Terrace Kitchen, and Garden View Kitchen). The facility also failed to ensure the filters were free from thick gray fuzzy substance for two of two ice machines in the Main Kitchen. Also, the facility failed to ensure staff members' personal belongings were not stored in the residents' dry storage, refrigerators and freezers for four of six kitchens (Rehabilitation Kitchen, Meadows Terrace Kitchen, Grove Terrace Kitchen, and Garden View Kitchen). Further, the facility failed to ensure the Dietary Manager (DM) and dietary aides were wearing proper hair and beard covering. The deficient practices had the potential to affect all 150 facility residents who were all receiving an oral diet.Findings include:Review of the facility's policy titled Food Service Policy and Procedure dated 2025 revealed in the section Personal Hygiene documented a hair and facial hair restraints such as hair nets, soft ball caps (with covered tops) disposal paper hats will be worn whenever performing task in production areas and throughout the prep and kitchen areas. Food handlers with facial hair should also be wearing a beard restraint. In the section Reviewing and Storing perishable, non-perishable food, and dry storage documented products will be labeled the day they were received, and stocked will be rotated, each item will be labeled with the months, day, and year. Products arrive at each facility with the best used by dates. Products will be stored in cooler and freezer between uses.During a walk-through observation on 03/06/2026 at 7:37 AM of the Main Kitchen with the DM revealed one Dietary Aide (DA) FF was at the three compartment sink without a hairnet and beard guard covering hair, DA GG was handling fish at the meat sink without a beard guard covering, and the DM was observed without a beard guard covering throughout the initial tour. Continued tour in the Main Kitchen revealed the walk-in refrigerator contained expired lettuce with the date 03/01/2026. The dry storage room revealed a Pork Roast Gravy Mix was not properly stored and labeled, and the ice machine filters contained a thick gray fuzzy substance.During a tour on 03/06/2026 at 8:11 AM with the DM in the Rehabilitation Kitchen revealed DA II did not have on a beard covering. Further observation of the kitchen revealed two blocks of cheese, lettuce and tomatoes, and unknown food items wrapped in aluminum foil, not labeled. Continued observation in the country kitchen area revealed staff member's beverages and a lunch container growing green and gray fuzzy substance on food items located in the resident's refrigerator, and staff members personal cups and food items in the cabinets. The DM stated the staff members were not supposed to store their food and beverages in the resident's area. During a tour on 03/06/2026 at 08:29 AM in the Meadows Terrace Kitchen with the DM revealed pancakes were expired with a written date of 02/10/2026, unknown item in aluminum foil not labeled, a frozen corndog in the freezer not properly stored or labeled, and a bag of French toast sticks not labeled. In addition, dietary staff personal belongings were found in the residents' dry storage area and refrigerator. During a tour on 03/06/2026 at 8:44 AM with the DM in the Grove Hall Kitchen revealed staff members personal belongings were stored in the dry storage area. During a tour on 03/06/2026 at 8:44 AM with the DM in the Garden View Kitchen revealed French toast sticks not labeled in the refrigerator.During an observation on 03/07/2026 at 11:08 AM in the Garden View Kitchen revealed DA II was not wearing a beard guard. During an interview on 03/07/2026 at 12:32 PM with the DM confirmed the protocol was to wear hair and beard coverings at all times. He continued to state the expectations for the food items should be labeled and dated, and they used a first in and first out method and that should be followed. Further, the DM stated employees' items should not be stored in the resident area.During an interview on 03/07/2026 at 12:30 PM with the Director of Nursing (DON), she revealed the employees should not be using the residents' kitchen to store their personal items.During an interview on 03/08/2026 at 9:45 AM with the Maintenance Director, they confirmed they were the ones that changed the filter in the ice machine and the filter was supposed to be changed every six months.

Based on observations, staff interviews, and review of facility policy titled, Medication Storage in the Care Center, the facility failed to ensure that expired medications and /or biologicals were not available for resident use in one of five medication storage rooms and failed to ensure medications were secured on one of 9 medication carts on one of three medication carts reviewed. Findings include: The facility policy titled Medication Storage in the Care Center, undated, revealed under Guideline: .Medications supply is accessible to licensed associates or staff members lawfully authorized to administer medications. Observation on 03/7/2026 at 10:14 AM revealed medications on top of an unattended medication cart located in between resident rooms on a hall on the Vineyard View Unit. The medications were prescribed to R130. They were fluticasone furoate and vilanterol inhalation powder and fluticasone propionate nasal spray. Interview and confirmation on 03/07/2026 at 10:16 AM with Licensed Practical Nurse (LPN) BB confirmed the two medications should not have been left on top of the medication cart, rather they should have been stored and secured inside the medication cart. Interview on 03/07/2026 at 10:26 AM with the Director of Nursing (DON) confirmed that no medications should be left unattended on top of a medication cart, rather they should always be stored and locked inside the medication cart. 2. Observation of a medication room on 03/07/2026 at 10:49 AM with LPN KK revealed Mucus Relief Guaifenesin 600mg Expectorant with an expiration date of 12/2025. LPN KK confirmed the medication was expired. Interview on 03/08/2026 at 9:30 AM on the Garden View Unit with LPN BB, Charge Nurse and the Nursing Supervisor revealed the medication room was checked weekly by the Unit Secretary and the night shift nurse. The Unit Secretary re-stocked the medication room. If there was an expired medication, it was given to the Unit Manager. If the medication was a narcotic and it was expired, it was given to the DON. Interview on 03/08/2026 at 9:45 AM with the DON revealed the medication room was checked by central supply along with the Unit Secretary and the Unit Manager. The Unit Secretaries were all Certified Medication Assistants (CMAs). The night shift charge nurse checked the medication room for expired medications weekly and the nurse consultant came quarterly to check the medications in the room.

Based on observations, resident and staff interviews, record review, and the facility policy titled, Storage and Replacement of Oxygen Equipment, the facility failed to ensure proper storage of oxygen equipment for one of 14 residents (R) (R124) reviewed with oxygen. This deficient practice had the potential to place the resident at risk for cross contamination and negatively impact the resident's quality of life.Review of the facility policy titled Storage and Replacement of Oxygen Equipment, documented under Policy: It is the policy of Orchard View to assure proper storage and replacement of oxygen equipment for those residents to whom oxygen therapy is prescribed by the physician. Under PROCEDURE: The procedure for accomplishing this includes, but is not limited to, the following. 2. It is the responsibility of the licensed nurse to date, label, and initial the plastic storage bag for containment of the nebulizer when not in use.Review of the electronic medical record (EMR) revealed R124 was admitted to the facility with pertinent diagnoses including but was not limited to pleural effusion, atelectasis, cardiomegaly, atherosclerotic heart disease, aortic stenosis, ascites / cirrhosis and obesity.Review of R124's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14, which indicates R124 was cognitively intact.Review of R124's orders dated 03/05/2026 documented Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter)-3 ml inhale orally every 4 hours as needed for SOB (shortness of breath) or Wheezing via nebulizer (device to dispense respiratory medication)Observation on 03/06/2026 at 9:31 AM and 4:27 PM revealed that the resident's nebulizer was not bagged. The nebulizer equipment (mask, tubing and mouthpiece) was uncovered at the time of the observation, sitting on the nightstand in the resident room. Interview/Observation on 03/7/2026 at 10:59 AM revealed a nebulizer lying on the nightstand in the resident's room. The mask, tubing, and mouthpiece were not bagged. R124 was unsure whether the mask, tubing, and mouthpiece should be bagged. No plastic bag was observed in the resident's room. Interview on 03/7/2026 at 11:18 AM with License Practical Nurse (LPN) BB confirmed that the nebulizer mask, tubing, and mouthpiece should be bagged.Interview on 03/7/2026 at 11:38 AM with Director of Nursing (DON) confirmed that the nebulizer mask, tubing, and mouthpiece should be bagged.

Based on record review and staff interviews, the facility failed to ensure a comprehensive person-centered care plan was developed for two of 51 sampled residents (R) (R9 and R8). This deficient practice had the potential to place R9 and R8 at risk of not receiving care and services in accordance with their needs. Findings include: A review of the facility policy titled Care Plan Policy, last reviewed September 2025, revealed under Procedure: .2. It is the responsibility of the Care Plan Coordinator to assess a resident's status and ensure that the resident's care plan is updated to reflect any changes based on the resident's current condition and needs. 1. Review of the electronic medical record (EMR) for R9 revealed admission on [DATE]. Review of diagnoses for R9 included, but were not limited to, major depressive disorder andmental disorder. Review of the annual Minimum Data Set (MDS) assessment for R9, dated 06/25/2025, revealed that section N (Medications) documented that the resident received an antipsychotic medication. Section V (Care Area Assessment [CAA] Summary) documented that psychotropic drug use was triggered and antipsychotic medication was administered to the resident in the last seven days or since admission. Review of the care plan for R9 revealed there was no care plan for the use of antipsychotic medication. Review of the physician's orders for R9 revealed an order dated 02/19/2026 for Risperdal oral tablet, give 0.25 milligrams (mg) by mouth every morning and at bedtime, related to major depressive disorder, single episode, severe with psychotic features. Review of the Medication Administration Record (MAR) for R9 dated March 2026, February 2026, and January 2026 revealed that Risperdal was administered as ordered. In an interview on 03/08/2026 at 10:05 AM, MDS Coordinator EE confirmed the annual MDS assessment dated [DATE] for R9 stated the resident received an antipsychotic during the look-back period. She further confirmed that there was no care plan for the antipsychotic medication and stated there should be. She stated care plans should be person-centered to ensure nursing staff were aware of the care the resident needed. In an interview on 03/08/2026 at 11:45 AM, the Director of Nursing (DON) stated that antipsychotic medications should be on the care plan and include individualized goals and interventions for the resident. She stated the care plan provided nursing staff information about the resident and a plan for providing care. 2. A review of the Quarterly MDS assessment dated [DATE], Section N (Medications) revealed that R8 received an antipsychotic and antidepressant medication. A review of R8's physician's orders revealed the resident was ordered the following medications: 10/31/25 citalopram hydrobromide Tablet 20 mg by mouth (PO) once per day (QD) for depression. 12/3/25 quetiapine fumarate Tablet 50 mg (quetiapine Fumarate) 1 tablet every evening for refractory depression. During an interview with MDS Coordinator EE on 03/07/2025 at 8:25 AM, she acknowledged that R8 was prescribed both an antipsychotic and antidepressant but noted that these medications had not been included in the care plan. During an interview with the Director of Nursing (DON) on 03/08/2026 at 10:35 AM, she stated her expectation that the MDS Coordinators would ensure each resident had a current, individualized care plan. She explained that care areas should include interventions tailored to each resident's care needs, preferences, medication use, and clinical status.

Based on record review, staff interviews, and review of the facility policy titled, Psychotropic Medications, the facility failed to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications for one of 51 sampled residents (R) (R58). Findings include:A review of the facility policy titled Psychotropic Medications with no date, revealed that as-needed (PRN) psychotropic drugs should be extended beyond 14 days unless the attending physician or prescribing practitioner evaluates the patient for the appropriateness of that medication.A review of R58's physician (MD) orders dated 02/06/2026 revealed an order for 1 mg (milligram) of Klonopin (clonazepam) by mouth every 24 hours as needed (PRN). The order had no stop date.A review of the Medication Administration Record (MAR) revealed R58 was administered Klonopin (clonazepam) 1 mg PO (by mouth) every 24 hours as needed on 02/10/2024 at 2302 (11:02 PM), 02/11/2026 at 2221 (10:21 PM), 02/13/2026 at 2200 (10:00 PM), 02/14/2026 at 2332 (11:32 PM), 02/16/2026 at 0443 (4:43 AM), 02/17/2026 at 2207 (10:07 PM), 02/19/2026 at 0021(12:21) AM, 02/23/2026 at 2046 (8:46 PM), 02/24/2026 at 2158 (9:58 PM), 02/26/2026 at 0624 (6:24 AM), 02/27/2026 at 2130 (9:30 PM), and 03/03/2026 at 0006 (12:06 AM).During an interview with the Assistant Director of Nursing (ADON) on 03/07/2026 at 8:18 AM, she explained that the pharmacy usually notified the facility if a stop date had not been assigned to a resident's psychotropic medication. She acknowledged that there was no stop date for R58's Klonopin, which should have had a 14-day stop date. She stated that this was an oversight.During an interview with the Director of Nursing (DON) on 03/8/2026 at 10:35 AM, she stated that Unit Managers were responsible for ensuring that all PRN psychotropic medications had a 14-day stop date. She added that the pharmacist would also notify the facility if a stop date was required for any medication. The DON acknowledged that R58 did not have a 14-day stop date assigned to their PRN Klonopin medication, which should have been implemented.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Self-administered medications, treatments, the facility failed to ensure medications were not left at the bedside of three of 51 sampled residents (R) (R7, R124, and R57) who were not assessed for medication self-administration. This deficient practice had the potential to place R7, R124, and R57 at risk for the unsafe use of medications and for other residents, staff and visitors to have access to medication.Findings include: Review of the facility policy titled Self-administered medications, treatments dated October 2020, revealed self-administration of medications or treatments by residents is permitted by a physician order that includes dosage, route, and any special instructions. The policy included, The RN (registered nurse) Manager assesses resident competency to self-administer medications and documents the resident's wishes in the nurses' notes. 1. Review of the electronic medical record (EMR) for R7 revealed diagnoses that included, but not limited to, metabolic encephalopathy, pneumonia, unspecified organism, spinal stenosis cervical region, and type two diabetes without complications. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R7 had a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of the Physician's Orders for R7 revealed no order for over-the-counter medication for nasal spray, saline enema, or analgesic cream. There also was no order for self-administration of medication for R7. During an observation and interview on 03/06/2026 at 8:40 AM in R7's room, nasal spray was found sitting next to the resident on her bedside table, also, a bottle of saline laxative and a tube of analgesic cream was found on the resident's dresser. Interview on 03/07/2026 at 10:23 AM with the Assistant Director of Nursing (ADON) confirmed the medications in the room and informed R7 that the items would have to be removed and removed them. Interview on 03/07/2026 at 10:26 AM with the Director of Nursing (DON) revealed that R7 should not have had nasal spray, a saline enema, or analgesic cream by her bedside and that all those medications were removed on 03/06/2026. The DON confirmed there was no order for those over-the-counter medications and that the resident was not assessed for self-administer of medications. 2. Review of the EMR revealed R124 was admitted to the facility with pertinent diagnoses including but were not limited to pleural effusion, atelectasis, cardiomegaly, atherosclerotic heart disease, aortic stenosis, ascites / cirrhosis and obesity. Review of R124's MDS assessment dated [DATE] revealed a BIMS score of 14, which indicates R124 was cognitively intact. Review of R124's care plan revealed no care plan in place for self-administration of medication. Observation on 03/06/2026 at 9:31 AM and 4:27 PM revealed a roll on cooling pain relief product was present at the bedside and the over the counter topical pain product was within the resident's reach. Interview/Observation on 03/07/2026 at 10:59 AM revealed roll-on cooling pain relieving gel had been removed from the resident's room. The resident was unsure where the medication had been taken. R124 confirmed that she used the roll-on cooling pain relieving gel independently. Interview on 03/7/2026 at 11:18 AM with License Practical Nurse (LPN) BB confirmed that the roll -on cooling pain relieving gel should not be in R124's room and that there were no orders for self administration. Interview on 03/7/2026 at 11:38 AM the DON confirmed that over the counter medications should not be kept in R124's room, including the roll -on cooling pain relieving gel. The DON reported that nurses' complete room rounds daily. Review of the EMR revealed R57 was admitted to the facility with pertinent diagnoses including but were not limited to anxiety disorder, urinary tract infection, hypertension and peripheral vascular disease. Review of R57's quarterly MDS assessment dated [DATE] revealed BIMS score of 15, which indicates R57 was cognitively intact. Section GG, functional status, revealed R57 was independent for activities of daily living (ADLs) and completes the activity by herself with no assistance Record review of R57 care plan revealed that there was no care plan for self administration of medication. Review of the physician orders for R57 revealed no physician orders for self-administration of medication. Observation and interview on 03/06/2026 at 8:38 AM and at 4:15 PM with R57 revealed Artificial Tear Eye Drops at bedside. R57 confirmed that she used eye drops independently. Interview/Observation on 03/7/2025 at 10:45 AM with R57 reported that her eye drops were no longer in her room. She confirmed that she uses eye drops and that License Practical Nurse (LPN) AA removed them from her room this morning. Interview on 03/07/2026 at 10:55 AM with LPN AA confirmed that she removed the Artificial Tear Eye Drops from the R57's room. She stated that R57 did not have orders to self administer medication, and therefore the eye drops should not have been left in the room. Interview on 03/07/2026 at 11:38 AM with DON confirmed that over the counter medications should not be kept in the R57's room, including the eye drops.

Based on observations, staff interviews, record review, and review of the facility policies titled, Infection Control Policy and Glucometer Disinfection, the facility failed to follow infection control procedures for one of 37 Rs (R154) receiving fingerstick glucose testing, to provide a safe and sanitary environment for one of 28 residents (R) (R2) receiving wound care, and one of nine Rs (R9) receiving catheter care. The deficient practices had the potential to increase the risk of infection transmission among residents and staff.Findings include: Review of the facility policy titled Infection Control Policy, undated revealed under section VI Standard Precaution, A. Infection measures that apply to all resident care, regardless of suspected or confirmed infections. B. Measures include: . 4. Environmental cleaning and disinfection a) Routine cleaning and disinfection of frequently touched or visibly soiled surfaces in common areas, resident rooms, and at the time of discharge. Review of the facility policy titled Glucometer Disinfection review/revision date 03/07/2026 revealed under section II Procedures, Use a germicidal disposable wipe to thoroughly clean heavily or visibly soiled glucometers. Dispose of the first wipe and use a second wipe to thoroughly wipe glucometer for 50 seconds. Additional wipe(s) maybe used if needed to assure a continuous wet contact time of 2 minutes. All the Glucometer to air dry before the next use. Review of the facility's policy titled Enhanced Barrier Precautions dated 04/01/2024, revealed the Policy section included, [Corporate name] facilities will implement enhanced barrier precautions (EBP) as required by CMS [Center for Medicaid and Medicare Services] as part of our infection control program. EBP will be used during high contact care activities for residents with infection or colonization with a CDC targeted MDRO [multi-drug-resistant organism] (when contact precautions do not apply or for any resident who has a chronic wound and/or indwelling medical device. The Procedure section included, Use gowns and gloves when providing high-contact care to residents while providing the following types of care: . device care or use: . urinary catheter . 1. Observation of fingerstick glucose testing on 03/7/2026 at 10:58 AM with Licensed Practical Nurse (LPN) LL revealed the nurse sanitized her hands and put on gloves; she took the supplies for the fingerstick glucose procedure into R154's room and put them on a clean washcloth that was on the bedside table. The nurse cleaned the resident's finger with alcohol and completed the procedure. Once the procedure was completed the nurse discarded the lancet and other used materials in the appropriate containers. The nurse put the used glucometer on the medication cart without a barrier. The LPN picked up the glucometer, cleaned it with one germicidal wipe and put the wet glucometer on a napkin to dry. The nurse confirmed she put the dirty glucometer on the cart. She cleaned the exposed area on the medication cart and took off her gloves. The LPN did not sanitize her hands. She went back into the resident's room and began pushing her in the wheelchair to the common area. Interview on 03/08/2026 at 9:45 am with the Director of Nursing (DON) revealed staff should wear gloves when disinfecting the glucometer and dispose of sharps in the sharp container. The staff should clean the glucometers. They usually have two machines so while the other was drying from use of the germicidal wipes, the staff should use the clean one. The medication cart should be wiped off in between use of the glucometers. Interview on 03/08/2026 at 9:50 AM with the Infection Control Nurse revealed when using a glucometer, before going into the resident's room, the nurse would take two cups. One cup was for the clean supplies and one cup for dirty items after the procedure. Once the glucometer was used, the dirty meter was put in one of the cups. The Infection Control Nurse indicated staff would put the barrier down on the medication cart before putting the glucometer down. All glucometers were cleaned the same way. 2. Review of the medical diagnoses included diagnoses of, but not limited to, pressure ulcer of sacral region, unspecified protein-calorie malnutrition, hypercalcemia, and Vitamin D deficiency. Review of the electronic medical record (EMR) revealed an annual Minimum Data Set (MDS) assessment dated [DATE] for R2 with a Brief Interview for Mental Status (BIMS) score of 3, which indicates severe cognitive impairment, section GG (Functional Abilities and Goals) indicates R2 is dependent for oral hygiene, toileting hygiene, upper and lower body dressing, personal hygiene, and toilet transfer; substantial maximal assistance - shower/bath; under section M (Pressure Ulcers) revealed 4 stage, 4 pressure ulcers, moisture associated skin damage; pressure reducing device for chair and bed; nutrition and hydration intervention. Observation and interview on 03/08/2026 at 8:45 AM, wound care to the sacral area was completed by the Wound Care Nurse with assistance by the Treatment CNA (Certified Nursing Assistant). Staff wore gowns and gloves, used a bedside table with a clean towel on it to put supplies, changed the soiled dressing and applied vaseline gauze and saline to the wound. The Wound Care Nurse changed gloves after treatment and reapplied the dressing. The Wound Care Nurse sanitized her hands after taking the gloves off. After the procedure the Wound Care Nurse did not take the used towel off the bedside table nor did she sanitize the table. The Wound Care Nurse confirmed she did not take the dirty towel off the bedside table nor did she sanitize the table. During an interview on 03/08/2026 at 9:55 AM with the Infection Control Nurse, she revealed that once the wound care procedure was complete, the bedside table needed to be cleaned. 3. Review of the diagnoses for R9 revealed diagnoses including, but not limited to, neuromuscular dysfunction of the bladder, urinary tract infection, and acute kidney failure. Review of the quarterly MDS for R9 dated 11/24/2205 revealed that section H (Bladder and Bowel) documented R9 had an indwelling urinary catheter. Review of the care plan for R9, initiated 09/23/2024, revealed the resident had an indwelling urinary catheter related to diagnoses of neurogenic bladder and urinary retention, and required enhanced barrier precautions. Interventions included providing catheter care every shift. Review of the physician's orders for R9 revealed an order dated 02/19/2026 for catheter care every shift. Further review revealed an order dated 01/15/2026 for EBP. Observation on 03/08/2026 at 09:20 AM revealed that CNA CC performed urinary catheter care for R9. Observation revealed CNA CC requested permission from R9 to perform the care, provided privacy, prepared one wash basin with warm soapy water and one with warm water, gathered supplies, positioned the resident, and performed catheter care. Observation during the procedure revealed that she performed hand hygiene between tasks, changed gloves, and performed hand hygiene between glove changes. Continued observation revealed that she cleaned the catheter from the insertion site outward and cleaned the perineal area from the catheter site outward, using a clean section of the cleaning and rinsing cloths with each swipe. Observation revealed that CNA CC did not wear a gown for the procedure. Observation of the door to R9's room revealed EBP signage and personal protective equipment (PPE), including gloves, gowns, masks, and face shields in an over-the-door hanging container visible to staff entering the room. The signage instructed staff to wear gloves and a gown for high-contact care, including indwelling urinary catheter care. In an interview on 03/08/2026 at 9:40 AM, CNA CC confirmed she did not wear a gown while performing urinary catheter care for R9. She confirmed the EBP signage and the supply of personal protective equipment (PPE) on the resident's door. She stated that based on the EBP instructional signage, she should have worn gloves and a gown while providing catheter care to R9. She further stated that she typically only wore a gown when providing care to residents with known infections. She stated she did not recall completing any EBP-related education since working at the facility. In an interview on 03/08/2026 at 9:50 AM, Registered Nurse (RN)/Unit Manager (UM) DD stated she expected staff to wear gloves and a gown when providing care that might involve splashes or during insertion of an indwelling device. She stated she would not expect staff to wear a gown when providing only catheter care. She confirmed that the EBP signage on the resident's door instructed staff to wear gloves and gowns when providing high-contact care, including urinary catheter care. She further stated that she was unaware of staff education on EBP. In an interview on 03/08/2026 at 10:50 AM, the DON stated she expected staff to follow the EBP guidelines when providing care to residents with indwelling medical devices. She stated nursing staff should wear gloves and a gown when providing urinary catheter care to prevent the spread of infections from resident to resident. She further stated that PPE and EBP signage were in place on each resident's door who required EBP, and staff were to follow the guidelines. She stated she would provide EBP education to nursing staff.

Based on observations, staff interviews, record review, and review of the facility's policy titled Assessment and Nursing Care Screening the facility failed to complete an accurate Minimum Data Set (MDS) assessment that indicated the use of an alarm for two of 15 residents (R) (R2) and (R108). This deficient practice had the potential to lead to several negative impacts on the residents physical and psychological well-being. Findings include: Review of the facility's undated policy titled Policy titled Assessment and Nursing Care Screening revealed, A nursing assessment, the first step in the nursing process, is completed on each new admission, quarterly, annually, and when a change in condition occurs. Under the Policy section revealed, The Minimum Data Set (MDS) Form records information obtained during the nursing assessment. The MDS Form becomes a permanent part of the medical record. Under the Procedures revealed, 1. A licensed nurse initiates a nursing assessment on newly admitted residents that occurred during the shift. 2. The MDS Form is used as a baseline for information for initiation of the Resident Care Plan. (a.) Documentation should reflect resident's involvement in completing the Resident Assessment Instrument (RAI).(b.)Ensure it is comprehensive and captures resident's needs, strengths, goals, life history, psychosocial, and preference. 3.The Admission Assessment Form serves as the interim care plan until the Interdisciplinary Team Meeting (IDT) meeting. 4.Information, which must be obtained over a period of time, is added to the assessment form by the nurse obtaining the information.5. For each 90-day IDT Team Meeting, the RN Manager or designee completes the quarterly MDS review and updates the resident care plan as necessary. 6. For each change in level of care, the appropriate discipline completes the portion of the MDS relevant to the change. 7. The MDS Form is placed in the Care Plan/MDS section of the chart. 1. Review of the electronic medical record (EMR) revealed resident (R2) was admitted to the facility with pertinent diagnoses that included but was not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, fracture of superior rim of unspecified pubis, subsequent encounter for fracture with routine healing, and cognitive communication deficit. Review of R2 quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) of 3, which indicated R2 was severe cognitive impairment; Section GG (Functional Abilities and Goals) revealed, R2 required assistance for activities of daily living (ADLs) and Section P (Restraints and Alarms) did not indicate the use of a chair alarm. Review of the Physician's Orders for R2 revealed there was no order for the use of the wheelchair alarm. However, review of R2's care plan with revision date of 10/15/2024 revealed, a Focus that indicated Resident is at fall/injury r/t (related) to meds, impaired mobility, medical factors, Hx (history) of falls incontinence. Interventions included Bed Alarm-Staff to ensure proper placement and proper functioning. Date initiated 8/15/2023; bed alarm-Ensure proper placement and proper functioning q (every) shift. Observation on 6/6/2025 at 9:43am revealed R2 sitting in the dining area sleeping in her wheelchair with an alarm hanging from the wheelchair. Observation on 6/6/2025 at 11:15 am revealed R2 sitting in the activity/ dining area with an alarm attached to the wheelchair Observation on 6/7/2025 at 9:22 am revealed R2 was noted to be sitting in a wheelchair in the activity/dining area with an alarm hanging on the wheelchair. Interview on 6/7/2025 at 10:55 am with Licensed Practical Nurse (LPN) DD confirmed that the alarm attached to the back of R2 wheelchair was to alert staff if the resident falls. Observation on 6/7/2025 at 12:30 pm revealed R2 sitting in the dining area with the alarm attached to her wheelchair. 2. Review of the EMR revealed R108 was admitted to the facility with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD), dementia (unspecified severity), cognitive communication deficits, and difficulty walking, muscle weakness and a healing intertrochanteric femur fractur, and history of falls. Review of R108's quarterly MDS assessment dated [DATE] revealed a BIMS of 5 which indicated R108 had severe cognitive impairment and Section GG (Functional Abilities and Goals) revealed no impairment to upper/lower extremities, wheelchair use; and Section P (Restraints and Alarms) did not indicate the use of a chair alarm. Review of the Physician's Orders for R108 revealed there was no order for use of alarms. However, review of R108's care plan with revision date of 10/15/2024 revealed a Focus that indicated [Name] is at Risk for Fall/Injury r/t advanced age, medical factors, impaired mobility. Interventions included, Chair alarm while out of bed date initiated 2/3/2025. Observation on 6/6/2025 at 9:43 am revealed R108 sitting in the dining area sleeping in her wheelchair with an alarm attached to chair. Observation 6/6/2025 at 11:15 am revealed R108 sitting in the activity/dining area with an alarm attached to his wheelchair. Observation on 6/7/2025 at 9:30 am revealed R108 was noted to be sitting in a wheelchair with alarm hanging on his wheelchair. Interview on 6/7/2025 at 10:55 am with LPN DD confirmed that the alarm on the back of the R108 chair was to alert staff if the resident falls. Observation on 6/7/2025 at 12:30 pm revealed R108 sitting in the activity/dining area with alarm attached to his wheelchair. Interview on 6/7/2025 at 4:25pm with the Director of Nursing (DON) revealed the alarms on the residents' chairs was used as preventive intervention for falls. The DON confirmed R2 and R108 alarm was not indicated on their MDS assessment. Interview on 6/7/2025 at 4:35 pm with the Minimum Data Set (MDS) Coordinators BB and CC both revealed that if a resident has an alarm on the chair, it should be included in Section P on the MDS indicator. MDS BB and MDS CC revealed after they review the residents' physician orders, the would put this information in the MDS and then a care plan would be developed to address the resident needs.

Based on observations, staff interviews, record review, and review of the facility's policy titled [Name of Organization] Policy: Restraint Use, the facility failed to ensure two of 15 residents (R) (R2 and R108) had a physician order for restraint use. Findings include: Review of the facility's policy titled [Name of Organization] Policy: Restraint Use dated 10/28/2024 revealed [Name of Organization] facilities create and maintain an environment that fosters minimal use of restraints. [Name of Organization] facilities ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. The purpose of selective restraint use is to enhance resident quality of life by assuring safety while promoting an optimal level of function. It is the intent of this facility to attain and maintain a restraint free environment. Under the Policy section revealed, 1. The need of each resident for alternatives to restraint use is assessed on occasion, at regularly scheduled Interdisciplinary Care Plan Conference reviews, and as needed. 2. The family of each resident is informed of the plan of care for restraint use at the time of the initial interdisciplinary resident care review and when a change is instituted. 3. A physician order is required to apply any type of restraint. 4.Monthly documentation in Clinical Notes includes type of restraint, date and time of use, reason for use, and resident tolerance. 5. In a situation that requires restraint use as a short-term intervention nursing administration. Is apprised of the issue, a physician order is obtained, families or a responsible party are notified within 24 hours, and the effect is documented in Clinical Notes on each shift for 24 hours. 6. Resident, family, or responsible person signs the Informed Consent Form for short term restraint use. 7. The interdisciplinary approved plan for restraint use is outlined in Resident Care Plans and is revised as needed. 1. Review of the electronic medical record (EMR) revealed resident (R2) was admitted to the facility with pertinent diagnoses that included but was not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, fracture of superior rim of unspecified pubis, subsequent encounter for fracture with routine healing, and cognitive communication deficit. Review of R2's quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) of 3, which indicated R2 was severe cognitive impairment; and Section GG (Functional Abilities and Goals) revealed, R2 required assistance for activities of daily living (ADLs). Review of the Physician's Orders for R2 revealed there was no order for the use of an alarm. Observation on 6/6/2025 at 9:43am revealed R2 sitting in the dining area sleeping in her wheelchair with an alarm hanging from the wheelchair. Observation on 6/6/2025 at 11:15 am revealed R2 sitting in the activity/ dining area with an alarm attached to the wheelchair Observation on 6/7/2025 at 9:22 am revealed R2 was noted to be sitting in a wheelchair in the activity/dining area with an alarm hanging on the wheelchair. Interview on 6/7/2025 at 10:55 am with Licensed Practical Nurse (LPN) DD confirmed that the alarm attached to the back of R2 wheelchair was to alert staff if the resident falls. Observation on 6/7/2025 at 12:30 pm revealed R2 sitting in the dining area with the alarm attached to her wheelchair. 2. Review of the EMR revealed R108 was admitted to the facility with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD), dementia (unspecified severity), cognitive communication deficits, and difficulty walking, muscle weakness and a healing intertrochanteric femur fractur, and history of falls. Review of R108's quarterly MDS assessment dated [DATE] revealed a BIMS of 5 which indicated R108 had severe cognitive impairment and Section GG (Functional Abilities and Goals) revealed no impairment to upper/lower extremities and wheelchair use. Review of the Physician's Orders for R108 revealed there was no order for the use of an alarm. Observation on 6/6/2025 at 9:43 am revealed R108 sitting in the dining area sleeping in her wheelchair with an alarm attached to chair. Observation 6/6/2025 at 11:15 am revealed R108 sitting in the activity/dining area with an alarm attached to his wheelchair. Observation on 6/7/2025 at 9:30 am revealed R108 was noted to be sitting in a wheelchair with alarm hanging on his wheelchair. Interview on 6/7/2025 at 10:55 am with LPN DD confirmed that the alarm on the back of the R108 chair was to alert staff if the resident falls. Observation on 6/7/2025 at 12:30 pm revealed R108 sitting in the activity/dining area with alarm attached to his wheelchair. Interview on 6/7/2025 at 4:25pm with the Director of Nursing (DON) confirmed R2 and R108 did not have an order for the alarm. Interview on 6/7/2025 at 4:40 pm with the Administrator revealed that it is the unit manager 's decision to put orders in place for alarms. The Administrator stated the alarms were used to reduce the risk of falls. The Administrator was not aware of residents needing an order for alarms. The Administrator stated moving forward he would work on a plan in Quality Assurance and Performance Improvement (QAPI) to eliminate the alarms and would look to implement another course of action.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Medication Storage in the Care Center, the facility failed to store medications in a locked compartment when unattended for one of five treatment carts. The facility census was 128. Findings include: Review of the policy, titled, Medication Storage in the Care Center dated July 2012, under the section titled, Intent revealed Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under the section titled, Procedural Guidelines, revealed 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access. During an observation on 2/14/2024 at 1:04 pm of a wound treatment, the Assistant Director of Nursing (ADON) unlocked the treatment cart to get supplies. She then went into the resident's room to complete wound care and left the treatment cart unlocked which was in the hallway. During an observation on 2/14/2024 at 1:40 pm, the ADON came back into the hallway after providing wound care for a resident; the treatment cart remained unlocked. ADON was asked if medications were stored in the cart. She opened each drawer, and the following medications were observed in the unlocked treatment cart: Medihoney, DermaSyn/AG, A&D Ointment, Wound Gel, skin protectant, antifungal cream, and betadine solution. Interview was conducted during this time with the ADON, verified the treatment cart was unlocked and had been unattended with the medications inside. During an interview on 2/15/2024 at 10:00 am with the Director of Nursing (DON), she stated the contents of the treatment carts included: dressings, ointments, and wound cleaning solutions. DON confirmed the treatment carts should be kept locked when unattended.

Based on staff interviews, record review, and review of the facility's policy titled, Abuse Prevention, Intervention, Investigation, and Reporting, the facility failed to ensure an injury of unknown origin was reported to the proper authorities immediately, but no later than two hours for one Resident (R) 31. The sample size was 24. Findings include: Review of abuse police titled, Abuse Prevention, Intervention, Investigation, and Reporting dated 2/15/2024 under the section titled Injury of Unknown Source: revealed, An injury for which both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, AND The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) OR the number of injuries observed at one particular point in time OR the incident of injuries over time. Reporting: 1. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property the incident will be immediately reported. Review of R31's medical records revealed she admitted to the facility on [DATE] with diagnoses of but not limited to, hypertensive heart disease without heart failure, unilateral primary osteoarthritis right knee, anxiety disorder, diabetes type II, unspecified dementia unspecified severity without behavioral disturbance, and unspecified fracture shaft of right fibula (11/30/2023) while in facility. Review of Nurse's Note dated 11/29/2023 at 11:25 pm revealed R31 complained of right leg pain. R31 reported that her leg hurt from the bottom of her foot to behind her thigh. Review of Nurse's Note dated 11/30/2023 at 6:39 pm revealed R31 complained of pain in right foot. R31's right foot was noted with redness, swelling, warmth and was painful to touch. The Medical Director (MD) and Responsible party (RP) were notified, and an x-ray was ordered. Review of Nurse's Note dated 12/1/2023 at 9:15 am revealed the MD and RP were contacted to discuss the results of the x-ray for R31. Review of Nurse's Note dated 12/1/2023 at 2:04 pm revealed R31 had a fracture (f/x) to her right distal fibula. Review of the facility's incident reports revealed there was no evidence of an incident report related to the right distal fibula fracture for R31. Interview on 2/15/2024 at 12:51 pm with the Director of Nursing (DON) reported she could not confirm when or how R31 received the f/x to her right ankle. The DON revealed she did not consider this to be an injury of unknown origin, and therefore did not report the injury to the proper authorities. Interview on 2/15/2024 at 1:50 pm with the Assistant Director of Nursing (ADON) revealed she could not confirm how R31 received the right distal fracture.

Based on staff interviews, record review and review of the facility's policy titled, Abuse Prevention, Intervention, Investigation, and Reporting, the facility failed to investigate an allegation of injury of unknown origin for one Resident (R) (R31). This failure not to conduct an investigation had the potential to result in other residents not being identified as potential victims of injury of unknown origin. The sample size was 24. Findings Include: Review of the facility's policy titled, Abuse Prevention, Intervention, Investigation, and Reporting dated 2/15/2014 under the section titled, Investigation revealed, 1. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, an investigation ensues. 3. Information gathering- The following information will be gathered: What allegedly occurred? Who is the alleged victim? Who allegedly did it? When did it happen? Where did it happen? 4. Document the description of the injury. 5. Interviews will be conducted of all pertinent parties. 9. When a resident has an injury of unknown sources, interviews will be conducted, and signed statements will be gathered from staff who cared for the resident prior to and just after the injury. Review of the Facility Incident Reports (FRIs) showed no documentation of an investigation to determine how R31 received the fracture to her right distal fibula. Interview on 2/15/2024 at 12:51 pm with the Director of Nursing (DON) revealed they did not thoroughly conduct an investigation into how R31 received a fracture to her right distal fibula. Interview on 2/15/2024 at 2:54 pm with Occupational Therapist Licensed (OT/L) EE reported he was unaware of how R31 received the fracture. OT/L EE reported he went to transport R31 for occupational therapy when R31 complained of pain to her right ankle and foot. OT/L EE revealed he did not transfer R31 for therapy and reported findings to the Therapy Director and documented it. No investigation was conducted.

Based on record review, observations, interviews, and review of policy titled Adaptive Devices, the facility failed to assure that one of one sampled resident (Resident [R] #32) was provided with a therapy-recommended adaptive device to facilitate self-feeding during mealtimes. Specifically, R#32 was to utilize right angled silverware during meals; however, observations revealed the resident was utilizing regular utensils. Findings include: A review of the facility policy titled, Adaptive Devices, dated 11/28/2016, revealed, It is our policy to utilize adaptive devices at mealtime to facilitate resident's meal consumption. Procedure: It is the responsibility of the Dietary Supervisor to assure the Physician's order for adaptive devices is included on the diet tray card. It is the responsibility of the Dietary employee preparing the tray at mealtime to place the specified adaptive device directly onto the tray before releasing the tray to be served. During observations on 05/25/2022 at 5:45 PM, during mealtime, revealed R#32 was sitting upright in bed, in room, self-feeding. The food was mechanical soft, and the resident was eating with a regular spoon. During observation on 05/26/2022 at 9:10 AM, during mealtime, R#32 was sitting upright in bed, self-feeding. The food was mechanical soft and the resident was eating with a regular spoon. During observation on 05/26/2022 at 12:54 PM, during mealtime, R#32 was in the dining room eating lunch, using a divided plate and regular utensils. A review of the Face Sheet revealed the facility admitted R#32 with diagnoses which included hypertensive [CONDITION(S)] and dysphagia. A review of R#32's quarterly Minimum Data Set (MDS), dated [DATE], revealed R#32 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Further review of the MDS revealed R#32 required supervision with the physical assistance of one-person for eating. A review of R#32's Care Plan, dated 12/28/2021, revealed R#32 had a problem of weight loss related to receiving a mechanically altered diet with pureed meats and nectar thickened liquids and required extensive eating assistance. The approaches included right angled silverware to assist with self-feeding and for staff to set-up the resident's tray and assist with meals as needed. A review of a dietary notes input by the Registered Dietitian (RD) FFF on 05/17/2022 revealed the resident had no significant weight change in the past 30 to 180 days. The note further indicated the resident received a mechanical soft diet with pureed meats and nectar thickened liquids. The note indicated that the resident took in approximately 75% for meals and required extensive assistance and utilized adaptive feeding devices. A review of the facility document titled, Restorative Nursing Program, dated 04/03/2021 revealed the equipment to be used for dining for R#32 was a divided plate, built up curved handle spoon, and Dycem. A review of the Physician's Orders for May 2022 revealed an order to provide right-handed silverware at meals. On 05/26/2022 at 12:07 PM, an interview was conducted over the telephone with RD FFF regarding R#32. RD FFF stated that R#32 had been eating well and was independent with eating, utilizing the right-angled utensils ordered for the resident for assistance with self-feeding. RD FFF stated when R#32 was using regular silverware, the resident was losing weight as it was difficult for the resident to self-feed. RD FFF stated that occupational therapy initiated the use of the adaptive equipment on or around 11/10/2021. RD FFF stated that the adaptive equipment was kept in the kitchen and the kitchen was aware of the need for adaptive equipment and it should be sent with the meal when it was served. On 05/26/2022 at 12:33 PM, an interview was conducted with Director of Rehabilitation (DOR) GGG. DOR GGG stated that R#32 was seen by occupational therapy (OT) back in April 2021, at which time the resident was placed on a restorative nursing program with the instruction to use a divided plate, built-up curved handled spoon, and Dycem (under the plate). DOR GGG further stated that R#32 was still on the program, and that in December 2021 the therapy staff reinforced the approach, as the resident had some decline with speech therapy and occupational therapy. They reiterated the need for a built-up spoon to be used. On 05/26/2022 at 10:13 AM, an interview was conducted with Licensed Practical Nurse (LPN) III. LPN III stated there were four residents who required assistance with feeding on the Grove Terrace unit. R#32 was not included in her list. LPN III further stated that R#32 does well with eating. LPN III stated that R#32 used a divided plate and regular silverware. Certified Nursing Assistant (CNA) JJJ, the team leader, was interviewed on 05/26/2022 at 12:57 PM in the dining room, where R#32 was eating at that time. CNA JJJ stated that the kitchen sent up any ordered adaptive equipment with the meal trays, and the CNAs were required to review the AAR book (the CNA book) to review the activities of daily living requirements for each resident. CNA JJJ stated that she would have to review the AAR book to determine if R#32 had any requirements for adaptive equipment. CNA JJJ showed reviewed the book and saw that R#32 was required to have right-handled silverware at meals. CNA JJJ stated that it should have come up from the kitchen. On 05/26/2022 at 1:06 PM, Registered Nurse (RN) EEE, Unit Manager, stated that she was unaware that R#32 required a right-handled utensil for mealtimes. She referred to the CNA AAR book and verified that it was documented in the book. On 05/26/2022 at 1:31 PM, an interview was conducted with Dietary Manager (DM) AA. The DM stated that when a resident required adaptive equipment the kitchen would receive a communication slip. Once the communication was received, the directive was put into the computer system so that when the individual menus were printed out it showed up on the menu. At the end of the plating line, the utensils were placed on the tray. If there was a directive for adaptive equipment that replaced the regular silverware, it was wrapped in the napkin in the same manner. The DM provided a copy of R#32's menu which revealed Angled Utensil was listed under the Beverages/Equipment section of the menu. On 05/26/2022 at 2:06 PM, the Director of Nursing (DON) stated in an interview that it was her expectation that orders for adaptive equipment should be followed. She expected staff, licensed and unlicensed, to follow and know what was on the AAR (CNA book). In an interview on 05/26/2022 at 3:47 PM, the Administrator stated that his expectation was that staff followed the orders as written.

Based on observation, interview, and record review, the facility failed to ensure accommodation of needs were met for one (Resident [R] #47) of 25 sampled residents. Specifically, the resident's call light was not maintained within the reach of the resident. Findings include: A review of R#47's annual Minimum Data Set (MDS), dated [DATE], revealed R#47 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MDS revealed R#47's Brief Interview for Mental Status (BIMS) score was four, indicating severe cognitive impairment. The MDS revealed R#47 was dependent on staff for all activities of daily living. A review of R#47's Care Plan, dated 03/24/2022, revealed that R#47 had self-care/mobility deficits due to advanced age, multiple medical factors, a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . One of the approaches for this care plan was to keep the call light within easy reach and check on needs frequently. An additional care plan, dated 03/24/2022, revealed R#47 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included keeping the call light within easy reach and checking needs on a frequent basis. Observations of R#47 on 05/23/2022 at 2:53 PM and on 05/25/2022 at 8:42 AM, 11:31 AM, and 3:10 PM revealed R#47 was lying in the bed with the call light hanging off the bed rail, outside of the reach of the resident. An interview with Certified Nursing Assistant (CNA) RR on 05/25/ at 3:17 PM revealed all call lights should be in the resident's hand or near the resident. The call light should be in a spot they could reach. An interview with Licensed Practical Nurse (LPN) HH on 05/25/2022 at 3:40 PM revealed the call light should be in the resident's hand or close to their hand. An interview with Restorative CNA OO on 05/25/2022 at 3:50 PM revealed the call light should always be within the resident's reach. On 05/25/2022 at 4:08 PM the Administrator revealed there was no policy and procedure for call lights. An interview with the Administrator and Director of Nursing on 05/26/2022 at 9:25 AM revealed the expectation was the call light should be within reach at all times.

Based on interview, record review, and review of policies titled Change in Resident Condition and Insulin Protocol, the facility failed to notify the physician and the responsible party following two events of [CONDITION(S)] for one (Resident [R] #33) of two sampled residents reviewed for a change in condition. Findings include: A review of the facility policy titled, Change in Resident Condition, initiated on 03/02/2021, revealed, .Healthcare professionals maintain communication with the physician, resident/patient and/or the responsible party when the resident/patient experiences changes in status which affect the current level of care. Procedure: The procedure for assuring compliance with this policy includes but is not limited to, the following measures: 1) The appropriate facility staff will immediately inform the resident/patient, physician and/or resident patient legal representative when there is: b. A significant change in the residence [sic]/ patient's physical, mental, or psychosocial status. 3) Notification regarding resident change in condition will be documented in the medical record including the licensed nurse assessment of the change in any directives given by the physician. Licensed nursing will document the following information the medical record: a. Date/time of notification b. Name of person notified c. Significant response(s) from the notified parties. A review of the facility's undated Insulin Protocol, provided by Physician JJ, revealed the following directive: 5. Call physician for finger stick blood glucose that are < [less than] 50 mg [milligrams]/dl [deciliter]. A review of the Face Sheet revealed the facility admitted R#33 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#33's quarterly Minimum Data Set (MDS), dated [DATE], revealed R#33 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out 15, which indicated no cognitive deficits. R#33 received insulin seven of seven days during the seven-day look back period. A review of R#33's Departmental Notes revealed a nurses note written by Unit Manager (UM) NN and dated 04/03/2022 at 3:47 AM. The note indicated at 2:45 AM the resident's blood sugar was taken and was 30. The resident was alert, shaking, and had trouble speaking. The resident was given orange juice and a sandwich and was able to eat without difficulty. At 3:40 AM, the resident's blood sugar was 93 and was able to speak clearly. The note did not include documentation that the physician or responsible party was notified. A review of R#33's Departmental Notes revealed a nurses note written by Licensed Practical Nurse (LPN) MMM and dated 05/24/2022 at 6:56 AM. The note indicated the nurse was called into the resident's room due to the resident yelling. The resident was shaking uncontrollably and yelling and was unable to respond to the nurse. The resident's blood sugar was checked and was 35. The nurse administered glucose and the resident's blood sugar dropped to 28. The nurse gave the resident a coke and orange juice and the resident's blood sugar eventually went back up. The last blood sugar taken was 228. The note did not contain documentation that the physician or responsible party was notified. On 05/23/2022 at 2:00 PM, R#33 was interviewed in the resident's room. During the interview, R#33 stated a history of experiencing hypoglycemic episodes in the mornings and one time it was as low as 28. The resident indicated that was not a pleasant feeling. During an interview on 05/25/2022 at 11:28 AM, R#33's responsible party stated there had been no contact from the facility when the R#33 had hypoglycemic events. On 05/25/2022 at 4:43 PM, Physician JJ stated for significant [CONDITION(S)] nursing staff were to call him. Physician JJ was asked if he was notified when R#33 experienced two recent hypoglycemic events. He responded that he did not remember, but he felt sure they would have called him because that's what they do. On 05/26/2022 at 9:07 AM, attempted to contact LPN MMM to discuss the hypoglycemic event that occurred on 05/24/2022 but LPN MMM was not available for interview. During an interview on 05/26/2022 at 9:18 AM, UM NN stated that if blood sugars were over 450, they followed Physician JJ's protocol found in the chart, and if the blood sugars were below 50 to also follow the protocol and to call the physician. UM NN further stated that she would document the event and notification in the nursing notes. UM NN stated she did not believe she called the physician when the resident had a low blood sugar on 04/03/2022. UM NN stated that the resident recovered quickly and was able to drink and eat a snack. UM NN stated, Notification of the doctor allows him to know what is happening and he can make changes as needed so it does not happen in the future. On 05/26/2022 at 9:31 AM, RN EEE stated in an interview if a resident's blood sugar was less than 50 the resident's physician should be notified. RN EEE stated the physician may need to change dosing of insulin to keep the resident from continuing to have hypoglycemic events. On 05/26/2022 at 2:05 PM, the Director of Nursing (DON) was made aware of the concern that the physician and responsible party had not been notified when R#33 had two separate hypoglycemic events. The DON stated her expectation regarding notification included to follow the physician's protocols/orders to treat the resident's hypoglycemic/hyperglycemic events, and if there were multiple events the physician should have been made aware. On 05/26/2022 at 3:44 PM, the Administrator was made aware of the concern regarding notification of the physician and responsible party. The Administrator stated that it was his expectation that the nursing staff follow protocols and to call the physician.

Based on observations, interviews, and record review, the facility failed to ensure staff followed a care plan for two of 25 sampled residents (Resident [R] #33 related to hypoglycemic/hyperglycemic episodes and R #52 related to oxygen usage) reviewed for care plans. Findings include: 1. A review of the Face Sheet revealed the facility admitted R#33 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#33's quarterly Minimum Data Set (MDS), dated [DATE], revealed R#33 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out 15, which indicated no cognitive deficits. R#33 received insulin seven of seven days during the seven-day look back period. The Care Plan, dated 06/21/2021, revealed that R#33 was at risk for abnormal bloods sugars and complications related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#33's Departmental Notes revealed a nurses note written by Unit Manager (UM) NN and dated 04/03/2022 at 3:47 AM. The note indicated at 2:45 AM the resident's blood sugar was taken and was 30. The resident was alert, shaking, and had trouble speaking. The resident was given orange juice and a sandwich and was able to eat without difficulty. At 3:40 AM, the resident's blood sugar was 93 and was able to speak clearly. The note did not include documentation that the physician or responsible party was notified. A review of R#33's Departmental Notes revealed a nurses note written by Licensed Practical Nurse (LPN) MMM and dated 05/24/2022 at 6:56 AM. The note indicated the nurse was called into the resident's room due to the resident yelling. The resident was shaking uncontrollably and yelling and was unable to respond to the nurse. The resident's blood sugar was checked and was 35. The nurse administered glucose and the resident's blood sugar dropped to 28. The nurse gave the resident a coke and orange juice and the resident's blood sugar eventually went back up. The last blood sugar taken was 228. The note did not contain documentation that the physician or responsible party was notified. 2. A review of the quarterly Minimum Data Set (MDS) assessment, dated 03/18/2022, revealed R#52 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficits. Additionally, R#52's MDS revealed R#52 had shortness of breath or trouble breathing with exertion, while sitting at rest, and lying flat. The MDS indicated R#52 was receiving oxygen therapy. A review of R#52's Care Plan, updated 03/11/2022, revealed the resident was at risk for impaired gas exchange/respiratory distress and shortness of breath due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An approach was to administer oxygen as ordered. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 05/23/2022 at 9:25 AM with R#52 confirmed R#52's oxygen was set at five liters per minute. An observation of R#52 in their room on 05/25/2022 at 2:56 PM revealed R#52 was receiving oxygen at five liters per minute. An interview with the Director of Nursing (DON) on 05/26/2022 at 1:25 PM revealed it was important for staff to follow facility policy regarding care plans. An interview with the Administrator on 05/26/2022 at 1:34 PM revealed he expected the staff to follow each resident's care plan.

Based on observations, interviews, record review, and review of Wound Care Suggestive Guidelines, the facility failed to ensure care and treatment was provided to treat a skin tear for one of two residents (Resident [R] #105) who was reviewed for non-pressure related skin conditions. Specifically, R#105 obtained a skin tear to the hand and the facility failed to assess the area and provide treatment according to the facility's wound care guidelines. Findings include: Review of the facility's Wound Care Suggestive Guidelines, undated, revealed skin tear treatment options were to monitor for infection, put arrow on dressing in direction of flap to protect integrity of flap. The guidelines further noted that the frequency of the dressing change was every three days and as needed. A review of R#105's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had no skin conditions. A review of Departmental Notes dated 05/20/2022 at 8:18 PM, revealed a nursing note that indicated the resident's responsible party reported R#105 slid out of their wheelchair during dinner with family outside of the facility. A skin tear was noted on the dorsal side of the left hand and the resident denied pain or discomfort. An observation on 05/23/2022 at 2:13 PM, revealed R#105 was in room with a dressing applied to left hand. The dressing had a date of 05/20/2022 written on the top of the bandage. An interview with R#105 at the time of the observation revealed R#105 reported that they had fallen, tried to stop the fall, and obtained a skin tear on the hand. A review of the medical record on 05/24/2022 at 1:26 PM revealed no orders for wound or skin care were located on the treatment administration record (TAR) for the month of May 2022. The resident did not have any treatments; therefore, the resident did not have a TAR. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations of R#105 on 05/24/2022 at 2:59 PM and again on 05/25/2022 at 10:09 AM revealed the dressing on the left hand was in place and had the date 05/20/2022 written on the dressing. During an interview on 05/25/2022 at 10:10 AM, Licensed Practical Nurse (LPN) KK indicated R#105 received a skin tear on left hand on 05/20/2022. LPN KK reported that when a skin tear was identified, the nurse who identified it should address it and decide what treatment was needed for the injury. The treatment nurse was then notified to assess the area and the treatment changed if the treatment nurse decided other treatment options were better. LPN KK attempted to look up the treatment order in the electronic medical record for R#105's skin tear. After looking for the order, LPN KK stated there was no order for a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 05/25/2022 at 3:41 PM, Unit Manager (UM) LL reported that if a resident obtained a skin tear, the nurse who identified it would implement the first treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . UM LL also indicated that when a resident obtained a skin tear there should be an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . UM LL reported that the dressing should have been changed at least every three days. During an interview on 05/25/2022 at 3:51 PM, LPN PP reported she was the treatment nurse and that she had not been made aware of a skin tear on R#105. During an interview on 05/26/2022 at 9:40 AM, the Director of Nursing (DON) reported that skin tears should be treated, family notified, and orders on the wound care protocol sheet should be implemented. The DON reported that the expectations of the staff was for the wound care protocols to be followed. During an interview with the Administrator on 05/26/2022 at 9:55 AM, he reported that the expectation was to follow the policy and procedure for treatments of skin tears.

Based on observations, interviews, record reviews, and review of policy titled, Oxygen Therapy Guidelines/Equipment changes, the facility failed to ensure oxygen was provided according to physician's orders for one of one resident (Resident [R] #52) who was reviewed for oxygen use. Specifically, R#52's was receiving oxygen at a rate of five liters per minute but the Physician's Orders were for oxygen at 4 liters per minute. Findings include: A review of the facility policy titled Oxygen Therapy Guidelines/Equipment changes, undated, revealed Protocol: III. The following sequence should be used in evaluating adjusting (titrating) a patient's oxygen therapy: F. Document new liter flow or discontinuance of oxygen therapy in patient chart and notify physician/RN [Registered Nurse]/RRT [Registered Respiratory Therapist] per accepted protocol mechanism. Clinical Responsibilities: II. The following guidelines will be adhered to in all oxygen therapy patients at all times: A. All oxygen titration will be communicated to and coordinated between the nurse and the RRT in charge of the patient. An observation on 05/23/2022 at 9:25 AM with R#52 in R#52's room revealed oxygen set at five liters per minute. An observation of R#52 in room on 05/25/2022 at 2:56 PM revealed R#52 was receiving oxygen at five liters per minute. A review of the Face Sheet for Resident (R) #52 revealed the facility admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) assessment, dated 03/18/2022, revealed R#52 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficits. Additionally, R#52's MDS revealed R#52 had shortness of breath or trouble breathing with exertion, while sitting at rest, and lying flat. The MDS indicated R#52 was receiving oxygen therapy. A review of the Physician's Orders for May 2022 revealed an order dated 03/11/2022 for oxygen at four liters via nasal cannula. A review of Departmental Notes, dated 03/22/2022, revealed a respiratory therapy note that indicated R#52's oxygen was in use via a nasal cannula at five liters per minute and that the resident requested the oxygen liter flow be increased from four liters per minute due to feeling short of breath the previous day after moving back to their room. The note further indicated R#52's oxygen saturation was 99%, and indicated the resident wanted to leave the liter flow rate at five liters per minute. Further review of Departmental Notes, dated 05/20/2022, 05/23/2022, and 05/25/2022 revealed documentation by respiratory therapy that R#52 was receiving oxygen via a nasal cannula at five liters per minute. An interview with Certified Nursing Assistant (CNA) QQ on 05/26/2022 at 11:10 AM revealed R#52's oxygen should be at four liters per minute. An interview with Licensed Practical Nurse (LPN) MM on 05/26/2022 at 11:15 AM revealed R#52's oxygen should be at four liters per minute. An interview with Respiratory Therapist SS on 05/26/2022 at 12:00 PM revealed R#52's oxygen should be on five liters of oxygen and had been for a few weeks. An interview with the Administrator on 05/26/2022 at 1:50 PM revealed all physician orders should be followed and any changes in an order should be communicated to the pharmacy and staff. An interview with the Director of Nursing (DON) on 05/26/2022 at 1:59 PM revealed all physician's orders were expected to be followed. If there were any changes made, they should be communicated to the staff.

Based on interviews, record review and review of job descriptions titled Administrator and Director of Nursing the facility failed to ensure adequate management and monitoring of abnormal vital signs and changes in condition for one of 22 sampled Residents (R#4). The facility census was 117. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy for F580, F600, and F835 on [DATE] at 11:40 a.m. Additionally, the Administrator and Director of Nursing were notified on [DATE] at 12:05 p.m. of the Immediate Jeopardy related to F868. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy is outlined as follows: R#4 was a [AGE] year-old female who was admitted to the facility on [DATE], following hospitalization for an acute ST elevation [MEDICAL CONDITION] infarct (STEMI). Skilled Occupational Therapy (OT) and Physical Therapy (PT) evaluated R#4 on [DATE] and began skilled therapy services on [DATE]. The facility failed to ensure that R#4's physician was notified of Physical Therapy's (PT) continued concerns of abnormal vital signs. The facility failed to notify the physician of the abnormal vital signs that were obtained for R#4 on [DATE]: heart rate (HR): 122 beats per minute, Blood pressure (bp): ,[DATE], Respiratory Rate (RR): 53 breaths per minute. Nursing staff failed to notify the physician that on [DATE] at 12:45 a.m. R#4 was found to have an oxygen saturation rate of 87% on room air with a respiratory rate of 28 breaths per minute and the facility failed to notify the physician that nursing staff started R#4 on oxygen at that time. Additionally, on [DATE] at 10:18 a.m. the Physical Therapist Assistant documented that R#4's vital signs were HR: 124, BP: ,[DATE], and documented that R#4's respiratory rate was 52 breaths per minute. On [DATE] (from 12:00 p.m. - 12:53 p.m.) the Speech Therapist documented that R#4's heartrate was ,[DATE] beats per minute. On [DATE] (from 3:50 p.m. - 4:20 p.m.) the Occupational Therapist documented that R#4 was very lethargic, with a heart rate of 105 beats per minute, and respirations were 33 breaths per minute. OT was unable to obtain a blood pressure, at that time, because R#4's blood pressure was too faint. A nurse note dated [DATE] at 7:51 p.m. documented that R#4's blood pressure was ,[DATE] and that R#4's oxygen saturation was 92% on 2 liters of oxygen via nasal canula. The physician was not notified of R#4's abnormal vital signs or that R#4 had been started on oxygen. On [DATE], at approximately 9:47 p.m., R#4 was found unresponsive. Licensed nursing staff-initiated CPR, due to the residents' full code status. The code, including EMS response and interventions, were unsuccessful and R#4 was pronounced dead at the facility on [DATE] at 10:17 p.m. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at: F580 - Notification of Changes 483.10(g)(14)(i)(B), Scope/Severity: J; F600 - Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J; F835 - Administration, 483.70 Scope/Severity: J; F868 - Quality assessment and assurance 483.75(g)(2)(i), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at F600 Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J. A Removal Plan, Credible Allegation of Compliance (AOC), was received. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the credible AOC, the State Survey Agency validated that the immediacy of the deficient practice (IJ) was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for neglect and notification of change. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing neglect and notification of change. In-service materials were reviewed to ensure appropriate training was given to the staff. Resident records were reviewed to ensure changes in condition were assessed, documented and the physician notified. Findings include: The facility had a job description for the Administrator. The job description included a summary that the Administrator was responsible for the overall management of the facility. The Administrator plans, develops, directs, monitors and supports all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility's program and services. The responsibilities of the Administrator included ensuring the quality and appropriateness of resident care meets or exceeds company and regulatory standards. The facility had a job description for the Director of Nursing (DON). The job description included a summary that the primary purpose of the DON job position was to plan, organize, develop, and direct the day-to-day functions of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility. The list of duties and responsibilities included assisting and developing methods for coordinating nursing services with other resident services to ensure the continuity of the residents' total regimen of care. Facility Administration, including the Administrator and DON, failed to effectively oversee clinical and nursing functions that were included in their job descriptions. 1. Administration failed to ensure that nursing staff notified the physician of abnormal vital signs obtained by therapy and nursing staff and failed to notify the physician that R#4 had been started on oxygen. 2. Administration failed to ensure that nursing staff assessed/reassessed R#4 for abnormal vital signs that were obtained by therapy and by nursing staff over multiple days. Record reviews and interviews with nursing staff and therapy staff provided conflicting information regarding how R#4 presented and who was aware of or who was notified of concerns regarding her abnormal vital signs. There was an absence of evidence that nursing addressed the abnormal vital signs documented by therapy and nursing staff on [DATE] and [DATE]. In addition, there was no evidence that R#4's physician was made aware of Physical Therapy's continued documented concerns regarding her elevated heart rate after [DATE]. There was no evidence that the physician was notified of R#4's abnormal vital signs documented during therapy sessions on [DATE], the subsequent implementation of oxygen for a decreased oxygen saturation and elevated respiratory rate during the early morning hours of [DATE] at 12:45 a.m. or the subsequent abnormal vital signs documented during therapy (PT, SLP, and OT) sessions on [DATE], or the abnormal blood pressure, of ,[DATE], obtained by nursing on [DATE], prior to R#4 being found unresponsive on [DATE] and expiring. During interviews on [DATE] at 1:45 p.m. and on [DATE] at 2:00 p.m., the DON stated that on [DATE] someone either called or came to her office and asked for a nurse to evaluate R#4, so she asked the Assistant Director of Nursing (ADON) to assess R#4. The DON stated that the RN Unit Manager AA was not there that day because she was on-call, so the ADON assessed R#4. After [DATE], the DON stated she was not aware of any further concerns until [DATE], when R#4 expired. During an interview on [DATE] at 12:45 p.m. with the Administrator and the DON, the Administrator confirmed that he was not aware of any concerns regarding R#4 while R#4 was at the facility, or after she expired, prior to surveyor inquiry. The DON stated that they both receive email alerts on information such as critical laboratory results, x-ray reports, and even pharmacy issues, so that they can make sure issues are addressed timely, but they were unaware of any concerns related to R#4. Cross refer to F600 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the company President re-educated facility administration oversight responsibilities with the Administrator with focus on monitoring and timely follow-up. The company President has been in daily contact with the Administrator to ensure that facility Administration actively oversees and ensures that nursing identifies changes in conditions including abnormal vital signs and the implementation of oxygen concerns, and acts timely on those concerns to ensure facility does not neglect residents and provides care and services to residents. The President will remain in weekly contact with the Administrator throughout the remainder of the year. This will be documented on the President Oversight Log to include Date, Time and Setting by the Administrator weekly for the remainder of the year. Administrator was also re-educated on Changes in Condition and Oxygen Administration, Reporting of Abuse in Nursing Homes, Resident Rights, and the Elder Justice Act. 2. On [DATE], the Administrator re-educated nursing administration oversight responsibilities with the DON to ensure that nursing identifies and acts to correct any identified problems/concerns related to changes in condition including vital signs or the implementation of oxygen in a timely manner in attempts to prevent any complications related to the management and treatment of [REDACTED]. Administrator has been monitoring nursing administration closely, and will be reviewing and initialing each Change In Conditions Audit Tool page as the DON, Nurse Managers, or Supervisors submit them, which will be daily, communicating with the DON daily, and following up on any identified issues in a timely manner. DON was also re-educated on Changes in Condition and Oxygen Administration, Reporting of Abuse in Nursing Homes, Resident Rights, and the Elder Justice Act. 3. Additional policies reviewed by the Administrator and DON were Vital Signs and Weights and Transfer-Emergency. These policies did not require change. 4. On [DATE], the Administrator and DON reviewed the policy regarding Change In Resident Condition and revised to specify that notification regarding resident change in condition will be documented in the medical record including the licensed nurse's assessment of the change and any directives given by the physician. 5. On [DATE] the Medical Director was updated on the facility's Change in Resident Condition policy. 6. Beginning on [DATE], for every day that therapy is providing services, a Therapy Audit Tool is submitted from the DOR to the DON/ADON documenting the occurrence of a change in condition. This Therapy Audit Tool includes the following information: Date, Unit/Room number, Resident Name, Change in condition, Reported To, and Action Taken by Nursing. The DON/ADON utilize the Therapy Audit Tool to assess the resident, to follow up with staff interviews, chart reviews, and patient assessment as needed for each resident. This Therapy Audit Tool will be utilized indefinitely. 7. On [DATE], the Administrator and DON initiated a system in which the Administrator and DON will review changes in condition including vital signs or the implementation of oxygen daily Monday through Friday and the nurse supervisor on weekends and holidays. This process will be audited by using a (revised, more robust) Change In Conditions Audit Tool that includes the following: Unit, Date, Room number, Resident Name, Change in Condition to include BP, Pulse, Respirations, 02 SAT, Other, Action Taken, to be completed daily and signed by the Charge Nurse that entered the change in condition, to be signed by the Supervisor to attest the change in condition was noted on their shift, and to be signed by the DON/ADON and Administrator indicated to ensure follow up has occurred. This Change in Conditions Audit Tool will be completed daily by charge nurses indefinitely. This will ensure that Administration effectively oversees and ensures that nursing identifies changes in condition and/or acts timely on reporting problems/concerns, documents actions/interventions, including physician notification, in an attempt to prevent further complications including death. If a change in condition was found not to have been addressed, the resident will be reassessed immediately to include physician follow up if warranted (i.e. if a resident exhibited a blood pressure reading that was unrelieved by measure already prescribed, implementation of oxygen, .). The physician will still be made aware of non-emergent events (i.e. if a resident experienced constipation and had a standing order for [MEDICATION NAME], incurred weight loss, .). and the resident records will be updated by nursing for any changes that were specified. 8. Administration is aware of the failure to react timely to changes in conditions including abnormal vital signs and the implementation of oxygen, may put residents at risk. Administration is aware that failure to provide care and services is neglect. Administration proactively putting processes in place to ensure that this failure does not happen again. Administration is auditing and monitoring to ensure that this does not reoccur. The actions completed (listed in the removal plan above) by the facility's Administration during this removal plan implementation includes the following areas: in¿ servicing of all facility nursing staff (to include agency) and therapy, completion of employee actions with individual re-education, and daily compliance monitoring by Nurse Management/ Administration. Additionally, facility Administration collaborated with physician and nursing consultant to achieve completion of reviews of residents' vital signs and a revision of the policy regarding Change in Resident Condition. The improved oversight of changes in condition including vital signs or the implementation of oxygen by the facility's Administration provides assurance that this will be properly managed. 9. The results of the compliance monitoring are being reviewed at monthly and quarterly QAA/QAPI meetings for data review, analysis, trend identification, and issue resolution presented by the DON/Administrator to include the Medical Director, and will continue for the remainder of the year, with the next meeting scheduled for [DATE]. 10. All corrective actions were completed on [DATE]. 11. The facility alleges that the immediacy of the jeopardy was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Verified via review of the Administrator Job Description and President Oversight Log, which included date, time and topics discussed between the company President and Administrator, including the [DATE] re-education of the Administrator on oversight and responsibilities. Also verified via interview on [DATE] at 1:15 p.m. with the Administrator who confirmed re-education on his responsibilities and daily contact with the company President, either in-person or by phone. 2. Verified via review of the Director of Nursing Job Description and review of the Change in Condition Audit Tools that were signed by the Administrator and the DON. Also verified via interviews on [DATE] at 12:00 p.m. with the DON and 1:15 p.m. with the Administrator. 3. Verified via review of the Vital Signs and Weights Policy, dated [DATE] and the Transfer-Emergency Policy, dated [DATE]. Also verified via interviews on [DATE] at 12:00 p.m. with the DON and at 1:15 p.m. with the Administrator that there were not any changes made to these policies. 4.Verified via review of the Change in Condition Policy, dated [DATE], which included the revised section and via record review that change in conditions were documented in the resident's medical record per the updated policy. 5. Verified via interview with the Medical Director on [DATE] at 3:25 p.m. 6.Verified via review of the Therapy Audit Tools which included change noted, who it was reported to and the action taken by nursing staff. Verified via review of the Therapy Audit Tools, dated [DATE] and [DATE] which included a log of resident changes noted by therapy staff, who the information was reported to, and the follow up from nursing. Also verified via an email from the Director of Rehab to the DON on [DATE] communicating that there were no changes to residents noted for that day. During interviews on [DATE] at 11:50 a.m. with the OT/Director of Rehab, at 4:05 p.m. with the ADON and on [DATE] at 12:00 p.m. with the DON, they confirmed the use of the Therapy Audit Tool and communication between nursing and therapy staff. 7. Verified via review of the Change in Condition Audit Tool. Also verified via interviews on [DATE] at 12:00 p.m. with the DON and 1:15 p.m. with the Administrator, who confirmed that the audit tools were implemented and being reviewed. 8.Verified via interviews on [DATE] at 12:00 p.m. with the DON and at 1:15 p.m. with the Administrator. 9.Verified via interviews on [DATE] at 12:00 p.m. with the DON and at 1:15 p.m. with the Administrator that the results of the compliance monitoring would continue to be reviewed at monthly and quarterly QAA meetings. 10. Verified via interviews and record reviews listed above. 11. The immediacy of the jeopardy was removed on [DATE].

Based on interviews, record reviews, and policy review, the facility failed to ensure the physician was notified of abnormal vital signs and the implementation of oxygen for one of 22 sampled residents (R#4). On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy for F580, F600, and F835 on [DATE] at 11:40 a.m. Additionally, the Administrator and Director of Nursing were notified on [DATE] at 12:05 p.m. of the Immediate Jeopardy related to F868. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy is outlined as follows: R#4 was a [AGE] year-old female who was admitted to the facility on [DATE], following hospitalization for an acute ST elevation [MEDICAL CONDITION] infarct (STEMI). Skilled Occupational Therapy (OT) and Physical Therapy (PT) evaluated R#4 on [DATE] and began skilled therapy services on [DATE]. The facility failed to ensure that R#4's physician was notified of Physical Therapy's (PT) continued concerns of abnormal vital signs. The facility failed to notify the physician of the abnormal vital signs that were obtained for R#4 on [DATE]: heart rate (HR): 122 beats per minute, Blood pressure (bp): ,[DATE], Respiratory Rate (RR): 53 breaths per minute. Nursing staff failed to notify the physician that on [DATE] at 12:45 a.m. R#4 was found to have an oxygen saturation rate of 87% on room air with a respiratory rate of 28 breaths per minute and the facility failed to notify the physician that nursing staff started R#4 on oxygen at that time. Additionally, on [DATE] at 10:18 a.m. the Physical Therapist Assistant documented that R#4's vital signs were HR: 124, BP: ,[DATE], and documented that R#4's respiratory rate was 52 breaths per minute. On [DATE] (from 12:00 p.m. - 12:53 p.m.) the Speech Therapist documented that R#4's heartrate was ,[DATE] beats per minute. On [DATE] (from 3:50 p.m. - 4:20 p.m.) the Occupational Therapist documented that R#4 was very lethargic, with a heart rate of 105 beats per minute, and respirations were 33 breaths per minute. OT was unable to obtain a blood pressure, at that time, because R#4's blood pressure was too faint. A nurse note dated [DATE] at 7:51 p.m. documented that R#4's blood pressure was ,[DATE] and that R#4's oxygen saturation was 92% on 2 liters of oxygen via nasal canula. The physician was not notified of R#4's abnormal vital signs or that R#4 had been started on oxygen. On [DATE], at approximately 9:47 p.m., R#4 was found unresponsive. Licensed nursing staff-initiated CPR, due to the residents' full code status. The code, including EMS response and interventions, were unsuccessful and R#4 was pronounced dead at the facility on [DATE] at 10:17 p.m. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at: F580 - Notification of Changes 483.10(g)(14)(i)(B), Scope/Severity: J; F600 - Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J; F835 - Administration, 483.70 Scope/Severity: J; F868 - Quality assessment and assurance 483.75(g)(2)(i), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at F600 Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J. A Removal Plan, Credible Allegation of Compliance (AOC), was received. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the credible AOC, the State Survey Agency validated that the immediacy of the deficient practice (IJ) was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for neglect and notification of change. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing neglect and notification of change. In-service materials were reviewed to ensure appropriate training was given to the staff. Resident records were reviewed to ensure changes in condition were assessed, documented and the physician notified. Findings include: The facility had a Change in Resident Condition policy, dated [DATE]. The policy documented that it was the intent of the facility to maintain communication with the physician when changes in a resident's condition warrant. The policy included that the physician is notified as soon as feasibly possible when the resident's physical, communicative, psychosocial or function status changes. The policy also documented that if a change occurs in a resident the licensed nurse will perform an assessment and report findings to the physician, and notification regarding resident change in condition will be documented in the medical record. However, facility nursing staff failed to notify R#4's physician of abnormal vital signs obtained by therapy and nursing staff. R#4 was admitted to the facility on [DATE], following hospitalization [DATE] through [DATE] for an acute ST elevation [MEDICAL CONDITION] infarct (STEMI). R#4's physician completed and signed a Physician Admission History and Physical form on [DATE]. Skilled Occupational Therapy (OT) and Physical Therapy (PT) evaluated R#4 on [DATE] and began treatment on [DATE]. Skilled Speech Therapy evaluated R#4 on [DATE] and began treatment on [DATE]. Review of PT notes from [DATE] revealed concerns related to R#4's elevated heart rate of 112 beats per minute (bpm), treatment was held, and nursing staff were notified. The PT note dated [DATE] 4:27 p.m. documented that R#4 was more lethargic compared to the previous day, heart rate and blood pressure were taken and showed 112 beats per minute (bpm) with a blood pressure of ,[DATE], and PT elected not to conduct therapy with R#4 at that time. Review of Nurses Notes from [DATE] revealed the Assistant Director of Nursing (ADON) assessed R#4 following PT's concern and documented the assessment in a nurse's note dated [DATE] 12:00 p.m. The ADON's nurse note on [DATE] documented that the resident was alert and responsive, but stated she was tired and included an assessment of vital signs (heart rate 109, blood pressure ,[DATE], respiratory rate 24, temperature 98.3, and oxygen saturation of 94% on room air). Further review of the [DATE] 4:27 p.m. PT note revealed that it also included that PT returned to re-evaluate R#4 to see if she was stable to continue with therapy after the ADON's assessment was completed. The PT note documented that on evaluation of R#4's vital signs the heart rate was again 112 and the respiratory rate was between ,[DATE] respirations per minute. The note indicates nursing was again notified and that further treatment was held until the physician evaluated R#4. During an interview on [DATE] at 12:00 p.m. PT BB confirmed that he evaluated R#4 on [DATE] and began treatment on [DATE]. PT BB stated after the ADON assessed R#4 on [DATE] that PT BB returned to check on R#4, he stated his concerns were the same. He confirmed that when he returned to R#4 again on [DATE], and her heart rate was still elevated, he reported the elevated heart rate to the charge nurse. Further review of PT notes revealed continued concerns documented on [DATE] and [DATE] concerning R#4's elevated heart rate. The PT notes also included that nursing was notified. The PT note dated [DATE] 2:00 p.m. documented that R#4 was assessed that morning and that vital signs were obtained including a heart rate of 112 beats per minute and a respiratory rate of 36 breaths per minute and nursing was alerted of the concerns. The [DATE] 4:13 p.m. PT note documented a heart rate of 120 bpm that morning and that nursing was notified. PT included in the note that he returned later in the morning to check on R#4, and her heart rate was 112 bpm which continued to be too high to mobilize status [REDACTED]. During an interview on [DATE] at 12:00 p.m. PT BB confirmed he reported R#4's abnormal vital signs and his concerns to nursing staff on [DATE] and [DATE]. Review of the clinical record for R#4 revealed a nurse note entry dated [DATE] at 6:52 p.m., which revealed that PT reported an elevated heart rate of 120, but also included that it was prior to the 9:00 a.m. medications, and that after 9:00 a.m. medications were administered the heart rate was rechecked and was 107. The [DATE] nurse's note also included that R#4's respirations were noted to be 33 breaths and that the supervisor was notified and the 3:00 p.m. to 11:00 p.m. nurse was notified to inform the physician if there were any changes noted. During an interview on [DATE] at 2:02pm Licensed Practical Nurse (LPN) GG confirmed that PT spoke with her about R#4. LPN GG stated that when she went in to assess R#4, R#4 had a respiratory rate of 33 but did not appear to be in distress. LPN GG recalled R#4's oxygen saturation being 96%. LPN GG stated that she did report the respiratory rate to the supervisor and asked about calling the physician and the supervisor told her no, not if R#4 was stable and not in distress, to monitor. LPN GG stated that it was odd to her, that with a respiratory rate of 33, R#4 was alert, watching tv and did not appear in distress. Review of the clinical records for R#4 for [DATE] and [DATE] revealed that there was no evidence that the physician was notified of therapy's continued concerns of an elevated heart rate, or elevated respiratory rate. There was not any communication written in the clinical record or in the physician's communication book. Review of the [DATE] Medication Administration Record [REDACTED]. On [DATE] SLP II treated R#4 from 11:31 a.m. to 12:10 p.m. and included in her [DATE] 1:59 p.m. therapy notes that R#4 was noted to have a rapid heart rate and respirations, however, was more alert and communicative and that R#4 responded that she felt okay. During an interview on [DATE] at 3:49 p.m., SLP II stated that she reported the rapid heart rate and respirations to the nurse, who was getting ready to go in with medications but did not recall the nurse's name. On a [DATE] 12:38 p.m. note, PTA CC included in her therapy notes that R#4's heart rate was 122 beats per minute and the manual blood pressure was ,[DATE] with very quiet heart sounds and respirations were 53 breaths per minute at rest. During interviews on [DATE] at 11:30 a.m. and [DATE] at 11:45 a.m., PTA CC stated that she reported the vital signs to the nurse and was not able to provide physical therapy to R#4 on [DATE] due to the poor vitals. However, there was no evidence in R#4's clinical record that the physician was notified of the abnormal vital signs that had been reported by therapy staff. A review of the [DATE] Medication Administration Record [REDACTED]. On [DATE] the night shift nurse (LPN LL), that worked from [DATE] from 11:00 p.m. to [DATE] at 7:00 a.m., documented in a [DATE] 2:45 a.m. nurse's note that at approximately 12:45 a.m., R#4 was noted to have rapid respirations of 28 breaths per minute and that R#4's oxygen saturation was 87% on room air. Supplemental oxygen was started at two liters via nasal cannula. There was no evidence in the clinical record that the physician was notified of R#4's rapid respirations, decreased oxygen saturation, or the implementation of oxygen on [DATE]. During an interview on [DATE] at 10:28 a.m. LPN LL confirmed that she did not notify the physician of R#4's rapid respirations, decreased oxygen saturation, and that R#4 had been started on oxygen on [DATE]. Review of LPN LL's [DATE] 2:45 a.m. nurse's note regarding the implementation of oxygen for R#4, over the course of the day revealed that R#4 had additional abnormal vital signs. A PTA note dated [DATE] 10:18 a.m., documented by PTA CC, included that vital signs for R#4 were obtained prior to therapy treatment and included a blood pressure of ,[DATE], heart rate of 124 beats per minute (bpm), very shallow breaths, and a respiratory rate of 52 shallow breaths per minute. The therapy notes documented that R#4 reported feeling bad that morning and her heart rate was above the recommended range for mobility training. The therapy note further documented that a pulse oximeter was donned to attempt to check oxygen saturation but was unable to obtain an oxygen saturation reading and that nursing was aware of vital signs that morning. Also, on [DATE], SLP II documented therapy notes from her session with R#4 on [DATE] (that occurred from 12:00 p.m.-12:53 p.m.). The therapy notes documented the new use of oxygen and included a heart rate of 48 and 49 during the session. During interviews on [DATE] at 3:49 p.m. and on [DATE] at 2:31 p.m., SLP II confirmed that she reported the abnormal heart rate (,[DATE]) to R#4's nurse on [DATE]. However, a review of R#4's clinical record revealed no evidence that the physician was notified of the abnormal vital signs that were by therapy staff. During an interview on [DATE] at 11:00 a.m. RN Unit Manager AA (RN AA) stated that she was not aware of the abnormal vital signs from therapy on [DATE]. RN AA stated that nursing staff came and got her on [DATE] at the 3:00 p.m. to 11:00 p.m. shift change and reported that R#4 was not acting like herself (R#4 was really quiet and staring off out the window). RN AA stated she went and talked to R#4, who was alert with no labored breathing. RN AA stated that the CNA obtained vital signs and there was nothing that alarmed her. RN AA stated that the evening shift LPN (LPN FF) accompanied her to R#4's room and R#4 acted as if they were bothering her by asking her if she was okay. During an interview on [DATE] at 11:30 a.m. LPN HH confirmed she was the nurse, for R#4, who worked day shift from 7:00 a.m. to 3:00 p.m. on [DATE]. LPN HH did not recall being notified of any abnormal vital signs for R#4 from therapy staff. LPN HH stated that therapy staff normally go in and review a patient and come out and report findings, that was a normal routine, but she did not recall them reporting anything out of the normal for R#4. In addition to the PTA and SLP notes from [DATE] that included abnormal vital signs, the Occupational Therapist (OT) also documented in a [DATE] 5:39 p.m. therapy note, for the therapy session with R#4 (that occurred from 3:50 p.m. - 4:20 p.m. on [DATE]) that R#4 presented as very lethargic and with a resting heart rate of 105 and that R#4's blood pressure was not able to be obtained because it was too faint. The note included that R#4 continued to present with a respiratory rate of 33+ breaths per minute while lying supine in bed, which was measured multiple times throughout the session. During interviews on [DATE] at 12:30 p.m. and [DATE] at 12:45 p.m., the OT Rehab Manager, stated that R#4 had no outward distress like someone you would think with the type of respirations (documented in the [DATE] note), that R#4 appeared comfortable, with no complaints of pain. The OT Rehab Manager stated that therapy staff took R#4's vital signs very seriously, that her pulse was faint so they would try it at different sites. He confirmed that he did convey the vital signs from his therapy session with R#4 on [DATE] to the nurse but did not recall who it was specifically that day. Following the [DATE] 5:39 p.m. OT note, a further review of the clinical record revealed a [DATE] 7:51 p.m. nurse's note (by LPN FF) that documented R#4's vital signs were: blood pressure of ,[DATE], pulse 91, respirations 20, and oxygen saturation of 92% on two liters per minute of oxygen via nasal cannula. During an interview on [DATE] at 11:00 a.m. LPN FF, who worked the [DATE] 3:00 p.m.- 11:00 p.m. shift stated that R#4 was extremely lethargic at the start of the shift and the CNA asked the Unit Manager to check R#4 out. LPN FF stated that she had not received report yet, so she went with the Unit Manager, who talked to R#4. LPN FF verified that she obtained R#4's vital signs around 3:20 p.m. or 3:25 p.m. and included that R#4's BP was ,[DATE], HR 91, RR 20, and oxygen saturation was 92% on two liters per minute of oxygen via nasal cannula. and that she had obtained these vital signs around 3:20 p.m. or 3:25 p.m. LPN FF documented that she told the Unit Manager about the vital signs and the Unit Manager had talked to R#4's family on the phone. (LPN FF documented these vital signs in the [DATE] 7:51 p.m. nurse's note). Record review revealed that there was no evidence that the Physician was notified of R#4's increased lethargy or her abnormally low blood pressure of ,[DATE] documented by LPN FF on [DATE]. During the [DATE] 11:00 a.m. interview, LPN FF confirmed that she did not notify the physician of R#4's blood pressure of ,[DATE]. Further review of the nurse's note entry on [DATE] at 11:55 p.m. revealed LPN FF entered R#4's room at approximately 9:47 p.m. to administer medications and observed R#4 take a deep breath which was held for ,[DATE] seconds before she took another breath for the same duration. The nurses note documented that R#4's skin color was ashen and the resident was not responsive to sternal rub. A code was called, and CPR was initiated. The nurse's note further revealed the arrival of EMS and the implementation of an Automated External Defibrillator (AED) device; however, they were unable to revive the resident and R#4 was pronounced dead on [DATE] at 10:17 p.m. There was no evidence that R#4's physician was made aware of Physical Therapy's continued documented concerns regarding her elevated heart rate after [DATE]. There is no evidence that the physician was notified of R#4's abnormal vital signs documented during therapy sessions (PT and SLP) on [DATE], the subsequent implementation of oxygen (by nursing) for a decreased oxygen saturation and elevated respiratory rate during the early morning hours of [DATE] (12:45 a.m.) or the subsequent abnormal vital signs documented during therapy (PT, SLP, and OT) sessions on [DATE], or the abnormal blood pressure of ,[DATE] that was obtained by nursing on [DATE]. During an interview on [DATE] at 3:56 p.m., Physician WW confirmed that he would have expected to have been notified of therapy's continued concerns for R#4's elevated heart rate interfering with PT treatment after [DATE]. Physician WW stated he would have expected to have been notified of the decreased oxygen saturation rate, elevated respirations, and use of the oxygen on [DATE]. Cross refer to F600 The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident R#4 expired in the facility on [DATE]. 2. Beginning on [DATE], after surveyor inquiries, DON and ADON began interacting with the Director of Rehab (DOR) to address any communication issues between therapy and nursing via emails. Any PT, OT, PTA, COTA, RT or SLP that observes a change in condition while performing treatment of [REDACTED]. The charge nurse would immediately assess the resident for any change in condition. If orders are in place to treat the change in condition, the charge nurse would follow the orders on the chart. If needed, the physician would be notified immediately to instruct the charge nurse as how to address the resident's change in condition (i.e. if a resident exhibited a blood pressure reading that was unrelieved by measure already prescribed, implementation of oxygen, .). The physician will still be made aware of non¿ emergent events (i.e. if a resident experienced constipation and had a standing order for [MEDICATION NAME], incurred weight loss, .) during weekly rounds by placing the event in the physician's notebook. Any assessment findings or new directives/orders will be documented by nursing in the resident's chart before the end of the shift. The PT, OT, PTA, COTA, RT or SLP would then communicate the change in condition to the DOR. The facility will immediately inform the resident, physician, and/or patient/patient legal representative resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility. 3. Beginning on [DATE], for every day that therapy is providing services, a Therapy Audit Tool is submitted from the DOR to the DON/ADON documenting the occurrence of a change in condition. This Therapy Audit Tool includes the following information: Date, Unit/Room number, Resident Name, Change in condition, Reported To, and Action Taken by Nursing. The DON/ADON utilize the Therapy Audit Tool to assess the resident, to follow up with staff interviews, chart reviews, and patient assessment as needed for each resident. This Therapy Audit Tool will be utilized indefinitely. Medical Director has given direction to DOR that therapy is able to contact the Medical Director immediately with any concern therapy may have that therapy feels may need addressing, provided that a nurse is with them on the call to ensure interactions can be carried out. 4. On [DATE], the Administrator/DON/ADON reviewed the policy regarding Change In Resident Condition and revised to specify that notification regarding resident change in condition will be documented in the medical record including the licensed nurse's assessment of the change and any directives given by the physician. 5. Any CNA that observes a change in condition while performing care of any resident throughout the facility would immediately contact the charge nurse. Any charge nurse that observes a change in condition while performing care of any resident throughout the facility would take the following actions. The charge nurse would immediately assess the resident for any change in condition. If orders are in place to treat the change in condition, the charge nurse would follow the orders on the chart. If needed, the physician would be notified immediately to instruct the charge nurse as how to address the resident's change in condition (i.e. if a resident exhibited a blood pressure reading that was unrelieved by measure already prescribed, implementation of oxygen, .). The physician will still be made aware of non-emergent events (i.e. if a resident experienced constipation and had a standing order for [MEDICATION NAME], incurred weight loss, .). Any assessment findings or new directives/orders will be documented by nursing in the resident's chart before the end of the shift. 6. On [DATE] the Administrator, DON, ADON and the nurse managers began the process of reviewing all active resident charts for changes in conditions since [DATE]. This was to ensure that changes in conditions including abnormal vital signs or the implementation of oxygen usage received follow up to include notifying the attending physician if necessary. This was performed by the unit managers using a Change In Conditions Audit Tool that listed the dates of the week reviewed, who performed the audit, the name of every resident on each unit, the abnormal blood pressure, pulse, respirations, or 02 saturation that required review, and the action taken. (Abnormal blood pressure would be indicated by any systolic BP greater than 150 or less than 90 or any diastolic BP less than 60 or greater than 100. Abnormal heart rate would be greater than 100 beats per minute or less than SO beats per minute. Abnormal respirations would be greater than 22 breaths per minute or less than 12 breaths per minute. Abnormal oxygen saturation is lower than 90%). The information was submitted to and reviewed by the Administrator, DON and ADON. This audit tool was used to ensure that any residents that had a change in condition regarding vital signs or the implementation of oxygen was followed up to include notifying the physician if necessary. 7. The unit managers reviewed vital signs of 116 of 116 residents. There were 41 residents that exhibited an abnormal vital sign that required intervention. Of those 41 residents, 7 had abnormal vital signs that had not been addressed. The vital signs for those 7 residents were communicated to the physician for follow up, the residents were reassessed immediately, and the resident records were addressed by nursing to document any changes that were warranted. 8. On [DATE], the Administrator and DON initiated a system in which the Administrator and DON will review changes in condition including vital signs or the implementation of oxygen daily Monday through Friday and the nurse supervisor on weekends and holidays. This process will be audited by using a revised Change In Conditions Audit Tool that includes the following: Unit, Date, Room number, Resident Name, Change in Condition to include BP, Pulse, Respirations, 02 SAT, Other, Action Taken, to be completed daily and signed by the Charge Nurse that entered the change in condition, to be signed by the Supervisor to attest the change in condition was noted on their shift, and to be signed by the DON/ADON and Administrator indicated to ensure follow up has occurred. This Change in Conditions Audit Tool will be completed daily by charge nurses indefinitely. This will ensure that Administration effectively oversees and ensures that nursing identifies changes in condition and/or acts timely on reporting problems/concerns, documents actions/interventions, including physician notification, in an attempt to prevent further complications including death. If a change in condition was found not to have been addressed, the resident will be reassessed immediately to include physician follow up if warranted (i.e. if a resident exhibited a blood pressure reading that was unrelieved by measure already prescribed, implementation of oxygen, .). The physician will still be made aware of non-emergent events (i.e. if a resident experienced constipation and had a standing order for [MEDICATION NAME], incurred weight loss, .). and the resident records will be updated by nursing for any changes that were specified. 9. In order to monitor changes in condition on all shifts daily to include weekends and holidays, the 24- hour report will be utilized by nursing staff to document any changes in condition including abnormal vital signs and the implementation of oxygen that require follow up. Nurse supervisors will review the 24-hour report every shift daily to include weekends and holidays. This 24-hour report will be utilized daily to ensure that all residents needs are met. If a problem is encountered during compliance monitoring, the Nurse Manager, Supervisor, DON, or ADON is responsible for providing documented employee actions and re-instruction of the nursing staff making the error. Any resident exhibiting the change in condition will be re-assessed immediately by nursing and will notify the DON immediately of any changes in condition. Any resident exhibiting a change in condition will be communicated to the physician for follow up if necessary (i.e. if a resident exhibited a blood pressure reading that was unrelieved by measure already prescribed, implementation of oxygen, .). The physician will still be made aware of non-emergent events (i.e. if a resident experienced constipation and had a standing order for [MEDICATION NAME], incurred weight loss, .) during weekly rounds by placing the event in the physician's notebook. Resident records will be updated by nursing for any changes that were specified by the end of the shift. Any further non-compliance for the same nursing staff will result in further progressive employee actions in accordance with facility protocol to ensure compliance. The facility will immediately inform the resident, physician, and/or patient/patient legal representative resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility. 10. To ensure that any change in conditions to include abnormal vital signs or implementation of oxygen are being recognized and placed on the 24-hour report by nursing staff, we are having the charge nurses document on the MAR indicated [REDACTED]. Resident records will be updated by nursing for any changes that were specified by the end of the shift. This will be completed indefinitely. 11. The unit managers will audit 10 resident MARs to ensure that charge nurses are in compliance with notification of change. This will occur for 3 times a week for 4 weeks, then twice weekly for 8 weeks, then weekly for the remainder of the year. This will be documented by utilizing the Change In Conditions Audit Tool that includes the following: Unit, Date, Room number, Resident Name, Change in Condition to include BP, Pulse, Respirations, 02 SAT, Other, Action Taken, Charge Nurse responsible, Supervisor signature, DON/ADON and Administrator review. This will ensure that changes in conditions will be captured on the 24-hour report to then be placed on the Change in Conditions Audit Tool that will be reviewed by the nurse supervisor, the DON/ADON and Administrator. 12. The unit managers/nurse supervisors will report to the DON/ADON whether or not there were any change in conditions during their shift daily, to include weekends and holidays. This will be documented by utilizing the Change In Conditions Audit Tool that includes the following: Unit, Date, Room number, Resident Name, Change in Condition to include BP, Pulse, Respirations, 02 SAT, Other, Action Taken, Charge Nurse responsible, Supervisor signature, DON/ADON and Administrator review. This will be completed indefinitely. 13. On [DATE] the Administrator, DON, and ADON implemented a plan to review all active resident charts throughout the facility to ensure that any resident who was receiving oxygen had an order from the attending physician. This was performed by the Respiratory Therapist using an Oxygen Usage Audit Tool that listed the date reviewed, who performed the audit, room number, resident name, 02 Delivery, 02 Saturation, and the date of the physician's 02order. The information was submitted to and reviewed by the Administrator, DON and ADON. This audit tool was used to ensure that the physician was knowledgeable of every resident in the facility that required implementation of oxygen. The Respiratory Therapist reviewed oxygen usage of 116 of 116 residents. There were 15 residents that use oxygen either full time or PRN. Of those 15 residents, 4 did not have orders in their charts (TRUNCATED)

Based on interviews, record reviews and policy review, the facility neglected to ensure that abnormal vital signs obtained by therapy staff and nursing staff were addressed by nursing staff for further treatment for one of 22 sampled residents (R#4) who expired in the facility. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy for F580, F600, and F835 on [DATE] at 11:40 a.m. Additionally, the Administrator and Director of Nursing were notified on [DATE] at 12:05 p.m. of the Immediate Jeopardy related to F868. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy is outlined as follows: R#4 was a [AGE] year-old female who was admitted to the facility on [DATE], following hospitalization for an acute ST elevation [MEDICAL CONDITION] infarct (STEMI). Skilled Occupational Therapy (OT) and Physical Therapy (PT) evaluated R#4 on [DATE] and began skilled therapy services on [DATE]. The facility failed to ensure that R#4's physician was notified of Physical Therapy's (PT) continued concerns of abnormal vital signs. The facility failed to notify the physician of the abnormal vital signs that were obtained for R#4 on [DATE]: heart rate (HR): 122 beats per minute, Blood pressure (bp): ,[DATE], Respiratory Rate (RR): 53 breaths per minute. Nursing staff failed to notify the physician that on [DATE] at 12:45 a.m. R#4 was found to have an oxygen saturation rate of 87% on room air with a respiratory rate of 28 breaths per minute and the facility failed to notify the physician that nursing staff started R#4 on oxygen at that time. Additionally, on [DATE] at 10:18 a.m. the Physical Therapist Assistant documented that R#4's vital signs were HR: 124, BP: ,[DATE], and documented that R#4's respiratory rate was 52 breaths per minute. On [DATE] (from 12:00 p.m. - 12:53 p.m.) the Speech Therapist documented that R#4's heartrate was ,[DATE] beats per minute. On [DATE] (from 3:50 p.m. - 4:20 p.m.) the Occupational Therapist documented that R#4 was very lethargic, with a heart rate of 105 beats per minute, and respirations were 33 breaths per minute. OT was unable to obtain a blood pressure, at that time, because R#4's blood pressure was too faint. A nurse note dated [DATE] at 7:51 p.m. documented that R#4's blood pressure was ,[DATE] and that R#4's oxygen saturation was 92% on 2 liters of oxygen via nasal canula. The physician was not notified of R#4's abnormal vital signs or that R#4 had been started on oxygen. On [DATE], at approximately 9:47 p.m., R#4 was found unresponsive. Licensed nursing staff-initiated CPR, due to the residents' full code status. The code, including EMS response and interventions, were unsuccessful and R#4 was pronounced dead at the facility on [DATE] at 10:17 p.m. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at: F580 - Notification of Changes 483.10(g)(14)(i)(B), Scope/Severity: J; F600 - Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J; F835 - Administration, 483.70 Scope/Severity: J; F868 - Quality assessment and assurance 483.75(g)(2)(i), Scope/Severity: J. Additionally, Substandard Quality of Care was identified with the requirements at F600 Freedom from Abuse, Neglect, and Exploitation 483.12, Scope/Severity: J. A Removal Plan, Credible Allegation of Compliance (AOC), was received. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the credible AOC, the State Survey Agency validated that the immediacy of the deficient practice (IJ) was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents for neglect and notification of change. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing neglect and notification of change. In-service materials were reviewed to ensure appropriate training was given to the staff. Resident records were reviewed to ensure changes in condition were assessed, documented and the physician notified. Findings include: The facility had a Change in Resident Condition policy, dated [DATE]. The policy documented that it was the intent of the facility to maintain communication with the physician when changes in a resident's condition warrant. The policy included that the physician is notified as soon as feasibly possible when the resident's physical, communicative, psychosocial or function status changes. The policy also documented that if a change occurs in a resident the licensed nurse will perform an assessment and report findings to the physician, and notification regarding resident change in condition will be documented in the medical record. The facility had a Vital Signs and Weights policy, dated [DATE]. The policy documented that heights, weights, and vital signs of residents were monitored regularly. The policy also included that temperature, pulse, respirations, blood pressure, height and weight are taken on all residents on admission, monthly, as ordered, and/or when needed. RN Managers or Charge Nurses are responsible for comparing the current vital signs with previous results, for taking appropriate action when variances are noted, and for writing a nursing note. However, facility nursing staff failed to reassess and document R#4's condition after abnormal vital signs were obtained and failed to notify R#4's physician of abnormal vital signs obtained by therapy and nursing staff. R#4 was admitted to the facility on [DATE], following hospitalization from [DATE] through [DATE] for acute ST elevation [MEDICAL CONDITION] infarct (STEMI). R#4's physician completed and signed a Physician Admission History and Physical form on [DATE]. Skilled Occupational Therapy (OT) and Physical Therapy (PT) evaluated R#4 on [DATE] and began treatment on [DATE]. Skilled Speech Therapy evaluated R#4 on [DATE] and began treatment on [DATE]. Review of PT notes from [DATE] revealed concerns related to R#4's elevated heart rate of 112 beats per minute (bpm), treatment was held, and nursing staff was notified. The PT note dated [DATE] 4:27 p.m. documented that R#4 was more lethargic compared to the previous day, heart rate and blood pressure taken and showed 112 beats per minute (bpm) with a blood pressure of ,[DATE], and PT elected not to conduct therapy with R#4 at that time. Review of Nurses Notes from [DATE] revealed the Assistant Director of Nursing (ADON) assessed R#4 following PT's concern and documented the assessment in a nurse's note dated [DATE] 12:00 p.m. The ADON's note on [DATE] documented that the resident was alert and responsive, but stated she was tired and included an assessment of vital signs (heart rate 109, blood pressure ,[DATE], respiratory rate 24, temperature 98.3, and oxygen saturation of 94% on room air). The note also documented that R#4 had refused her medications that morning, and she was encouraged to take her medications. The ADON also included an entry in the physician's notebook. Review of R#4's physician's notebook revealed an entry on [DATE] documenting that R#4 was alert but lethargic, that PT had requested a nurse assessment, that R#4 had refused her medications that morning and had been encouraged to take them. A resting heart rate of 116 beats per minute was also included in the entry and that the pulse would be reassessed after taking medications. Further review of the [DATE] entry in the physician's notebook revealed an entry of noted in the physician's response column. During interviews on [DATE] at 2:03pm and [DATE] at 11:20 a.m., the ADON confirmed that she assessed R#4 and made the entry in the physician's notebook on [DATE]. She stated that she reported the information to Registered Nurse (RN) Unit Manager AA the following day, on [DATE], and was not aware of any further abnormal vital signs or concerns for R#4 after [DATE]. Review of the PT noted dated [DATE] 4:27 p.m. revealed that PT returned to R#4 after the ADON assessment on [DATE]. PT again took R#4's vital signs and the heart rate was again 112 beats per minute and the respiratory rate was between ,[DATE] respirations per minute. The note documents nursing was again notified, and that further treatment was held until the physician evaluated R#4. During an interview on [DATE] at 12:00 p.m. PT BB confirmed that he evaluated R#4 on [DATE] and began treatment on [DATE]. PT BB stated that when he evaluated R#4 on [DATE], R#4 was alert, talking, answering questions and actually kind of snippy. However, the next day, on [DATE], she was not really answering questions and kept her eyes closed. He stated he assessed her vital signs and did not provide physical therapy that day, that her condition prevented treatment that day. PT BB stated that during the evaluation (on [DATE]) everything was normal, R#4 was weak of course, but her vital signs were stable, but on [DATE] he had concerns. After the ADON assessed her on [DATE] and PT BB returned to check on R#4, he stated his concerns were the same. He confirmed that when he returned to R#4 again on [DATE], and her heart rate was still elevated, he reported it to the charge nurse, but could not recall which charge nurse. Further review of PT notes revealed continued concerns documented on [DATE] and [DATE] concerning R#4's elevated heart rate. The PT notes also included that nursing was notified. The [DATE] 2:00 p.m. PT note documented that R#4 was assessed that morning. The note documents that vital signs were obtained that included a heart rate of 112 beats per minute and a respiratory rate of 36 breaths per minute and that nursing was alerted of concerns. The [DATE] 4:13 p.m. PT note documented a heart rate of 120 bpm that morning and that nursing was notified. PT included in the note that he returned later in the morning to check on R#4, and her heart rate was 112 bpm which continued to be too high to mobilize, the resident, and that nursing was again notified. The PT note also documented that if the resident continued to demonstrate an elevated heart rate at rest the next week, she would be discharged from physical therapy. During an interview on [DATE] at 12:00 p.m. PT BB confirmed he reported R#4's abnormal vital signs and his concerns to nursing staff on [DATE] and [DATE]. However, a review of R#4's clinical record revealed no evidence that any nurse note entry or an assessment of R#4 for was conducted on [DATE]. Review of a nurses noted dated [DATE] 6:52 p.m. (documented by LPN GG) revealed that PT reported an elevated heart rate of 120, but also included that it was prior to R#4's 9:00 a.m. medications, and that after 9:00 a.m. medications were administered, R#4's heart rate was rechecked and was 107. The [DATE] nurse's note also documented that R#4's respirations were noted to be 33 breaths per minute and that the supervisor was notified and the 3:00 p.m. to 11:00 p.m. nurse was notified to inform the physician if there were any changes noted. During an interview on [DATE] at 2:02 p.m. Licensed Practical Nurse (LPN) GG confirmed that PT spoke with her about R#4. LPN GG stated that when she went in to assess R#4, the resident had a respiratory rate of 33 breaths per minute but did not appear to be in distress. LPN GG recalled R#4's oxygen saturation being 96%. LPN GG stated that she did report the respiratory rate to the supervisor and asked about calling the physician and the supervisor told her no, not if R#4 was stable and not in distress, to monitor. LPN GG stated that it was odd to her, that with a respiratory rate of 33 breaths per minute, that R#4 was alert, watching tv and did not appear in distress. There was no evidence in the clinical record or on the physician's communication book that the physician was notified of PT's continued concerns of an elevated heart rate from [DATE] and [DATE] or of the elevated respiratory rate from [DATE] for R#4. Review of the [DATE] Medication Administration Record [REDACTED]. On [DATE] SLP II treated R#4 from 11:31a.m. to 12:10 p.m. and included in her therapy notes that R#4 was noted to have a rapid heart rate and respirations, however, was more alert and communicative and that R#4 responded that she felt okay. During an interview on [DATE] at 3:49 p.m., SLP II stated that she reported the rapid heart rate and respirations to the nurse, who was getting ready to go in with medications, but did not recall the nurse's name. Review of a PTA note dated [DATE] at 12:38 p.m. documented in her therapy notes that R#4 presented supine in bed with very short, shallow quick respirations. Vital signs were attempted multiple times, and difficult secondary to very thready/shallow, sporadic pulse at radial, carotid, and brachial arteries. The note documented that the PTA (PTA CC) listened to R#4's chest with a stethoscope, and R#4's heart rate was 122 beats per minute and the manual blood pressure was ,[DATE] with very quiet heart sounds and respirations were 53 breaths per minute at rest. The PTA note also documented that R#4 reported feeling okay, but her voice was very soft and slow speech. The note included that mobility was not indicated at that time secondary to adverse vital signs. During interviews on [DATE] at 11:30 a.m. and [DATE] at 11:45 a.m., PTA CC stated that she reported the vital signs to the nurse and was not able to provide physical therapy to R#4 on [DATE] due to the poor vitals. A review of R#4's clinical record revealed there were not any nurses' notes documenting that R#4 was reassessed after the abnormal vital signs obtained by therapy staff. A review of the [DATE] MAR indicated [REDACTED]. During an interview on [DATE] at 11:30 a.m., LPN HH confirmed she was the nurse (for R#4) who worked day shift (7:00 a.m. to 3:00 p.m.) on [DATE]. She did not recall being notified of any concerns for R#4 from therapy staff. She also did not recall having any concerns for R#4 on [DATE]. During an interview on [DATE] at 4:15 p.m. LPN MM confirmed she worked evening shift (3:00 p.m. to 11:00 p.m.) on [DATE] (for R#4). She did not recall any concerns regarding abnormal vital signs for R#4 from [DATE]. Record review revealed that LPN LL worked on [DATE] from 11:00 p.m. to [DATE] at 7:00 a.m., a nurse's note entry at 2:45 a.m. documented that at approximately 12:45 a.m., R#4 was noted to have rapid respirations of 28 breaths per minute. R#4's oxygen saturation was 87% on room air. R#4 denied shortness of breath, pain/discomfort. Supplemental oxygen was started at two liters via nasal cannula. The nurse note included vital signs after the oxygen was implemented of an oxygen saturation of at 98%, Respirations 20, Temperature 97.6, Pulse 91, blood pressure of ,[DATE] and that the resident denied needs at that time, and frequent checks continued. There was no evidence in the clinical record that the physician was notified of R#4's rapid respirations, decreased oxygen saturation, or the implementation of oxygen on [DATE]. During an interview on [DATE] at 10:28 a.m. LPN LL confirmed that she failed to notify the physician of R#4's rapid respirations, decreased oxygen saturation and that R#4 had been started on oxygen. Further review of the [DATE] notes for R#4 over the course of the day revealed additional abnormal vital signs. PT note on [DATE] 10:18 a.m. (documented by PTA CC) revealed that vital signs were obtained prior to therapy treatment and included that R#4's blood pressure was ,[DATE], with a heart rate of 124 beats per minute, very shallow, and a respiratory rate of 52 shallow breaths per minute. The therapy note documented that R#4 reported feeling bad that morning and the heart rate was above the recommended range for mobility training. The therapy note further documented that a pulse oximetry was donned to attempt to check oxygen saturation but was unable to obtain a reading and that nursing was aware of vital signs that morning. During interviews on [DATE] at 11:30 a.m. and [DATE] at 11:45 a.m., PTA CC confirmed that she reported the vital signs to nursing staff on [DATE] and was not able to provide treatment to R#4. Further review of therapy notes on [DATE], SLP II documented therapy notes from her session with R#4 on [DATE] that occurred from 12:00 p.m. until 12:53 p.m., the new use of oxygen and included a heart rate of 48 and 49 beats per minute during the session. During interviews on [DATE] at 3:49 p.m. and on [DATE] at 2:31 p.m., SLP II confirmed that she reported the abnormal heart rate to R#4's nurse on [DATE]. SLP II stated that she obtained the heart rate from the pulse oximeter device and showed the nurse the pulse oximeter and reported the heart rate, and the nurse went straight into R#4's room. A review of R#4's clinical record revealed no evidence that the physician was notified of the abnormal vital signs that were obtained and reported by therapy staff. In addition, there was no evidence of any nursing entries in the clinical record for the 7:00 a.m. to 3:00 p.m. shift on [DATE] to reflect that nursing staff assessed/reassessed R#4. A review of the [DATE] MAR indicated [REDACTED]. During an interview on [DATE] at 11:30 a.m. LPN HH confirmed she was the nurse for R#4 who worked day shift from 7:00 a.m. to 3:00 p.m. on [DATE]. LPN HH did not recall being notified of any abnormal vital signs for R#4 from therapy staff. LPN HH stated that therapy staff normally go in and review a patient and come out and report findings, that was a normal routine, but she did not recall them reporting anything out of the normal for R#4. During an interview on [DATE] at 11:00 a.m. RN Unit Manager AA (RN AA) stated that she was not aware of the abnormal vital signs from therapy on [DATE]. RN AA stated that nursing staff came and got her on [DATE] during the 3:00 p.m.- 11 p.m. shift change and reported that R#4 was not acting like herself. R#4 was reported to be really quiet and staring off out the window. RN AA stated she went and talked to R#4, who was alert with no labored breathing. RN AA stated that the CNA obtained vital signs and there was nothing that alarmed her. RN AA stated that the evening shift LPN (LPN FF) accompanied her to R#4's room and R#4 acted as if they were bothering her by asking her if she was okay. However, there was no evidence that RN AA's documented her assessment of R#4, including the vital signs, in the clinical record. In addition to the PTA and SLP notes from [DATE] regarding the abnormal vital signs, the Occupational Therapist (OT) also documented in a [DATE] 5:39 p.m. therapy note, for the therapy session with R#4 (that occurred from 3:50 p.m. - 4:20 p.m. on [DATE]) that R#4 presented as very lethargic and with a resting heart rate of 105 with blood pressure unable to be obtained due to being too faint. The note included that R#4 continued to present with a respiratory rate of 33+ breaths per minute while lying supine in bed, which was measured multiple times throughout the session. During interviews on [DATE] at 12:30 p.m. and [DATE] at 12:45 p.m., the OT Rehab Manager, stated that R#4 had no outward distress like someone you would think with the type of respirations documented in the [DATE] note, that R#4 appeared comfortable, with no complaints of pain. The OT Rehab Manager stated he had tried to engage R#4 by talking to her about a tv show she was watching, to assess her cognition. He stated that therapy staff took R#4's vital signs very seriously, that her pulse was faint so they would try it at different sites. He confirmed that he did convey the vital signs from his therapy session with R#4 on [DATE] to the nurse but did not recall who it was specifically that day. Following the [DATE] 5:39 p.m. OT note, a further review of the clinical record revealed a [DATE] 7:51 p.m. nurse's note (documented by LPN FF) that documented R#4 was supine in bed, awake, with lethargy. When asked are you ok, are you in pain, are you wet? R#4 was documented as responding, I'm ok, I'm not wet, I'll let you know if I'm not okay. The note continued to include that the Unit Manager checked R#4 at the change of shift and noted increased lethargy and the Unit Manager had spoken to the resident's responsible party. The nurses note included that R#4 had the following vital signs: blood pressure of ,[DATE], pulse 91, respirations 20, and oxygen saturation of 92% on two liters per minute of oxygen via nasal cannula. During an interview on [DATE] at 11:00 a.m. LPN FF who worked on [DATE] from 3:00 p.m. until 11:00 p.m. shift stated that R#4 was extremely lethargic at the start of the shift and the CNA asked the Unit Manager to check R#4 out. LPN FF stated that she had not received report yet, so she went with the Unit Manager, who talked to R#4. LPN FF stated that the Unit Manager touched R#4 on her shoulder and the resident opened her eyes. The Unit Manager asked the resident if she was okay, and R#4 said she was okay. LPN FF stated that the Unit Manager told R#4 she was concerned about the resident and R#4 told the Unit Manager she was okay and would let them know if she was not. LPN FF said the Unit Manager tapped R#4 on her shoulder again and asked her again if she was okay and R#4 gave the Unit Manager a look like leave me alone and then closed her eyes. LPN FF clarified that she obtained the vital signs (that was documented in the [DATE] 7:51 p.m. nurse's note and included a blood pressure of ,[DATE], pulse 91, respirations 20, and oxygen saturation of 92% on two liters per minute of oxygen via nasal cannula.) around 3:20 p.m. or 3:25 p.m. Continued interview on [DATE] at 11:00 a.m. with LPN FF confirmed that she did not recheck R#4's blood pressure or notify the physician. LPH FF stated that she meant to recheck R#4's blood pressure but got busy doing other things. There was no evidence that the abnormally low blood pressure of ,[DATE] (documented LPN FF's [DATE] nurse's note) was reassessed and there was not any evidence that the physician was notified. During an interview on [DATE] at 11:00 a.m. with the Unit Manager, and review of LPN FF's nurse's note dated [DATE] 7:51 p.m., the Unit Manager said she did not recall R#4's blood pressure being that low (,[DATE]) and stated if she had been aware, she would have rechecked the blood pressure manually and notified the physician. After the [DATE] 7:51p.m. nurse note entry (that includes a blood pressure of ,[DATE] taken earlier in the shift), the next nurse's note entry on [DATE] at 11:55 p.m. details LPN FF entering R#4's room at approximately 9:47 p.m. to administer medications and observed R#4 to take her last breath. A code was called, and CPR was initiated without success and R#4 was pronounced dead at 10:17 p.m. on [DATE]. During an interview on [DATE] at 3:56 p.m., Physician WW confirmed that he was notified of (via his physician communication book) of R#4's elevated heart rate on [DATE]. He stated he would have expected R#4 to be reassessed by nursing, after the vital signs reported by therapy on [DATE] and [DATE]. He would have also expected nursing to do a manual reassessment of the blood pressure of ,[DATE], and if it were still abnormal to notify him. Record reviews and interviews with nursing staff and therapy staff provided conflicting information regarding how R#4 presented and who was aware of or who was notified of concerns regarding R#4's vital signs. There is no evidence of documented nursing assessments/reassessments to address the abnormal vital signs documented by therapy staff on [DATE] and on the day shift for [DATE]. In addition, nursing staff failed to reassess R#4 after obtaining a blood pressure of ,[DATE] on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident R#4 expired in the facility on [DATE]. 2. On [DATE], the Administrator/DON/ADON reviewed the policy regarding Change In Resident Condition and revised to specify that notification regarding resident change in condition will be documented in the medical record including the licensed nurse's assessment of the change and any directives given by the physician. 3. On [DATE], we began in-services to educate every nursing staff (to include agency) and therapy regarding Reporting of Abuse in Nursing Homes, Resident Rights, and the Elder Justice Act. These in¿ services include education on what constitutes neglect, the explanation that negligent omission to act which causes injury to a resident, or failure to provide treatment or care to a resident are examples of abuse and neglect, the residents' right to be free from abuse and neglect, the Elder Justice Act definition of elder mistreatment as intentional actions that cause harm or create serious risk of harm and the Elder Justice Act definition of neglect as the refusal or failure to fulfill any part of a person's obligations or duties to care for an older adult. If the facility fails to provide care and services, if a nurse fails to reassess resident after obtaining vital signs, if a nurse fails to contact a physician timely, are all examples of neglect. These in-services are being conducted by the ADON, unit managers, staff development coordinator, utilization review nurse and supervisors on weekends. This requirement will also be included in orientation of any new hires by the staff development coordinator. As of [DATE], 10 of 11 (91%) FT RNs, 20 of 35 (57%) FT/Agency LPNs, 43 of 52 (83%) FT/Agency CNAs and 9 out of 9 (100%) therapists were educated on Reporting of Abuse in Nursing Homes, Resident Rights, and the Elder Justice Act. As of [DATE], 2 of 4 (50%) PT/PRN RNs, 7 of 16 (44%) PT/PRN LPNs, and 15 of 29 (52%) PT/PRN CNAs were educated on Reporting of Abuse in Nursing Homes, Resident Rights, and the Elder Justice Act. 4. Any staff member that is FT, PT, Agency staff, PRN, on vacation, or on FMLA will receive these in¿ services on the next scheduled workday prior to beginning their shift by the ADON, unit managers, staff development coordinator, utilization review nurse or supervisors on weekends. 5. On [DATE], Social Services began verbally reviewing and re-educating all residents who are not cognitively impaired in the facility individually on Residents Rights to include abuse and neglect, to include 42 of 44 residents. Those were documented in the Social Services notes. Residents were also provided a Residents' Rights in Nursing Homes Consumer Information Sheet (that includes the phone number to the National Citizen's Coalition for Nursing Home Reform) for their review and safe keeping. Social Services provides in the Admission packets information regarding residents' rights, physicians notification, advanced directives, services covered by Medicare and Medicaid, and community-based services. Social Services also annually reviews residents' rights during care plan conference with families. 6. If anyone identifies a change in condition including abnormal vital signs or the implementation of oxygen while performing care of any resident throughout the facility, they would immediately contact the charge nurse. The charge nurse would immediately assess the resident for any change in condition. If orders are in place to treat the change in condition, the charge nurse would follow the orders on the chart. If needed, the physician would be notified immediately to instruct the charge nurse as how to address the resident's change in (i.e. if a resident exhibited a blood pressure reading that was unrelieved by measure already prescribed, implementation of oxygen, .). The physician will still be made aware of non-emergent events (i.e. if a resident experienced constipation and had a standing order for [MEDICATION NAME], incurred weight loss, .) during weekly rounds by placing the event in the physician's notebook. Any assessment findings or new directives/orders will be documented by nursing in the resident's chart before the end of the shift. The facility will immediately inform the resident, physician, and/or patient/patient legal representative resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility. 7. All corrective actions were completed on [DATE]. 8. The immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1.Verified via review of the closed clinical record for R#4. 2.Verified via review of the Change in Condition Policy, dated [DATE]. Also verified via interviews on [DATE] at 4:05 p.m. with the ADON, on [DATE] at 12:00 p.m. with the DON and at 1:15 p.m. with the Administrator. 3.Verified via review of in-service materials including: Residents' Rights in Nursing Homes Consumer Information Sheet, The Elder Justice Act: Background and Issues for Congress, and information on report of abuse in long term care. Verified via review of the Oxygen Administration Policy and Change in Condition Policy. Also verified via review of in-service education sign in sheets. Also verified via interviews conducted on [DATE] at 10:15 a.m. with Certified Nursing Assistant (CNA) CCC, at 10:30 a.m. with CNA DDD, at 10:45 a.m. with CNA EEE, at 11:00 a.m. with CNA FFF, on [DATE] with the ADON at 11:46 a.m., RN Unit Manager/Weekend Supervisor QQQQ at 11:51 a.m., LPN ZZ at 12:03 p.m., LPN JJ at 12:15 p.m., LPN VV at 12:40 p.m., LPN AAA at 12:40 p.m., RN Nurse Manager QQ at 12:55 p.m., LPN OO at 12:05 p.m., LPN BBB at 1:15 p.m., on [DATE] at 11:55 a.m. with CNA's GGG and HHH, at 12:15 p.m. with Temporary Nurse Aide III and CNA JJJ, at 12:27 p.m. with CNA's RR and TT, at 1:25 p.m. with CNA's LLL and MMM, at 2:09 p.m. with CNA's NNN and OOO, at 2:20 p.m. with CNA's PPP and QQQ, at 2:30 p.m. with Agency CNA RRR, at 2:35 p.m. with CNA SSS, Nurse Aide Training Student TTT and Temporary Nurse Aide UUU, at 3:45 p.m. with CNA VVV and CNA WWW, at 3:55 p.m. with CNA's XXX and YYY, on [DATE] with SLP ZZZ at 11:20 a.m., COTA AAAA at 11:30 a.m., PT BBBB at 11:40 a.m., OT/Director of Rehab at 11:50 a.m., PT BB at 11:55 a.m., PTA CC at 12:05 p.m., SLP CCCC at 12:15 p.m., PT DDDD at 12:20 p.m., COTA GGGG at 1:25 p.m., RN Unit Manager AA at 1:45 p.m., LPN HH at 2:00 p.m., LPN EEEE at 2:14 p.m., LPN IIII at 2:30 p.m., LPN JJJJ at 2:40 p.m., LPN PPPP and LPN MM at 3:00 p.m., RN Unit Manager LLLL at 3:10 p.m., LPN MMMM and LPN NNNN at 3:20 p.m., RN Supervisor OOOO at 3:45 p.m., on [DATE] at 10:20 a.m. with Social Services Director, with the DON at 12:00 p.m., the Administrator at 1:15 p.m., the Utilization Review Nurse at 2:0 (TRUNCATED)

Based on interviews, record review and policy review, the facility's Quality Assessment and Assurance (QAA) committee failed to meet on at least a quarterly basis to conduct QAA activities to identify potential or actual concerns that have caused or have the potential to cause serious harm to residents. The facility census was 117. On 3/1/2021 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy for F580, F600, and F835 on 3/1/2021 at 11:40 a.m. Additionally, the Administrator and Director of Nursing were notified on 3/3/2021 at 12:05 p.m. of the Immediate Jeopardy related to F868. The noncompliance related to the Immediate Jeopardy was identified to have existed on 1/18/2021. A Removal Plan (Credible Allegation of Compliance) was received. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, the State Survey validated that the immediacy of the deficient practice (IJ) was removed on 3/5/2021. The facility remained out of compliance while the facility continued management level staff oversight of residents for neglect and notification of change. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing neglect and notification of change. In-service materials were reviewed to ensure appropriate training was given to the staff. Resident records were reviewed to ensure changes in condition were assessed, documented and the physician notified. Findings include: The facility had a Quality Assurance and Performance Improvement Plan. The plan's purpose included that it provided guidance for the overall quality improvement program, and quality assurance performance improvement (QAPI) principles would drive the decision-making within the organization. The plan documented that the Administrator had responsibility and was accountable for ensuring that QAPI was implemented throughout the organization. The plan further documented that the QAA committee would meet quarterly. However, a QAA subcommittee may meet more frequently. However, the facility's QAA committee failed to meet on at least a quarterly basis. A review of Quality Assurance (QA) Committee Meeting attendance records and minutes revealed that the facility conducted meetings on 1/23/2020 and 3/9/2020. However, after 3/9/2020, the facility did not have another QA committee meeting until 2/11/2021. During interviews on 3/2/2021 at 4:00 p.m. and on 3/3/2021 at 9:40 a.m. the Administrator confirmed that the facility had not conducted any QA meetings between 3/9/2020 and 2/11/2021. The facility's failure to meeting regularly to conduct QAA activities prevented the facility from providing oversight and potentially identifying concerns related to physician notification and neglect that had the potential to cause or caused serious harm to residents, including R#4. Cross refer to F600 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 3/1/2021 and 3/3/2021, the Administrator/DON held a Special Called QA Meetings that were attended by the Medical Director, Nurse Practitioner, DON, ADON, units managers, MDS nurses and the utilization review nurse to guide our response to the identified errors related to Resident R#4. Administrator discussed the findings of the complaint survey of February 3, 2021. Administrator reminded all of the importance of taking care of the health and safety of all of our residents. Administrator read the Immediate Jeopardy templates to the group. Administrator passed out copies of the templates for review by all to discuss the deficiencies noted in F580O, F600, F835, and F868. Much discussion and amendments were made to the document and audit tools. A Root Cause Analysis was developed to know how to recognize these issues and to keep them from re-occurring. Administrator apprised all that we will be meeting in the future to review and ensure that all are included in the implementation of the plan. 2. On 3/2/2021, the Administrator/DON/ADON reviewed the policy regarding Change In Resident Condition and revised to specify that notification regarding resident change in condition will be documented in the medical record including the licensed nurse's assessment of the change and any directives given by the physician. 3. The results of the compliance monitoring are being reviewed at monthly and quarterly QAA/QAPI meetings for data review, analysis, trend identification, and issue resolution presented by the DON/Administrator to include the Medical Director, and will continue for the remainder of the year, with the next meeting scheduled for 3/31/2021. 4. The QAA/QAPI policy and process have been reviewed. The policy did not require changes. 5. We have restarted our QA committee by holding Special Called QA meetings on 2/11/2021, 3/1/2021 and 3/3/2021. In addition to our quarterly QAA/QAPI meetings which are attended by all department heads, the Medical Director and Pharmacy consultant, we are implementing monthly QAA/QAPI meetings for the remainder of the year, with called meetings as necessary. The monthly QAA meetings will primarily be attended by the Medical Director, Administrator, DON, ADON, MOS nurses, and unit managers, but others may be included as we evaluate the effectiveness of our interventions. A Root Cause Analysis was developed to know how to recognize these issues and to keep them from re-occurring. Audit Tools have been implemented that will need to be evaluated. New interventions or audit tools may be introduced throughout the remainder of the year as we react to these issues and the creation of Performance Improvement Plans. All scheduled and called meetings will be followed up to include outcomes to include the Medical Director's input. Interventions will be re-evaluated to make sure they are effective, and if they are not, new interventions will be put in place. Ensuring that the facility's QA committee is active, and meeting regularly will aid in identifying actual and potential problems that have the potential to or that have caused harm to residents. 6. All corrective actions were completed on 3/4/2021. 7. The facility alleges that the immediacy of the jeopardy was removed on 3/5/2021. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1.Verified via review of the 3/1/2021 and 3/3/2021 Called QA Committee Meeting sign- in sheets and minutes, including a copy of the Jeopardy removal plan and revisions made during the meeting and review of the IJ Templates. Also verified via review of the Root Cause Analysis Report Form that the facility completed on R#4 on 3/4/2021. During an interview on 3/8/2021 at 4:20 p.m., the Administrator provided an updated Root Cause Analysis form that the facility had made additional revisions on to more thoroughly addressed neglect. Also verified via interviews on 3/7/2021 at 11:46 a.m. with the ADON, at 11:51 a.m. with RN Unit Manager QQQQ, at 12:55 p.m. with RN Unit Manager QQ, on 3/9/2021 at 1:45 p.m. with RN Unit Manager AA, at 3:10 p.m. with RN Unit Manager LLLL, on 3/10/2021 at 12:00 p.m. with the DON, at 2:05 p.m. with the Utilization Review Nurse, at 1:15 p.m. with the Administrator, at 2:30 p.m. with RN Unit Manager SSSS at 2:30 p.m., at 3:45 p.m. with MDS nurse TTTT, and at 3:55 p.m. with MDS nurses UUUU and VVVV. 2.Verified via review of the Change in Resident Condition Policy, dated 3/2/2021, which included the revisions. The Medical Director also confirmed knowledge of the revised policy regarding Change in Resident Condition during an interview on 3/10/2021 at 3:25 p.m. 3.Verified via interviews on 3/10/2021 at 12:00 p.m. with the DON and at 1:15 p.m. with the Administrator. 4.Verified via review of the Quality Assurance and Performance Improvement Plan. Also verified via interviews on 3/10/2021 at 12:00 p.m. with the DON and at 1:15 p.m. with the Administrator. 5. Verified via review of the QA sign-in sheets and minutes dated 2/11/2021, 3/1/2021, and 3/3/2021 meetings. Also verified via interviews on 3/10/2021 at 12:00 p.m. with the DON, at 1:15 p.m. with the Administrator and at 3:25 p.m. with the Medical Director. During an interview on 3/9/2021 at 11:50 a.m. the OT/Director of Rehab confirmed that he would be attending QA meetings. 6. Verified via the interviews and record reviews documented above. 7. The immediacy of the jeopardy was removed on 3/5/2021.

Based on record review and staff interview, it was determined that the facility failed to ensure that its Quality Assessment and Assurance (QA&A) committee identified care concerns, developed and implemented interventions to address identified care problems, and evaluated the effectiveness to resolve the care issue related to the transfers of four (4) residents (#30, #61, E, and #165), three (3) of whom sustained a fall during staff assisted transfers, and two (2) of whom were injured. Therefore, it was determined that actual harm and the likelihood of further serious injury, harm, impairment and or death had existed since 8/9/15 for resident #165 and continues. During an interview on 1/8/16 at 4:40 p.m. the Assistant Director of Nursing (ADON), detailed the facility's system for tracking falls. She stated that when a resident experienced a fall, the nurse on duty at the time would assess the resident and complete an incident report. The incident report would then be given to the shift supervisor or unit manager on duty at the time who completes the Supervisor Incident Investigation form and investigates the circumstances of the fall. The shift supervisor or unit manager would also implement a new intervention to address the fall at that time. The incident report is then entered into a fall listing (by the ADON) in order to identify any trends. The fall and incident report are also reviewed during Patient At Risk (PAR) meetings that are held daily. The fall, incident report, supervisor investigation form and new interventions are reviewed during the PAR meetings. If any additional interventions are needed they are developed and then implemented and communicated by the Unit Manager to licensed nursing staff and certified nursing assistants on the unit where the fall occurred. The ADON stated that the data collected from the fall lists, such as the number of falls, time of day, and location of falls, are reported to the QA&A committee to identify possible trends. During an interview with the Administrator on 1/8/16 at 5:45 p.m., he stated that the QA&A committee meets as a whole on a quarterly basis and always reviews falls for trends such as with time of day, location, and injuries. However, the administrator confirmed that the QA&A committee had not identified a concern regarding the incorrect number of staff being present to assist residents during transfers. There was no evidence the QA&A committee identified a concern related to resident falls from staff assisted transfers. Therefore no new interventions were not developed and implemented to prevent recurrence.

Based on resident and interviews, medical record review, hospital radiology report review, facility incident reports review, facility staff written statement review and the fall follow-up care policy review and the fall prevention program policy, the facility failed to ensure that supervision, care related to transfers for four (4) residents (R#165, E, #61 and #60), three (3) of who suffered actual harm, serious injuries of the thirty-seven )37) sampled residents as follows: 1. It was determined that the provider's noncompliance is one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to resident #165 and had existed since 8/9/15 (the date resident #165 fell while being transferred by only one (1) person, rather than two (2) staff persons); 2. Resident E suffered actual harm, a serious injury of a fracture while being transferred by only one (1) person, rather than two (2) staff persons on 1/4/16, and remains on-going; 3. Resident #61 suffered actual harm serious injury on 12/17/2015, Resident #61 suffered actual harm serious injury on 12/17/2015, of a left intertrochantic hip fracture requiring surgical intervention related to the transfer, in which staff failed to ensure the resident was safe, the facility also failed to investigate the fall, when the resident was assisted by one (1) staff in the bathroom, the staff allowed the resident to stand without assistance, the staff turned around to reach into the closet, when the staff turned back around, the resident was in the floor. This failure caused, is likely to cause, serious injury, harm, impairment, or death to resident #61 and remains on-going, and;Resident #61 suffered actual harm serious injury on 12/17/2015, of a left intertrochantic hip fracture requiring surgical intervention related to the transfer, in which staff failed to ensure the resident was safe, the facility also failed to investigate the fall, when the resident was assisted by one (1) staff in the bathroom, the staff turned back around, the resident was in the floor. 4. Resident #30 was transferred via mechanical lift 12/22/2015 at 5:55 a.m. with two (2) staff persons instead of three (3) staff persons without injuries sustained. The facility's failure caused and is likely to cause, serious injury, harm, impairment, or death to residents that required staff assistance with limited mobility, transfers and risk for falls beginning on and a mechanical lift for transfers, and remains ongoing. he Administrator and the Director of Nursing were informed on 1/7/2016 at 7:00 p.m. that an Immediate Jeopardy (IJ) existed beginning on 8/9/15 and remains ongoing. The census was one hundred and sixty-five (165). Findings include: Review of the to the Resident Census and Conditions of Residents form (CMS 672) it had 165 residents. Eighty four (84) of its 165 residents required the assistance of one or two staff for transfers. Another fifty three (53) of the 165 were totally dependent on staff for transfers, for a total of one-hundred-thirty-seven (137) residents at risk for serious injury, harm, impairment, or death. Review of the facility's Fall Prevention Program Policy revealed the following procedures: 1. Upon admission, quarterly and with any significant change in resident condition, the resident will be assessed for risk of falls utilizing the Fall Risk Assessment Form, Resident Assessment Instrument (RAI), preadmission history and admission assessment of gait, balance, vision, mental function and medication use. 2. Once the resident is assessed for high risk of falls, an individualized plan of care will be developed to include goals directed at prevention and reduction of falls and fall related injuries. 3. Upon completion of assessments for a high-risk resident, a Licensed Nurse is responsible for ensuring that the tasks that were identified to improve the resident's safety are implemented. 4. Fall Prevention In-service Training will be required for all employees on an annual basis at a minimum. 5. See Policy and Procedure for follow-up Care for Resident Fall. Review of the facility's Fall Follow-up Care Policy revealed the following procedure for providing follow-up care, but not limited to, the following: The licensed nurse if responsible for immediate notification of the supervisor, the attending physician and the responsible party or family of the resident; Documentation in the medical record and communication of fall to oncoming shift nursing staff will be the responsibility of the licensed nurse, and; Resident plan of care will be reviewed timely and revised as indicated. 1. Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/17/15 admission assessment form documented the resident required extensive assistance with Activities of Daily Living (ADL's) and maximum assistance with 2 persons for transfers. The 7/17/15 admission nurse's note documented the resident was assisted up with maximum assistance from two staff persons. Licensed nursing staff coded the resident on the admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 7/24/15 and on the 14 day MDS assessment (ARD 7/29/15) as being provided with extensive assistance by two or more staff for transfers and extensive assistance by one person for toileting. The July 2015 and August 2015 Aide Assignment Records (AARs) documented the resident was to be transferred with the assistance of two persons. Licensed nursing staff developed a plan of care on 8/3/15. The plan of care included a problem documenting the resident was at risk for falls and injury related to medical factors, weakness, impaired mobility, and status [REDACTED]. However, a review of the plan of care revealed no specific interventions were developed to address the specific transfer needs, including the type of transfers and how many staff were to assist resident #165 until 8/10/15. On 8/10/15 the plan of care was revised to include a fall and subsequent left ankle fracture the resident sustained [REDACTED]. An intervention that the resident would be a 2 person transfer was added at that time. However, the intervention was not specific to include what type of transfer with 2 persons assistance the resident would require. Unit manager II clarified during an interview on 1/8/16 at 4:25 p.m. that a transfer with 2 persons assistance meant 2 staff persons were to physically assist the resident using a gait belt. In addition, the unit manager confirmed that the resident was to be assisted with transfers with 2 staff persons prior to the fall that occurred on 8/9/15. A review of the August 2015 AAR revealed an entry on 8/9/15 at 1:09 p.m. that documented the resident was in the bathroom, once he/she finished toileting, the CNA provided the resident with a walker so that resident could pivot back to a chair. When the resident moved to stand, his/her knee gave out and the CNA assisted the resident to slide down to the floor. The licensed nurse was notified of the incident. A nurse's note entry on 8/9/15 at 1:20 p.m. documented the licensed nurse was called to the resident's bathroom by the CNA. The resident was observed on the floor on his/her back with the left leg underneath the right leg. The resident complained of pain to the left leg and the left ankle was observed to be flexed inward. A further review of the nurse's note entry documented that the resident was transferred to the hospital for evaluation. Review of the X-ray report dated 8/9/15 the revealed a Left ankle Oblique Fracture through the distal left fibula at the level of the syndesmosis with an apparent Nondisplaced Fracture involving the medial malleolus. Licensed nursing staff completed an Incident report on 8/9/15 concerning the fall that occurred. The Supervisor Incident Investigation form (dated 8/9/15 at 7 p.m.) included with the Incident Report detailed that the CNA had been instructed earlier in the shift to have two staff persons present when transferring the resident. However, the CNA did not ask for assistance and instead attempted to transfer the resident alone. The form included a Safety Precautions section that documented actions taken to correct any unsafe act or condition. Licensed nursing staff documented that CNAs were to follow assistance instructions on the AARs and use assistance as indicated. The form also documented that all staff were responsible for implementation of the corrective actions immediately. Unit manager II stated during an interview on 1/8/16 at 5:14 p.m. that the CNA involved in the incident on 8/9/15 was an agency CNA (not employed by the facility). The CNA was placed on a do not use list and had not worked at the facility since the incident on 8/9/15. However, there was no evidence that any education or inservices were conducted with additional staff to ensure the appropriate amount of assistance was being provided to residents to prevent additional accidents and injuries. The resident was discharged from the facility to an inpatient rehabilitation facility on 8/19/15. 2. Resident E had [DIAGNOSES REDACTED]. Review of the 10/10/15 Physical Therapy discharge notes revealed that at the time of discharge the resident was a minimal to moderate assist with transfers. It noted the resident was discharged due to poor motivation and lack of progress. During an interview with the Physical Therapist and the Occupational Therapist on 1/7/16 at 1:07 p.m., they both stated that at the time of discharge from the Rehabilitation Unit the resident was discharged with a slide board with contact guard assist for transfers. They stated that licensed nursing staff did not notify the therapy department of the resident refusing to use the slide board. They both stated that if the resident was not using the slide board, the transfer method should be the mechanical lift because the resident was too weak to be transferred using a standing pivot. The Physical Therapist stated he would not transfer the resident by himself using a pivot transfer because it would be too much. During an interview with the Nurse Manager AA on 1/7/16 at 4:00 p.m., she stated that the resident used the slide board for about a month but then refused to use it and the family did not want staff to use the mechanical lift. She stated she did not know who made the decision to start using a two person pivot transfer. Stated she assumed the CNAs decided to use that technique since the resident refused to use the slide board and the family member refused the mechanical lift. Nurse Manager AA stated that the CNAs should not have made that decision on their own. She stated if there is a change in the resident's transfer status, then she would expect the CNAs to notify her or the nurses and she would consult with therapy. Review of the resident's plan of care dated 7/24/15 noted a problem of impaired mobility related to weakness with a recent fall resulting in a right tibia/fibula fracture (prior to admission to the facility) with bed mobility and transfers using appropriate devices with a note to see 7/10/15 order to transfer using a mechanical lift with two person assist per rehab recommendation. However, the note was crossed out with no further instructions for the resident's transfer requirements. During an interview with the resident on 1/5/16 at 8:30 a.m., she stated that last night (1/4/16) a Certified Nursing Assistant (CNA) dropped her while she was transferring her from the wheelchair to the bed. She further stated that the CNA hurt her right leg. Review of the 1/4/16 nurses note revealed the resident complained the CNA hurt her right leg when putting the resident to bed. Range of motion was done without complaints. It further noted the resident wanted to go to bed, the CNA tried and eased the resident to the floor. The resident stated the CNA hurt her leg and voiced no complaints at that time to the nurse. During an interview with Nurse Manager AA on 1/5/16 at 9:00 a.m., she stated she was not aware of the incident on 1/4/16. She stated the nurse on duty at the time of the fall did not do an incident report, did not document the incident on 24 hour report and did not report the incident to the next oncoming shift (11 p.m. to 7 a.m.). After surveyor inquiry, the Nurse Manager assessed the resident and notified the Physician who then ordered an X-ray to be obtained. She further stated on 1/6/16 at 2:45 p.m., the CNAs were to refer to the Aide Assignment Record (AAR) or the care plan for a resident's transfer requirements. Review of the x-ray report dated 1/5/16, revealed that the Right Foot has Degenerative Joint Disease, Osteopenia without fracture; Right ankle swollen soft tissue without fracture, and Right Tibia with subtle cortical disruption - suspicious of non-displaced fracture. However, review of the AARs for 11/2015, 12/2015 and 01/2016 with the Nurse Manager revealed there were no instructions printed on the forms for the resident's transfer requirements. She stated it was licensed nursing staffs' responsibility to update the AAR with the resident's transfer requirements but it was overlooked. She also confirmed the resident's plan of care did not specify how to transfer the resident. Review of the October 2015 AAR noted that on 10/27/15 the mechanical lift with a two person assist was discontinued but was not revised to reflect the resident's transfer requirements. She stated that the resident should have been a two person transfer with a gait belt because the resident did not have full use of her right leg. Review of the nurse's notes dated 1/5/16 at 10:12 a.m., which was done after surveyor inquiry, revealed the resident complained of new pain to the right leg from her hip to her toes. It noted that she verified with 3 p.m. to 11 p.m shift Licensed Practical Nurse (LPN) and the 3 p.m. to 11 p.m. CNA who worked with the resident on 1/4/16 that the resident was lowered to the floor on 1/4/16 on the 3 p.m. to 11 p.m. shift. The CNA was using a gait belt during the one person transfer with the resident. The resident's legs were weak and she had to be lowered to the floor. Review of the written statement provided by CNA DD on 1/5/16, revealed the CNA was assisting the resident to the bed. When she helped the resident stand, the resident immediately stated she could not stand and started to bend her knees. At that time the CNA eased the resident down and let her sit on the floor. The CNA then stepped out of the door to alert the nurse. During an interview with CNA DD on 1/7/16 at 9:55 a.m., she stated that when she came on duty for 3 p.m. to 11 p.m. shift on 1/4/16, she got a report from the day shift CNA and nurse telling her the resident could stand and pivot with a gait belt. She stated they did not specify if the resident could transfer with the assist of one or two staff and she did not ask. She also stated that she did not look at the AAR to check the resident's transfer requirements. Review of the 1/6/16 physician's orders [REDACTED]. 3. Resident #61, had a nurse's note dated 12/17/15 at 8:00 a.m. It documented that the resident's left knee gave out while in the bathroom and he/she fell and hit the right side of their head and back. The note further documented that the resident complained of head pain and left leg pain. The note detailed that the resident would be sent to the emergency room . There was no further documentation in the clinical record concerning the specific circumstances of the fall on 12/17/15. Review of of the emergency room record revealed the resident remained in the hospital with a left intertrochantic hip fracture requiring surgical intervention. During an interview with Unit Manager AA, on 1/6/16 at 12:50 p.m. she confirmed that she and the Charge Nurse EE had failed to complete an incident report on the fall that occurred on 12/17/15, and was unable to provided any details or circumstances of that fall. 4. Resident #30 had [DIAGNOSES REDACTED]. There was a plan of care on 1/9/15 for risk for falls, injury related to weakness, impaired mobility, cognitive loss, bilateral amputee since 2003, heart disease, balance deficit, incontinence, impaired vision and hearing, medications, history of falls. A care plan intervention for this problem included to transfer the resident with appropriate devices, the use of the mechanical lift, and with three person assistance and to handle gently. A record review for this resident revealed a nurse's note entry for 12/22/15 at 5:55 a.m. that documented that the resident was lowered to the floor during a transfer. There was no injury noted and the family was notified. Review of the Incident Report of 12/22/15 also revealed that the resident had to be lowered to floor during a transfer, and there was no injury. During an interview on 1/7/16 at 4:30 p.m. with certified nursing assistant (CNA) FF she stated that she usually worked with this resident and that she worked with the resident on 12/22/15 at 6:00 a.m. CNA FF stated that she had just bathed the resident and called the Charge Nurse, SS to help her to lift the resident from the bed to the wheelchair, using the mechanical lift. There was only CNA FF and charge nurse SS in the room to assist with the transfer. Even though, during this interview on 1/7/16 at 4:30 p.m., CNA FF stated that she knew where to look for the correct instructions on how to transfer the resident, including how many staff were to help with the transfer, she incorrectly stated that the resident required at least two persons assistance with the transfer and use of the mechanical lift. Review of he 1/7/16 written statement from CNA FF documented that while lowering the resident on to the reclining wheelchair, it was discovered the resident was too far forward in the wheelchair, which began to tilt forward. The CNA FF said she positioned herself behind the resident, with arms underneath the residents shoulders, while the Charge Nurse SS held the resident legs. CNA FF and Charge Nurse SS were unable to slide resident into the proper position in the wheelchair; therefore they slid the resident forward on to the floor and slid the wheelchair from underneath the resident. A full body assessment, with range of motion was preformed, with no injury found. Review of the facility's Quality Improvement Falls Investigation Report (IRC) of 12/22/15 noted that the mechanical lift was used at the time of the fall. However, the Falls (IRC) for 12/22/15 for this resident had not identified the exact circumstances of what occurred and how many staff members were present or involved with the 12/22/15 unusual occurrence/incident. Interview with the Director of Nursing (DON) on 1/7/16 at 4:00 p.m. revealed that she did not have additional information, including how many staff were present in the room at the time of the 12/22/15 incident with this resident. She stated that she did not have any witness statements from the staff who were present at the time of the incident on 12/22/15. The facility failed to ensure that the plan of care for the mechanical lift with three staff person assistance was completed on 12/22/15 during the 5:55 a.m. fall/unusual occurrence. Even though there was documentation of a follow-up inservice by the facility on 12/22/15 and 12/23/15 to all 11 p.m. to 7 a.m. nursing staff who were working on 12/22/15, the facility failed to address the insufficient number of staff (2) who were working with the resident during the 12/22/15 at 5:55 a.m. transfer.

Based on record review and staff interview, it was determined the facility failed to develop a plan of care to include the specific transfer needs for one resident (#165) from a total sample of thirty-seven (37) residents. The resident then sustained a fall and fracture 8/9/15 while being assisted with a transfer by only one Certified Nursing Assistant instead of two staff persons as documented on the Aide Assignment Record (AAR). Therefore, it was determined that actual harm existed for resident #165 and the likelihood of further serious injury or harm existed for residents who required staff assistance with transfers since 8/9/15 and continues. Findings include: Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/17/15 Admission Assessment form documented the resident required extensive assistance with Activities of Daily Living (ADL's) and maximum assistance with 2 persons for transfers. The 7/17/15 Admission Nurse's Note documented the resident was assisted up with maximum assistance from two staff persons. Licensed nursing staff coded the resident on the Admission Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) of 7/24/15 and on the 14 day MDS assessment (ARD 7/29/15) as being provided with extensive assistance by two or more staff for transfers and extensive assistance by one person for toileting. The July 2015 and August 2015 Aide Assignment Records (AAR's) documented the resident was to be transferred with the assistance of two persons. Licensed nursing staff developed a plan of care on 8/3/15. However, review of the plan of care revealed no specific interventions were developed to address the specific transfer needs, including the type of transfers and how many staff were to assist resident #165 until 8/10/15. On 8/10/15 the plan of care was updated to include a fall and subsequent left ankle fracture the resident sustained [REDACTED]. An intervention that the resident would be a 2 person transfer was added at that time. The resident was discharged from the facility to an Inpatient Rehabilitation facility on 8/19/15. During interviews on 1/8/16 at 3:30 p.m. and 4:40 p.m. the Assistant Director of Nursing (ADON) was unable to provide any additional information regarding why resident #165's plan of care, when initially developed, did not include the specific transfer needs until after the fall and fracture on 8/9/15. Cross reference to F323.

Based on resident and staff interviews, medical record review, hospital radiology report review, facility incident reports review, facility staff written statement review and the fall follow-up care policy review, it was determined that the facility had failed to review and revise the plan of care to reflect the transfer needs for two (2) (E and #165) residents which resulted in serious injuries who sustained fractures in the facility and failed to revise the plan of care for one (1) (#237) resident who had a significant change in condition in Actvities of Daily Living (ADL), decline in cognition and bowel/bladder incontinence of the thirty-seven (37) residents. The facility ' s noncompliance with one or more requirements of participation has caused actual harm, serious injury, harm, and is likely to cause impairment, or death to a resident Therefore, it was determined that the Immediate Jeapardy (IJ) began on 8/9/15 and remains on-going. Findings include: Review of the Resident Census and Conditions of Residents form (CMS 672) it included one-hundred and sixty-five (165) residents. Eighty-four (84) of the 165 residents required the assistance of one or two staff for transfers and another fifty- three (53) of the 165 were totally dependent on staff for transfers. 1. Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/17/15 Admission Assessment form documented the resident required extensive assistance with Activities of Daily Living (ADL's) and maximum assistance with 2 persons for transfers. The 7/17/15 Admission Nurse's note documented the resident was assisted up with maximum assistance from two staff persons. Licensed nursing staff coded the resident on the Admission Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) of 7/24/15 and on the 14 day MDS assessment (ARD 7/29/15) as being provided with extensive assistance by two or more staff for transfers and extensive assistance by one person for toileting. The July 2015 and August 2015 Aide Assignment Records (AAR's) documented resident was to be transferred with the assistance of two persons. Licensed nursing staff developed a plan of care on 8/3/15. However, a review of the plan of care revealed no specific interventions were developed to address the specific transfer needs, including the type of transfers and how many staff were to assist resident #165 until 8/10/15. On 8/10/15 the plan of care was revised to include a fall and subsequent Left Ankle Fracture the resident sustained [REDACTED]. An intervention that the resident would be a 2 person transfer was added at that time. However, the intervention was not specific to include what type of transfer with 2 persons assistance the resident would require. Unit manager II clarified during an interview on 1/8/16 at 4:25 p.m. that a transfer with 2 persons assistance meant 2 staff persons were to physically assist the resident using a gait belt. In addition, the Unit Manager confirmed that the resident was to be assisted with transfers with 2 staff persons prior to the fall that occurred on 8/9/15. The resident was discharged from the facility to an inpatient rehabilitation facility on 8/19/15. Cross reference to F323 2. Resident E had [DIAGNOSES REDACTED]. Review of the resident's plan of care dated 7/24/15 noted a problem of impaired mobility related to weakness with a recent fall resulting in a right tibia/fibula fracture (prior to admission to the facility) with an approach for staff to assist with bed mobility and transfers using appropriate devices with a note to review the 7/10/15 order to transfer the resident using a mechanical lift and two (2) person assist per the Rehabilitation Department recommendation. However, the note was crossed out, indicating that the recommendation was not valid with no further instructions for transfer requirements. During an interview with the resident on 1/5/16 at 8:30 a.m., she stated that last night (1/4/16) a Certified Nursing Assistant (CNA) dropped her while she was transferring her from the wheelchair to the bed. She further stated that the CNA hurt her right leg. Review of the 1/4/16 nurses note revealed the resident complained the CNA hurt her right leg when putting the resident to bed. Range of motion was completed without complaints. It further noted the resident wanted to go to bed, the CNA tried to transfer the resident without assistance of another staff and failed, thus she eased the resident to the floor. The resident stated the CNA hurt her leg and voiced no complaints at that time to the nurse. During an interview with nurse manager AA on 1/5/16 at 9:00 a.m., she stated she was not aware of the incident on 1/4/16. She stated the nurse on duty at the time of the fall did not do an incident report, did not document the incident on 24 hour report and did not report the incident to the next oncoming shift (11p.m. to 7 a.m.). After surveyor request/intervention, the nurse manager assessed the resident and notified the physician who then ordered an X-ray to be obtained. Review of the x-ray report dated 1/5/16, revealed that the Right Foot has [MEDICAL CONDITION] Joint Disease, Osteopenia without fracture; Right ankle swollen soft tissue without fracture, and Right Tibia with subtle cortical disruption - suspicious of non-displaced fracture. She further stated on 1/6/16 at 2:45 p.m., the CNA's were to refer to the Aide Assignment Record (AAR) or the care plan for a resident's transfer requirements. However, review of the AARs for November 2015, December 2015 and January 2016 with the nurse manager revealed there were no instructions printed on the forms for the resident's transfer requirements. She stated it was Licensed nursing's staffs responsibility to update the AAR with the resident's transfer requirements but that it was overlooked. She also confirmed the resident's plan of care did not specify how to transfer the resident and was not revised after the mechanical lift was discontinued on 10/27/15. Review of the October 2015, AAR noted that on 10/27/15 the mechanical lift with a two person assist was discontinued but was not revised to reflect the resident's transfer requirements. Cross reference to F323 3. Resident #237 had a 14 day MDS assessment with an Assessment Reference Date (ARD) of 9/27/15 completed by licensed nursing staff on 10/7/15. A Quarterly MDS Assessment with an ARD of 12/21/15 was completed on 12/23/15. A review of the MDS assessments revealed a decline in the areas of cognition and incontinence from September 2015 to December 2015. The Brief Interview for Mental Status (BIMS) score declined from 12 to 5. The resident's bladder continence declined from being occasionally incontinent to being always incontinent and bowel continence declined from being always continent to being frequently incontinent. However, a review of the plan of care revealed no revisions with new interventions to address the decline in cognition, bowel/ bladder incontinence or the decline in Activities of Daily Living (ADL). During an interview on 1/8/16 at 12:25 p.m., the Assistance Director of Nursing (ADON) confirmed that licensed nursing staff had not addressed the declines in cognition, bowel/ bladder incontinence or the decline in Activities of Daily Living (ADL). Cross reference to F315

b Relates to resident Mattie Davis room [ROOM NUMBER]A Order changed to Crush Meds only on 8/22/14-Resident was taking [MEDICATION NAME] prior to order. Interview with Ben Porter Consultant Pharmacist on 9/16/14 at 12:30 pm revealed that he has been reviewing all resident's for crush meds and what medications were ok. He discovered that one resident, Ms. (NAME REDACTED) Davis, was on [MEDICATION NAME] (a new drug) with a change to crushed meds on 8/22/14. This is his first visit since that change and discovered this medication cannot be crushed. He alert the Unit Manager to check with Psychritis was to an alternative and is awaiting an answer from the MD. He says the nurses should be looking at new orders to determine if they can be crushed. If unsure, they should contact him or the dispensing pharmacy. He reveals that resident are being changed to medication that can be crushed. Revealed he doesn't share everything he finds with the DON or Administrator but does most things. He had made the Unit Manager Yolanda aware but had not brought it to the attention of the DON or Administrator. 9/17/14 at 10:00 am Interview with Ben Porter, Pharmacist: he contacted the dispensing pharmacy related to if they were made aware this resident had been changed to crush meds on 8/22/14. Ben says the nurses should have faxed this information to the pharmacy. The dispensing pharmacy confirms they were aware of the new orders, but somehow overlooked Crushed Med portion of the new orders. Since this is a new medication, the DO NOT CRUSH warning doesn't just come up when entered into their system. Interview on 9/18/14 at 12:05 pm Janice Keiling LPN, who has been giving Ms. (NAME REDACTED) her meds on 9/16/14. Says that she and the other nurses were crushing the [MEDICATION NAME] from the 8/22/14 until 9/16/14. New order for crushed meds on 8/22/14 and to give [MEDICATION NAME] with food. Resident had order for [MEDICATION NAME] 80 mg po every day. RR of the September MAR indicated [REDACTED]. RR of the pharmacy bubble pack which was refilled on 8/7/14 revealed no indications of can't be crushed. Based on observation, review and staff interviews, the facility failed to ensure that the crush med order as ordered for resident #230 from a survey sample of twenty-one (21). Findings Include: Review of the Physician orders [REDACTED].M. Registered Nurse (RN)____revealed that the resident was given two [MEDICATION NAME] 50mg tablets for a total of 100mg whole tablets by mouth with water. An interview with RN __ 9/15/14 at 03:25 P.M. stated resident only wants her calcium and vitamin pill crushed. I did explain to the resident this morning there was a new order for all med's to be crushed. The resident said she might try tomorrow with a little pudding. This resident can speak for herself. Review of last Quarterly Minimum Data System dated 7/13/14-Section C-Cognitive Patters BIMS score 15;Section E-Behavior-no behaviors noted section I Active Diagnosis-[MEDICAL CONDITION], Heart failure, HTN, Cardiac pacemaker and unspecified disease of spinal cord. Section K-Swallowing disorder-None of above. Medication Pass observation 9/15/14@01:40PM nurse Dijana Hrepic,RN administered to Resident #230 [MEDICATION NAME] 50mg x 2 tabs po resident was asked by nurse if surveyor could watch medication administration and resident #230 said yes. Resident #230 took the medication with water and swallowed with no difficulty noted. Review of the clinical record on 9/15/14@02:55PM revealed a new order dated 9/11/14@05:30PM 1.crush med resident 2.D/C o.k. to give po meds either crushed or whole if not contraindicated or as per resident request. Orginal Physician order [REDACTED]. Review of the MAR indicated [REDACTED].The order for o.k. to give meds either crushed or whole if not contraindicated as per pts request was DC'd 9/11/14 and marked thru. Interview with Dijana Hrepick,RN 9/15/14@03:25PM stated she only wants her calcium and vitamin pill crushed. I did explain to the resident this morning there was an new order for all med's to be crushed. The resident said she might try tomorrow with a little pudding. This resident can speak for herself. Review of Physician orders [REDACTED]. speech therapy to evaluate and treat-resident c/o of difficulty of swallowing,EGD later2. uric acid level. SLP 700 Plan of treatment for [REDACTED]. SLP dated 9//11/14 after evaluation recommended modifying diet pt's diet to mechanical soft. Review of Acute Care Visit dated 9/8/14 Physician documented history resident c/o of dysphagia and rt toe pain-new problem-1.dysphagia 2.ST to evaluate,EGD later. Review of Nurse Progress Note dated 9/8/14@06:30PM Dr. Patel here on unit-Res c/o of right great toe pain and trouble swallowing. Dr. Patel spoke with resident new orders received. 9/8/14@2030P-resident id RP (self). Informed of lab orders for A.M. and speech eval orders. 9/11/14-speech Therapist on unit to assess new orders received. 9/11/14@1800 new order noted. Resident is responsible for self and is aware of new orders.verbalizes understanding. Review of Nurse Progress Notes dated 9/15/14 entry time 09:00AM resident stated I don't want my med's crushed I only want my calcium and vitamin pill crushed. Explained to res that there is order for med's to be crushed by speech therapist. Nurse Progress note dated 9/15/14 @ 16:31-New orders noted and R.P. aware of new orders. Nurse Progress Note dated 9/15/14@16:30 called Dr. Patel and informed __?__ that res. had received pills whole. Dr. Patel stated to not to change order and to continue to crush res meds. CP dated Resident is able to take PO meds whole due to dysphagia or refusal to swallow. Meds are crushed unless MAR indicated [REDACTED].Goal -resident will receive meds as ordered by MD without episodes of choking during the next 3 months.-Approaches-Medications will be crushed as per MD order;Meds will be administered in vehical of choice,if PO intake allowed within dietary restrictions (pudding,juice,applesauce) unless otherwise specified;Licensed Nurse will consult MD for clarification for prescribed medication which can not be crushed (MD may prescribe different form of medication) Resident able to swallow meds but at times prefers they maybe crushed will administered meds per resident preference-DC-Approaches-nurse will check with resident daily for daily preference at each med's administration.DC Revised CP dated 9/11/14-Resident having increased difficulty swallowing whole med's-will crush all meds. approach-9/11/14-Administer all meds crushed. Review of last MDS dated [DATE]-Section c-cognitive pattersn BIMS score 15;Section E-Behavior-no behaviors noted'section I Activie diagnosis-[MEDICAL CONDITION],heart failure,HTN,V45.01-Cardiac pacemaker;336.9-unspecified disease of spinal cord. Section K-Swallowing disorder-None of above. Residetn admitted to facility 4/9/14.Review of Med Physician consultation from The Medical Center resident was post hospitalization following post anterior cervical surgery. Past medical history include hypertension,pacemaker,[MEDICAL CONDITION].

b Professional standards for RN who did not follow MD orders to give crushed medications. Medication Pass observation 9/15/14@01:40PM nurse Dijana Hrepic,RN administered to Resident #230 [MEDICATION NAME] 50mg x 2 tabs po resident was asked by nurse if surveyor could watch medication administration and resident #230 said yes. Resident #230 took the medication with water and swallowed with no difficulty noted. Review of the clinical record on 9/15/14@02:55PM revealed a new order dated 9/11/14@05:30PM 1.crush med resident 2.D/C o.k. to give po meds either crushed or whole if not contraindicated or as per resident request. Orginal Physician order [REDACTED]. Review of the MAR indicated [REDACTED].The order for o.k. to give meds either crushed or whole if not contraindicated as per pts request was DC'd 9/11/14 and marked thru. Interview with Dijana Hrepick,RN 9/15/14@03:25PM stated she only wants her calcium and vitamin pill crushed. I did explain to the resident this morning there was an new order for all med's to be crushed. The resident said she might try tomorrow with a little pudding. This resident can speak for herself. Review of Physician orders [REDACTED]. speech therapy to evaluate and treat-resident c/o of difficulty of swallowing,EGD later2. uric acid level. SLP 700 Plan of treatment for [REDACTED]. SLP dated 9//11/14 after evaluation recommended modifying diet pt's diet to mechanical soft. Review of Acute Care Visit dated 9/8/14 Physician documented history resident c/o of dysphagia and rt toe pain-new problem-1.dysphagia 2.ST to evaluate,EGD later. Review of Nurse Progress Note dated 9/8/14@06:30PM Dr. Patel here on unit-Res c/o of right great toe pain and trouble swallowing. Dr. Patel spoke with resident new orders received. 9/8/14@2030P-resident id RP (self). Informed of lab orders for A.M. and speech eval orders. 9/11/14-speech Therapist on unit to assess new orders received. 9/11/14@1800 new order noted. Resident is responsible for self and is aware of new orders.verbalizes understanding. Review of Nurse Progress Notes dated 9/15/14 entry time 09:00AM resident stated I don't want my med's crushed I only want my calcium and vitamin pill crushed. Explained to res that there is order for med's to be crushed by speech therapist. Nurse Progress note dated 9/15/14 @ 16:31-New orders noted and R.P. aware of new orders. Nurse Progress Note dated 9/15/14@16:30 called Dr. Patel and informed __?__ that res. had received pills whole. Dr. Patel stated to not to change order and to continue to crush res meds. CP dated Resident is able to take PO meds whole due to dysphagia or refusal to swallow. Meds are crushed unless MAR indicated [REDACTED].Goal -resident will receive meds as ordered by MD without episodes of choking during the next 3 months.-Approaches-Medications will be crushed as per MD order;Meds will be administered in vehical of choice,if PO intake allowed within dietary restrictions (pudding,juice,applesauce) unless otherwise specified;Licensed Nurse will consult MD for clarification for prescribed medication which can not be crushed (MD may prescribe different form of medication) Resident able to swallow meds but at times prefers they maybe crushed will administered meds per resident preference-DC-Approaches-nurse will check with resident daily for daily preference at each med's administration.DC Revised CP dated 9/11/14-Resident having increased difficulty swallowing whole med's-will crush all meds. approach-9/11/14-Administer all meds crushed. Review of last MDS dated [DATE]-Section c-cognitive pattersn BIMS score 15;Section E-Behavior-no behaviors noted'section I Activie diagnosis-[MEDICAL CONDITION],heart failure,HTN,V45.01-Cardiac pacemaker;336.9-unspecified disease of spinal cord. Section K-Swallowing disorder-None of above. Residetn admitted to facility 4/9/14.Review of Med Physician consultation from The Medical Center resident was post hospitalization following post anterior cervical surgery. Past medical history include hypertension,pacemaker,[MEDICAL CONDITION].

A standard survey conducted on July 3, 2014, prior to this July 25, 2014 abbreviated survey, identified immediate jeopardy at F490 at the S/S of "K" related to facility administrations' failure to ensure resident safety by failing to ensure that direct-care staff were made aware, per the established facility system, of resident mechanical lift transfer requirements (to include the number of staff required for safe transfer), failing to provide maintenance of mechanical lifts as specified by the manufacturer, and failing to provide training identified by the facility as required for direct-care staff regarding resident mechanical lift transfers. The facility implemented a credible allegation of jeopardy removal on July 2, 2014 regarding F490 cited at the S/S of "K", and based on the facility's credible allegation of jeopardy removal, the immediate jeopardy was removed on July 3, 2014; however, the noncompliance continued at F490 at a lower S/S of "E" to allow for the future assessment of the facility's continued application of the corrective actions implemented per the credible allegation of jeopardy removal. Then, during the current abbreviated survey on July 25, 2014, immediate jeopardy was again identified at F490 at the S/S of "K" based on facility administrations' failure ensure the administration of resident medications in conformance with physicians' orders. The continuing noncompliance at F490, cited on the Form CMS-2567 for the standard survey of July 3, 2014, has been brought forward to this Form CMS-2567, which also documents the noncompliance at F490 at the S/S of "K" identified as a result of this abbreviated survey of July 25, 2014, as referenced below: Based on observation, record review, and staff interview, facility administration failed to ensure that resident drug therapy was provided in accordance with physicians' orders. This failure resulted in significant medication errors involving two (2) residents (#1 and #3), for whom the facility failed to provide drug therapy as ordered by the physician, on the total survey sample of nine (9) residents. Resident #1 was administered thirteen (13) medications, including the narcotic drugs [MEDICATION NAME] and [MEDICATION NAME] and the antipsychotic drug [MEDICATION NAME], that were ordered by the physician to be administered to another resident. Resident #1 later experienced stupor, somnolence, and [MEDICAL CONDITION], was transferred to the hospital where he was severely obtunded, was diagnosed with [REDACTED]. Resident #3 had a physician's orders [REDACTED]. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy during interview on July 24, 2014 at 1:43 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 21, 2014, when Resident #1 was administered in error doses of the medications [MEDICATION NAME], [MEDICATION NAME], galantamine, [MEDICATION NAME], tamsulosin, [MEDICATION NAME] Solution, and Doc Plus, which were actually ordered by the physician to be administered to another resident. During an interview with the Administrator conducted on July 25, 2014 at 1:05 p.m., the Administrator acknowledged awareness of facility-identified problems related to medication administration to residents, but presented no evidence of an ongoing system to track resolution of identified problems. Findings include: Cross refer to F333. Based on observation, medication pass observation, and record review, the facility failed to ensure that Resident #1 and Resident #3 were free of significant medication errors. Resident #1 received doses of thirteen (13) medications ordered to be administered to another resident, including doses of [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mgs, galantamine ER 16 mgs, [MEDICATION NAME] 12.5 mgs, [MEDICATION NAME] MN ER 60 mgs, [MEDICATION NAME] 20 mgs, tamsulosin 0.4 mg, [MEDICATION NAME] 150 mgs, [MEDICATION NAME] Solution, and Dok Plus tablets. Resident #1 was later noted to exhibit stupor, somnolence, and [MEDICAL CONDITION], was transferred to the hospital, diagnosed with [REDACTED]. Resident #3 received doses of [MEDICATION NAME], vitamin C, and multivitamin/mineral tablets which were not crushed prior to administration, even though a physician's orders [REDACTED]. During an interview with the Administrator and the DON conducted on 07/24/2014 at 1:43 p.m., the Administrator stated he had immediately been made aware of the medication error of 07/21/2014 during which Resident #1 received multiple doses of another resident's medications and was then hospitalized with a drug overdose. The Administrator stated that upon learning of the medication error involving Resident #1, he initiated corrective action related to this incident, including policy review and the provision of in-service training for licensed nursing staff related to the facility's procedure to be used by nursing staff to correctly identify residents during medication administration. During a later interview with the Administrator and DON conducted on 07/25/2014 at 1:05 p.m., the Administrator was questioned regarding the method by which the facility routinely monitored the administration of resident medications and of his involvement in that process. The Administrator stated that a nurse consultant of the facility's contract pharmacy company conducted quarterly observations of facility licensed nursing staff as they prepared and administered medications to residents. The Administrator stated that he and the DON then received copies of these consultant nurse quarterly medication pass observation reports which documented any problems identified during observation. As an example, the DON presented a copy of the March 2014 consultant nurse's report which identified a problem related to a licensed nurse failing to flush a resident's gastrostomy tube with the correct amount of water prior to medication administration. When the Administrator was asked about his involvement in the resolution of issues involving medication administration identified by the consultant nurse during the quarterly medication pass observations, including the March 2014 medication pass issue referenced above, the Administrator stated that he did not take direct action on problematic issues identified in the quarterly medication pass observation reports, but rather referred any identified problems to the DON for addressing. The DON was then asked about the process by which the facility addressed these problems/issues, as related to the quarterly medication pass observations, which were referred to her by the Administrator for resolution. The DON stated she referred these types of issues to the Unit Managers to address. However, when asked about a system by which the facility provided tracking to ensure follow-up and resolution of an identified problem once the problem, such as a medication administration issue, had been referred by the Administrator to the DON, and then to the Unit Managers, the DON stated that there was no system for follow-up, and the Administrator could provide no evidence of a system to ensure the tracking of identified medication administration problems to ensure the development of effective corrective action. Additionally, the following continuing noncompliance related to F490 was identified during the prior July 3, 2014 standard survey: Cross refer to F323. Based on record review, observation, and staff interview, the facility failed to ensure safe mechanical lift transfers for two (2) residents (#254 and #17), who required transfer via mechanical lifts. Resident #254 was assessed on the Minimum Data Set assessment to have required two (2) - plus staff persons for transfer, and had also been assessed by the Physical Therapist to require the assistance of two (2) staff persons during mechanical lift transfers. However, Resident #254 fell and received a [MEDICAL CONDITION] requiring four (4) staples while being transferred via mechanical lift by only one (1) staff. Facility maintenance staff later found the lift utilized for Resident #254 to have a loose bolt, but the facility could provide no evidence of routine maintenance of this lift, as specified by the manufacturer. For Resident #17, who fell during mechanical lift transfer, the facility identified, as a result of this fall, a need to provide additional in-service training regarding mechanical lift transfer; but, the facility failed to provide this staff training to ensure staffs' proficiency in the provision of transfer via mechanical lift. During an interview with the Administrator conducted on 06/30/2014 at 5:40 p.m., the Administrator was questioned regarding the 06/01/2014 incident during which Resident #254 sustained a fall with injury while being transferred via mechanical lift. The Administrator acknowledged awareness of this 06/01/2014 incident involving Resident #254's fall during lift transfer, further stating he had been made aware of the incident a couple of days after the fall occurred. When the Administrator was questioned about the actions he had taken in response to Resident #254's fall after being made aware of the fall, the Administrator stated he had taken no action. He stated that he had concluded that the fall was not a result of a mechanical failure, but rather was a "person issue." The Administrator further acknowledged, however, that the facility had conducted no staff in-service training regarding mechanical lift transfers since Resident #254's fall. During a subsequent interview with the Administrator conducted on 07/01/2014 at 4:30 p.m., the Administrator acknowledged the failure to ensure the necessary staff training related to the use of mechanical lifts, and acknowledged the need for additional staff training. Based on the above, despite acknowledging having prior knowledge of Resident #254's fall involving the mechanical lift transfer, and despite asserting there being an issue with staff performance related to this lift transfer during which the resident fell , the Administrator acknowledged taking no action, to include providing no additional staff training, in response to Resident #254's fall and injury during lift transfer.

A standard survey conducted on July 3, 2014, prior to this July 25, 2014 abbreviated survey, identified immediate jeopardy at F520 at the S/S of "K" related to the facility's failure to ensure the Quality Assessment and Assurance (QA) Committee's participation in, an oversight of, the development of a corrective plan of action developed by the facility in response to falls which occurred during resident mechanical lift transfers. The facility implemented a credible allegation of jeopardy removal on July 2, 2014 regarding F520 cited at the S/S of "K", and based on the facility's credible allegation of jeopardy removal, the immediate jeopardy was removed on July 3, 2014; however, the noncompliance continued at F520 at a lower S/S of "E" to allow for the future assessment of the facility's continued application of the corrective actions implemented per the credible allegation of jeopardy removal. Then, during the current abbreviated survey on July 25, 2014, immediate jeopardy was again identified at F520 at the S/S of "K" based on the facility's failure ensure effective QA Committee involvement in the oversight of the facility's system of medication administration. The continuing noncompliance at F520, cited on the Form CMS-2567 for the standard survey of July 3, 2014, has been brought forward to this Form CMS-2567, which also documents the noncompliance at F520 at the S/S of "K" identified as a result of this abbreviated survey of July 25, 2014, as referenced below: Based on observation, clinical record review, and staff interview, the facility failed to ensure that the Quality Assessment and Assurance (QA) Committee provided ongoing monitoring and oversight of plans of action developed in response to identified quality deficiencies, to include identified problems related to resident medication administration. This abbreviated survey revealed significant medication errors involving two (2) residents (#1 and #3) on the survey sample of nine (9) residents. Resident (#1) received doses of [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mgs, galantamine ER 16 mgs, [MEDICATION NAME] 12.5 mgs, [MEDICATION NAME] MN ER 60 mgs, [MEDICATION NAME] 20 mgs, tamsulosin 0.4 mg, [MEDICATION NAME] 150 mgs, [MEDICATION NAME] Solution, and Dok Plus which were ordered for administration to another resident. Resident #1 was later transferred to the hospital, was lethargic, hypotensive, and severely obtunded, was diagnosed with [REDACTED]. Resident #3 had a physician's orders [REDACTED].#3 received uncrushed doses of [MEDICATION NAME], vitamin C, and multivitamin/mineral tablets during medication administration, and was observed to cough and wheeze. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy during interview on July 24, 2014 at 1:43 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on July 21, 2014, when Resident #1 was administered in error doses of the medications [MEDICATION NAME], [MEDICATION NAME], galantamine, [MEDICATION NAME], tamulosin, [MEDICATION NAME] Solution, and Doc Plus, which were actually ordered by the physician to be administered to another resident. Findings include: During an interview conducted on 07/25/2014 at 1:05 p.m. with the Administrator and DON, the Administrator was questioned regarding the QA Committee's involvement in the oversight of the facility's processes involved in the administration of medications to residents. The Administrator stated the facility had a process by which a consultant nurse conducted quarterly medication pass observations of licensed nursing staff during the administration of medications to residents, and also reviewed resident medical records during this process. The Administrator stated that when these reviews revealed systemic problems, these systemic problems would be submitted to the QA Committee for the Committee's review. The Administrator relayed an example of a past problem which had been identified and reported to the QA Committee, that problem being a noted problem with resident glucose monitoring. The Administrator specifically stated that the problem related to resident glucose monitoring had been under the QA Committee's review for a period of one (1) year. Additionally, during this interview, the DON stated that when she received reports from the consultant nurse which identified problems related to resident drug administration, these problems were then presented to Unit Managers who were expected to determine and implement solutions. However, the DON acknowledged that there was no system in place to track any procedural changes put into place by Unit Managers in response to identified problems related to resident drug administration to ensure the development of corrective actions, the monitoring of any corrective actions, or the involvement of the QA Committee if indicated. During a subsequent interview conducted on 07/29/2014 at 12:35 p.m. during an onsite monitoring visit, the DON was specifically questioned regarding the quality deficiency related to resident glucose monitoring which the Administrator had revealed, during the 07/25/2014, 1:05 p.m. interview referenced above, to have been under the QA Committee's review for a one (1) year period. The DON was asked to provide evidence of any corrective actions developed and put into place regarding this problem with resident glucose monitoring, and to provide evidence of ongoing monitoring and oversight by the QA Committee related to this identified quality deficiency involving resident drug therapy/glucose monitoring; however, the DON acknowledged there was no evidence of ongoing QA Committee tracking and monitoring of this issue. In addition, the DON was also asked about a 03/03/2014 quarterly report summary which was provided by the DON and which was completed by the consultant nurse. In this 03/03/2014 quarterly report (which preceded this abbreviated survey of 07/25/2014 by approximately 5 months), the consultant nurse documented an assessment of the facility's medication systems, including a review of resident medication administration records, and noted a problem related to resident fingerstick blood sugar and insulin doses not being accurately documented. The DON acknowledged that despite the issue of glucose monitoring having been under review by the QA Committee for a period of one (1) year, and despite the consultant nurse's notation in the 03/03/2014 consultant nurse's report (only approximately five (5) months ago) identifying a continued problem with the documentation of fingerstick blood sugar and insulin drug therapy, there was no evidence of continued QA Committee oversight regarding this identified quality deficiency related to resident drug therapy. Additionally, the following continuing noncompliance related to F520 was identified during the prior July 3, 2014 standard survey: Cross refer to F323. Based on record review and staff interview, the facility failed to ensure safe transfer via mechanical lift for two (2) residents (#254 and #17) who required mechanical lift transfer. Resident #254, per Minimum Data Set assessment and Physical Therapist evaluation, required the assistance of two (2) staff persons during mechanical lift transfers, but fell and sustained a [MEDICAL CONDITION] when transferred by lift by only one (1) staff. The lift utilized for Resident #254's transfer, which had received no routine maintenance as per the manufacturer, was inspected by maintenance staff and found to have a loose bolt. Resident #17 fell during mechanical lift transfer, and the facility determined a need to provide staff training related to this fall, but then failed to provide this staff training. An interview was conducted with the Administrator on 07/02/2014 at 3:50 p.m. related to the facility's QA Committee and the facility's QA Committee process. During this interview, the Administrator, who had acknowledged during an earlier 06/30/2014, 5:40 p.m. interview that he had been made aware of Resident #254's 06/01/2014 fall involving the mechanical lift transfer soon after the incident, was asked if the QA Committee had been informed of the falling incident involving Resident #254. The Administrator was also asked about the QA Committee's involvement in the corrective action plan (which included the development of a new policy regarding mechanical lift use in the facility formulated by the Administrator and DON; the development and implementation of a monthly, and an additional as-needed, mechanical lift inspection procedure by the Maintenance Director using the Monthly Lift Checklist and Service Log; implementation of a procedure involving weekly management staff monitoring of direct-care staff conformance with the completion of resident lift assessments and Care Plans; and direct-care staff training regarding these newly established policies and procedures) which had been developed and implemented as part of the facility's credible allegation of jeopardy removal related to this standard survey. The Administrator stated that the QA Committee had not been involved in the development or the implementation of the corrective action plan. The Administrator further stated that the QA Committee met quarterly, but that a QA Committee meeting had not been due, per the regular schedule, since the incident involving Resident #254, and that a QA Committee meeting had not been conducted. Based on the above, the facility failed to ensure the involvement of, and input by, the QA Committee in the development and implementation of the corrective action plan developed by the facility in response to an incident involving a resident fall with injury during mechanical lift transfer. The facility thus failed to ensure oversight by the QA Committee of the implementation of, and facility staff's conformance with, the corrective action plan, and failed to ensure the Committee's evaluation of the effectiveness of this corrective action plan.

Based on clinical record review, medication pass observation, hospital Nurse's Notes form review, hospital Physician's Documentation form review, hospital Physician's Orders form review, hospital History and Physical form review, Lexi-Comp Geriatric Dosage Handbook 12th Edition review, facility Medication Administration - General Guidelines review, website MayoClinic.org review, facility staff written statement review, and staff interview, the facility failed to ensure that residents were free of significant medication errors, related to one (1) resident (#1) who received doses of medications which included, but were not limited to, [MEDICATION NAME], and [MEDICATION NAME] ([MEDICATION NAME]), in the absence of physician's orders for their administration, and related to one (1) resident (#3), who was to receive crushed medications due to swallowing difficulty but was administered uncrushed medications, on the total survey sample of nine (9) residents. The facility also failed to ensure the training of licensed nursing staff who administered resident medications, regarding the facility's policies and procedures related to the administration of resident medication, to two (2) of seven (7) licensed nursing staff members interviewed. Resident #1 was administered the medications [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mgs, galantamine ER 16 mgs, [MEDICATION NAME] 12.5 mgs, [MEDICATION NAME] MN ER 60 mgs, [MEDICATION NAME] 20 mgs, tamulosin 0.4 mg, [MEDICATION NAME] 150 mgs, [MEDICATION NAME] Solution, and Dok Plus tablets in error, having no physician's order for their administration. Resident #1 was later noted to exhibit stupor, somnolence, and [MEDICAL CONDITION], was transferred to the hospital emergency room , was determined to have a low blood oxygen saturation level of 87 percent and to be lethargic, unarousable, hypotensive, and severely obtunded. Resident #1 received multiple doses of the narcotic overdose antidote drug [MEDICATION NAME], was diagnosed with [REDACTED]. For Resident #3, who had a physician's order specifying that the resident's medications were to be crushed and a reference on the Medication Administration Record [REDACTED]. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility Administrator and Director of Nursing (DON) were informed of the immediate jeopardy during interview on July 24, 2014 at 1:43 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on July 21, 2014, when Resident #1 was administered in error doses of the medications [MEDICATION NAME], [MEDICATION NAME], galantamine, [MEDICATION NAME], tamulosin, [MEDICATION NAME] Solution, and Doc Plus, which were actually ordered by the physician to be administered to another resident. During the July 24, 2014, 1:43 p.m. interview referenced above, the Administrator acknowledged the medication error during which Resident #1 received in error the medications ordered to be administered to another resident. Findings include: Review of the facility's Medication Administration - General Guidelines revealed the following: - The Intent of these Guidelines was that medications would be administered as prescribed, in accordance with good nursing principles; - The Procedural Guidelines section of these Medication Administration - General Guidelines specified, in parts 7 (a - c), that residents were to be identified before medication was administered, and that when in doubt, nursing staff were to check the resident ' s identification band and/or photograph; if necessary, staff were to verify the resident ' s identification with other nursing center personnel; - Part 19 of these Guidelines specified that medication tablets could be crushed or capsules emptied when a resident had difficulty swallowing; and, - Part 20(E) identified that the need for crushing medications was indicated on resident Medication Administration Records (MARs). 1. Record review for Resident #1 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 05/04/2014 which documented a birthdate in August of 1928, indicating that the resident was [AGE] years of age. Section C - Cognitive Patterns of this MDS documented that Resident #1 had a Brief Interview for Mental Status Summary Score of 07, indicating that the resident had severe cognitive impairment. Section C - Cognitive Patterns also documented Resident #1 to have the presence of signs and symptoms of [MEDICAL CONDITION] which included inattention (having difficulty focusing attention). Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Review of Resident #1's July 2014 Physician's Order form revealed additional [DIAGNOSES REDACTED]. Review of Resident #1's Nurses Progress Notes (NPN) revealed an entry dated 07/21/2014 and timed at 10:30 a.m. which documented the medication pass nurse had reported to Licensed Practical Nurse (LPN) "BB" that she had given Resident #1 the wrong medicines. During a telephone interview with LPN "BB" conducted on 07/24/2014 at 10:30 a.m., LPN "BB" identified LPN "CC" to have been the medication nurse who reported having made the medication error involving Resident #1 on 07/21/2014. LPN "BB" stated that on 07/21/2014, LPN "CC" had prepared the morning medications which were ordered for Resident #2, but later reported that she had administered these medications in error to Resident #1. During a telephone interview with LPN "CC" conducted on 07/25/2014 at 3:23 p.m., LPN "CC" acknowledged that on 07/21/2014, she had administered the medications ordered for Resident #2 to Resident #1 by mistake. Record review for Resident #2 (the resident for whom the medications administered to Resident #1 on 07/21/2014 in error were actually ordered) revealed the July 2014 Physician's Orders form specified that at 9:00 a.m. each day, Resident #2 was to receive two (2) [MEDICATION NAME] 10 milligram (mg) tablets, an [MEDICATION NAME] 5 mg capsule, a [MEDICATION NAME] 1 mg tablet, an [MEDICATION NAME] 0.5 mg capsule, a [MEDICATION NAME] 10 mg tablet, a galantamine ER 16 mg capsule, a [MEDICATION NAME] 12.5 mg capsule, an [MEDICATION NAME] MN ER 60 mg tablet, a [MEDICATION NAME] 20 mg tablet, a tamsulosin 0.4 mg capsule, 30 milliliters of [MEDICATION NAME] Solution, a [MEDICATION NAME] 150 mg capsule, and two (2) Dok Plus tablets. However, as indicated in the 07/21/2014, 10:30 a.m. NPN referenced above, LPN "CC" administered these medications, including doses of [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, and [MEDICATION NAME] 1 mg in error to Resident #1 during the 9:00 a.m. medication pass of 07/21/2014. Review of Resident #1's July 2014 Physician's Orders form revealed no physician's orders specifying that Resident #1 receive doses of [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mgs, galantamine ER 16 mgs, [MEDICATION NAME] 12.5 mgs, [MEDICATION NAME] MN ER 60 mgs, [MEDICATION NAME] 20 mgs, tamsulosin 0.4 mg, [MEDICATION NAME] Solution, [MEDICATION NAME] 150 mgs, or Dok Plus tablets, all of which he received in error, as indicated in the 07/21/2014, 10:30 a.m. NPN referenced above. Further review of Resident #1's July 2014 Physician's Order form revealed Resident #1 did have physician's orders specifying that at 9:00 a.m. each day, he was to receive an aspirin 81 mg. chewable tablet, a [MEDICATION NAME] CD 240 mg capsule, a multivitamin with mineral tablet, a [MEDICATION NAME] SR 500 mg capsule, a potassium 20 milliEquivalents (mEq) tablet, a [MEDICATION NAME] ER 150 mg capsule, a vitamin D 400 tablet, and one capful of polyethylene [MEDICATION NAME] powder. However, review of Resident #1's July 2014 Medication Administration Record [REDACTED]. A NPN entry of 07/21/2014 and timed at 11:15 a.m. documented that the Nurse Manager had been informed of the medication error involving Resident #1 (when the resident received [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mgs, galantamine ER 16 mgs, [MEDICATION NAME] 12.5 mgs, [MEDICATION NAME] MN ER 60 mgs, [MEDICATION NAME] 20 mgs, tamsulosin 0.4 mg, 30 milliliters of [MEDICATION NAME] Solution, [MEDICATION NAME] 150 mgs, and Dok Plus tablets in error), as documented in the 07/21/2014, 10:30 a.m. NPN referenced above. This Nurse Manager instructed nursing staff to notify the physician of the medication error and to monitor Resident #1's condition and vital signs every thirty (30) minutes. A subsequent NPN entry of 07/21/2014 timed at 12:00 p.m. for Resident #1 documented the initiation of nursing staffs' monitoring of the resident, and documented vital sign readings which included systolic and diastolic blood pressure readings within the normal range of 126 millimeters/mercury (mm/Hg) and 66 mm/Hg, respectively. This NPN also documented that Resident #1 was alert, responsive, and wandering around the facility in the wheelchair. A NPN entry of 07/21/2014 timed at 12:30 p.m. for Resident #1 documented that the physician's office had been contacted to report the narcotics the resident had received and the medication error, and that nursing staff had been informed to continue monitoring the condition of Resident #1. This NPN entry also documented that Resident #1's systolic and diastolic blood pressure readings were 114 mm/Hg and 56 mm/Hg, respectively, and that the resident was up in the wheelchair and alert at that time. A NPN entry of 07/21/2014 timed at 1:30 p.m. for Resident #1 documented vital sign readings which included systolic and diastolic blood pressure readings of 102 and 61, respectively, and a respiratory rate of 18 respirations per minute. A NPN entry of 07/21/2014 at 2:00 p.m. then documented that while Resident #1's systolic blood pressure had increased to 120 mm/Hg, the diastolic blood pressure had fallen to 42 mm/Hg. A subsequent NPN entry of 07/21/2014 timed at 2:30 p.m. for Resident #1 documented that the resident was up and ambulating in the wheelchair, but also documented lower systolic and lower diastolic blood pressure readings of 98 and 44, respectively, and a lower respiratory rate of 10 respirations per minute. A NPN entry of 07/21/2014 timed at 2:45 p.m. for Resident #1 documented that the resident was up in the wheelchair but stated he was getting sleepy and wanted to go to bed, and a NPN entry of 07/21/2014 timed at 3:10 p.m. documented Resident #1 was in bed sleeping, having deep labored respirations but was easily aroused. A NPN entry of 07/21/2014 timed at 4:00 p.m., however, documented that at that time, Resident #1 was experiencing stupor and was very somnolent and slow to arouse, and documented that Emergency Medical Services (EMS) 911 was notified of the resident's condition. A later NPN entry of 07/21/2014 timed at 5:10 p.m. for Resident #1 documented that the resident had been transferred by EMS to the hospital emergency room , and a subsequent NPN entry of 07/22/2014 timed at 1:45 a.m. documented that Resident #1 had been admitted to the hospital ICU with a [DIAGNOSES REDACTED]. A hospital Nurse's Notes (NN) entry for Resident #1 documented a hospital arrival date and time of 07/21/2014 at 5:49 p.m., with the [DIAGNOSES REDACTED]. This hospital NN entry documented that Resident #1 was transferred to the hospital from the nursing facility, and that nursing staff stated the resident had been given someone else's medication. The Presentation section of this hospital NN entry documented that upon Resident #1's 07/21/2014 hospital arrival, EMS staff stated that at 10:30 a.m. on that date, the resident had accidentally received another patient's medications, and had then become lethargic. EMS staff stated Resident #1 had received a two (2) milligram (mg) dose of the narcotic antidote drug [MEDICATION NAME] ([MEDICATION NAME]) while in route to the hospital, and had then become somewhat more responsive. The Vital Signs portion of this hospital NN entry documented that on 07/21/2014 at 6:28 p.m., Resident #1 had systolic and diastolic blood pressure readings of 128 and 58 mm/Hg, respectively; a respiratory rate of 21 respirations per minute; and a pulse oximetry reading which documented a blood oxygen saturation level of 97 percent on two (2) liters of oxygen per minute (the website MayoClinic.org indicated that a normal pulse oximetry reading for blood oxygen saturation was between 95 to 100 percent, and that values under 90 percent were considered low, indicating hypoxemia). However, the Vital Signs section of the 07/21/2014 hospital NN entry referenced above documented that on 07/21/2014 at 7:31 p.m., Resident #1's respiratory rate had declined to 18 per minute, and the pulse oximetry reading documented a blood oxygen saturation level of 96 percent. The Administered Medications section of this NN entry then documented that on 07/21/2014 at 7:40 p.m., Resident #1 received a second dose of the narcotic antidote [MEDICATION NAME] by intravenous push at a dose of 0.4 mg. The Vital Signs section of the 07/21/2014 hospital NN entry for Resident #1 then documented that on 07/21/2014 at 9:46 p.m. (despite Resident #1 having received the 7:40 p.m. 0.4 mg dose of [MEDICATION NAME], as documented above), Resident #1's systolic/diastolic blood pressure had declined to 92 and 52 mm/Hg, respectively. A 07/21/2014, 9:55 p.m. hospital NN entry documented that by then, Resident #1's respiratory rate had declined to 15 respirations per minute and the pulse oximetry reading had also declined, revealing a blood oxygen saturation level of 92 percent while on two (2) liters per minute of oxygen. The Administered Medications section of this hospital NN entry documented that Resident #1 was then given a third dose of the narcotic antidote [MEDICATION NAME] 0.4 mg by intravenous push on 07/21/2014 at 10:29 p.m. A subsequent entry in the hospital NN Vital Signs section dated 07/22/2014 at 12:16 a.m. documented that while Resident #1's systolic/diastolic blood pressure had increased to 110 and 71 mm/Hg, respectively, the resident's pulse oximetry reading indicated that the blood oxygen saturation level had declined to 87 percent while receiving two (2) liters of oxygen per minute. The hospital Physician's Documentation (PD) form for Resident #1 documented that the resident had presented to the Emergency Department after a known accidental drug overdose involving another resident's medications which included, but were not limited to, [MEDICATION NAME] 20 mgs, Oxy IR 5 mgs, and [MEDICATION NAME] 5 mgs. The Disposition section of this PD form documented Resident #1's hospital admission with the Preliminary [DIAGNOSES REDACTED]. A hospital Physician's Orders form dated 07/21/2014 and timed at 11:19 p.m. for Resident #1 documented an order to admit the resident to the hospital ICU with the [DIAGNOSES REDACTED]. The hospital History and Physical (H&P) for Resident #1 documented in the History of Present Illness section that Resident #1 had been given the wrong medication, including [MEDICATION NAME], Oxy IR ([MEDICATION NAME]) and [MEDICATION NAME], and became overdosed, lethargic, unarousable and hypotensive. This History of Present Illness section also documented that when Resident #1 was transferred to the hospital, he was severely obtunded, required the administration of fluids and [MEDICATION NAME] as treatment for [REDACTED]. The Assessment portion of this hospital H&P documented [DIAGNOSES REDACTED]. The Plan section of this H&P documented that after receiving treatment while in the hospital, Resident #1 was medically cleared to return to the nursing facility. A nursing facility NPN entry of 07/22/2014 timed at 7:30 p.m. for Resident #1 documented that the resident had returned to the nursing facility, and documented that the resident's systolic blood pressure of 126 mm/Hg and diastolic blood pressure of 80 mm/Hg had returned to the normal range at the time of facility readmission. A Facility Incident Report Form (FIRF) dated 07/22/2014 which was reported by the facility to the State Survey Agency on that date documented that on 07/21/2014, Resident #1 had received medications that were not ordered for him, resulting in a significant change in Resident #1's mental and physical status. This FIRF documented that after Resident #1 had received another resident's medication, he became lethargic and hypotensive, and was subsequently transferred to the hospital where he was admitted and diagnosed with [REDACTED]. This FIRF further identified Nurse "CC" to have been the nurse who administered Resident #1 the medications in error. In a 07/23/2014 written statement provided by LPN "CC", the nurse who administered medications in error to Resident #1 during the morning medication pass of 07/21/2014, LPN "CC" documented that she had prepared the medications of Resident #2 for administration, and then realized that neither Resident #2 nor Resident #1 (who were roommates) were in the room. LPN "CC" documented that a minute or two later, a resident approached her whom she addressed by the name of Resident #2, and that when she told him his medications were ready for administration, the resident said "Okay". LPN "CC" documented that she asked the resident if he was Resident #2, and he answered in the affirmative, so at that time, she administered to the resident the medications she had prepared for Resident #2. In her written statement, LPN "CC" acknowledged that she did not notice the identification wristband on the resident's wrist prior to administering the medication, and asserted that there was no picture identification on the resident's MAR by which to identify the resident. LPN "CC" documented that after she had administered these medications to the resident who she thought was Resident #2, the resident went into the room. Approximately five (5) minutes later, a resident who she thought was Resident #1 approached LPN "CC" and asked for his medications, but when the nurse addressed this resident by the name of Resident #1, he informed her that he was not Resident #1, but rather was Resident #2. LPN "CC" documented that she immediately realized the medication error she had made earlier during which she administered the medications of Resident #2 to Resident #1, and documented that she immediately informed Nurse "BB" of the error. During a telephone interview with LPN "BB" conducted on 07/24/2014 at 10:30 a.m., LPN "BB" stated that during the morning medication pass of 07/21/2014, he had been accompanying newly-employed LPN "CC" during medication pass. LPN "BB" stated that LPN "CC" prepared Resident #2's medications, but when LPN "CC" discovered that neither Resident #2, nor roommate Resident #1, was in the room, she sat Resident #2's prepared medications aside and began preparing Resident #1's medications. LPN "BB" stated that at that time, he noted a resident's feeding pump alarm to be sounding, so he stepped away from the medication cart to attend to the feeding pump. LPN "BB" stated that when he returned to the medication cart, LPN "CC" informed him that she had administered Resident #1's medications, but LPN "BB" stated that he observed Resident #1's medications, previously prepared by LPN "CC", still sitting on the medication cart, and it was at that time when he realized that LPN "CC" had administered the medications ordered for Resident #2 to Resident #1 by mistake. LPN "BB" further stated that he noted that the residents' pictures were in place on the MAR, and identification arm bands were in place on both Resident #1 and Resident #2, and that LPN "CC" should have checked to verify the identify of Resident #1 before administering to him the wrong medications. Review of the Lexi-Comp Geriatric Dosage Handbook, 12th Edition, revealed that [MEDICATION NAME], one of the medications which Resident #1 (who had [DIAGNOSES REDACTED]. The Warning/Precautions section of this Handbook indicated [MEDICATION NAME] could cause Central Nervous System (CNS) depression and sedation. This Warnings/Precaution section also indicated that [MEDICATION NAME] could cause respiratory depression and should be used with caution in residents with respiratory disease. This Handbook documented, in the Overdose/Toxicology section, that [MEDICATION NAME] overdose symptoms included respiratory depression and CNS depression. This Handbook further documented, in the Drug Interactions section, that [MEDICATION NAME] could interact with other CNS depressant drugs, such as other opioid [MEDICATION NAME], which could result in respiratory depression, [MEDICAL CONDITION], and profound sedation. Review of the Lexi-Comp Geriatric Dosage Handbook referenced above revealed that [MEDICATION NAME], another one of the medications which Resident #1 had received in error on 07/21/2014, was classified as a narcotic opioid [MEDICATION NAME], the same classification as [MEDICATION NAME]. This Handbook documented in the Warnings/Precautions section that [MEDICATION NAME] should be used with caution in residents having respiratory diseases. This Handbook documented in the Overdose/Toxicology section that the symptoms of [MEDICATION NAME] overdose included respiratory depression and CNS depression, and documented in the Drug Interactions section that [MEDICATION NAME] could interact with other CNS depressant drugs (such as [MEDICATION NAME]) and could potentiate the effects (i.e., respiratory depression and CNS depression) of other opiate agonists (such as [MEDICATION NAME]). Further review of the Lexi-Comp Geriatric Dosage Handbook referenced above revealed that [MEDICATION NAME] ([MEDICATION NAME]), which Resident #1 had also received in error on 07/21/2014, was classified as an antipsychotic medication. This Handbook documented, in the Adverse Reactions section, that [MEDICATION NAME] could have CNS effects including drowsiness and lethargy, and could also result in [MEDICAL CONDITION]. The Drug Interactions section of this Handbook documented that the sedative effects of [MEDICATION NAME] could be additive to other CNS depressants, including narcotic [MEDICATION NAME] (such as [MEDICATION NAME] and [MEDICATION NAME]). During an interview with the Director of Nursing (DON) conducted on 07/24/2014 at 11:00 a.m., the DON acknowledged the medication error during which LPN "CC" administered the wrong medications to Resident #1. The DON further stated that during medication passes, medication nurses should check resident photographs, check resident arm bands, or solicit the help of other staff members if unsure of the identity of a resident prior to administering medication to the resident. Additionally, during the above referenced 07/25/2014, 3:23 p.m. telephone interview with LPN "CC" (the nurse who on 07/21/2014 administered to Resident #1 the medications ordered for Resident #2), LPN "CC" stated that she had recently been hired by the facility on 06/16/2014. When LPN "CC" was questioned as to the training she had received upon employment related to her responsibilities as a medication administration nurse, LPN "CC" stated she had been given an LPN Orientation Checklist and a copy of the LPN Job Description to review, but LPN "CC" denied having received a review of the facility's policies and procedures related to medication administration. During an interview with LPN "EE" conducted on 07/25/2014 at 11:20 a.m., LPN "EE" stated she had been employed by the facility for approximately two (2) years, and stated that she administered resident medications as part of her responsibilities. However, LPN "EE" further denied having received a review of the facility's medication administration policies and procedures prior to being assigned to administer resident medications. During an interview with the DON conducted on 07/25/2014 at 1:05 p.m., when questioned about the facility's training program for licensed nursing staff related to the facility's policies and procedures for medication administration, the DON acknowledged the lack of evidence to indicate that all licensed nursing staff had received this training prior to being assigned to administer medications to residents. Based on the above, facility LPN "CC", who was a newly-employed nurse and who denied having received a review of the facility's medication administration Policies and Procedures, administered multiple thirteen (13) medications in error, including [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, and [MEDICATION NAME] 1 mg, to Resident #1 (who had [DIAGNOSES REDACTED].#1's picture attached to the MAR, checking the resident's identification name band, or asking another staff member for help in identifying the resident, as specified by the facility's Medication Administration - General Guidelines as referenced above. It was later determined that the medications administered to Resident #1 in error were actually ordered for Resident #2. Resident #1 subsequently experienced stupor, somnolence, and [MEDICAL CONDITION], was transferred to the hospital via EMS where his blood oxygen saturation level declined from 97 percent to 87 percent (indicating [MEDICAL CONDITION]), received multiple doses of the narcotic antidote [MEDICATION NAME], was diagnosed with [REDACTED]. 2. Record review for Resident #3 revealed a Quarterly MDS assessment having an Assessment Reference Date of 06/29/2014 which documented a Birth Date in April of 1920, indicating the resident was [AGE] years of age. Section C - Cognitive patterns documented that Resident #3 had a BIMS Summary Score of 05, indicating that the resident had severe cognitive impairment, and Section I - Active [DIAGNOSES REDACTED]. During medication pass observation conducted on 07/24/2014 at 8:42 a.m., LPN "DD" was observed to prepare medications which included a [MEDICATION NAME] 5 mg tablet, a [MEDICATION NAME] 20 mg tablet, a vitamin C 500 mg tablet, and a multivitamin with mineral tablet for administration to Resident #3. During the preparation of these medications, LPN "DD" did not crush any of these tablets. LPN "DD" then poured a cup of non-thickened water, entered into the room of Resident #3 and administered the whole, uncrushed tablets, along with the non-thickened water, to the resident. Resident #3 was observed to exhibit difficulty swallowing these whole tablets, cough multiple times and wheezing during the process of ingesting the uncrushed medications. Review of Resident #3's clinical record revealed the July 2014 Physician's Order form specified the 9:00 a.m. administration of a [MEDICATION NAME] 5mg tablet, a [MEDICATION NAME] 20 mg tablet, a multivitamin/mineral tablet, and a vitamin C tablet daily, and also specified that the resident receive a regular diet. A subsequent 07/15/2014 verbal physician's order documented on Resident #3's July 2014 Physician's Orders form then changed the resident's diet to a puree diet with nectar thickened liquids, and ordered to crush the resident's medications unless otherwise contraindicated. Review of the Lexi-Comp Geriatric Dosage Handbook, 12th Edition, revealed no listed contraindication for the crushing of [MEDICATION NAME], multivitamin/mineral, or vitamin C tablets. However, as documented during the 07/24/2014 medication pass observation referenced above, LPN "DD" failed to crush doses each of these medications, as ordered, prior to administration to Resident #3. Additionally, the facility's Medication Administration - General Guidelines referenced above specified, in Part 20(E), that the need for crushing medications was indicated on resident MARs, and review of Resident #3's July 2014 MAR indicated [REDACTED]. However, LPN "DD" administered uncrushed [MEDICATION NAME], multivitamin/mineral, and vitamin C tablets to Resident #3 during the 07/24/2014, 8:42 a.m. medication pass observation referenced above. During an interview with Unit Manager LPN "EE" conducted on 07/24/2014 at 10:05 a.m., LPN "EE" acknowledged that LPN "DD" should have crushed Resident #3's [MEDICATION NAME], vitamin C, and multivitamin/mineral tablets prior to administration to the resident. A Speech Therapy Rehabilitation Screen for Resident #3 dated 07/17/2014 and signed by the Speech Therapist noted the resident's diet of puree foods with nectar-thickened liquids and documented a risk of coughing/choking with regular textures. Based on the above, despite Resident #3 having a current physician's order specifying that his medications be crushed, despite the facility's Medication Administration - General Guidelines specifying that medications be administered as prescribed and that medication tablets could be crushed, as listed on the MAR, when a resident had difficulty swallowing, and despite the resident having been assessed by the Speech Therapist to have a swallowing deficit and to be at risk of coughing/choking with regular textures, LPN "DD" administered uncrushed [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, vitamin C 500 mg, and multivitamin/mineral tablets to Resident #3 during the morning medication pass of 07/24/2014. Resident #3 was then observed to exhibit difficulty swallowing the uncrushed tablets, and was observed to cough multiple times and to wheeze.

Based on medication pass observation, clinical record review, hospital Nurse's Notes form review, hospital Physician's Orders form review, website MayoClinic.org review, staff interview, and review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, the facility failed to ensure that services were provided in accordance with professional standards of quality, regarding medication administration in conformance with physicians' orders for one (1) resident (#1) who received doses of medications which included, but were not limited to, [MEDICATION NAME], and [MEDICATION NAME] in the absence of physician's orders, and for one (1) resident (#3), who was to receive crushed medications due to swallowing difficulty but was administered multiple doses of uncrushed medications, on the total survey sample of nine (9) residents. The facility also failed to ensure licensed nursing staff training regarding the facility's policies and procedures related to the administration of resident medication to two (2) of seven (7) licensed nursing staff members interviewed, thereby failing to ensure licensed nursing staff proficiency regarding medication administration. After the medication error involving Resident #1, the resident was later noted to be somnolent and hard to arouse after having received multiple medications in error, was transferred to the hospital and found to be lethargic, hypotensive, and severely obtunded. Resident #1 received multiple doses of the narcotic antidote [MEDICATION NAME] and was admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. For Resident #3, the resident was observed to have difficulty swallowing, and to cough and wheeze, after receiving multiple doses of uncrushed medications which were ordered by the physician to be crushed. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility Administrator and Director of Nursing (DON) were informed of the immediate jeopardy during interview on July 24, 2014 at 1:43 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on July 21, 2014, when Resident #1 was administered in error doses of the medications [MEDICATION NAME], [MEDICATION NAME], galantamine, [MEDICATION NAME], tamsulosin, [MEDICATION NAME] Solution, and Doc Plus, which were actually ordered by the physician to be administered to another resident. During the July 24, 2014, 1:43 p.m. interview referenced above, the Administrator acknowledged the medication error during which Resident #1 received in error the medications ordered to be administered to another resident. Findings include: Review of the National Council of State Board of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed the following: The Model Nursing Administrative Rules, Chapter 2.3.2, Standards Related to Licensed Practical/Vocational Nurse Responsibilities for Nursing Practice Implementation, specified in Part 2.3.2(i)(3) that the nurse administers medications accurately. 1. Resident #1's 05/04/14 Quarterly Minimum Data Set (MDS) assessment documented, in Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) Summary Score of 07, indicating severe cognitive impairment, and documented [DIAGNOSES REDACTED]. A 07/21/2014, 10:30 a.m. Nurses Progress Notes (NPN) entry for Resident #1 documented that a nurse informed Licensed Practical Nurse (LPN) "BB" that she had administered Resident #1 the wrong medication. During 07/24/2014, 10:30 a.m. telephone interview, LPN "BB" acknowledged that on 07/21/2014 he had been notified by LPN "CC" that she had administered medications to Resident #1 which were ordered for Resident #2. Resident #2's July 2014 Physician's Orders specified that Resident #2 was to receive doses of [MEDICATION NAME] 20 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mg, galantamine ER 16 mg, [MEDICATION NAME] 12.5 mg, [MEDICATION NAME] MN ER 60 mg, [MEDICATION NAME] 20 mg, tamsulosin 0.4 mg, [MEDICATION NAME] Solution 30 milliliters, [MEDICATION NAME] 150 mg, and Dok Plus daily at 9:00 a.m. However, a 07/22/2014 Facility Incident Report Form documented that on 07/21/2014, Resident #1 had mistakenly been given these medications which were not ordered for him, but rather were ordered for another resident (Resident #2). Further review of Resident #1's clinical record revealed a 07/21/2014, 4:00 p.m. NPN which documented that Resident #1 was stuporous and somnolent, and a 07/21/2014, 5:10 p.m. NPN documented that Resident #1 had been transferred by Emergency Medical Services (EMS) to the hospital. A 07/21/2014 hospital Nurse's Notes (NN) entry documented Resident #1 to have a [DIAGNOSES REDACTED]. The Administered Medications section of this NN entry documented that on 07/21/2014 at 7:40 p.m., Resident #1 again received [MEDICATION NAME] at a dose of 0.4 mg. The hospital NN Vital Signs section documented that 9:46 p.m., Resident #1's systolic/diastolic blood pressure had declined to 92 and 52 millimeters of mercury (mm/Hg), respectively, and the NN Administered Medications section documented that at 10:29 p.m., Resident #1 was given another [MEDICATION NAME] dose of 0.4 mg. A 07/22/2014, 12:16 a.m. hospital NN Vital Signs entry documented Resident #1's blood oxygen saturation level had declined to 87 percent (with MayoClinic.org listing values under 90 percent as low), and a hospital Physician's Orders form documented an order to admit Resident #1 to the ICU with the [DIAGNOSES REDACTED]. Resident #1's hospital History and Physical documented that after being given the wrong medication, Resident #1 had become overdosed, lethargic, and hypotensive, was transferred to the hospital and was severely obtunded, required treatment which included [MEDICATION NAME] administration, and was admitted to the hospital ICU. During a 07/24/2014, 10:30 a.m. telephone interview, LPN "BB" stated that during morning medication pass on 07/21/2014, LPN "CC" prepared Resident #2's medications for administration, but then administered the medications ordered for Resident #2 to Resident #1 in error. LPN "BB" further stated that LPN "CC" should have identified Resident #1 by checking pictures of the residents on the Medication Administration Record [REDACTED]. During a 07/25/2014, 3:23 p.m. telephone interview, LPN "CC" acknowledged the 07/21/2014 incident during which she administered Resident #1 medications ordered for Resident #2, but further stated, in relation to her responsibilities as a medication administration nurse, that she had not been provided with a review of the facility's medication policies/procedures upon hire by the facility. During a 07/25/2014, 11:20 a.m. interview with LPN "EE", LPN "EE" also denied having received a review of the facility's medication administration policies prior to her assignment to administer resident medications. Based on the above, despite the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules specifying in Part 2.3.2(i)(3) that the nurse was to administer medications accurately, LPN "CC" failed to provide care to Resident #1 in accordance with this professional standard of practice by administering multiple doses of medication to Resident #1 in error. Nurse "CC" failed to verify Resident #1's correct identity prior to administering to Resident #1 medications, which included [MEDICATION NAME], and [MEDICATION NAME], that were ordered for administration to Resident #2. Resident #1 was later stuporous, somnolent, and hypotensive, was transferred to the hospital, given the narcotic antidote [MEDICATION NAME], diagnosed with [REDACTED]. Additionally, also based on the above, the facility failed to ensure nurse proficiency by failing to ensure that all licensed nursing staff received training regarding the medication administration policies and procedures. Cross refer to F333, example 1, for more information regarding Resident #1. 2. Resident #3's 06/29/2014 Quarterly MDS assessment documented in Section I - Active [DIAGNOSES REDACTED]. Resident #3's July 2014 Physician's Order form specified administration of 9:00 a.m. daily doses of [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 20 mgs, multivitamin/mineral, and vitamin C 500 mgs, all in tablet form. A 07/15/14 verbal physician's order then specified that Resident #3's medications were to be crushed. However, during a 07/24/2014, 8:42 a.m. observation, LPN "DD" prepared Resident #3's [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, vitamin C 500 mg, and multivitamin/mineral tablets for administration, but without crushing these tablets as ordered, then administered the uncrushed tablets to the resident. Resident #3 was observed to cough and wheeze while swallowing the uncrushed tablets. During a 07/24/2014, 10:05 a.m. interview, Unit Manager LPN "EE" stated that LPN "DD" should have crushed the [MEDICATION NAME], vitamin C, and multivitamin/mineral tablets before giving them to Resident #3. Based on the above, despite the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules specifying in Part 2.3.2(i)(3) that a nurse was to administer medications accurately, and despite Resident #3 having a physician's order specifying that solid medications be crushed, LPN "DD" administered uncrushed [MEDICATION NAME], vitamin C, and multivitamin/mineral tablets to Resident #3, and the resident was observed to cough and wheeze while taking the medications. Cross refer to F333, example 2, for more information regarding Resident #3.

A standard survey conducted on July 3, 2014, prior to this July 25, 2014 abbreviated survey, identified immediate related to noncompliance at F224 at the scope/severity (S/S) of "J" related to the facility's failure to ensure the assistance of two (2) staff persons during mechanical lift transfer per assessed need and the failure to ensure the safe working order of mechanical lifts. The facility implemented a credible allegation of jeopardy removal on July 2, 2014 regarding F224 cited at the scope/severity (S/S) of "J", and based on the facility's credible allegation of jeopardy removal, the immediate jeopardy was removed on July 3, 2014; however, the noncompliance continued at F224 at a lower S/S of "D" to allow for the future assessment of the facility's continued application of the corrective actions implemented per the credible allegation of jeopardy removal. Then, during the current abbreviated survey conducted on July 25, 2014, immediate jeopardy was again identified at F224 at the S/S of "J" based on the facility's failure to administer medications in conformance with physicians' orders. The continuing noncompliance cited at F224, documented on the Form CMS-2567 for the standard survey of July 3, 2014, has been brought forward to this Form CMS-2567, which also documents the noncompliance at F224 at the S/S of "J" identified as a result of this abbreviated survey of July 25, 2014, as referenced below: Based on clinical record review, hospital Nurse's Notes form review, hospital Physician's Documentation form review, hospital Physician's Orders form review, hospital History and Physical form review, facility Medication Administration - General Guidelines review, website MayoClinic.org review, facility staff written statement review, and staff interview, the facility failed to provide care in a manner which prohibited the neglect of one (1) resident (#1) who was administered medications including, but not limited to, [MEDICATION NAME], and [MEDICATION NAME], which were ordered for another resident and for which Resident #1 had no physician's orders, on the total survey sample of nine (9) residents. Resident #1 was administered doses of [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mgs, galantamine ER 16 mgs, [MEDICATION NAME] 12.5 mgs, [MEDICATION NAME] MN ER 60 mgs, [MEDICATION NAME] 20 mgs, tamulosin 0.4 mg, [MEDICATION NAME] 150 mgs, [MEDICATION NAME] Solution, and Dok Plus tablets in error. Resident #1 later experienced stupor and somnolence requiring transfer to the hospital, where the resident's blood oxygen saturation level dropped to 87 percent and he was noted to have [MEDICAL CONDITION] and to be severely obtunded. Resident #1 received multiple doses of the narcotic overdose antidote [MEDICATION NAME], was diagnosed with [REDACTED]. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy during interview on July 24, 2014 at 1:43 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on July 21, 2014, when Resident #1 was administered in error doses of the medications [MEDICATION NAME], [MEDICATION NAME], galantamine, [MEDICATION NAME], tamulosin, [MEDICATION NAME] Solution, and Dok Plus, which were actually ordered by the physician to be administered to another resident. During the July 24, 2014, 1:43 p.m. interview referenced above, the Administrator acknowledged the medication error during which Resident #1 received in error the medications ordered to be administered to another resident. Findings include: Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment of 05/04/2014 revealed an August 1928 birthdate, revealing the resident to be [AGE] years old. MDS Section C - Cognitive Patterns documented a Brief Interview for Mental Status Summary Score of 07, indicating severe cognitive impairment, and Section I - Active [DIAGNOSES REDACTED]. Review of Resident #1's clinical record revealed a 07/21/2014, 10:30 a.m. Nurses Progress Notes (NPN) entry which documented that a medication pass nurse reported she had made a medication error and had reported this medication error to Licensed Practical Nurse (LPN) "BB". The medication pass nurse stated she had administered the wrong medications to Resident #1. During a telephone interview conducted on 07/24/14 at 10:30 a.m., LPN "BB" stated that on 07/21/14, medication pass nurse LPN "CC" acknowledged to him that she had made a medication error which involved Resident #1. LPN "CC" stated that she had administered to Resident #1 the morning medications which were ordered for Resident #2. In a written statement dated 07/23/2014, LPN CC" documented that on 07/21/2014, as she approached the room that Resident #1 and Resident #2 shared as roommates, she prepared Resident #2's medications but realized that Resident #2 and Resident #1 were not in the room. LPN "CC" documented that a resident then approached her and when she called him by the name of Resident #2 to confirm his identity, the resident indicated he was Resident #2, and LPN "CC" administered Resident #2's medications to this resident. LPN "CC" indicated she did not see the resident's identification wristband, and alleged an absence of an identification picture on the Medication Administration Record (MAR). LPN "CC" documented that later, another resident approached her whom she addressed by the name of Resident #1, but that resident then told her he was Resident #2, and she realized she had given Resident #2's medications in error to Resident #1. During the 07/24/2014, 10:30 a.m. telephone interview with LPN "BB" referenced above, LPN "BB" stated that upon discovering LPN "CC" had administered to Resident #1 the medications ordered for Resident #2, LPN "BB" stated he had noted that the residents' pictures were in place on the MAR and that identification armbands were in place on Resident #1 and Resident #2. LPN "BB" stated that LPN "CC" should have verified Resident #1's identity using the picture identification or identification wristband. The facility's Medication Administration - General Guidelines specified, in the Procedural Guidelines section, that nursing staff were to identify residents prior to medication administration, and that when in doubt, nursing staff were to check the resident's identification band and/or photograph, and if necessary, to verify identification with other nursing staff. Review of Resident #2's July 2014 Physician's Orders form revealed orders for doses of [MEDICATION NAME] 20 mgs, [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mgs, galantamine ER 16 mgs, [MEDICATION NAME] 12.5 mgs, [MEDICATION NAME] MN ER 60 mgs, [MEDICATION NAME] 20 mgs, tamsulosin 0.4 mg, 30 milliliters of [MEDICATION NAME] Solution, [MEDICATION NAME] 150 mgs, and two (2) Dok Plus tablets. However, as documented in the 07/21/2014, 10:30 a.m. NPN referenced above, and as acknowledged by LPN "CC" in the 07/23/2014 written statement referenced above, LPN "CC" administered these medications by mistake to Resident #1 during the 07/21/2014 morning medication pass. A NPN entry of 07/21/14 at 12:00 p.m. for Resident #1 (after having received Resident #2's medications in error) documented the resident's systolic/diastolic blood pressure readings remained within the normal range of 126 millimeters/mercury (mm/Hg) and 66 mm/Hg, respectively, and that the resident was alert, responsive, and in the wheelchair. However, a 07/21/2014, 4:00 p.m. NPN entry then documented that Resident #1 had become stuporous, very somnolent, and slow to arouse, and documented that Emergency Medical Services (EMS) was called for the transfer of Resident #1 to the hospital. A 07/21/2014 hospital Nurse's Notes (NN) entry for Resident #1 documented a [DIAGNOSES REDACTED].#1 had received another resident's medication, including the narcotic [MEDICATION NAME], and that EMS staff had given Resident #1 a two (2) mg dose of the narcotic antidote [MEDICATION NAME] while in route to the hospital. The Vital Signs section of the 07/21/2014 hospital NN entry referenced above documented that at 7:31 p.m. on that date, Resident #1's pulse oximetry reading revealed a blood oxygen saturation level of 96 percent (MayoClinic.org listed blood oxygen saturation levels under 90 percent as being low). This NN entry also documented, in the Administered Medications section, that at 7:40 p.m., Resident #1 received a second dose of [MEDICATION NAME], at a 0.4 mg dose. The Vital Signs section of Resident #1's 07/21/2014 hospital NN entry then documented that at 9:46 p.m., Resident #1's systolic/diastolic blood pressure had declined to 92 and 52 mm/Hg, respectively, and a 9:55 p.m. NN entry documented that the resident's pulse oximetry reading had declined to a blood oxygen saturation level of 92 percent. The hospital NN Administered Medications section then documented administration of a third dose of [MEDICATION NAME], 0.4 mg by intravenous push, on 07/21/2104 at 10:29 p.m.; however, a later hospital NN Vital Signs section entry of 07/22/2014 at 12:16 a.m. documented that Resident #1's blood oxygen saturation level had declined to 87 percent. A hospital Physician's Documentation form for Resident #1 documented that the resident had an accidental drug overdose involving another resident's medications which included [MEDICATION NAME], Oxy IR ([MEDICATION NAME]), and [MEDICATION NAME] ([MEDICATION NAME]). A 07/21/14 hospital Physician's Orders form for Resident #1 then specified to admit the resident to the ICU with [DIAGNOSES REDACTED]. Resident #1's hospital History and Physical documented Resident #1's medication error, including [MEDICATION NAME], Oxy IR, and [MEDICATION NAME], and that upon hospital transfer, the resident was severely obtunded, received [MEDICATION NAME] and fluids as treatment for [REDACTED]. During an interview conducted on 07/24/2014 at 11:00 a.m., the DON acknowledged that LPN "CC" had administered the wrong medications to Resident #1, and that prior to medication administration, nurses were to check resident photographs, arm bands, or obtain assistance from other staff, per facility policy, if unsure of resident identity. Based on the above, despite Resident #1 having [DIAGNOSES REDACTED].#1, even though these medications were ordered by the physician for administration to Resident #2. LPN "CC neglected Resident #1 by failing to correctly verify the resident's identity by failing to check the resident's picture identification attached to the MAR, failing to check the resident's identification wristband, and/or failing to verify the resident's identity with another staff member, as specified by facility policy, prior to administering all thirteen (13) medications in error to Resident #1. Resident #1 became stuporous, somnolent, and hypotensive, was transferred to the hospital where his blood oxygen saturation level declined to 87 percent, required the administration of [MEDICATION NAME], and was diagnosed with [REDACTED]. Additionally, the following continuing noncompliance related to F224 was identified during the prior July 3, 2014 standard survey: Resident #254's Quarterly Minimum Data Set assessment of 04/28/2014 documented [DIAGNOSES REDACTED]. Section G - Functional Status documented Resident #254 to be totally dependent for transfer and to have required two (2) - plus person assistance for transfer during the look-back period. A 04/29/2014 Fall Risk assessment indicated Resident #254's Total Fall Risk Score to be 14, and documented that a Total Score of 10 or above represented a high risk for falls. A Plan of treatment for [REDACTED].#254 documented the initiation of skilled physical therapy on 05/12/2014, which continued through 05/23/2014. This PTR form also documented the Physical Therapist's determination that Resident #254 required the assistance of two (2) staff persons via mechanical lift for safe transfer upon discharge from skilled physical therapy on 05/23/2014. During a 06/23/2014, 10:50 a.m. telephone interview, Occupational Therapist "GG" stated, and Physical Therapist "II" concurred, that at the time of discharge from therapy services on 05/23/2014, Resident #254 required transfer via a mechanical lift with the assistance of two (2) staff persons. However, further record review revealed no evidence to indicate that, after Resident #254's discharge from physical therapy services on 05/23/14, the facility instructed direct-care staff to ensure the assistance of two (2) persons while transferring the resident via mechanical lift. Interview with the DON on 06/24/2014 at 4:35 p.m. revealed that the Physical Therapist's determination that Resident #254 required the assistance of two (2) staff persons during lift transfers should have been added to the Aide Assignment Record to instruct direct-care staff, but acknowledged that the resident's need for the assistance of two (2) persons during lift transfers had been omitted from the Aide Assignment Record. A 06/01/2014, 4:45 p.m. Nurse's Notes entry then documented that while a nursing assistant was transferring Resident #254 from the bed to the chair via mechanical lift, the lift toppled, the resident landed on the floor, and a laceration of approximately four (4) centimeters (cms) was observed on the back of the resident's head. A verbal physician's order of 06/01/2014 specified Resident #254's hospital transfer for this fall and [MEDICAL CONDITION]. A 06/01/2014 hospital ED Nurse's Notes entry for Resident #254 documented that upon hospital arrival, the resident was noted with a bleeding laceration to the mid-parietal area of the head. A 06/01/2014 hospital Physician Documentation (PD) entry documented a 3.2 cm laceration to Resident #254's left occiput which was closed with four (4) 1-0 staples, and documented that Resident #254 was then discharged back to the nursing facility. A facility Incident Report for Resident #254's fall documented that on 06/01/2014, Licensed Practical Nurse (LPN) "JJ" observed the resident on the floor with a four (4) centimeter [MEDICAL CONDITION] and observed the lift net to be only partially attached. This Incident Report further documented that the certified nursing assistant (CNA) stated Resident #254 had been "squirming around", the lift malfunctioned, and the resident fell . During a 06/30/2014, 4:35 p.m. interview with CNA "KK", the CNA who transferred Resident #254 on 06/01/2014 when the resident fell during lift transfer, CNA "KK" stated she had begun to transfer the resident in the lift without the assistance of another staff member. She stated Resident #254 began to move in the lift and the lift then stuck. She stated as she pushed buttons on the lift and pushed on the lift bar, the lift would not initially move but then began to move downward and Resident #254 fell , hitting his head on the floor. During a 06/30/2014, 5:00 p.m. interview, CNA "KK" stated she had not known how many staff were to assist in Resident #254's transfer when he fell during the lift transfer of 06/01/14. During interview on 06/19/2014 at 4:15 p.m., the DON acknowledged that only one (1) staff person was transferring Resident #254 via mechanical lift when he fell on [DATE]. In addition, a telephone interview with the Maintenance Director on 06/25/2014 at 9:05 a.m. revealed there had been a mechanical issue with the lift used during Resident #254's 06/01/2014 transfer. He stated that inspection of the lift after Resident #254's fall revealed that a mechanical lift shifter bolt/screw had come loose. The Maintenance Director stated that the facility did not perform regular inspections and maintenance for mechanical lifts. Review of the Invacare Manual/Electric Patient Lift User Manual revealed the Manual to specify monthly inspection/adjustment of manual/electric portable patient lifts used in the institutional setting to check components of the lift including, but not limited to, the caster base, the casters and axle bolts, the lift shifter handle, the lift mast and boom, the lift swivel bar, the manual/hydraulic pump/electric [MEDICATION NAME] assembly, and the lift slings and hardware. However, even though the manufacturer mandated monthly mechanical lift inspections to ensure the necessary maintenance, the Maintenance Director acknowledged during the 06/25/2014, 9:05 a.m. interview referenced above that the facility did not conduct monthly inspections and maintenance on the mechanical lifts used by the facility for resident transfers. Based on the above, despite Resident #254 having been assessed to be totally dependent for transfer and to be at high risk for falls, and despite Resident #254 being assessed by the Physical Therapist to require the assistance of two (2) staff persons for mechanical lift transfers, Resident #254 was transferred via mechanical lift by only one (1) CNA. The resident fell to the floor during this transfer and sustained a [MEDICAL CONDITION] which required four (4) staples to close. Maintenance staff later determined the lift to have a loose bolt on the shifter handle, but the facility had failed to provide monthly maintenance and inspections for this mechanical lift (or any mechanical lift utilized in the facility), despite the lift manufacturer's requirement that monthly inspections/adjustments be conducted on all mechanical lifts. The failure of the facility to ensure two (2) persons to assist during the mechanical lift transfer of Resident #254 on 06/01/2014, and the failure of the facility to ensure the monthly inspection/maintenance of the lift utilized during this transfer, with the resident subsequently falling during this transfer and sustaining a [MEDICAL CONDITION] requiring four (4) staples for closure, represented neglect for Resident #254.

A standard survey conducted on July 3, 2014, prior to this July 25, 2014 abbreviated survey, identified immediate jeopardy at F282 at the S/S of "J" related to the facility's failure to ensure the provision of staff in-service training as specified by a resident's Care Plan for fall-prevention, failure to provide a specialty mattress in accordance with a resident's Care Plan, and failure to provide incontinence care in accordance with an incontinent resident's Care Plan. The facility implemented a credible allegation of jeopardy removal on July 2, 2014 regarding F282 cited at the S/S of "J", and based on the facility's credible allegation of jeopardy removal, the immediate jeopardy was removed on July 3, 2014; however, the noncompliance continued at F282 at a lower S/S of "D" to allow for the future assessment of the facility's continued application of the corrective actions implemented per the credible allegation of jeopardy removal. Then, during the current abbreviated survey on July 25, 2014, ongoing immediate jeopardy was again identified at F282 at the S/S of "J" based on the facility's failure to administer medications in conformance with physicians' orders. The continuing noncompliance at F282, cited on the Form CMS-2567 for the standard survey of July 3, 2014, has been brought forward to this Form CMS-2567, which also documents the noncompliance at F282 at the S/S of "J" identified as a result of this abbreviated survey of July 25, 2014, as referenced below: Based on clinical record review, medication pass observation, Medication Administration Record [REDACTED].org review, and staff interview, the facility failed to ensure that services were provided in accordance with the Care Plan, regarding medication administration in accordance with physicians' orders, for one (1) resident (#1) who received medications including without physician's orders, and for one (1) resident (#3) who received uncrushed tablets even though a physician's order specified that the medications were to be crushed, on the total survey sample of nine (9) residents. Resident #1 received doses of [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mgs, galantamine ER 16 mgs, [MEDICATION NAME] 12.5 mgs, [MEDICATION NAME] MN ER 60 mgs, [MEDICATION NAME] 20 mgs, tamsulosin 0.4 mg, [MEDICATION NAME] 150 mgs, [MEDICATION NAME] Solution, and Dok Plus tablets in error, later exhibited stupor, somnolence, and [MEDICAL CONDITION], was transferred to the hospital, and was diagnosed with [REDACTED]. Resident #3 had a physician's order to crush medications, but was administered uncrushed [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, vitamin C 500 mg, and multivitamin/mineral tablets, and was observed to cough and wheeze while swallowing these medications. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy during interview on July 24, 2014 at 1:43 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on July 21, 2014, when Resident #1 was administered in error doses of the medications [MEDICATION NAME], [MEDICATION NAME], galantamine, [MEDICATION NAME], tamsulosin, [MEDICATION NAME] Solution, and Doc Plus, which were actually ordered by the physician to be administered to another resident. During the July 24, 2014, 1:43 p.m. interview referenced above, the Administrator acknowledged the medication error during which Resident #1 received in error the medications ordered to be administered to another resident. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment of 05/04/2014 documented in Section I - Active [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan revealed a Problem/Need, originally dating from 02/14/2014, which documented [DIAGNOSES REDACTED]. A listed Care Plan Goal related to this Problem/Need was that Resident #1 would have all needs met daily, and the Care Plan further identified Approaches which included, but were not limited to, the administration of the resident's medications as ordered. However, a 07/21/2014, 10:30 a.m. Nurses Progress Notes (NPN) entry documented that a nurse reported to Licensed Practical Nurse (LPN) "BB" that Resident #1 had been given the wrong medication. A 07/24/2014, 10:30 a.m. telephone interview with LPN "BB" revealed that on 07/21/2014, LPN "CC" had administered to Resident #1, in error, the morning medications ordered for Resident #2. Resident #2's July 2014 Physician's Orders specified daily 9:00 a.m. doses of [MEDICATION NAME] 20 mgs, [MEDICATION NAME] 5 mgs, [MEDICATION NAME] 1 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 10 mgs, galantamine ER 16 mgs, [MEDICATION NAME] 12.5 mgs, [MEDICATION NAME] MN ER 60 mgs, [MEDICATION NAME] 20 mgs, tamsulosin 0.4 mg capsule, 30 milliliters of [MEDICATION NAME] Solution, [MEDICATION NAME] 150 mgs, and 2 Dok Plus tablets. Review of Resident #1's July 2014 Physician's Orders form revealed no physician's orders specifying that Resident #1 receive any of these medications. However, as documented in the 07/21/2014, 10:30 a.m. NPN entry referenced above, LPN "CC" administered doses of all of these medications to Resident #1 on that date. A 07/21/14, 2:45 p.m. NPN entry documented that Resident #1 stated he was sleepy. A subsequent 07/21/14, 4:00 p.m. NPN documented that Emergency Medical Services (EMS) was notified that Resident #1 was experiencing stupor and was very somnolent and slow to arouse, and a 07/21/14, 5:10 p.m. NPN then documented Resident #1's hospital transfer. A 07/21/2014 hospital Nurse's Notes (NN) entry for Resident #1 documented a [DIAGNOSES REDACTED]. The hospital NN Vital Signs section documented a 7:31 p.m. blood oxygen saturation of 96 percent for Resident #1 (MayoClinic.org listed blood oxygen saturation of 95-100 % as normal), and the hospital NN Administered Medications section documented the 7:40 p.m. administration of a second dose of [MEDICATION NAME] at a 0.4 mg dose. This hospital NN entry then documented a lower blood oxygen saturation level of 92 percent at 9:55 p.m., and the NN Administered Medications section documented another 0.4 mg dose of [MEDICATION NAME] at 10:29 p.m. Resident #1's hospital History and Physical (H&P) documented the medication error during which Resident #1 received the wrong medications, including [MEDICATION NAME], and [MEDICATION NAME], and that the resident then became overdosed, lethargic, unarousable and hypotensive. This H&P further documented that Resident #1 became severely obtunded, received fluids and [MEDICATION NAME] for the overdose, and was admitted to the hospital ICU. During a 07/24/2014, 11:00 a.m. interview, the DON acknowledged that on 07/21/2014, LPN "CC" administered medications to Resident #1 in error. Based on the above, despite Resident #1's Care Plan specifying that the resident receive medications as ordered by the physician, LPN "CC" administered multiple medications in error, including [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 5 mgs, and [MEDICATION NAME] 1 mg, to Resident #1 in the absence of physician's orders specifying that the resident receive these medications. Resident #1 was later noted with stupor, somnolence, and [MEDICAL CONDITION], was transferred to the hospital, received multiple doses of [MEDICATION NAME], and was diagnosed with [REDACTED]. Cross refer to F333, example 1, for more information regarding Resident #1. 2. Resident #3's Quarterly MDS assessment of 06/29/2014 documented the resident's April 1920 birthdate, and documented diagnoses, in Section I - Active Diagnosis, which included, but were not limited to, Hypertension and Depression. Review of Resident #3's Care Plan revealed a Problem/Need, originally dated 04/17/2014, which noted the resident's advanced age of [AGE] years, and also listed an additional [DIAGNOSES REDACTED].#1 would have all needs met daily, and identified Approaches which included the administration of medications as ordered, further specifying that staff refer to the resident's Medication Administration Record [REDACTED] Resident #3's July 2014 Physician's Order form specified administration of [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, multivitamin/mineral, and vitamin C tablets at 9:00 a.m. daily. A 07/15/14 verbal physician's order then specified that Resident #3's medications be crushed, and Resident #3's July 2014 MAR indicated [REDACTED]. During a 07/24/2014, 8:42 a.m. medication pass observation, LPN "DD" prepared Resident #3's medications, including [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, vitamin C 500 mg, and multivitamin/mineral tablets, but did not crush these tablets as ordered and as instructed per the resident's MAR. Instead, LPN "DD" administered the uncrushed tablets to Resident #3, and the resident coughed and wheezed as he swallowed the uncrushed medications. During a 07/24/2014, 10:05 a.m. interview, Unit Manager LPN "EE" acknowledged that Resident #3's medications should have been crushed as ordered before administration. Based on the above, despite Resident #3 having a current physician's order specifying that medications be crushed, despite Resident #3's Care Plan specifying that the resident receive medications as ordered and instructing nursing staff to refer to the MAR, and despite Resident #3's MAR indicated [REDACTED]. Cross refer to F333, example 2, for more information regarding Resident #3. Additionally, the following continuing noncompliance related to F282 was identified during the prior July 3, 2014 standard survey: A. Resident #17's 05/01/2014 Minimum Data Set (MDS) assessment documented in Section G - Functional Status that the resident was totally dependent for transfer, with limited range of motion in the lower extremities, and Section I - Active [DIAGNOSES REDACTED]. Review of Resident #17's Care Plan revealed an entry originally dated 11/08/2013 which identified as a Problem/Need that the resident was at risk for falls with injury related to risks which included, but were not limited to, a History of Falls, Arthritic Deformities of Both Feet, Generalized Weakness and a Cerebral Infarction. The Care Plan indicated that the Goal related to Resident #17's risk for falls was to ensure the resident was at a decreased risk for falls and fall-related injuries. The Care Plan further identified multiple Approaches to address Resident #17's risk for falls, with one Approach being to transfer the resident with the appropriate devices. A 06/11/2014, 2:50 p.m. Nurse's Notes entry documented that staff were transferring Resident #17 using a mechanical lift, the lift tilted over on its side, and the resident sustained [REDACTED]. A Supervisor Incident Investigation report for Resident #17's 06/11/2014 fall documented that the mechanical lift tilted to the right during transfer, that the resident's weight may not have been distributed evenly while positioned in the lift, and that this incident would be referred to the Interdisciplinary Team (IDT) and the Patients At Risk (PAR) committee for review. Review of the 06/12/2014 PAR Committee notes revealed that the IDT reviewed Resident #17's fall of 06/11/2014 and specified to provide staff in-service training regarding proper lift net placement and the use of the lift stabilizer bar. Review of Resident #17's Care Plan referenced above revealed an entry dated 06/12/2014, added as part of the Problem/Need entry identifying the resident's fall-risk, which documented that the PAR Committee had reviewed the resident's 06/11/2014 fall from the mechanical lift while being transferred by two (2) people during which the lift tipped over. An additional Care Plan entry, also dated 06/12/2014, was added as an Approach for the resident's fall-risk and specified that staff receive in-service training regarding the proper placement of the net and use of the stabilizer legs on the mechanical lift. However, review of the June 2014 staff in-service training record revealed no evidence of staff training for proper net placement and stabilizer bar use for mechanical lifts as specified by Resident #17's 06/12/2014 Care Plan Approach referenced above which had been added to the Care Plan in response to the resident having fallen from the mechanical lift during transfer. During an interview with Registered Nurse (RN) "UU" conducted on 06/19/2014 at 2:19 p.m., RN "UU" acknowledged that the staff in-service training specified by the Care Plan of Resident #17 related to mechanical lift use had not been provided. During a later interview with the DON conducted on 06/19/2014 at 2:40 p.m., the DON also acknowledged that the facility had failed to provide the staff in-service training as specified by Resident #17's Care Plan. Based on the above, despite Resident #17 having been assessed to be at an increased risk for falls, despite Resident #17 sustaining a fall with injury during a mechanical lift transfer, and despite the resident's Care Plan specifying staff training, as mandated by the IDT in response to this fall, regarding proper net placement and stabilizer bar use for mechanical lifts, the facility failed to provide this staff in-service training specified by the Care Plan to ensure the resident's continued safety during mechanical lift transfers, to thus achieve the Care Plan Goal of ensuring the resident would be at decreased risk for falls and fall-related injuries Cross refer to F323, example #2, for more information regarding Resident #17. B. Resident #116's 03/17/2014 MDS documented in Section I - Active [DIAGNOSES REDACTED]. Section J - Health Conditions documented a history of falls. Review of the Care Plan for Resident #116 revealed a Problem/Need, originally dating from 12/20/2013, which identified the resident's risk for falls. Approaches listed on this Care Plan to address Resident #116's fall-risk included the use of a bolster mattress to be applied to the resident's bed. However, observations conducted on 06/17/2014 at 5:30 p.m. and on 06/18/2014 at 7:05 a.m. and 12:20 p.m. revealed a flat mattress on the resident's bed, not a bolster mattress as specified by the Care Plan. During an interview with Nurse Manager "AA" conducted on 06/18/2014 at 1:00 p.m., Nurse "AA" stated her expectation would be that a bolster mattress should be used on Resident #116's bed, as specified by the resident's Care Plan. Cross refer to F323, example #3, for more information regarding Resident #116. C. Resident "C"'s MDS assessment of 04/06/2014 documented [DIAGNOSES REDACTED]. The Care Plan of Resident "C" identified as a Problem/Need that the resident had a self-care deficit related to multiple medical factors and required the assistance of staff with toileting, further indicating that the resident was incontinent of bowel/bladder. A Goal related to this Problem/Need was that Resident "C" would have no infections, and Care Plan Approaches included that the resident would be cleansed after incontinent episodes. However, observation of Resident "C" on 06/19/14 at 9:55 a.m. revealed Certified Nursing Assistant (CNA) "CC" to wipe the perineal area, place the soiled washcloth back into the clean soapy water basin, then dampen three (3) additional washcloths in the contaminated soapy water basin and continue to wipe the perineal area. The CNA then dampened a clean washcloth in a rinse water basin, rinsed the perineal area, placed the soiled rinse cloth back in the clean rinse water basin and again wiped the resident's perineal area, further contaminating the cloth with bowel movement. She then placed the soiled cloth back in the rinse water, dampened another washcloth with the contaminated rinse water and cleaned the resident. During interview at the time of this observation, CNA "CC" acknowledged her failure to change the contaminated water in the soapy/rinse water basins. During a 06/19/2014, 11:13 a.m. interview, the DON acknowledged that staff failed to provide proper cleansing during the incontinence care provided to Resident "C". Cross refer to F315 for more information regarding Resident "C".

Based on clinical record review, observation, Rehabilitation Screen form review, Fall Risk form review, Plan Of treatment for [REDACTED]., facility employee written statement review, and staff interview, the facility failed to ensure safe mechanical lift transfers by failing to ensure the presence of two (2) persons as assessed to provide safety during mechanical lift transfer, failing to ensure staff training regarding mechanical lift use, and/or failing to provide routine maintenance as specified by the manufacturer to ensure safe mechanical lift operation for two (2) residents (#254 and #17) who required transfer via mechanical lift, of three (3) sampled residents evaluated for mechanical lift transfers, and failed to provide a chair alarm and bolster mattress as specified for the safety of one (1) resident (#116), who had a history of [REDACTED]. The Residents Using Mechanical Lift form provided by the facility documented eighty-eight (88) residents who required transfer utilizing a mechanical lift, and the facility's July 2014 Patient Lift Checks and Services form documented a total of twelve (12) mechanical lifts that were used in the facility. For Resident #254, who had been assessed by the Physical Therapist to require a mechanical lift and the assistance of two (2) staff persons during mechanical lift transfers, the resident was transferred via mechanical lift by only one (1) staff member, and sustained a fall which resulted in a laceration to the back of the head which required four (4) staples for closure. After Resident #254's fall, the mechanical lift utilized for the transfer, and for which the facility had provided no routine maintenance, was found to have a loose bolt. In addition, Resident #17 fell during a mechanical lift transfer and sustained a skin tear, and the facility's investigation indicated a potential problem with the resident's weight distribution during the transfer; however, the facility then failed to provide the staff in-service training identified as a corrective action in response to this resident's fall from the mechanical lift. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on July 1, 2014 at 9:00 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on June 1, 2014 (the date Resident #254 fell during a transfer via mechanical lift while being transferred by only one (1) facility staff person, rather than two (2) persons as indicated by the resident's assessed need, and after the facility failed to conduct routine maintenance on the mechanical lift), continued through July 2, 2014, and was removed on July 3, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on July 2, 2014. During an interview conducted on 06/30/2014 at 5:40 p.m., the Administrator acknowledged an awareness of Resident #254's fall from the mechanical lift during transfer, but further acknowledged that no corrective actions had been implemented after the fall. During an interview conducted on 06/30/2014 at 5:10 p.m., the Director of Nursing (DON) acknowledged that the facility did not have a specific policy regarding mechanical lift use. An allegation of jeopardy removal was received on July 2, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on July 3, 2014, and the facility remained out of compliance at a lower scope and severity of "E" while the facility's provision of staff in-service training and the newly-implemented process of routine mechanical lift inspections continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and procedures related to the transfer of residents utilizing mechanical lifts, and related to the routine inspection and maintenance of mechanical lifts. Resident records were reviewed to ensure that resident assessments and Care Plan accurately reflected the transfer status of residents. Findings include: 1. Record review for Resident #254 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 04/28/2014 which documented an original facility Entry Date of 01/29/2014. Section C - Cognitive Patterns indicated that Resident #254 had a Brief Interview for Mental Status (BIMS) Summary Score of "0", indicating that the resident had severe cognitive impairment, and Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #254 was totally dependent for transfer and had required the support of two (2) - plus staff persons for every transfer during the entire seven (7) day look-back period. A Rehabilitation Screen form for Resident #254, dated 04/08/2014 and labeled as a Quarterly Screen, documented that Physical Therapy had screened the resident and noted the resident to need transfer via a mechanical lift with the assistance of two (2) staff persons. A quarterly Fall Risk form dated 04/29/2014 then assessed Resident #254 to have a Total Fall Risk Score of 14, which indicated that the resident was at a high risk for falls. This Fall Risk form specified that a Total Score of 10 or above represented a high risk for falls. A verbal physician's orders [REDACTED].#254's monthly May 2014 physician's orders [REDACTED]. A Plan of treatment for [REDACTED].#254 having a Start of Care Date of 05/12/2014 documented that the resident began receiving physical therapy on that date, which continued three (3) times per week through 05/23/2014. The Physical Therapist documented on this PTR form that Resident #254's Primary/Pertinent [DIAGNOSES REDACTED]. The Physical Therapist also documented that for the three (3) week period during which Resident #254 received physical therapy, his Functional Level for safe transfers improved from requiring 75 percent assistance with two (2) staff persons to requiring only 50 percent staff assistance, but still requiring the assistance of two (2) staff persons for safe transfer as of the 05/23/2014 discharge date of Skilled Physical Therapy. During a telephone interview conducted on 06/23/2014 at 10:50 a.m. with Occupational Therapist (OT) "GG" and Physical Therapist (PT) "II", PT "II" stated that he and another physical therapist had provided skilled physical therapy services to Resident #254 during the three week period in May 2014 during which the resident received therapy services. OT "GG" stated, and Physical Therapist "II" confirmed, that they had reviewed Resident #254's Rehabilitation Screen and the PTR form referenced above and that Resident #254 had been assessed to require a mechanical lift with the assistance of two (2) staff persons for transfer upon the initiation of skilled therapy services in May 2014. OT "GG" further stated, and PT "II" confirmed, that during the course of Resident #254's skilled therapy services, his function had improved slightly, but that at the time of discharge from therapy services on 05/23/2014, he still required a mechanical lift and the assistance of two (2) staff persons for transfer. However, further record review for Resident #254, to include review of the Aide Assignment Record, the Care Plan, and the Nurse's Notes, revealed no evidence to indicate that either licensed nursing staff or certified nursing assistant (CNA) staff had been notified of the need to utilize two (2) staff persons during mechanical lift transfers, or had been instructed to utilize two (2) staff persons during lift transfers of the resident, after 05/23/2014, when the Physical Therapy PTR referenced above specified the need for two (2) staff persons with mechanical lift transfers. During an interview with the DON conducted on 06/24/2014 at 4:35 p.m., the DON stated that the need for two (2) staff persons during mechanical lift transfer involving Resident #254 should have been added to the Aide Assignment Record to instruct staff. The DON stated that in cases where the Physical Therapist indicated that changes were needed related to the provision of resident care, such as the need for two (2) person transfers, the PT would inform a nurse manager of the needed change in care and this would be added to the Aide Assignment Sheet. The DON acknowledged that the PT specification that Resident #254 needed the assistance of two (2) staff while being transferred by mechanical lift had not been added to the resident's Aide Assignment Record, and she did not know why this information had been omitted. Further record review for Resident #254 then revealed a Nurse's Progress Notes entry of 06/01/2014 at 4:45 p.m. which documented that the nurse had been called to the resident's room to observe the resident on the floor and to have a laceration approximately four (4) centimeters (cms) in size to the back of the head. The nurse documented that the nursing assistant stated she was transferring Resident #254 from the bed to the chair when the resident toppled the mechanical lift and landed on the floor. A verbal physician's orders [REDACTED].#254 to the hospital Emergency Department (ED) status [REDACTED]. A Nurse's Progress Notes entry of 06/01/2014 at 4:40 p.m. for Resident #254 documented that the ambulance had been notified, and a Nurse's Progress Notes entry of 06/01/2014 at 5:05 p.m. documented that the ambulance had arrived to transfer the resident to the hospital Emergency Department. A hospital ED Nurse's Notes entry documented Resident #254's hospital arrival on 06/01/2014. The Presentation section of this ED Nurse's Notes entry documented that on 06/01/2014 at 5:43 p.m., Resident #254 presented to the hospital via ambulance with a laceration to the back of the head which the Emergency Medical Services staff stated resulted from a fall of approximately four (4) feet from the lift. The Assessment section of this ED Nurse's Notes entry documented that Resident #254 had sustained a laceration to the mid-parietal area, with some bleeding noted. A hospital Physician Documentation (PD) entry of 06/01/2014 documented that Resident #254 had fallen from the seated position while transferring, striking the back of his head and causing a laceration. The Exam portion of this PD entry documented a 3.2 cm laceration to Resident #254's left occiput. The Laceration portion of this PD documented that Resident #254's head laceration was closed with four (4) 1-0 staples using a staple gun, and that the wound was dressed with 4-by-4 gauze. The Disposition portion of this PD documented that on 06/01/2014 at 7:27 p.m., Resident #254 was discharged back to the nursing facility. A nursing facility Nurse's Progress Notes entry of 06/01/2014 at 9:10 p.m. documented that Resident #254 had returned from the hospital to the nursing facility, and documented that the resident had four (4) staples in place to the injury on the back of the head. Review of Resident #254's Aide Assignment Record revealed a 06/02/2014 entry which indicated that it was only on that date (the day after 06/01/2014 when the resident fell from the lift while being assisted by only one CNA, but 10 days after the resident's 05/23/2014 discharge from skilled physical therapy services when it was determined by the Physical Therapist that the resident continued to require a mechanical lift and the assistance of two (2) staff persons for transfer) that CNA staff were instructed to utilize two (2) staff persons and a mechanical lift at all times for transfers of the resident. A Supervisor Incident Investigation (SII) report which documented a facility investigation into the 06/01/2014, 4:30 p.m. fall involving Resident #254 indicated that a CNA had been attempting to transfer the resident from the bed to the chair. This SII report documented the CNA reported that Resident #254 was "squirming" in the mechanical lift being used for the transfer, the mechanical lift malfunctioned, and the resident fell to the floor. The SII report documented that upon assessment, the nurse noted bleeding and a four (4) centimeter laceration to the back of Resident #254's head, that a new order was obtained to transfer the resident to the hospital Emergency Department, and that the resident later returned to the facility having staples to the head wound. An Incident Report (IR) referencing Resident #254's fall documented that on 06/01/2014 at 4:30 p.m., Licensed Practical Nurse (LPN) "JJ" had been alerted by a CNA that Resident #254 had fallen. LPN "JJ" documented that Resident #254 was lying on the the floor in his room with the mechanical lift net under him and still partially attached to the lift, and that the resident was noted with a four (4) centimeter laceration to the back of the head. LPN "JJ" documented the CNA reported that Resident #254 was "squirming around" in the lift during transfer and the lift malfunctioned, sending the resident to the floor. In a written statement dated 06/01/2014 provided by LPN "JJ", the LPN documented that she had been called to Resident #254's room by CNA "KK", and that upon entering the room, she had observed the resident lying on his back on the floor at the foot of the bed with the mechanical lift net still underneath him. LPN "JJ" documented that the lift net was also still partially attached (on 2 points) to the mechanical lift. LPN "JJ" documented that CNA "KK" stated that Resident #254 had fallen out of the mechanical lift during transfer while "squirming around", and she believed the lift had malfunctioned. CNA "KK" stated to LPN "JJ" that it appeared to her that as Resident #254 moved around in the lift, he was about to fall, but that rather than trying to catch him, CNA "KK" had pushed a button on the lift to guide the resident to the floor; however, CNA "KK" stated that the lift "plunged" the resident down quickly, causing him to hit the back of his head on the floor. During an interview with CNA "KK" conducted on 06/30/2014 at 4:35 p.m., CNA "KK" stated that the mechanical lift she utilized during the 06/01/2014 transfer of Resident #254 when the resident fell and was injured had functioned properly prior to this resident's transfer. She acknowledged that on 06/01/2014, she had attempted to transfer Resident #254 with the mechanical lift without the assistance of another staff member. She stated that when using a mechanical lift for transfers, she normally did transfer residents with the assistance of a second staff member, but that on 06/01/2014, as she awaited a second staff person to come to assist, she began Resident #254's lift transfer by herself. She stated that as Resident #254's lift transfer began, the resident began to move and she was afraid the resident would fall, so she attempted to lower the lift, but the lift stuck. She stated she tried to push buttons on the lift and then pushed on the bar to which the lift sling was attached, but the lift would not move. She stated the lift then began to move downward and she could not stop it, and Resident #254 fell to the floor, hitting his head on the floor and causing the laceration. During a subsequent interview with CNA "KK" on 06/30/2014 at 5:00 p.m., CNA "KK" stated she had not been aware prior to Resident #254's 06/01/2014 lift transfer of how many staff were required to assist with lift transfers of the resident. During an interview with the DON conducted on 06/19/2014 at 4:15 p.m., the DON acknowledged that at the time of Resident #254's 06/01/2014 fall, only one (1) staff person was transferring the resident using the mechanical lift. The DON further stated that the facility's procedure for mechanical lift transfers had been that only one (1) staff person was required with the use of a mechanical lift, unless a resident's Care Plan required otherwise. The DON also stated that the facility did not have a specific written policy regarding mechanical lift use, but rather followed the mechanical lift company (Invacare) guidelines. Review of the Invacare Manual/Electric Portable Patient Lift User Manual revealed that although the manufacturing company recommended the use of two (2) assistants for all lifting preparation and transferring procedures, the lift could permit proper operation by one (1) assistant; however, the Manual further clarified that the use of only one (1) assistant for transfers was to be based on the evaluation of the health care professional for each individual resident. During the 06/19/2014, 4:15 p.m. interview referenced above, the DON acknowledged that although the Invacare mechanical lift guidelines which staff were to follow referenced the use of one (1) assistant during lift transfers in some cases, the guidelines did indicate that the use of only one (1) assistant during lift transfer was to be based on the evaluation of each individual resident by the health care professional. During a subsequent 06/30/2014, 5:10 p.m. interview with the DON, when asked about the Physical Therapist's determination that Resident #254 needed two (2) staff persons to assist when transferring the resident via mechanical lift, the DON stated she had not been aware that the physical therapy evaluation had determined the resident to need two (2) staff persons to assist. In addition, further review of the Invacare Manual/Electric Portable Patient Lift Use Manual revealed that the manufacturer specified, in Section 2 - Safety, that staff should not use a mechanical lift without a complete understanding of the instructions for use, including an understanding of positioning of the swivel bar; general operation of the lift; using the sling; and lifting and transferring the resident. However, during the 06/30/2014, 4:35 p.m. interview with CNA "KK" referenced above, CNA "KK" stated that she had not received any additional training regarding the use of the mechanical lift since the 06/01/2014 mechanical lift transfer which resulted in Resident #254's fall, saying that she had not received training on mechanical lift operation for "years". During the 06/30/2014, 5:10 p.m. interview with the DON referenced above, the DON acknowledged that no additional staff in-service training regarding mechanical lift use had been provided to any direct-care staff since the 06/01/2014 falling incident involving Resident #254 and CNA "KK". The facility provided an Attendance Report for CNA "KK" which documented that the CNA had received Invacare Lift Training on 04/08/2005. In addition, during a 06/24/2014, 4:35 p.m. telephone interview with the DON regarding Resident #254's 06/01/2014 fall from the mechanical lift, the DON stated it was her understanding that the mechanical lift utilized for the transfer had experienced a mechanical failure. During a telephone interview with the Maintenance Director conducted on 06/25/2014 at 9:05 a.m., the Maintenance Director acknowledged there had been a mechanical issue with the mechanical lift utilized during Resident #254's fall from the lift during transfer. The Maintenance Director stated there had been a problem with the mechanical lift shifter in which a bold/screw came loose. He stated that this mechanical problem had been noted after Resident #254's fall, and that the lift had been repaired at that time. When asked about the facility's maintenance program to ensure the safety of resident lifts, the Maintenance Director stated that while maintenance staff did make repairs to lifts based on a log which listed specific issues to be addressed and which was kept at the nurse's station, the facility did not perform any form of routine, regular maintenance regarding mechanical lifts. He further stated that even if maintenance staff did check a piece of equipment such as a lift for proper function, this function check was not documented and thus maintenance checks could be missed. Review of the Invacare Manual/Electric Patient Lift User Manual revealed that Section 10.1, entitled Maintenance Safety Inspection Checklist, specified the following monthly inspection/adjustment of manual/electric portable patient lifts being utilized in the institutional setting: - The caster base was to be inspected monthly for missing hardware; to ensure the lift base opened/closed with ease; to inspect the casters and axle bolts for tightness; to inspect the casters for smooth swivel and roll; and to inspect and clear the wheels of debris. - The lift shifter handle was to be inspected monthly to ensure smooth operation and that it locked the lift adjustable base whenever engaged. - The lift mast was to be inspected monthly for bends or deflections; also to ensure that the mast was securely assembled to the boom, which the Manual specified as a "MUST". - The lift boom was to be inspected monthly to check all hardware and swivel bar supports; to inspect for bends or deflections; to inspect bolted joints of the boom for wear; to ensure that the boom was centered between the lift base legs; and to check the mast pivot bolt under the rubber book to ensure that the bold was tightly secured. - The lift swivel bar was to be inspected monthly to check the bolt and hooks for wear or damage, and to check the sling hooks for wear or deflection. - The manual/hydraulic pump/electric actuator assembly was to be inspected monthly to check for leakage; to inspect the hardware on the mast and boom; to check for wear or deterioration; and to assess the cycle to ensure smooth, quiet operation. - The pump handle was to be checked monthly to monitor for smooth operation. - The lift control valve was to be checked monthly to ensure that the valve opened and closed easily. - The lift slings and hardware were to be checked monthly to inspect the sling material and straps for wear; an additional specification was that all sling attachments were to be checked both monthly, and each time the lift was used, to ensure proper connection and patient safety. However, even though the Invacare Manual/Electric Portable Patient Lift Manual specified the monthly inspection of institutional lifts, per the maintenance scheduled referenced above, to ensure the necessary maintenance for maximum safety, the facility provided no evidence of a routine maintenance program or of routine inspections of any mechanical lifts being utilized in the facility, including the lift which was reported to have malfunctioned during the 06/01/2014 transfer of Resident #254, when the resident fell to the floor and sustained a laceration to the back of the head. The lack of a routine maintenance program for facility lifts was acknowledged by the Maintenance Director during the the 06/25/2014, 9:05 a.m. interview referenced above. During a subsequent interview with the Maintenance Director conducted on 06/30/2014 at 3:00 p.m., the Maintenance Director again stated that the mechanical lift utilized for Resident #254's 06/01/2014 transfer which resulted in the resident's fall had been noted to have a loose bolt on the shifter bar upon inspection after the fall. When asked if any changes had been made to institute a regular maintenance program for mechanical lifts since the 06/25/2014, 9:05 interview referenced above during which the Maintenance Director had acknowledged the lack of a system which ensured routine and regular maintenance on mechanical lifts, the Maintenance Director acknowledged that as of that date of 06/30/2014, the facility had still not developed and implemented a system of routine mechanical lift maintenance. Based on the above, despite Resident #254 having been assessed via MDS assessment to have [DIAGNOSES REDACTED].#254 being assessed by the Physical Therapist to require the assistance of two (2) staff persons with the mechanical lift for safe transfer, Resident #254 was transferred via a mechanical lift by only one (1) CNA who voiced experiencing difficulty with operation of the lift during the transfer, and the resident then fell to the floor and sustained a head laceration which required four (4) staples for closure. Investigation by facility maintenance staff after the fall revealed the lift to have a loose bolt on the shifter handle, but the facility acknowledged that, despite the lift manufacturer's requirement for routine maintenance, no routine maintenance had been performed on the mechanical lift used during Resident #254's transfer, or on any other mechanical lift used by the facility. 2. Record review for Resident #17 revealed a Quarterly MDS assessment having an Assessment Reference Date of 05/01/2014 which documented in Section G - Functional Status that the resident was totally dependent on staff for transfer, and had functional limitation in range of motion in both lower extremities. Section I - Active [DIAGNOSES REDACTED].#17 had [DIAGNOSES REDACTED]. A Nurse's Notes entry of 06/11/2014 at 2:50 p.m. for Resident #17 documented that while staff were transferring the resident from the bed to a reclining chair using a mechanical lift, the lift tilted over on its side. This Nurse's Notes entry documented that the resident was assessed and had no complaints of pain, but that a skin tear was noted to the resident's right arm. An Incident Report (IR) for Resident #17 documented that on 06/11/2014, two (2) CNAs were transferring the resident from the bed to a reclining chair using a mechanical lift. This IR documented that as Resident #17 was positioned over the chair in the lift, one side was heavier than the other, the mechanical lift fell over on its side, and the resident fell on the floor. The IR further documented that an assessment at that time revealed Resident #17's vital signs to be within normal limits, but a skin tear on the resident's right arm was identified and treatment was initiated. A Supervisor Incident Investigation (SII) report which reference Resident #17's 06/11/2014 fall from the mechanical lift documented, in the Incident Review section, that the mechanical lift tilted to the right while the resident was positioned up in the lift, causing a skin tear when the resident's arm hit part of the lift. This SII report documented that Resident #17's weight may not have been distributed evenly while positioned up in the lift. The SII report also listed in the Safety Precautions section that as an action taken to correct the unsafe action/condition, this incident would be referred to the Interdisciplinary Team and the Patient's At Risk (PAR) Committee for review. Review of the the PAR Committee notes of 06/12/2014 at 11:00 a.m. revealed that the Interdisciplinary Team (IDT) had reviewed the incident involving Resident #17 and indicated to provide in-service training to staff on the proper placement of the net and the use of the stabilizer bar on the mechanical lift. However, a review conducted on 06/19/2014 at 1:30 p.m. of staff in-service training records presented by the facility, and which had been conducted by the facility during the month of June 2014, revealed no evidence of staff training related to proper placement of the net and use of the stabilizer bar on mechanical lifts. During an interview with Registered Nurse (RN) "UU" conducted on 06/19/2014 at 2:19 p.m., RN "UU" stated that the specified in-service training for CNA staff regarding mechanical lift use had not been provided. During a subsequent interview with the DON, the Assistant Director of Nursing, and RN "UU" conducted on 06/19/2014 at 2:40 p.m., these staff members acknowledged that the in-service training related to mechanical lift use which had been required by the IDT in response to the 06/11/2014 mechanical lift accident involving Resident #17 had not been done prior to that date of 06/19/2014; rather, this in-service training had been completed on that date of 06/19/2014 at 2:30 p.m. Based on the above, despite Resident #17 sustaining a fall and injury during a mechanical lift transfer; despite the facility's investigation of the fall identifying a potential problem with staff failing to ensure an even distribution of the resident's weight in the lift during the transfer; and despite the IDT specifying additional staff training regarding the proper net placement and stabilizer bar use of mechanical lifts, the facility failed to provide this staff in-service training until this failure was identified during the standard survey. 3. Record review for Resident #116 revealed an MDS having an Assessment Reference Date of 03/17/2014 which documented in Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) Summary Score of 3, indicating that the resident had severe cognitive impairment. Section I - Active [DIAGNOSES REDACTED].#116 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#116 specified that staff was to apply a chair alarm when the resident was out of bed in a wheelchair. However, during observations of Resident #116 conducted on 06/17/2014 at 5:20 p.m., and on 06/18/2014 at 7:05 a.m. and at 12:15 p.m., Resident #116 was observed sitting in a wheelchair without a chair alarm in place. During an interview with CNA "GG" conducted on 06/18/2014 at 12:30 p.m., CNA "GG" stated that Resident #116 was not to use an alarm when out of bed in the wheelchair. During a later interview with Nurse Manager "AA" conducted on 06/18/2014 at 1:00 p.m., Nurse "AA" stated she was unaware of the physicians order for the chair alarm for Resident #116, and acknowledged that the chair alarm was not being used as ordered for the resident. This nurse also stated that if there was an order for [REDACTED]. In addition, Resident #116's Care Plan identified the resident's risk for falls, and an Approach specified the application of a bolster mattress to the resident's bed. However, during observations conducted in the room of Resident #116 on 06/17/2014 at 5:30 p.m., and on 06/18/2014 at 7:05 a.m. and 12:20 p.m., there was no bolster mattress in place on the resident's bed; rather, a flat mattress was on the resident's bed during these observations. During an interview with CNA "GG" conducted on 06/18/2014 at 12:30 p.m., CNA "GG" stated that when she assisted Resident #116 from her bed in the mornings, she had not observed a special mattress in place. During an interview with Nurse Manager "AA" on 06/18/2014 at 3:30 p.m., this nurse acknowled

Based on observation, clinical record review, and staff interview, facility administration failed to ensure resident safety by failing to ensure that direct-care staff were made aware, per the established facility system, of resident mechanical lift transfer requirements (to include the number of staff required for safe transfer); failing to provide maintenance of mechanical lifts as specified by the manufacturer; and/or failing to provide training identified by the facility as required for direct-care staff regarding mechanical lift transfers for two (2) residents (#254 and #17). Facility administration also failed to ensure the provision of resident care equipment (chair alarm/bolster mattress) identified by the facility as required to address the fall-potential for one (1) resident (#116). The total survey sample was thirty-eight (38) residents. The Residents Using Mechanical Lift form provided by the facility documented eighty-eight (88) residents who required transfer utilizing a mechanical lift, and the facility's July 2014 Patient Lift Checks and Services form documented a total of twelve (12) mechanical lifts that were used in the facility. Specifically, Resident #254 had been assessed by the Physical Therapist to require the assistance of two (2) staff persons during mechanical lift transfer, but fell while being transferred via mechanical lift by only one (1) staff person and sustained a [MEDICAL CONDITION] which required four (4) staples for closure. The mechanical lift utilized for Resident #254's transfer, which had received no routine maintenance, was later found to have a loose bolt. For Resident #17, who fell during a transfer with a mechanical lift and sustained a skin tear, the facility identified the need for additional staff training as corrective action, but failed to provide this training. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on July 1, 2014 at 9:00 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on June 1, 2014 (the date Resident #254 fell during a transfer via mechanical lift while being transferred by only one (1) facility staff person, rather than two (2) persons as indicated by the resident's assessed need, and after the facility failed to conduct routine maintenance on the mechanical lift), continued through July 2, 2014, and was removed on July 3, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on July 2, 2014. During an interview conducted on 06/30/2014 at 5:40 p.m., the Administrator indicated that he was aware that Resident #254 had fallen during transfer, but stated he had taken no corrective action after this incident. An allegation of jeopardy removal was received on July 2, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on July 3, 2014, and the facility remained out of compliance at a lower scope and severity of "E" while the facility's provision of staff in-service training and the newly-implemented process of routine mechanical lift inspections continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and procedures related to the transfer of residents utilizing mechanical lifts, and related to the routine inspection and maintenance of mechanical lifts. Resident records were reviewed to ensure that resident assessments and Care Plan accurately reflected the transfer status of residents. Findings include: Cross refer to F323. Based on record review, observation, and staff interview, the facility failed to ensure safe mechanical lift transfers for two (2) residents (#254 and #17), who required transfer via mechanical lifts. Resident #254 was assessed on the Minimum Data Set assessment to have required two (2) - plus staff persons for transfer, and had also been assessed by the Physical Therapist to require the assistance of two (2) staff persons during mechanical lift transfers. However, Resident #254 fell and received a [MEDICAL CONDITION] requiring four (4) staples while being transferred via mechanical lift by only one (1) staff. Facility maintenance staff later found the lift utilized for Resident #254 to have a loose bolt, but the facility could provide no evidence of routine maintenance of this lift, as specified by the manufacturer. For Resident #17, who fell during mechanical lift transfer, the facility identified, as a result of this fall, a need to provide additional in-service training regarding mechanical lift transfer; but, the facility failed to provide this staff training to ensure staffs' proficiency in the provision of transfer via mechanical lift. During an interview with the Administrator conducted on 06/30/2014 at 5:40 p.m., the Administrator was questioned regarding the 06/01/2014 incident during which Resident #254 sustained a fall with injury while being transferred via mechanical lift. The Administrator acknowledged awareness of this 06/01/2014 incident involving Resident #254's fall during lift transfer, further stating he had been made aware of the incident a couple of days after the fall occurred. When the Administrator was questioned about the actions he had taken in response to Resident #254's fall after being made aware of the fall, the Administrator stated he had taken no action. He stated that he had concluded that the fall was not a result of a mechanical failure, but rather was a "person issue." The Administrator further acknowledged, however, that the facility had conducted no staff in-service training regarding mechanical lift transfers since Resident #254's fall. During a subsequent interview with the Administrator conducted on 07/01/2014 at 4:30 p.m., the Administrator acknowledged the failure to ensure the necessary staff training related to the use of mechanical lifts, and acknowledged the need for additional staff training. Based on the above, despite acknowledging having prior knowledge of Resident #254's fall involving the mechanical lift transfer, and despite asserting there being an issue with staff performance related to this lift transfer during which the resident fell , the Administrator acknowledged taking no action, to include providing no additional staff training, in response to Resident #254's fall and injury during lift transfer. It was determined that the immediate jeopardy had been removed on 07/03/2014, at which time the facility had implemented the following credible allegation of jeopardy removal with the following interventions: A. On 07/01/2014, the Administrator and DON developed and implemented a Policy Statement for Mechanical Lift Transfers which related to the following: the use of mechanical lifts in accordance with physicians' orders; the assessment of all residents, as per MDS requirements, regarding the need for assistance with transfers, mobility and repositioning; the criteria for determining the need of each resident for mechanical lift transfers; the number of staff persons required to be present during mechanical lift transfers (a minimum of two staff persons, unless a resident's assessment indicates more assistance is required); the frequency of resident assessment required to assess mechanical lift use for a resident; the method utilized to ensure the awareness of direct-care staff of the mechanical lift requirements for each resident. B. On 07/01/2014, the Administrator and the Maintenance Director developed a mechanical lift service schedule. All mechanical lifts were checked on 07/01/2014, after which all lifts were either returned to the units for use or were held for repair. A new procedure mandates a monthly check of all mechanical lifts using the Monthly Lift Checks and Service Log, which will be completed monthly on an ongoing basis by the Maintenance Director. This report will then be forwarded to the Administrator for review. Any problems with a mechanical lift between monthly checks will require a licensed nurse to visibly tag the lift as being "Out of Service" and place the need for repair request on the Log. A lift can then be returned to use only after the licensed nurse has been informed by the maintenance department that the lift has been repaired. This system will be ongoing. All problems identified related to mechanical lifts shall be recorded on the Maintenance Log; the nurses who initially removed a lift from service for repair and who placed it back into service will initial and date this Log. The maintenance staff will also initial and date the Log when the lift is put back into service. The Administrator and DON will monitor for compliance by reviewing each wing's maintenance log weekly for a year and documenting this audit on the Weekly Maintenance Log Monitoring Form. C. On 07/01/2014, the Administrator and DON met with the Nurse Managers and directed them to complete medical record reviews for residents requiring mechanical lift transfers. This included ensuring that the physicians' order and lift assessment results were properly reflected on the Resident Care Plans and Aide Assignment Records. This audit was completed on 07/01/2014. The Assessment for Mechanical Lift Transfer has been utilized to assess each resident's needs to utilize a mechanical lift and the number of staff required to transfer the resident safely using the mechanical lift. The DON, the Assistant Director of Nursing (ADON), and the Utilization Review Nurse (URN) have checked every resident's medical record to make sure that there is a current lift assessment and that appropriate information has been transferred and care planned. This will be completed for each resident upon admission, and upon completion of a Significant Change MDS or Quarterly MDS. this will be monitored weekly by the DON, ADON or URN for a year using the Weekly Mechanical Lift Assessment Monitoring Log. D. On 07/02/2014, mechanical lift transfer assessments were completed for all other residents using the Assessment for Mechanical Lift Transfer tool. New assessments will be conducted for all residents upon any significant change in condition or quarterly MDS review. The DON, ADON and URN have checked every resident chart to ensure the presence of a current lift assessment and that appropriate information has been transferred and care planned. This process will be monitored weekly by the DON, ADON or URN for a year by completing the Weekly Mechanical Lift Assessment Monitoring Form. E. On 07/02/2014, mandatory staff in-service training had been provided during all shifts. All mandatory staff in-services have included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair. Forty-eight (48) of the facility's seventy-eight (78) licensed nurses had received this in-service training by the end of the third shift of 07/02/2014. The remaining thirty (30) licensed nurses, many of whom work only infrequently on an as-needed basis, were not currently available for this mandatory in-service training due to their being on leave status or not having worked during this period of staff training. All of these remaining thirty (30) licensed nurses will receive this mandatory in-service training as they report for work and before being allowed to provide resident care. In addition, this mandatory in-service training had been provided to ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff as of 07/02/2014. The remaining forty (40) CNA staff (which includes 27 CNAs who work only periodically), who were unavailable for the mandatory in-service at this time, will receive this in-service training as they report for work and before being allowed to provide resident care. The facility will conduct mandatory annual in-service training related to mechanical lift use, and this training will be mandatory for all newly-employed staff during new-hire orientation. Quarterly competency checks will be completed during shifts by wing for no less than 18 employees per week from all nurses and CNAs using the Mechanical Lifts/Slings and Transfer Check Off tool for a one year period of time. These checks will be performed by the In-Service Director, Unit Manager, or Nursing Supervisor. RN Managers and Supervisors will be responsible for instruction of all charge nurses to monitor all lift techniques for compliance with physicians' orders. This system will be reinforced by weekly audit monitoring, observation and staff interviews to be performed by the DON or ADON. F. On 07/02/2014, the facility implemented a procedure by which the results of facility monitoring audits, including the monthly check of mechanical lifts using the Monthly Lift Checks and Service Log, as-needed mechanical lift repairs made between the monthly checks monitored by the Administrator/DON via the Weekly Maintenance Log Monitoring Form, and the monitoring of staffs' compliance with resident mechanical lift assessments and care planning conducted weekly by the DON/ADON/URN via the Weekly Mechanical Lift Assessment Monitoring Log, will be presented by the Administrator and DON at the next Quality Assurance Committee Meeting on 07/23/2014, and at every quarterly Quality Assurance Committee meeting for the following year. During the standard survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the allegation of jeopardy removal referenced above, with findings as follow: - On 07/01/2014, the facility's newly developed procedure related to a mechanical lift service maintenance schedule was reviewed. It was determined that all mechanical lifts being used in the facility had been checked for proper function, and it was confirmed that a new procedure mandated a monthly inspection of all mechanical lifts. This monthly lift inspection is to be documented on the Monthly Lift Checks and Service Log. Additionally, it was confirmed that a new procedure had been established to ensure the repair of lifts if needed between monthly inspections, and the oversight of this mechanical lift maintenance process will involve management staffs' weekly monitoring for compliance via the Weekly Maintenance Log Monitoring Form. - On 07/02/2014, the facility's newly developed Policy regarding mechanical lift use was reviewed and it was confirmed that the Policy referenced the following: the assessment requirements for resident transfer/mobility/repositioning; the criteria for determining mechanical lift necessity and the frequency of assessment; the number of staff persons required during lift transfer; the method of instruction for direct-care staff regarding resident mechanical lift requirements. - On 07/02/2014, facility record review and interview with the Administrator, DON and Training Coordinator confirmed that the facility had reviewed the medical records of residents, including those requiring mechanical lift transfers, to ensure that Resident Care Plans and Aide Assignment Records reflected the lift requirements of residents. It was also confirmed via policy review and interview with the Administrator, DON and Training Coordinator that lift requirement assessments will be completed, per policy, upon resident admission and upon completion of a Significant Change MDS or Quarterly MDS. This process will be monitored weekly by management staff via the Weekly Mechanical Lift Assessment Monitoring Log. - On 07/02/2014, interview with the DON and review of facility staff in-service training records revealed that the facility had provided training to the majority of direct-care nursing staff regarding the policies and procedures for mechanical lift use, the use of the mechanical lifts and slings, the routine equipment inspection process, and the procedure for the reporting of equipment needing repair between routine equipment inspections. It was also confirmed, via policy review and interview with the Administrator and DON, that the remaining licensed nursing and CNA staff who were unavailable and had not yet received in-service training would receive this training upon their return to work, before being allowed to provide direct resident care. - On 07/03/2014, it was confirmed via interview with the Administrator and the Medical Director that all monitoring to be completed by management staff to ensure direct care staffs' conformance with these newly implemented policies and procedures would be presented to, and reviewed by, the facility's QA Committee at quarterly meetings for the QA Committee's review and oversight. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on 07/03/2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 07/01/2014, the facility had developed a Policy and Procedure related to mechanical lift use and maintenance. A new mechanical lift service schedule was formulated involving the a monthly check of all mechanical lifts by the Maintenance Director and as-needed repair for problems with mechanical lifts between monthly checks, complete with a system used by nursing staff for identifying and documenting needed lift repairs. Also, a process for ensuring the timely assessment and care planning for resident mechanical lift use was enacted, and a weekly audit system was developed to monitor staffs' conformance with this process. However, facility staffs' conformance with the newly implemented weekly audit system regarding resident assessment and care planning, and the newly implemented monthly check of all mechanical lifts could not be assessed at the time of survey exit, and will therefore need to be evaluated at a future date. In addition, as of 07/02/2014, mandatory staff in-service training, which included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair had been provided to forty-eight (48) of the facility's seventy-eight (78) licensed nurses, and ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff. However, the remaining thirty (30) licensed nurses, and forty (40) CNA staff, many of whom work only periodically or on an as-needed basis, were not currently available for this mandatory in-service training, and will receive in-service as they report for work; therefore, the completion of this mandatory staff in-service training for these remaining staff members could not be assessed at the time of survey exit and will need to be evaluated at a future date. Also, on 07/02/2014, the facility developed and implemented a process by which nursing staff will undergo quarterly competency checks regarding mechanical lift use and proficiency; therefore, the facility's compliance with this newly implemented process of ensuring the direct-care staffs' ongoing competency regarding resident transfers via mechanical lifts will need to be evaluated at a future date. Additionally, as part of the corrective actions formulated by the facility, facility management staff will conduct monitoring audits (including a monthly check of mechanical lifts using the Monthly Lift Checks and Service Log; as-needed mechanical lift repairs between monthly checks via the Weekly Maintenance Log Monitoring Form; monitoring of staffs' compliance with resident mechanical lift assessments/care planning via Weekly Mechanical Lift Assessment Monitoring Log) the results of which will be presented to the facility's QA Committee for their review and analysis. However, the next QA Committee meeting will not be held until 07/23/2014, and thus the QA Committee's involvement in this process could not be fully assessed at the time of survey completion; therefore, the non-compliance continues, with the scope and severity level reduced to the "E" level.

Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance (QA) Committee's participation in, and oversight of, the development of a corrective plan of action developed by the facility in response to falls which occurred during mechanical lift transfers for two (2) residents (#254 and #17) who required transfer via mechanical lift from a total survey sample of thirty-eight (38) residents. The Residents Using Mechanical Lift form provided by the facility documented eighty-eight (88) residents who required transfer utilizing a mechanical lift, and the facility's July 2014 Patient Lift Checks and Services form documented a total of twelve (12) mechanical lifts that were used in the facility. Resident #254 had been assessed by the Physical Therapist to require the assistance of two (2) staff persons during mechanical lift transfers, but sustained a fall resulting in a [MEDICAL CONDITION] requiring four (4) staples for closure while being transferred by only one (1) staff person during transfer utilizing a lift for which no routine maintenance had been provided. In addition, Resident #17's fall and injury during a mechanical lift transfer resulted in the facility identifying the need for additional staff training related to mechanical lift transfers, but the facility then failed to provide this training. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on July 1, 2014 at 9:00 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on June 1, 2014 (the date Resident #254 fell during a transfer via mechanical lift while being transferred by only one (1) facility staff person, rather than two (2) persons as indicated by the resident's assessed need, and after the facility failed to conduct routine maintenance on the mechanical lift), continued through July 2, 2014, and was removed on July 3, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on July 2, 2014. During an interview conducted on 07/02/2014 at 3:50 p.m., the Administrator acknowledged there had been no involvement of the QA Committee in the facility's corrective plan related to resident falls involving mechanical lift transfers. An allegation of jeopardy removal was received on July 2, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on July 3, 2014, and the facility remained out of compliance at a lower scope and severity of "E" while the facility's provision of staff in-service training and the newly-implemented process of routine mechanical lift inspections continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and procedures related to the transfer of residents utilizing mechanical lifts, and related to the routine inspection and maintenance of mechanical lifts. Resident records were reviewed to ensure that resident assessments and Care Plan accurately reflected the transfer status of residents. Findings include: Cross refer to F323. Based on record review and staff interview, the facility failed to ensure safe transfer via mechanical lift for two (2) residents (#254 and #17) who required mechanical lift transfer. Resident #254, per Minimum Data Set assessment and Physical Therapist evaluation, required the assistance of two (2) staff persons during mechanical lift transfers, but fell and sustained a [MEDICAL CONDITION] when transferred by lift by only one (1) staff. The lift utilized for Resident #254's transfer, which had received no routine maintenance as per the manufacturer, was inspected by maintenance staff and found to have a loose bolt. Resident #17 fell during mechanical lift transfer, and the facility determined a need to provide staff training related to this fall, but then failed to provide this staff training. An interview was conducted with the Administrator on 07/02/2014 at 3:50 p.m. related to the facility's QA Committee and the facility's QA Committee process. During this interview, the Administrator, who had acknowledged during an earlier 06/30/2014, 5:40 p.m. interview that he had been made aware of Resident #254's 06/01/2014 fall involving the mechanical lift transfer soon after the incident, was asked if the QA Committee had been informed of the falling incident involving Resident #254. The Administrator was also asked about the QA Committee's involvement in the corrective action plan (which included the development of a new policy regarding mechanical lift use in the facility formulated by the Administrator and DON; the development and implementation of a monthly, and an additional as-needed, mechanical lift inspection procedure by the Maintenance Director using the Monthly Lift Checklist and Service Log; implementation of a procedure involving weekly management staff monitoring of direct-care staff conformance with the completion of resident lift assessments and Care Plans; and direct-care staff training regarding these newly established policies and procedures) which had been developed and implemented as part of the facility's credible allegation of jeopardy removal related to this standard survey. The Administrator stated that the QA Committee had not been involved in the development or the implementation of the corrective action plan. The Administrator further stated that the QA Committee met quarterly, but that a QA Committee meeting had not been due, per the regular schedule, since the incident involving Resident #254, and that a QA Committee meeting had not been conducted. Based on the above, the facility failed to ensure the involvement of, and input by, the QA Committee in the development and implementation of the corrective action plan developed by the facility in response to an incident involving a resident fall with injury during mechanical lift transfer. The facility thus failed to ensure oversight by the QA Committee of the implementation of, and facility staff's conformance with, the corrective action plan, and failed to ensure the Committee's evaluation of the effectiveness of this corrective action plan. It was determined that the immediate jeopardy had been removed on 07/03/2014, at which time the facility had implemented the following credible allegation of jeopardy removal with the following interventions: A. On 07/01/2014, the Administrator and DON developed and implemented a Policy Statement for Mechanical Lift Transfers which related to the following: the use of mechanical lifts in accordance with physicians' orders; the assessment of all residents, as per MDS requirements, regarding the need for assistance with transfers, mobility and repositioning; the criteria for determining the need of each resident for mechanical lift transfers; the number of staff persons required to be present during mechanical lift transfers (a minimum of two staff persons, unless a resident's assessment indicates more assistance is required); the frequency of resident assessment required to assess mechanical lift use for a resident; the method utilized to ensure the awareness of direct-care staff of the mechanical lift requirements for each resident. B. On 07/01/2014, the Administrator and the Maintenance Director developed a mechanical lift service schedule. All mechanical lifts were checked on 07/01/2014, after which all lifts were either returned to the units for use or were held for repair. A new procedure mandates a monthly check of all mechanical lifts using the Monthly Lift Checks and Service Log, which will be completed monthly on an ongoing basis by the Maintenance Director. This report will then be forwarded to the Administrator for review. Any problems with a mechanical lift between monthly checks will require a licensed nurse to visibly tag the lift as being "Out of Service" and place the need for repair request on the Log. A lift can then be returned to use only after the licensed nurse has been informed by the maintenance department that the lift has been repaired. This system will be ongoing. All problems identified related to mechanical lifts shall be recorded on the Maintenance Log; the nurses who initially removed a lift from service for repair and who placed it back into service will initial and date this Log. The maintenance staff will also initial and date the Log when the lift is put back into service. The Administrator and DON will monitor for compliance by reviewing each wing's maintenance log weekly for a year and documenting this audit on the Weekly Maintenance Log Monitoring Form. C. On 07/01/2014, the Administrator and DON met with the Nurse Managers and directed them to complete medical record reviews for residents requiring mechanical lift transfers. This included ensuring that the physicians' order and lift assessment results were properly reflected on the Resident Care Plans and Aide Assignment Records. This audit was completed on 07/01/2014. The Assessment for Mechanical Lift Transfer has been utilized to assess each resident's needs to utilize a mechanical lift and the number of staff required to transfer the resident safely using the mechanical lift. The DON, the Assistant Director of Nursing (ADON) and the Utilization Review Nurse (URN) have checked every resident's medical record to make sure that there is a current lift assessment and that appropriate information has been transferred and care planned. This will be completed for each resident upon admission, and upon completion of a Significant Change MDS or Quarterly MDS. this will be monitored weekly by the DON, ADON or URN for a year using the Weekly Mechanical Lift Assessment Monitoring Log. D. On 07/02/2014, mechanical lift transfer assessments were completed for all other residents using the Assessment for Mechanical Lift Transfer tool. New assessments will be conducted for all residents upon any significant change in condition or quarterly MDS review. The DON, ADON and URN have checked every resident chart to ensure the presence of a current lift assessment and that appropriate information has been transferred and care planned. This process will be monitored weekly by the DON, ADON, or URN for a year by completing the Weekly Mechanical Lift Assessment Monitoring Form. E. On 07/02/2014, mandatory staff in-service training had been provided during all shifts. All mandatory staff in-services have included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair. Forty-eight (48) of the facility's seventy-eight (78) licensed nurses had received this in-service training by the end of the third shift of 07/02/2014. The remaining thirty (30) licensed nurses, many of whom work only infrequently on an as-needed basis, were not currently available for this mandatory in-service training due to their being on leave status or not having worked during this period of staff training. All of these remaining thirty (30) licensed nurses will receive this mandatory in-service training as they report for work and before being allowed to provide resident care. In addition, this mandatory in-service training had been provided to ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff as of 07/02/2014. The remaining forty (40) CNA staff (which includes 27 CNAs who work only periodically), who were unavailable for the mandatory in-service at this time, will receive this in-service training as they report for work and before being allowed to provide resident care. The facility will conduct mandatory annual in-service training related to mechanical lift use, and this training will be mandatory for all newly-employed staff during new-hire orientation. Quarterly competency checks will be completed during shifts by wing for no less than 18 employees per week from all nurses and CNAs using the Mechanical Lifts/Slings and Transfer Check Off tool for a one year period of time. These checks will be performed by the In-Service Director, Unit Manager, or Nursing Supervisor. RN Managers and Supervisors will be responsible for instruction of all charge nurses to monitor all lift techniques for compliance with physicians' orders. This system will be reinforced by weekly audit monitoring, observation and staff interviews to be performed by the DON or ADON. F. On 07/02/2014, the facility implemented a procedure by which the results of facility monitoring audits, including the monthly check of mechanical lifts using the Monthly Lift Checks and Service Log, as-needed mechanical lift repairs made between the monthly checks monitored by the Administrator/DON via the Weekly Maintenance Log Monitoring Form, and the monitoring of staffs' compliance with resident mechanical lift assessments and care planning conducted weekly by the DON/ADON/URN via the Weekly Mechanical Lift Assessment Monitoring Log, will be presented by the Administrator and DON at the next Quality Assurance Committee Meeting on 07/23/2014, and at every quarterly Quality Assurance Committee meeting for the following year. During the standard survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the allegation of jeopardy removal referenced above, with findings as follow: - On 07/01/2014, the facility's newly developed procedure related to a mechanical lift service maintenance schedule was reviewed. It was determined that all mechanical lifts being used in the facility had been checked for proper function, and it was confirmed that a new procedure mandated a monthly inspection of all mechanical lifts. This monthly lift inspection is to be documented on the Monthly Lift Checks and Service Log. Additionally, it was confirmed that a new procedure had been established to ensure the repair of lifts if needed between monthly inspections, and the oversight of this mechanical lift maintenance process will involve management staffs' weekly monitoring for compliance via the Weekly Maintenance Log Monitoring Form. - On 07/02/2014, the facility's newly developed Policy regarding mechanical lift use was reviewed and it was confirmed that the Policy referenced the following: the assessment requirements for resident transfer/mobility/repositioning; the criteria for determining mechanical lift necessity and the frequency of assessment; the number of staff persons required during lift transfer; the method of instruction for direct-care staff regarding resident mechanical lift requirements. - On 07/02/2014, facility record review and interview with the Administrator, DON and Training Coordinator confirmed that the facility had reviewed the medical records of residents, including those requiring mechanical lift transfers, to ensure that Resident Care Plans and Aide Assignment Records reflected the lift requirements of residents. It was also confirmed via policy review and interview with the Administrator, DON and Training Coordinator that lift requirement assessments will be completed, per policy, upon resident admission and upon completion of a Significant Change MDS or Quarterly MDS. This process will be monitored weekly by management staff via the Weekly Mechanical Lift Assessment Monitoring Log. - On 07/02/2014, interview with the DON and review of facility staff in-service training records revealed that the facility had provided training to the majority of direct-care nursing staff regarding the policies and procedures for mechanical lift use, the use of the mechanical lifts and slings, the routine equipment inspection process, and the procedure for the reporting of equipment needing repair between routine equipment inspections. It was also confirmed, via policy review and interview with the Administrator and DON, that the remaining licensed nursing and CNA staff who were unavailable and had not yet received in-service training would receive this training upon their return to work, before being allowed to provide direct resident care. - On 07/03/2014, it was confirmed via interview with the Administrator and the Medical Director that all monitoring to be completed by management staff to ensure direct care staffs' conformance with these newly implemented policies and procedures would be presented to, and reviewed by, the facility's QA Committee at quarterly meetings for the QA Committee's review and oversight. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on 07/03/2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 07/01/2014, the facility had developed a Policy and Procedure related to mechanical lift use and maintenance. A new mechanical lift service schedule was formulated involving the a monthly check of all mechanical lifts by the Maintenance Director and as-needed repair for problems with mechanical lifts between monthly checks, complete with a system used by nursing staff for identifying and documenting needed lift repairs. Also, a process for ensuring the timely assessment and care planning for resident mechanical lift use was enacted, and a weekly audit system was developed to monitor staffs' conformance with this process. However, facility staffs' conformance with the newly implemented weekly audit system regarding resident assessment and care planning, and the newly implemented monthly check of all mechanical lifts could not be assessed at the time of survey exit, and will therefore need to be evaluated at a future date. In addition, as of 07/02/2014, mandatory staff in-service training, which included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair had been provided to forty-eight (48) of the facility's seventy-eight (78) licensed nurses, and ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff. However, the remaining thirty (30) licensed nurses, and forty (40) CNA staff, many of whom work only periodically or on an as-needed basis, were not currently available for this mandatory in-service training, and will receive in-service as they report for work; therefore, the completion of this mandatory staff in-service training for these remaining staff members could not be assessed at the time of survey exit and will need to be evaluated at a future date. Also, on 07/02/2014, the facility developed and implemented a process by which nursing staff will undergo quarterly competency checks regarding mechanical lift use and proficiency; therefore, the facility's compliance with this newly implemented process of ensuring the direct-care staffs' ongoing competency regarding resident transfers via mechanical lifts will need to be evaluated at a future date. Additionally, as part of the corrective actions formulated by the facility, facility management staff will conduct monitoring audits (including a monthly check of mechanical lifts using the Monthly Lift Checks and Service Log; as-needed mechanical lift repairs between monthly checks via the Weekly Maintenance Log Monitoring Form; monitoring of staffs' compliance with resident mechanical lift assessments/care planning via Weekly Mechanical Lift Assessment Monitoring Log) the results of which will be presented to the facility's QA Committee for their review and analysis. However, the next QA Committee meeting will not be held until 07/23/2014, and thus the QA Committee's involvement in this process could not be fully assessed at the time of survey completion; therefore, the non-compliance continues, with the scope and severity level reduced to the "E" level.

b Relates to resident Mattie Davis room [ROOM NUMBER]A Order changed to Crush Meds only on 8/22/14-Resident was taking [MEDICATION NAME] prior to order. Interview with Ben Porter Consultant Pharmacist on 9/16/14 at 12:30 pm revealed that he has been reviewing all resident's for crush meds and what medications were ok. He discovered that one resident, Ms. (NAME REDACTED) Davis, was on [MEDICATION NAME] (a new drug) with a change to crushed meds on 8/22/14. This is his first visit since that change and discovered this medication cannot be crushed. He alert the Unit Manager to check with Psychritis was to an alternative and is awaiting an answer from the MD. He says the nurses should be looking at new orders to determine if they can be crushed. If unsure, they should contact him or the dispensing pharmacy. He reveals that resident are being changed to medication that can be crushed. Revealed he doesn't share everything he finds with the DON or Administrator but does most things. He had made the Unit Manager Yolanda aware but had not brought it to the attention of the DON or Administrator. 9/17/14 at 10:00 am Interview with Ben Porter, Pharmacist: he contacted the dispensing pharmacy related to if they were made aware this resident had been changed to crush meds on 8/22/14. Ben says the nurses should have faxed this information to the pharmacy. The dispensing pharmacy confirms they were aware of the new orders, but somehow overlooked Crushed Med portion of the new orders. Since this is a new medication, the DO NOT CRUSH warning doesn't just come up when entered into their system. Interview on 9/18/14 at 12:05 pm Janice Keiling LPN, who has been giving Ms. (NAME REDACTED) her meds on 9/16/14. Says that she and the other nurses were crushing the [MEDICATION NAME] from the 8/22/14 until 9/16/14. New order for crushed meds on 8/22/14 and to give [MEDICATION NAME] with food. Resident had order for [MEDICATION NAME] 80 mg po every day. RR of the September MAR indicated [REDACTED]. RR of the pharmacy bubble pack which was refilled on 8/7/14 revealed no indications of can't be crushed. Based on observation, review and staff interviews, the facility failed to ensure that the crush med order as ordered for resident #230 from a survey sample of twenty-one (21). Findings Include: Review of the Physician orders [REDACTED].M. Registered Nurse (RN)____revealed that the resident was given two [MEDICATION NAME] 50mg tablets for a total of 100mg whole tablets by mouth with water. An interview with RN __ 9/15/14 at 03:25 P.M. stated resident only wants her calcium and vitamin pill crushed. I did explain to the resident this morning there was a new order for all med's to be crushed. The resident said she might try tomorrow with a little pudding. This resident can speak for herself. Review of last Quarterly Minimum Data System dated 7/13/14-Section C-Cognitive Patters BIMS score 15;Section E-Behavior-no behaviors noted section I Active Diagnosis-[MEDICAL CONDITION], Heart failure, HTN, Cardiac pacemaker and unspecified disease of spinal cord. Section K-Swallowing disorder-None of above. Medication Pass observation 9/15/14@01:40PM nurse Dijana Hrepic,RN administered to Resident #230 [MEDICATION NAME] 50mg x 2 tabs po resident was asked by nurse if surveyor could watch medication administration and resident #230 said yes. Resident #230 took the medication with water and swallowed with no difficulty noted. Review of the clinical record on 9/15/14@02:55PM revealed a new order dated 9/11/14@05:30PM 1.crush med resident 2.D/C o.k. to give po meds either crushed or whole if not contraindicated or as per resident request. Orginal Physician order [REDACTED]. Review of the MAR indicated [REDACTED].The order for o.k. to give meds either crushed or whole if not contraindicated as per pts request was DC'd 9/11/14 and marked thru. Interview with Dijana Hrepick,RN 9/15/14@03:25PM stated she only wants her calcium and vitamin pill crushed. I did explain to the resident this morning there was an new order for all med's to be crushed. The resident said she might try tomorrow with a little pudding. This resident can speak for herself. Review of Physician orders [REDACTED]. speech therapy to evaluate and treat-resident c/o of difficulty of swallowing,EGD later2. uric acid level. SLP 700 Plan of treatment for [REDACTED]. SLP dated 9//11/14 after evaluation recommended modifying diet pt's diet to mechanical soft. Review of Acute Care Visit dated 9/8/14 Physician documented history resident c/o of dysphagia and rt toe pain-new problem-1.dysphagia 2.ST to evaluate,EGD later. Review of Nurse Progress Note dated 9/8/14@06:30PM Dr. Patel here on unit-Res c/o of right great toe pain and trouble swallowing. Dr. Patel spoke with resident new orders received. 9/8/14@2030P-resident id RP (self). Informed of lab orders for A.M. and speech eval orders. 9/11/14-speech Therapist on unit to assess new orders received. 9/11/14@1800 new order noted. Resident is responsible for self and is aware of new orders.verbalizes understanding. Review of Nurse Progress Notes dated 9/15/14 entry time 09:00AM resident stated I don't want my med's crushed I only want my calcium and vitamin pill crushed. Explained to res that there is order for med's to be crushed by speech therapist. Nurse Progress note dated 9/15/14 @ 16:31-New orders noted and R.P. aware of new orders. Nurse Progress Note dated 9/15/14@16:30 called Dr. Patel and informed __?__ that res. had received pills whole. Dr. Patel stated to not to change order and to continue to crush res meds. CP dated Resident is able to take PO meds whole due to dysphagia or refusal to swallow. Meds are crushed unless MAR indicated [REDACTED].Goal -resident will receive meds as ordered by MD without episodes of choking during the next 3 months.-Approaches-Medications will be crushed as per MD order;Meds will be administered in vehical of choice,if PO intake allowed within dietary restrictions (pudding,juice,applesauce) unless otherwise specified;Licensed Nurse will consult MD for clarification for prescribed medication which can not be crushed (MD may prescribe different form of medication) Resident able to swallow meds but at times prefers they maybe crushed will administered meds per resident preference-DC-Approaches-nurse will check with resident daily for daily preference at each med's administration.DC Revised CP dated 9/11/14-Resident having increased difficulty swallowing whole med's-will crush all meds. approach-9/11/14-Administer all meds crushed. Review of last MDS dated [DATE]-Section c-cognitive pattersn BIMS score 15;Section E-Behavior-no behaviors noted'section I Activie diagnosis-[MEDICAL CONDITION],heart failure,HTN,V45.01-Cardiac pacemaker;336.9-unspecified disease of spinal cord. Section K-Swallowing disorder-None of above. Residetn admitted to facility 4/9/14.Review of Med Physician consultation from The Medical Center resident was post hospitalization following post anterior cervical surgery. Past medical history include hypertension,pacemaker,[MEDICAL CONDITION].

Based on clinical record review, facility Plan of treatment for [REDACTED].#254), who was assessed to require the assistance of two (2) persons during mechanical lift transfers related to a decrease in function secondary to [MEDICAL CONDITION], and for one (1) resident (#116), for whom the application of a chair alarm was ordered by the physician for a continued fall-risk, from a total survey sample of thirty-eight (38) residents. For Resident #254, the facility failed to revise the Care Plan to include the use of two (2) staff persons during mechanical lift transfers, as indicated by the Physical Therapist, related to a decrease in the resident's function secondary to [MEDICAL CONDITION]. Resident #254 then fell while being transferred via mechanical lift by only one (1) staff person and sustained a laceration to the back of the head which required four (4) staples for closure. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on July 1, 2014 at 9:00 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on June 1, 2014 (the date Resident #254 fell during a transfer via mechanical lift while being transferred with the assistance of only one (1) facility staff person, rather than two (2) persons as indicated by the resident's assessed need), continued through July 2, 2014, and was removed on July 3, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on July 2, 2014. During an interview with the Director Of Nursing (DON) conducted on 06/19/2014 at 4:15 p.m., the DON stated that the facility did not have a specific written policy related to mechanical lift use, and that the procedure for mechanical lift transfers called for one (1) staff person to assist. The DON further acknowledged, however, that additional staff assistance would be required during lift transfer if a resident's Care Plan indicated the need for additional staff. An allegation of jeopardy removal was received on July 2, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on July 3, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility's provision of staff in-service training and the newly-implemented process of routine mechanical lift inspections continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and procedures related to the transfer of residents utilizing mechanical lifts, and related to the routine inspection and maintenance of mechanical lifts. Resident records were reviewed to ensure that resident assessments and Care Plans accurately reflected the transfer status and requirements of residents. Findings include: 1. Resident #254's Quarterly Minimum Data Set (MDS) assessment of 04/28/2014 documented in Section I - Active [DIAGNOSES REDACTED]. A Plan of treatment for [REDACTED].#254 received skilled physical therapy through 05/23/2014, with the Primary/Pertinent [DIAGNOSES REDACTED]. The Physical Therapist documented that Resident #254 required two (2) staff persons for safe transfer via mechanical lift as of 05/23/2014. Review of Resident #254's Care Plan revealed a Problem/Need originally dated 02/11/2014 which indicated that the resident was at risk for falls related to multiple factors, to include [MEDICAL CONDITION] Disorder. Approaches listed on Resident #254's Care Plan to address the resident's fall-risk included the use of a mechanical lift during transfers as indicated; however, there was no reference on this Care Plan which identified the number of staff required to assist during mechanical lift transfers of Resident #254. There was no evidence to indicate that Resident #254's Care Plan had been revised to reflect the Physical Therapist's determination, via the May 2014 PTR referenced above, that two (2) staff persons were required to assist during mechanical lift transfers of the resident. During an interview with Registered Nurse (RN) "AA" conducted on 06/30/2014 at 5:00 p.m., RN "AA" stated that when the Physical Therapist made recommendations regarding resident care or changes in resident care, the Physical Therapist was to inform the nurse manager who would then add the required resident care need to the Care Plan. RN "AA" stated that the facility had Patients At Risk meetings daily and that the nurse manager should have been informed of the Physical Therapist's determination that Resident #254 needed the assistance of two (2) staff persons during mechanical lift transfers. RN "AA" stated that this notification did not happen regarding Resident #254's need for two (2) person assist with transfer, and acknowledged that the resident's Care Plan had not been revised. A 06/01/2014, 4:45 p.m. Nurse's Progress Notes entry for Resident #254 then documented that the resident was noted on the floor in his room having a laceration to the head, and a 06/01/2014 verbal physician's orders [REDACTED]. A 06/01/2014 hospital Physician Documentation entry documented that Resident #254 had fallen while transferring, striking the back of his head and causing a 3.2 centimeter (cm) laceration to the left occiput which was closed with four (4) staples before the resident was discharged back to the nursing facility. A facility Incident Report (IR) documented that on 06/01/2014, Licensed Practical Nurse (LPN) "JJ" had been informed by a certified nursing assistant (CNA) that Resident #254 had fallen. In a 06/01/2014 written statement provided by LPN "JJ", the LPN documented that she had been called to Resident #254's room by CNA "KK" and observed that the resident had fallen. LPN "JJ" documented that CNA "KK" stated that Resident #254 had fallen out of the mechanical lift during transfer. During a 06/30/14, 4:35 p.m. interview, CNA "KK" acknowledged that on 06/01/14, she attempted to transfer Resident #254 in the lift without the assistance of a second staff person, and stated during a later 06/30/2014, 5:00 p.m. interview that she had not known how many staff were to assist in transferring the resident at the time of the 06/01/2014 mechanical lift transfer. Based on the above, despite Resident #254 having been assessed via MDS assessment to have [DIAGNOSES REDACTED].#254's Care Plan to reflect that the resident required the assistance of 2 staff persons during transfer via mechanical lift. Resident #254 then sustained a fall in the mechanical lift while being transferred via lift by only one (1) CNA, with the resident falling to the floor and sustaining a [MEDICAL CONDITION] which required four (4) staples for closure. Cross refer to F323, example 1, for more information regarding Resident #254. 2. Resident #116's MDS assessment of 03/17/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, [MEDICAL CONDITIONS] and Dementia. MDS Section J - Health Conditions documented that Resident #116 had a history of [REDACTED]. Review of Resident #116's Care Plan revealed a 12/20/2013 Problem/Need which identified, as had the MDS referenced above, that the resident was at risk for falls. This Care Plan identified multiple interventions to address Resident #116's risk for falls, including the use of a bed alarm when in bed. Further review of Resident #116's Care Plan, however, revealed no evidence to indicate that the Care Plan had been revised to reflect the implementation of a chair alarm when the resident was out of bed in the wheelchair, as specified by the 06/04/2014 physician's orders [REDACTED]. Observations conducted on 06/17/2014 at 5:20 p.m. and on 06/18/2014 at 7:05 a.m. and 12:15 p.m. revealed Resident #116 seated in a wheelchair with no chair alarm attached. During a 06/18/2014, 1:00 p.m. interview, Nurse Manager "AA" acknowledged that the chair alarm was not being used for Resident #116. Cross refer to F323, example #3, for more information regarding Resident #116. It was determined that the immediate jeopardy had been removed on 07/03/2014, at which time the facility had implemented the following credible allegation of jeopardy removal with the following interventions: A. On 07/01/2014, the Administrator and DON developed and implemented a Policy Statement for Mechanical Lift Transfers which related to the following: the use of mechanical lifts in accordance with physicians' orders; the assessment of all residents, as per MDS requirements, regarding the need for assistance with transfers, mobility and repositioning; the criteria for determining the need of each resident for mechanical lift transfers; the number of staff persons required to be present during mechanical lift transfers (a minimum of two staff persons, unless a resident's assessment indicates more assistance is required); the frequency of resident assessment required to assess mechanical lift use for a resident; the method utilized to ensure the awareness of direct-care staff of the mechanical lift requirements for each resident. B. On 07/01/2014, the Administrator and the Maintenance Director developed a mechanical lift service schedule. All mechanical lifts were checked on 07/01/2014, after which all lifts were either returned to the units for use or were held for repair. A new procedure mandates a monthly check of all mechanical lifts using the Monthly Lift Checks and Service Log, which will be completed monthly on an ongoing basis by the Maintenance Director. This report will then be forwarded to the Administrator for review. Any problems with a mechanical lift between monthly checks will require a licensed nurse to visibly tag the lift as being "Out of Service" and place the need for repair request on the Log. A lift can then be returned to use only after the licensed nurse has been informed by the maintenance department that the lift has been repaired. This system will be ongoing. All problems identified related to mechanical lifts shall be recorded on the Maintenance Log; the nurses who initially removed a lift from service for repair and who placed it back into service will initial and date this Log. The maintenance staff will also initial and date the Log when the lift is put back into service. The Administrator and DON will monitor for compliance by reviewing each wing's maintenance log weekly for a year and documenting this audit on the Weekly Maintenance Log Monitoring Form. C. On 07/01/2014, the Administrator and DON met with the Nurse Managers and directed them to complete medical record reviews for residents requiring mechanical lift transfers. This included ensuring that the physicians' order and lift assessment results were properly reflected on the Resident Care Plans and Aide Assignment Records. This audit was completed on 07/01/2014. The Assessment for Mechanical Lift Transfer has been utilized to assess each resident's needs to utilize a mechanical lift and the number of staff required to transfer the resident safely using the mechanical lift. The DON, the Assistant Director of Nursing (ADON), and the Utilization Review Nurse (URN) have checked every resident's medical record to make sure that there is a current lift assessment and that appropriate information has been transferred and care planned. This will be completed for each resident upon admission, and upon completion of a Significant Change MDS or Quarterly MDS. This will be monitored weekly by the DON, ADON, or URN for a year using the Weekly Mechanical Lift Assessment Monitoring Log. D. On 07/02/2014, mechanical lift transfer assessments were completed for all other residents using the Assessment for Mechanical Lift Transfer tool. New assessments will be conducted for all residents upon any significant change in condition or quarterly MDS review. The DON, ADON, and URN have checked every resident chart to ensure the presence of a current lift assessment and that appropriate information has been transferred and care planned. This process will be monitored weekly by the DON, ADON or URN for a year by completing the Weekly Mechanical Lift Assessment Monitoring Form. E. On 07/02/2014, mandatory staff in-service training had been provided during all shifts. All mandatory staff in-services have included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair. Forty-eight (48) of the facility's seventy-eight (78) licensed nurses had received this in-service training by the end of the third shift of 07/02/2014. The remaining thirty (30) licensed nurses, many of whom work only infrequently on an as-needed basis, were not currently available for this mandatory in-service training due to their being on leave status or not having worked during this period of staff training. All of these remaining thirty (30) licensed nurses will receive this mandatory in-service training as they report for work and before being allowed to provide resident care. In addition, this mandatory in-service training had been provided to ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff as of 07/02/2014. The remaining forty (40) CNA staff (which includes 27 CNAs who work only periodically) who were unavailable for the mandatory in-service at this time will receive this in-service training as they report for work and before being allowed to provide resident care. The facility will conduct mandatory annual in-service training related to mechanical lift use, and this training will be mandatory for all newly-employed staff during new-hire orientation. Quarterly competency checks will be completed during shifts by wing for no less than 18 employees per week from all nurses and CNAs using the Mechanical Lifts/Slings and Transfer Check Off tool for a one year period of time. These checks will be performed by the In-Service Director, Unit Manager, or Nursing Supervisor. RN Managers and Supervisors will be responsible for instruction of all charge nurses to monitor all lift techniques for compliance with physicians' orders. This system will be reinforced by weekly audit monitoring, observation and staff interviews to be performed by the DON or ADON. F. On 07/02/2014, the facility implemented a procedure by which the results of facility monitoring audits, including the monthly check of mechanical lifts using the Monthly Lift Checks and Service Log, as-needed mechanical lift repairs made between the monthly checks monitored by the Administrator/DON via the Weekly Maintenance Log Monitoring Form, and the monitoring of staffs' compliance with resident mechanical lift assessments and care planning conducted weekly by the DON/ADON/URN via the Weekly Mechanical Lift Assessment Monitoring Log, will be presented by the Administrator and DON at the next Quality Assurance Committee Meeting on 07/23/2014, and at every quarterly Quality Assurance Committee meeting for the following year. During the standard survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the allegation of jeopardy removal referenced above, with findings as follow: - On 07/01/2014, the facility's newly developed procedure related to a mechanical lift service maintenance schedule was reviewed. It was determined that all mechanical lifts being used in the facility had been checked for proper function, and it was confirmed that a new procedure mandated a monthly inspection of all mechanical lifts. This monthly lift inspection is to be documented on the Monthly Lift Checks and Service Log. Additionally, it was confirmed that a new procedure had been established to ensure the repair of lifts if needed between monthly inspections, and the oversight of this mechanical lift maintenance process will involve management staffs' weekly monitoring for compliance via the Weekly Maintenance Log Monitoring Form. - On 07/02/2014, the facility's newly developed Policy regarding mechanical lift use was reviewed and it was confirmed that the Policy referenced the following: the assessment requirements for resident transfer/mobility/repositioning; the criteria for determining mechanical lift necessity and the frequency of assessment; the number of staff persons required during lift transfer; the method of instruction for direct-care staff regarding resident mechanical lift requirements. - On 07/02/2014, facility record review and interview with the Administrator, DON and Training Coordinator confirmed that the facility had reviewed the medical records of residents, including those requiring mechanical lift transfers, to ensure that Resident Care Plans and Aide Assignment Records reflected the lift requirements of residents. It was also confirmed via policy review and interview with the Administrator, DON and Training Coordinator that lift requirement assessments will be completed, per policy, upon resident admission and upon completion of a Significant Change MDS or Quarterly MDS. This process will be monitored weekly by management staff via the Weekly Mechanical Lift Assessment Monitoring Log. - On 07/02/2014, interview with the DON and review of facility staff in-service training records revealed that the facility had provided training to the majority of direct-care nursing staff regarding the policies and procedures for mechanical lift use, the use of the mechanical lifts and slings, the routine equipment inspection process, and the procedure for the reporting of equipment needing repair between routine equipment inspections. It was also confirmed, via policy review and interview with the Administrator and DON, that the remaining licensed nursing and CNA staff who were unavailable and had not yet received in-service training would receive this training upon their return to work, before being allowed to provide direct resident care. - On 07/03/2014, it was confirmed via interview with the Administrator and the Medical Director that all monitoring to be completed by management staff to ensure direct care staffs' conformance with these newly implemented policies and procedures would be presented to, and reviewed by, the facility's QA Committee at quarterly meetings for the QA Committee's review and oversight. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on 07/03/2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 07/01/2014, the facility had developed a Policy and Procedure related to mechanical lift use and maintenance. A new mechanical lift service schedule was formulated involving a monthly check of all mechanical lifts by the Maintenance Director and as-needed repair for problems with mechanical lifts between monthly checks, complete with a system used by nursing staff for identifying and documenting needed lift repairs. Also, a process for ensuring the timely assessment and care planning for resident mechanical lift use was enacted, and a weekly audit system was developed to monitor staffs' conformance with this process. However, facility staffs' conformance with the newly implemented weekly audit system regarding resident assessment and care planning and the newly implemented monthly check of all mechanical lifts could not be assessed at the time of survey exit, and will therefore need to be evaluated at a future date. In addition, as of 07/02/2014, mandatory staff in-service training which included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair had been provided to forty-eight (48) of the facility's seventy-eight (78) licensed nurses, and ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff. However, the remaining thirty (30) licensed nurses and forty (40) CNA staff, many of whom work only periodically or on an as-needed basis, were not currently available for this mandatory in-service training, and will receive in-service as they report for work; therefore, the completion of this mandatory staff in-service training for these remaining staff members could not be assessed at the time of survey exit and will need to be evaluated at a future date. Also, on 07/02/2014, the facility developed and implemented a process by which nursing staff will undergo quarterly competency checks regarding mechanical lift use and proficiency; therefore, the facility's compliance with this newly implemented process of ensuring the direct-care staffs' ongoing competency regarding resident transfers via mechanical lifts will need to be evaluated at a future date. Additionally, as part of the corrective actions formulated by the facility, facility management staff will conduct monitoring audits (including a monthly check of mechanical lifts using the Monthly Lift Checks and Service Log; as-needed mechanical lift repairs between monthly checks via the Weekly Maintenance Log Monitoring Form; monitoring of staffs' compliance with resident mechanical lift assessments/care planning via Weekly Mechanical Lift Assessment Monitoring Log) the results of which will be presented to the facility's QA Committee for their review and analysis. However, the next QA Committee meeting will not be held until 07/23/2014, and thus the QA Committee's involvement in this process could not be fully assessed at the time of survey completion; therefore, the non-compliance continues, with the scope and severity level reduced to the "D" level.

Based on clinical record review, observation, facility Supervisor Incident Investigation report review, facility Patients At Risk Committee notes review, facility staff inservice training record review, and staff interview, the facility failed to ensure the provision of staff in-service training as specified by the Care Plan for one (1) resident (#17), who was assessed to be at risk for falls and whose Care Plan mandated additional staff training related to a fall during mechanical lift transfer; failed to provide a bolster mattress in accordance with the Care Plan for one (1) resident (#116), who had been assessed to be at risk for falls and whose Care Plan mandated the use of a bolster mattress to address this fall-risk; and failed to provide incontinence care as specified by the Care Plan for one (1) resident ("C"), who was incontinent of bladder and bowel and whose care plan specified to cleanse the resident after episodes of incontinence to prevent infections, from a total survey sample of thirty-eight (38) residents. For Resident #17, the facility had identified a need for additional staff training in response to a fall the resident sustained [REDACTED]. The facility added this required staff training as an Approach to Resident #17's Care Plan to address the resident's risk for falls. The facility, however, then failed to conduct this staff in-service training, as specified by the resident's Care Plan, to ensure the resident's safety during mechanical lift transfers, thus resulting in a continued risk for subsequent falls during transfer. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on July 1, 2014 at 9:00 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on June 1, 2014 (the date Resident #254 fell during a transfer via mechanical lift while being transferred by only one (1) facility staff person, rather than two (2) persons as indicated by the resident's assessed need, and after the facility failed to conduct routine maintenance on the mechanical lift), continued through July 2, 2014, and was removed on July 3, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on July 2, 2014. During an interview with the Administrator and DON conducted on 07/01/2014 at 2:30 p.m., both staff members agreed that the facility had not provided the necessary in-service training to facility staff related to the provision of care when using mechanical lifts. An allegation of jeopardy removal was received on July 2, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on July 3, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility's provision of staff in-service training and the newly-implemented process of routine mechanical lift inspections continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and procedures related to the transfer of residents utilizing mechanical lifts, and related to the routine inspection and maintenance of mechanical lifts. Resident records were reviewed to ensure that resident assessments and Care Plans accurately reflected the transfer status of residents. Findings include: 1. Resident #17's 05/01/2014 Minimum Data Set (MDS) assessment documented in Section G - Functional Status that the resident was totally dependent for transfer, with limited range of motion in the lower extremities, and Section I - Active [DIAGNOSES REDACTED]. Review of Resident #17's Care Plan revealed an entry originally dated 11/08/2013 which identified as a Problem/Need that the resident was at risk for falls with injury related to risks which included, but were not limited to, a History of Falls, Arthritic Deformities of Both Feet, Generalized Weakness and a Cerebral Infarction. The Care Plan indicated that the Goal related to Resident #17's risk for falls was to ensure the resident was at a decreased risk for falls and fall-related injuries. The Care Plan further identified multiple Approaches to address Resident #17's risk for falls, with one Approach being to transfer the resident with the appropriate devices. A 06/11/2014, 2:50 p.m. Nurse's Notes entry documented that staff were transferring Resident #17 using a mechanical lift, the lift tilted over on its side, and the resident sustained [REDACTED]. A Supervisor Incident Investigation report for Resident #17's 06/11/2014 fall documented that the mechanical lift tilted to the right during transfer, that the resident's weight may not have been distributed evenly while positioned in the lift, and that this incident would be referred to the Interdisciplinary Team (IDT) and the Patients At Risk (PAR) committee for review. Review of the 06/12/2014 PAR Committee notes revealed that the IDT reviewed Resident #17's fall of 06/11/2014 and specified to provide staff in-service training regarding proper lift net placement and the use of the lift stabilizer bar. Review of Resident #17's Care Plan referenced above revealed an entry dated 06/12/2014, added as part of the Problem/Need entry identifying the resident's fall-risk, which documented that the PAR Committee had reviewed the resident's 06/11/2014 fall from the mechanical lift while being transferred by two (2) people during which the lift tipped over. An additional Care Plan entry, also dated 06/12/2014, was added as an Approach for the resident's fall-risk and specified that staff receive in-service training regarding the proper placement of the net and use of the stabilizer legs on the mechanical lift. However, review of the June 2014 staff in-service training record revealed no evidence of staff training for proper net placement and stabilizer bar use for mechanical lifts as specified by Resident #17's 06/12/2014 Care Plan Approach referenced above which had been added to the Care Plan in response to the resident having fallen from the mechanical lift during transfer. During an interview with Registered Nurse (RN) "UU" conducted on 06/19/2014 at 2:19 p.m., RN "UU" acknowledged that the staff in-service training specified by the Care Plan of Resident #17 related to mechanical lift use had not been provided. During a later interview with the DON conducted on 06/19/2014 at 2:40 p.m., the DON also acknowledged that the facility had failed to provide the staff in-service training as specified by Resident #17's Care Plan. Based on the above, despite Resident #17 having been assessed to be at an increased risk for falls, despite Resident #17 sustaining a fall with injury during a mechanical lift transfer, and despite the resident's Care Plan specifying staff training, as mandated by the IDT in response to this fall, regarding proper net placement and stabilizer bar use for mechanical lifts, the facility failed to provide this staff in-service training specified by the Care Plan to ensure the resident's continued safety during mechanical lift transfers, to thus achieve the Care Plan Goal of ensuring the resident would be at decreased risk for falls and fall-related injuries Cross refer to F323, example #2, for more information regarding Resident #17. 2. Resident #116's 03/17/2014 MDS documented in Section I - Active [DIAGNOSES REDACTED]. Section J - Health Conditions documented a history of falls. Review of the Care Plan for Resident #116 revealed a Problem/Need, originally dating from 12/20/2013, which identified the resident's risk for falls. Approaches listed on this Care Plan to address Resident #116's fall-risk included the use of a bolster mattress to be applied to the resident's bed. However, observations conducted on 06/17/2014 at 5:30 p.m. and on 06/18/2014 at 7:05 a.m. and 12:20 p.m. revealed a flat mattress on the resident's bed, not a bolster mattress as specified by the Care Plan. During an interview with Nurse Manager "AA" conducted on 06/18/2014 at 1:00 p.m., Nurse "AA" stated her expectation would be that a bolster mattress should be used on Resident #116's bed, as specified by the resident's Care Plan. Cross refer to F323, example #3, for more information regarding Resident #116. 3. Resident "C"'s MDS assessment of 04/06/2014 documented [DIAGNOSES REDACTED]. The Care Plan of Resident "C" identified as a Problem/Need that the resident had a self-care deficit related to multiple medical factors and required the assistance of staff with toileting, further indicating that the resident was incontinent of bowel/bladder. A Goal related to this Problem/Need was that Resident "C" would have no infections, and Care Plan Approaches included that the resident would be cleansed after incontinent episodes. However, observation of Resident "C" on 06/19/14 at 9:55 a.m. revealed Certified Nursing Assistant (CNA) "CC" to wipe the perineal area, place the soiled washcloth back into the clean soapy water basin, then dampen three (3) additional washcloths in the contaminated soapy water basin and continue to wipe the perineal area. The CNA then dampened a clean washcloth in a rinse water basin, rinsed the perineal area, placed the soiled rinse cloth back in the clean rinse water basin and again wiped the resident's perineal area, further contaminating the cloth with bowel movement. She then placed the soiled cloth back in the rinse water, dampened another washcloth with the contaminated rinse water and cleaned the resident. During interview at the time of this observation, CNA "CC" acknowledged her failure to change the contaminated water in the soapy/rinse water basins. During a 06/19/2014, 11:13 a.m. interview, the DON acknowledged that staff failed to provide proper cleansing during the incontinence care provided to Resident "C". Cross refer to F315 for more information regarding Resident "C". It was determined that the immediate jeopardy had been removed on 07/03/2014, at which time the facility had implemented the following credible allegation of jeopardy removal with the following interventions: A. On 07/01/2014, the Administrator and DON developed and implemented a Policy Statement for Mechanical Lift Transfers which related to the following: the use of mechanical lifts in accordance with physicians' orders; the assessment of all residents, as per MDS requirements, regarding the need for assistance with transfers, mobility and repositioning; the criteria for determining the need of each resident for mechanical lift transfers; the number of staff persons required to be present during mechanical lift transfers (a minimum of two staff persons, unless a resident's assessment indicates more assistance is required); the frequency of resident assessment required to assess mechanical lift use for a resident; the method utilized to ensure the awareness of direct-care staff of the mechanical lift requirements for each resident. B. On 07/01/2014, the Administrator and the Maintenance Director developed a mechanical lift service schedule. All mechanical lifts were checked on 07/01/2014, after which all lifts were either returned to the units for use or were held for repair. A new procedure mandates a monthly check of all mechanical lifts using the Monthly Lift Checks and Service Log, which will be completed monthly on an ongoing basis by the Maintenance Director. This report will then be forwarded to the Administrator for review. Any problems with a mechanical lift between monthly checks will require a licensed nurse to visibly tag the lift as being "Out of Service" and place the need for repair request on the Log. A lift can then be returned to use only after the licensed nurse has been informed by the maintenance department that the lift has been repaired. This system will be ongoing. All problems identified related to mechanical lifts shall be recorded on the Maintenance Log; the nurses who initially removed a lift from service for repair and who placed it back into service will initial and date this Log. The maintenance staff will also initial and date the Log when the lift is put back into service. The Administrator and DON will monitor for compliance by reviewing each wing's maintenance log weekly for a year and documenting this audit on the Weekly Maintenance Log Monitoring Form. C. On 07/01/2014, the Administrator and DON met with the Nurse Managers and directed them to complete medical record reviews for residents requiring mechanical lift transfers. This included ensuring that the physicians' order and lift assessment results were properly reflected on the Resident Care Plans and Aide Assignment Records. This audit was completed on 07/01/2014. The Assessment for Mechanical Lift Transfer has been utilized to assess each resident's needs to utilize a mechanical lift and the number of staff required to transfer the resident safely using the mechanical lift. The DON, the Assistant Director of Nursing (ADON), and the Utilization Review Nurse (URN) have checked every resident's medical record to make sure that there is a current lift assessment and that appropriate information has been transferred and care planned. This will be completed for each resident upon admission, and upon completion of a Significant Change MDS or Quarterly MDS. This will be monitored weekly by the DON, ADON, or URN for a year using the Weekly Mechanical Lift Assessment Monitoring Log. D. On 07/02/2014, mechanical lift transfer assessments were completed for all other residents using the Assessment for Mechanical Lift Transfer tool. New assessments will be conducted for all residents upon any significant change in condition or quarterly MDS review. The DON, ADON, and URN have checked every resident chart to ensure the presence of a current lift assessment and that appropriate information has been transferred and care planned. This process will be monitored weekly by the DON, ADON, or URN for a year by completing the Weekly Mechanical Lift Assessment Monitoring Form. E. On 07/02/2014, mandatory staff in-service training had been provided during all shifts. All mandatory staff in-services have included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair. Forty-eight (48) of the facility's seventy-eight (78) licensed nurses had received this in-service training by the end of the third shift of 07/02/2014. The remaining thirty (30) licensed nurses, many of whom work only infrequently on an as-needed basis, were not currently available for this mandatory in-service training due to their being on leave status or not having worked during this period of staff training. All of these remaining thirty (30) licensed nurses will receive this mandatory in-service training as they report for work and before being allowed to provide resident care. In addition, this mandatory in-service training had been provided to ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff as of 07/02/2014. The remaining forty (40) CNA staff (which includes 27 CNAs who work only periodically), who were unavailable for the mandatory in-service at this time, will receive this in-service training as they report for work and before being allowed to provide resident care. The facility will conduct mandatory annual in-service training related to mechanical lift use, and this training will be mandatory for all newly-employed staff during new-hire orientation. Quarterly competency checks will be completed during shifts by wing for no less than 18 employees per week from all nurses and CNAs using the Mechanical Lifts/Slings and Transfer Check Off tool for a one year period of time. These checks will be performed by the In-Service Director, Unit Manager, or Nursing Supervisor. RN Managers and Supervisors will be responsible for instruction of all charge nurses to monitor all lift techniques for compliance with physicians' orders. This system will be reinforced by weekly audit monitoring, observation and staff interviews to be performed by the DON or ADON. F. On 07/02/2014, the facility implemented a procedure by which the results of facility monitoring audits, including the monthly check of mechanical lifts using the Monthly Lift Checks and Service Log, as-needed mechanical lift repairs made between the monthly checks monitored by the Administrator/DON via the Weekly Maintenance Log Monitoring Form, and the monitoring of staffs' compliance with resident mechanical lift assessments and care planning conducted weekly by the DON/ADON/URN via the Weekly Mechanical Lift Assessment Monitoring Log, will be presented by the Administrator and DON at the next Quality Assurance Committee Meeting on 07/23/2014, and at every quarterly Quality Assurance Committee meeting for the following year. During the standard survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the allegation of jeopardy removal referenced above, with findings as follow: - On 07/01/2014, the facility's newly developed procedure related to a mechanical lift service maintenance schedule was reviewed. It was determined that all mechanical lifts being used in the facility had been checked for proper function, and it was confirmed that a new procedure mandated a monthly inspection of all mechanical lifts. This monthly lift inspection is to be documented on the Monthly Lift Checks and Service Log. Additionally, it was confirmed that a new procedure had been established to ensure the repair of lifts if needed between monthly inspections, and the oversight of this mechanical lift maintenance process will involve management staffs' weekly monitoring for compliance via the Weekly Maintenance Log Monitoring Form. - On 07/02/2014, the facility's newly developed Policy regarding mechanical lift use was reviewed and it was confirmed that the Policy referenced the following: the assessment requirements for resident transfer/mobility/repositioning; the criteria for determining mechanical lift necessity and the frequency of assessment; the number of staff persons required during lift transfer; the method of instruction for direct-care staff regarding resident mechanical lift requirements. - On 07/02/2014, facility record review and interview with the Administrator, DON and Training Coordinator confirmed that the facility had reviewed the medical records of residents, including those requiring mechanical lift transfers, to ensure that Resident Care Plans and Aide Assignment Records reflected the lift requirements of residents. It was also confirmed via policy review and interview with the Administrator, DON and Training Coordinator that lift requirement assessments will be completed, per policy, upon resident admission and upon completion of a Significant Change MDS or Quarterly MDS. This process will be monitored weekly by management staff via the Weekly Mechanical Lift Assessment Monitoring Log. - On 07/02/2014, interview with the DON and review of facility staff in-service training records revealed that the facility had provided training to the majority of direct-care nursing staff regarding the policies and procedures for mechanical lift use, the use of the mechanical lifts and slings, the routine equipment inspection process, and the procedure for the reporting of equipment needing repair between routine equipment inspections. It was also confirmed, via policy review and interview with the Administrator and DON, that the remaining licensed nursing and CNA staff who were unavailable and had not yet received in-service training would receive this training upon their return to work, before being allowed to provide direct resident care. - On 07/03/2014, it was confirmed via interview with the Administrator and the Medical Director that all monitoring to be completed by management staff to ensure direct care staffs' conformance with these newly implemented policies and procedures would be presented to, and reviewed by, the facility's QA Committee at quarterly meetings for the QA Committee's review and oversight. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on 07/03/2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 07/01/2014, the facility had developed a Policy and Procedure related to mechanical lift use and maintenance. A new mechanical lift service schedule was formulated involving a monthly check of all mechanical lifts by the Maintenance Director and as-needed repair for problems with mechanical lifts between monthly checks, complete with a system used by nursing staff for identifying and documenting needed lift repairs. Also, a process for ensuring the timely assessment and care planning for resident mechanical lift use was enacted, and a weekly audit system was developed to monitor staffs' conformance with this process. However, facility staffs' conformance with the newly implemented weekly audit system regarding resident assessment and care planning and the newly implemented monthly check of all mechanical lifts could not be assessed at the time of survey exit, and will therefore need to be evaluated at a future date. In addition, as of 07/02/2014, mandatory staff in-service training which included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair had been provided to forty-eight (48) of the facility's seventy-eight (78) licensed nurses, and ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff. However, the remaining thirty (30) licensed nurses and forty (40) CNA staff, many of whom work only periodically or on an as-needed basis, were not currently available for this mandatory in-service training, and will receive in-service as they report for work; therefore, the completion of this mandatory staff in-service training for these remaining staff members could not be assessed at the time of survey exit and will need to be evaluated at a future date. Also, on 07/02/2014, the facility developed and implemented a process by which nursing staff will undergo quarterly competency checks regarding mechanical lift use and proficiency; therefore, the facility's compliance with this newly implemented process of ensuring the direct-care staffs' ongoing competency regarding resident transfers via mechanical lifts will need to be evaluated at a future date. Additionally, as part of the corrective actions formulated by the facility, facility management staff will conduct monitoring audits (including a monthly check of mechanical lifts using the Monthly Lift Checks and Service Log; as-needed mechanical lift repairs between monthly checks via the Weekly Maintenance Log Monitoring Form; monitoring of staffs' compliance with resident mechanical lift assessments/care planning via Weekly Mechanical Lift Assessment Monitoring Log) the results of which will be presented to the facility's QA Committee for their review and analysis. However, the next QA Committee meeting will not be held until 07/23/2014, and thus the QA Committee's involvement in this process could not be fully assessed at the time of survey completion; therefore, the non-compliance continues, with the scope and severity level reduced to the "D" level.

Based on clinical record review, Fall Risk form review, Plan Of treatment for [REDACTED]. the assistance of two (2) persons during mechanical lift transfer per the assessed need, and by failing to ensure the safe working order of a mechanical lift utilized during lift transfer, for one (1) resident (#254), who was assessed to be at risk for falls and to require the assistance of two (2) staff persons during lift transfer, of three (3) sampled residents evaluated for transfer by mechanical lift, from a total survey sample of thirty-eight (38) residents. Rather than ensuring the presence of two (2) staff during the mechanical lift transfer of Resident #254 per the resident's assessed need, only one (1) staff person initiated a bed-to-chair transfer of the resident via mechanical lift (for which the facility had failed to conduct the monthly inspections specified by the manufacturer to ensure safe working order). Resident #254 fell to the floor during this lift transfer, hitting his head on the floor and sustaining a laceration to the head which required four (4) staples for closure. After Resident #254's fall during lift transfer, inspection by facility maintenance staff of the mechanical lift used during the transfer revealed the lift to have a loose bolt. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on July 1, 2014 at 9:00 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on June 1, 2014 (the date Resident #254 fell during transfer via mechanical lift while being transferred by only one (1) staff person, rather than two (2) persons as indicated by the resident's assessed need, and after the facility failed to conduct routine maintenance on the mechanical lift), continued through July 2, 2014, and was removed on July 3, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on July 2, 2014. During interview on 06/30/2014 at 5:40 p.m., the Administrator acknowledged Resident #254's fall involving the mechanical lift, but also acknowledged the initiation of no corrective actions by the facility since this incident. An allegation of jeopardy removal was received on July 2, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on July 3, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility's provision of staff in-service training and the newly-implemented process of routine mechanical lift inspections continued. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and procedures related to the transfer of residents utilizing mechanical lifts, and related to the routine inspection and maintenance of mechanical lifts. Resident records were reviewed to ensure that resident assessments and Care Plans accurately reflected the transfer status and requirements of residents. Findings include: Resident #254's Quarterly Minimum Data Set assessment of 04/28/2014 documented [DIAGNOSES REDACTED]. Section G - Functional Status documented Resident #254 to be totally dependent for transfer and to have required two (2) - plus person assistance for transfer during the look-back period. A 04/29/2014 Fall Risk assessment indicated Resident #254's Total Fall Risk Score to be 14, and documented that a Total Score of 10 or above represented a high risk for falls. A Plan of treatment for [REDACTED].#254 documented the initiation of skilled physical therapy on 05/12/2014, which continued through 05/23/2014. This PTR form also documented the Physical Therapist's determination that Resident #254 required the assistance of two (2) staff persons via mechanical lift for safe transfer upon discharge from skilled physical therapy on 05/23/2014. During a 06/23/2014, 10:50 a.m. telephone interview, Occupational Therapist "GG" stated, and Physical Therapist "II" concurred, that at the time of discharge from therapy services on 05/23/2014, Resident #254 required transfer via a mechanical lift with the assistance of two (2) staff persons. However, further record review revealed no evidence to indicate that, after Resident #254's discharge from physical therapy services on 05/23/14, the facility instructed direct-care staff to ensure the assistance of two (2) persons while transferring the resident via mechanical lift. Interview with the DON on 06/24/2014 at 4:35 p.m. revealed that the Physical Therapist's determination that Resident #254 required the assistance of two (2) staff persons during lift transfers should have been added to the Aide Assignment Record to instruct direct-care staff, but acknowledged that the resident's need for the assistance of two (2) persons during lift transfers had been omitted from the Aide Assignment Record. A 06/01/2014, 4:45 p.m. Nurse's Notes entry then documented that while a nursing assistant was transferring Resident #254 from the bed to the chair via mechanical lift, the lift toppled, the resident landed on the floor, and a laceration of approximately four (4) centimeters (cms) was observed on the back of the resident's head. A verbal physician's orders [REDACTED].#254's hospital transfer for this fall and [MEDICAL CONDITION]. A 06/01/2014 hospital ED Nurse's Notes entry for Resident #254 documented that upon hospital arrival, the resident was noted with a bleeding laceration to the mid-parietal area of the head. A 06/01/2014 hospital Physician Documentation (PD) entry documented a 3.2 cm laceration to Resident #254's left occiput which was closed with four (4) 1-0 staples, and documented that Resident #254 was then discharged back to the nursing facility. A facility Incident Report for Resident #254's fall documented that on 06/01/2014, Licensed Practical Nurse (LPN) "JJ" observed the resident on the floor with a four (4) centimeter [MEDICAL CONDITION] and observed the lift net to be only partially attached. This Incident Report further documented that the certified nursing assistant (CNA) stated Resident #254 had been "squirming around", the lift malfunctioned, and the resident fell . During a 06/30/2014, 4:35 p.m. interview with CNA "KK", the CNA who transferred Resident #254 on 06/01/2014 when the resident fell during lift transfer, CNA "KK" stated she had begun to transfer the resident in the lift without the assistance of another staff member. She stated Resident #254 began to move in the lift and the lift then stuck. She stated as she pushed buttons on the lift and pushed on the lift bar, the lift would not initially move but then began to move downward and Resident #254 fell , hitting his head on the floor. During a 06/30/2014, 5:00 p.m. interview, CNA "KK" stated she had not known how many staff were to assist in Resident #254's transfer when he fell during the lift transfer of 06/01/14. During interview on 06/19/2014 at 4:15 p.m., the DON acknowledged that only one (1) staff person was transferring Resident #254 via mechanical lift when he fell on [DATE]. In addition, a telephone interview with the Maintenance Director on 06/25/2014 at 9:05 a.m. revealed there had been a mechanical issue with the lift used during Resident #254's 06/01/2014 transfer. He stated that inspection of the lift after Resident #254's fall revealed that a mechanical lift shifter bolt/screw had come loose. The Maintenance Director stated that the facility did not perform regular inspections and maintenance for mechanical lifts. Review of the Invacare Manual/Electric Patient Lift User Manual revealed the Manual to specify monthly inspection/adjustment of manual/electric portable patient lifts used in the institutional setting to check components of the lift including, but not limited to, the caster base, the casters and axle bolts, the lift shifter handle, the lift mast and boom, the lift swivel bar, the manual/hydraulic pump/electric [MEDICATION NAME] assembly, and the lift slings and hardware. However, even though the manufacturer mandated monthly mechanical lift inspections to ensure the necessary maintenance, the Maintenance Director acknowledged during the 06/25/2014, 9:05 a.m. interview referenced above that the facility did not conduct monthly inspections and maintenance on the mechanical lifts used by the facility for resident transfers. Based on the above, despite Resident #254 having been assessed to be totally dependent for transfer and to be at high risk for falls, and despite Resident #254 being assessed by the Physical Therapist to require the assistance of two (2) staff persons for mechanical lift transfers, Resident #254 was transferred via mechanical lift by only one (1) CNA. The resident fell to the floor during this transfer and sustained a [MEDICAL CONDITION] which required four (4) staples to close. Maintenance staff later determined the lift to have a loose bolt on the shifter handle, but the facility had failed to provide monthly maintenance and inspections for this mechanical lift (or any mechanical lift utilized in the facility), despite the lift manufacturer's requirement that monthly inspections/adjustments be conducted on all mechanical lifts. The failure of the facility to ensure two (2) persons to assist during the mechanical lift transfer of Resident #254 on 06/01/2014, and the failure of the facility to ensure the monthly inspection/maintenance of the lift utilized during this transfer, with the resident subsequently falling during this transfer and sustaining a [MEDICAL CONDITION] requiring four (4) staples for closure, represented neglect for Resident #254. Cross refer to F323, example 1, for more information regarding Resident #254. It was determined that the immediate jeopardy had been removed on 07/03/2014, at which time the facility had implemented the following credible allegation of jeopardy removal with the following interventions: A. On 07/01/2014, the Administrator and DON developed and implemented a Policy Statement for Mechanical Lift Transfers which related to the following: the use of mechanical lifts in accordance with physicians' orders; the assessment of all residents, as per MDS requirements, regarding the need for assistance with transfers, mobility and repositioning; the criteria for determining the need of each resident for mechanical lift transfers; the number of staff persons required to be present during mechanical lift transfers (a minimum of two staff persons, unless a resident's assessment indicates more assistance is required); the frequency of resident assessment required to assess mechanical lift use for a resident; the method utilized to ensure the awareness of direct-care staff of the mechanical lift requirements for each resident. B. On 07/01/2014, the Administrator and the Maintenance Director developed a mechanical lift service schedule. All mechanical lifts were checked on 07/01/2014, after which all lifts were either returned to the units for use or were held for repair. A new procedure mandates a monthly check of all mechanical lifts using the Monthly Lift Checks and Service Log, which will be completed monthly on an ongoing basis by the Maintenance Director. This report will then be forwarded to the Administrator for review. Any problems with a mechanical lift between monthly checks will require a licensed nurse to visibly tag the lift as being "Out of Service" and place the need for repair request on the Log. A lift can then be returned to use only after the licensed nurse has been informed by the maintenance department that the lift has been repaired. This system will be ongoing. All problems identified related to mechanical lifts shall be recorded on the Maintenance Log; the nurses who initially removed a lift from service for repair and who placed it back into service will initial and date this Log. The maintenance staff will also initial and date the Log when the lift is put back into service. The Administrator and DON will monitor for compliance by reviewing each wing's maintenance log weekly for a year and documenting this audit on the Weekly Maintenance Log Monitoring Form. C. On 07/01/2014, the Administrator and DON met with the Nurse Managers and directed them to complete medical record reviews for residents requiring mechanical lift transfers. This included ensuring that the physicians' order and lift assessment results were properly reflected on the Resident Care Plans and Aide Assignment Records. This audit was completed on 07/01/2014. The Assessment for Mechanical Lift Transfer has been utilized to assess each resident's needs to utilize a mechanical lift and the number of staff required to transfer the resident safely using the mechanical lift. The DON, the Assistant Director of Nursing (ADON), and the Utilization Review Nurse (URN) have checked every resident's medical record to make sure that there is a current lift assessment and that appropriate information has been transferred and care planned. This will be completed for each resident upon admission, and upon completion of a Significant Change MDS or Quarterly MDS. This will be monitored weekly by the DON, ADON, or URN for a year using the Weekly Mechanical Lift Assessment Monitoring Log. D. On 07/02/2014, mechanical lift transfer assessments were completed for all other residents using the Assessment for Mechanical Lift Transfer tool. New assessments will be conducted for all residents upon any significant change in condition or quarterly MDS review. The DON, ADON, and URN have checked every resident chart to ensure the presence of a current lift assessment and that appropriate information has been transferred and care planned. This process will be monitored weekly by the DON, ADON, or URN for a year by completing the Weekly Mechanical Lift Assessment Monitoring Form. E. On 07/02/2014, mandatory staff in-service training had been provided during all shifts. All mandatory staff in-services have included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair. Forty-eight (48) of the facility's seventy-eight (78) licensed nurses had received this in-service training by the end of the third shift of 07/02/2014. The remaining thirty (30) licensed nurses, many of whom work only infrequently on an as-needed basis, were not currently available for this mandatory in-service training due to their being on leave status or not having worked during this period of staff training. All of these remaining thirty (30) licensed nurses will receive this mandatory in-service training as they report for work and before being allowed to provide resident care. In addition, this mandatory in-service training had been provided to ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff as of 07/02/2014. The remaining forty (40) CNA staff (which includes 27 CNAs who work only periodically), who were unavailable for the mandatory in-service at that time, will receive this in-service training as they report for work and before being allowed to provide resident care. The facility will conduct mandatory annual in-service training related to mechanical lift use, and this training will be mandatory for all newly-employed staff during new-hire orientation. Quarterly competency checks will be completed during shifts by wing for no less than 18 employees per week from all nurses and CNAs using the Mechanical Lifts/Slings and Transfer Check Off tool for a one year period of time. These checks will be performed by the In-Service Director, Unit Manager, or Nursing Supervisor. RN Managers and Supervisors will be responsible for instruction of all charge nurses to monitor all lift techniques for compliance with physicians' orders. This system will be reinforced by weekly audit monitoring, observation and staff interviews to be performed by the DON or ADON. F. On 07/02/2014, the facility implemented a procedure by which the results of facility monitoring audits, including the monthly check of mechanical lifts using the Monthly Lift Checks and Service Log, as-needed mechanical lift repairs made between the monthly checks monitored by the Administrator/DON via the Weekly Maintenance Log Monitoring Form, and the monitoring of staffs' compliance with resident mechanical lift assessments and care planning conducted weekly by the DON/ADON/URN via the Weekly Mechanical Lift Assessment Monitoring Log, will be presented by the Administrator and DON at the next Quality Assurance Committee Meeting on 07/23/2014, and at every quarterly Quality Assurance Committee meeting for the following year. During the standard survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the allegation of jeopardy removal referenced above, with findings as follow: - On 07/01/2014, the facility's newly developed procedure related to a mechanical lift service maintenance schedule was reviewed. It was determined that all mechanical lifts being used in the facility had been checked for proper function, and it was confirmed that a new procedure mandated a monthly inspection of all mechanical lifts. This monthly lift inspection is to be documented on the Monthly Lift Checks and Service Log. Additionally, it was confirmed that a new procedure had been established to ensure the repair of lifts if needed between monthly inspections, and the oversight of this mechanical lift maintenance process will involve management staffs' weekly monitoring for compliance via the Weekly Maintenance Log Monitoring Form. - On 07/02/2014, the facility's newly developed Policy regarding mechanical lift use was reviewed and it was confirmed that the Policy referenced the following: the assessment requirements for resident transfer/mobility/repositioning; the criteria for determining mechanical lift necessity and the frequency of assessment; the number of staff persons required during lift transfer; the method of instruction for direct-care staff regarding resident mechanical lift requirements. - On 07/02/2014, facility record review and interview with the Administrator, DON and Training Coordinator confirmed that the facility had reviewed the medical records of residents, including those requiring mechanical lift transfers, to ensure that Resident Care Plans and Aide Assignment Records reflected the lift requirements of residents. It was also confirmed via policy review and interview with the Administrator, DON and Training Coordinator that lift requirement assessments will be completed, per policy, upon resident admission and upon completion of a Significant Change MDS or Quarterly MDS. This process will be monitored weekly by management staff via the Weekly Mechanical Lift Assessment Monitoring Log. - On 07/02/2014, interview with the DON and review of facility staff in-service training records revealed that the facility had provided training to the majority of direct-care nursing staff regarding the policies and procedures for mechanical lift use, the use of the mechanical lifts and slings, the routine equipment inspection process, and the procedure for the reporting of equipment needing repair between routine equipment inspections. It was also confirmed, via policy review and interview with the Administrator and DON that the remaining licensed nursing and CNA staff who were unavailable and had not yet received in-service training would receive this training upon their return to work, before being allowed to provide direct resident care. - On 07/03/2014, it was confirmed via interview with the Administrator and the Medical Director that all monitoring to be completed by management staff to ensure direct care staffs' conformance with these newly implemented policies and procedures would be presented to, and reviewed by, the facility's QA Committee at quarterly meetings for the QA Committee's review and oversight. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on 07/03/2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 07/01/2014, the facility had developed a Policy and Procedure related to mechanical lift use and maintenance. A new mechanical lift service schedule was formulated involving a monthly check of all mechanical lifts by the Maintenance Director and as-needed repair for problems with mechanical lifts between monthly checks, complete with a system used by nursing staff for identifying and documenting needed lift repairs. Also, a process for ensuring the timely assessment and care planning for resident mechanical lift use was enacted, and a weekly audit system was developed to monitor staffs' conformance with this process. However, facility staffs' conformance with the newly implemented weekly audit system regarding resident assessment and care planning, and the newly implemented monthly check of all mechanical lifts could not be fully assessed at the time of survey exit, and will therefore need to be evaluated at a future date. In addition, as of 07/02/2014, mandatory staff in-service training which included the policies and procedures for mechanical lift use, the use of the mechanical lift and assorted slings, equipment inspection, incident reporting, and proper reporting of equipment needing repair had been provided to forty-eight (48) of the facility's seventy-eight (78) licensed nurses, and ninety-six (96) of the facility's one-hundred-thirty-six (136) CNA staff. However, the remaining thirty (30) licensed nurses and forty (40) CNA staff, many of whom work only periodically or on an as-needed basis, were not currently available for this mandatory in-service training and will receive in-service as they report for work; therefore, the completion of this mandatory staff in-service training for these remaining staff members could not be assessed at the time of survey exit and will need to be evaluated at a future date. Also, on 07/02/2014, the facility developed and implemented a process by which nursing staff will undergo quarterly competency checks regarding mechanical lift use and proficiency; therefore, the facility's compliance with this newly implemented process of ensuring the direct-care staffs' ongoing competency regarding resident transfers via mechanical lifts will need to be evaluated at a future date. Additionally, as part of the corrective actions formulated by the facility, facility management staff will conduct monitoring audits (including a monthly check of mechanical lifts using the Monthly Lift Checks and Service Log; as-needed mechanical lift repairs between monthly checks via the Weekly Maintenance Log Monitoring Form; monitoring of staffs' compliance with resident mechanical lift assessments/care planning via Weekly Mechanical Lift Assessment Monitoring Log) the results of which will be presented to the facility's QA Committee for their review and analysis. However, the next QA Committee meeting will not be held until 07/23/2014, and thus the QA Committee's involvement in this process could not be fully assessed at the time of survey completion; therefore, the non-compliance continues, with the scope and severity level reduced to the "D" level.

b Professional standards for RN who did not follow MD orders to give crushed medications. Medication Pass observation 9/15/14@01:40PM nurse Dijana Hrepic,RN administered to Resident #230 [MEDICATION NAME] 50mg x 2 tabs po resident was asked by nurse if surveyor could watch medication administration and resident #230 said yes. Resident #230 took the medication with water and swallowed with no difficulty noted. Review of the clinical record on 9/15/14@02:55PM revealed a new order dated 9/11/14@05:30PM 1.crush med resident 2.D/C o.k. to give po meds either crushed or whole if not contraindicated or as per resident request. Orginal Physician order [REDACTED]. Review of the MAR indicated [REDACTED].The order for o.k. to give meds either crushed or whole if not contraindicated as per pts request was DC'd 9/11/14 and marked thru. Interview with Dijana Hrepick,RN 9/15/14@03:25PM stated she only wants her calcium and vitamin pill crushed. I did explain to the resident this morning there was an new order for all med's to be crushed. The resident said she might try tomorrow with a little pudding. This resident can speak for herself. Review of Physician orders [REDACTED]. speech therapy to evaluate and treat-resident c/o of difficulty of swallowing,EGD later2. uric acid level. SLP 700 Plan of treatment for [REDACTED]. SLP dated 9//11/14 after evaluation recommended modifying diet pt's diet to mechanical soft. Review of Acute Care Visit dated 9/8/14 Physician documented history resident c/o of dysphagia and rt toe pain-new problem-1.dysphagia 2.ST to evaluate,EGD later. Review of Nurse Progress Note dated 9/8/14@06:30PM Dr. Patel here on unit-Res c/o of right great toe pain and trouble swallowing. Dr. Patel spoke with resident new orders received. 9/8/14@2030P-resident id RP (self). Informed of lab orders for A.M. and speech eval orders. 9/11/14-speech Therapist on unit to assess new orders received. 9/11/14@1800 new order noted. Resident is responsible for self and is aware of new orders.verbalizes understanding. Review of Nurse Progress Notes dated 9/15/14 entry time 09:00AM resident stated I don't want my med's crushed I only want my calcium and vitamin pill crushed. Explained to res that there is order for med's to be crushed by speech therapist. Nurse Progress note dated 9/15/14 @ 16:31-New orders noted and R.P. aware of new orders. Nurse Progress Note dated 9/15/14@16:30 called Dr. Patel and informed __?__ that res. had received pills whole. Dr. Patel stated to not to change order and to continue to crush res meds. CP dated Resident is able to take PO meds whole due to dysphagia or refusal to swallow. Meds are crushed unless MAR indicated [REDACTED].Goal -resident will receive meds as ordered by MD without episodes of choking during the next 3 months.-Approaches-Medications will be crushed as per MD order;Meds will be administered in vehical of choice,if PO intake allowed within dietary restrictions (pudding,juice,applesauce) unless otherwise specified;Licensed Nurse will consult MD for clarification for prescribed medication which can not be crushed (MD may prescribe different form of medication) Resident able to swallow meds but at times prefers they maybe crushed will administered meds per resident preference-DC-Approaches-nurse will check with resident daily for daily preference at each med's administration.DC Revised CP dated 9/11/14-Resident having increased difficulty swallowing whole med's-will crush all meds. approach-9/11/14-Administer all meds crushed. Review of last MDS dated [DATE]-Section c-cognitive pattersn BIMS score 15;Section E-Behavior-no behaviors noted'section I Activie diagnosis-[MEDICAL CONDITION],heart failure,HTN,V45.01-Cardiac pacemaker;336.9-unspecified disease of spinal cord. Section K-Swallowing disorder-None of above. Residetn admitted to facility 4/9/14.Review of Med Physician consultation from The Medical Center resident was post hospitalization following post anterior cervical surgery. Past medical history include hypertension,pacemaker,[MEDICAL CONDITION].