Every finding on record at Paul E Patton Eastern KY Veterans Center

Based on interview, record review, and facility policy review it was determined that the facility failed to ensure an allegation of abuse was reported to the Administrator of the facility and the appropriate state agencies as required for one (1) of thirty-two (32) sampled residents (Resident #305). The findings include: Review of the facility policy and procedure titled Abuse Policy and Procedures, revised 09/25/17, revealed all alleged violations involving abuse or mistreatment of [REDACTED]. Review of Resident #305's medical record revealed the facility admitted the resident on 04/17/18 with [DIAGNOSES REDACTED]. Review of Resident #305's Minimum Data Set assessment dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). Staff assessment of Mental Status was performed and staff indicated that the resident had both short-term and long-term memory problems. Interview on 05/17/18 at 10:00 AM with Resident #305 revealed the resident was able to answer questions appropriately and stated that a couple of weeks ago a Certified Nursing Assistant (CNA) hurt him/her when providing care. Resident #305 stated the CNA was attempting to turn him/her and when she removed the blanket that the resident's left side was lying on, the resident stated she pulled it so hard that his/her left leg was jerked upward, almost touching my shoulder blade. The resident stated that he/she instructed the CNA to stop, telling her that it had hurt him/her. Resident #305 stated that the CNA replied to the resident that the resident needed to try and help be repositioned. Further interview with Resident #305 revealed he/she did not report the CNA's action to any facility staff until 05/14/18, at which time the resident reported the incident to the Nurse Manager. Interview on 05/17/18 at 10:49 AM with the Nurse Manager revealed that Resident #305's daughter reported the allegation to her on 05/14/18 at about 11:45 AM. The Nurse Manager stated she spoke with Resident #305 who told her that a CNA (name unknown, but gave a description matching CNA #3) had been rough with him/her during care. The resident stated that the CNA had pulled the cover out from under him/her which had hurt his/her leg. The Nurse Manager stated she took CNA #3 into her office and asked her about the allegation, and CNA #3 stated she did not remember the incident happening. The Nurse Manager stated she directed CNA #3 not to go back into Resident #305's room. The Nurse Manager then reported the allegation to the Director of Nursing (DON). However, the Nurse Manager stated she did not document the reported allegation. Interview on 05/17/18 at 11:45 AM with CNA #3 revealed she stated she did not remember being rough with Resident #305, and had provided care to the resident until 05/14/18, when the Unit Manager had questioned her about the incident and instructed her not to go back into Resident #305's room. Interview on 05/17/18 at 12:07 PM with the DON revealed that she was made aware of the incident on 05/14/18 at about 2:30 PM. The DON stated she did not initiate an investigation into the reported allegation when it was reported to her because she was informed that CNA #3 had been instructed by the Unit Manager not to go back into Resident #305's room. However, the DON stated she was aware that CNA #3 was continuing to care for other facility residents. Interview on 05/17/18 at 4:41 PM with the Social Services employee, who is designated as the investigator for abuse allegations, revealed that she was not notified of the allegation made by Resident #305 until 05/17/18, at which time she initiated an investigation. Interview on 05/17/18 at 7:13 PM with the Administrator revealed he had not been informed of the allegation made by Resident #305 until 05/17/18, at which time an investigation was initiated and CNA #3 was suspended pending the outcome of the investigation.

Based on interview, record review, and facility policy review, it was determined the facility failed to immediately initiate an investigation of an allegation of physical abuse for one (1) of thirty-two (32) sampled residents (Resident #305), and failed to protect further potential abuse while the investigation was in progress. The findings include: Review of the facility policy and procedure entitled Abuse Policy and Procedures, revised 09/25/17, revealed all alleged violations involving abuse would be thoroughly investigated immediately, and in order to protect residents from further potential abuse employees of the facility who have been accused of resident abuse will be placed on leave pending the outcome of the investigation. Review of the Medical Record for Resident #305 revealed the facility admitted the resident on 04/17/18 with [DIAGNOSES REDACTED]. Review of Resident #305's Minimum Data Set assessment dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). Staff assessment of Mental Status was performed and staff indicated that the resident had both short-term and long-term memory problems. Interview on 05/17/18 at 10:00 AM with Resident #305 revealed the resident was able to answer all questions appropriately. The resident stated he/she had reported an allegation of abuse to the Nurse Manager on 05/14/18. Resident #305 stated that a Certified Nursing Assistant (CNA) (identified by the facility as CNA #3) had been rough with him/her while providing care a couple of weeks ago (exact date unknown). Interview on 05/17/18 at 10:49 AM with the Nurse Manager confirmed that Resident #305 had reported to her on 05/14/18, that a CNA matching the description of CNA #3 had been rough with him/her while providing care. The Nurse Manager stated she spoke with CNA #3 on 05/14/18, who denied the allegation. The Nurse Manager stated she instructed CNA #3 to not go back into Resident #305's room, but allowed the CNA to continue to care for other facility residents. The Nurse Manager stated she reported the allegation of abuse to the Director of Nursing (DON) on 05/14/18. Interview on 05/17/18 at 12:07 PM with the DON confirmed that she had been notified by the Nurse Manager on 05/14/18, that Resident #305 had made an allegation of abuse against CNA #3, and that the Nurse Manager had informed her that she had instructed CNA #3 not to provide care to Resident #305. However, the DON failed to initiate an investigation into the allegation, failed to protect residents from further potential abuse by allowing CNA #3 to continue to provide care to other residents, and failed to notify Social Services of the allegation. Interview with the Social Services employee on 05/17/18 at 4:41 PM, revealed she was designated as the facility investigator for allegations involving abuse. However, the Social Services employee stated she had failed to initiate an abuse investigation related to the allegations made by Resident #305 on 05/14/18, because she was not notified of the abuse allegation until 05/17/18. The Social Services employee stated at that time an abuse investigation was initiated. Interview on 05/17/18 at 7:13 PM with the Administrator revealed that he was not notified of the allegation of abuse made by Resident #305 on 05/14/18 until 05/17/18. The Administrator stated at that time an investigation was initiated and CNA #3 was suspended from the facility pending the outcome of the investigation, to protect other residents from potential abuse.

Based on observation, record review, interview, and review of the facility policy it was determined the facility failed to implement the comprehensive plan of care for one (1) of thirty-two (32) sampled residents. Review of Resident #59's comprehensive care plan revealed the resident required a splint to the right hand. However, observations of Resident #59 revealed the resident was not wearing the splint as required. The findings include: Review of the facility policy, Care Plans-Comprehensive, Med-Pass, revised (MONTH) 2010, revealed the comprehensive care plan would be utilized by staff as a reference for daily resident care, as well as a tool for relaying each resident's personal preferences and routine. Review of the medical record revealed the facility admitted Resident #59 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #59's Minimum Data Set (MDS) significant change assessment, dated 03/29/18, revealed the facility assessed the resident to be severely cognitively impaired. The MDS also revealed Resident #59 was totally dependent on staff for all activities of daily living (ADLs) and required two (2) or more staff persons to complete all ADL care. Review of an Occupational Therapy (OT) Progress and Discharge Summary for Resident #59, dated 03/01/18, revealed OT had performed passive stretch exercises to the resident's right hand since 02/27/18 for preparation to initiate a right hand splint for the resident. Further review of the discharge summary revealed Resident #59 was discharged to nursing staff with a splinting schedule established for nursing staff to follow. Review of Resident #59's comprehensive plan of care, dated 03/29/18, revealed staff would ensure that the resident utilized a right resting hand splint, which was to be applied for two hours and then removed for two hours alternately throughout the daytime hours. Observation of Resident #59 on 05/16/18 at 10:33 AM, found the resident lying on the right side, both hands were clinched/contracted, with no splint applied. Continued observation of Resident #59 on 05/16/18 at 1:21 PM, revealed the resident was observed to have no hand splint in place. Observation of Resident #59 on 05/17/18 at 9:22 AM, revealed the resident lying on the left side with the head of the bed elevated 45 degrees. No splints were observed to be applied. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed the records did not reflect that the resident had the hand splint applied as ordered. Interview with State Registered Nurse Aide (SRNA) #1 on 05/17/18 at 9:28 AM, revealed she checked the plan of care for her assigned residents daily, but had not applied the resident's hand splint on 05/17/18 as required. Interview with Licensed Practical Nurse (LPN) #1 on 05/16/18 at 4:18 PM, revealed she did not recall the resident having splints ordered and did not recall ever seeing splints on the resident. LPN #1 checked the MAR and TAR for (MONTH) (YEAR) and stated that it was not on those records for them to check to make sure the splints were on/off as ordered. She also stated it was the responsibility of the nurse assigned to the resident to monitor and ensure that care was being provided for residents as dictated by the plan of care. Interview with LPN #2 on 05/16/18 at 4:18 PM, revealed she was also unaware that Resident #59 was required to utilize a hand splint. Interview with the Director of Nursing (DON) on 05/17/18 at 7:24 PM, revealed it was the nurse aide's responsibility to place the splints on and off the residents, but the nurse had to sign off to ensure it had been done. The DON confirmed that for the month of (MONTH) (YEAR) there was no documentation on Resident #59's MAR/TAR to alert the nurse to check and ensure the splint was applied as required.

Based on observation, interview, and review of the facility's dress code policy, the facility failed to prepare and serve food in accordance with professional standards for food service safety. On 02/27/17, during initial observation in the kitchen, two (2) male employees were observed not wearing beard restraints to ensure facial hair was covered. The findings include: Review of the facility's policy, Dress Code, with a revised date of 11/01/16, revealed hair nets/restraints must be worn by dietary staff while in the kitchen/food preparation area. Observation on 02/27/17 at 11:40 AM, during initial tour of the kitchen revealed two (2) male staff members with facial hair were working in the kitchen. Further observation revealed they were not wearing beard restraints. Interview with the Dietary Manager on 02/27/17 at 11:45 AM, revealed she understood employees were not required to wear beard restraints as long as facial hair was thin and well groomed. Further interview with the Dietary Manager revealed beard restraints were available in the kitchen for staff use; however, staff had not been trained that beard restraints were required to be worn to cover facial hair.

Based on observation, interview, record review, and facility policy, it was determined the facility failed to ensure staff followed established handwashing procedures to prevent/control the spread of infections when providing wound care for two (2) of twenty-three (23) sampled residents (Residents #4 and #6). The findings include: Review of the facility's Handwashing/Hand Hygiene policy (revision date July 2014) revealed facility staff would perform handwashing before and after putting on gloves, before handling clean or soiled dressings/gauze pads, before moving from a contaminated body site to a clean body site during resident care, after handling used dressings, and after removing gloves. 1. Record review revealed the facility readmitted Resident #4 on 02/08/17 with a 3 centimeter (cm) x 2.5 cm non-stageable pressure ulcer to the coccyx area and an old healed left hip scar that was red and fluid filled. According to the Nurse's Notes dated 02/08/17, at 2:00 PM, after the left hip was cleaned, the wound had, copious drainage, large amount noted. Further review of the Nurse's Notes on 02/08/17 revealed the physician was called and a culture and sensitivity (C&S) of the left hip was ordered. Review of the C&S results obtained on 02/08/17 of the left hip drainage revealed a moderate growth of gram-positive cocci and [MEDICATION NAME] faecalis bacteria was present in the left hip wound. Observation of wound care provided by the Wound Care Registered Nurse (RN #1) for Resident #4 was conducted on 02/28/17 at 9:30 AM. RN #1 was observed to wash her hands upon entering the resident's room and then put on gloves. The RN proceeded to remove the soiled dressing from the coccyx wound revealing a reddened unopened area on the coccyx. RN #1 then removed the soiled dressing containing a small to moderate amount of clear/yellowish drainage from the resident's left hip wound wearing the same gloves. The nurse was observed to put on clean gloves and clean the coccyx wound with 4x4 gauze wet with Sea-Clens without washing her hands after removing the soiled dressings. 2. Review of the medical record revealed the facility admitted Resident #6 on 11/09/16 with [DIAGNOSES REDACTED]. Review of the Admission Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #6 to have two (2) unstageable wounds upon admission (left sacral area and left scapula area). A C&S specimen obtained from the left sacral area on 11/08/16 revealed a moderate growth of gram-negative bacilli and E-coli (Escherichia-coli) bacteria was present in the sacral wound. Observations of Resident #6's wound care on 02/28/17 at 10:00 AM, revealed RN #1 washed her hands and then put on gloves prior to beginning care for the resident. The RN was observed to remove the soiled dressing from the resident's left sacral area. The dressing was noted to contain a moderate amount of yellowish drainage. RN #1 was observed to put on clean gloves and, without washing her hands, cleaned the left hip wound with 4x4 gauze wet with Sea-Clens. Interview with RN #1 on 02/28/17, at 10:10 AM revealed she had not been trained to perform handwashing after removing the soiled dressing. RN #1 stated she believed it was okay as long as she performed the glove change between each step of wound care. Interview with the Director of Nursing (DON) on 03/01/17, at 4:10 PM, revealed facility staff should perform handwashing after removing a soiled dressing, according to the facility's policy/procedure. The DON stated the Certified Wound Nurse (RN #1) monitored the Wound Nurse weekly to observe wound care technique and no problems with handwashing had been reported to her. In addition, the DON stated all staff had been trained regarding the handwashing policy/procedures.

Based on interview, record review, and review of the facility abuse policy, it was determined the facility failed to conduct required Adult Caregiver Misconduct Registry checks for two (2) of five (5) employee files reviewed. The findings include: Review of the facility policy, Abuse Prevention Program, (not dated) revealed the personnel director or designee will conduct employment background checks, reference checks, and criminal conviction checks on person making application for employment with this facility. Such investigation will be initiated prior to employment or immediately after an offer of employment, contingent upon the information obtained. Review of the employee file for Employee #1 revealed the employee was hired on 12/01/15. There was no evidence the Adult Caregiver Misconduct Registry check had been conducted prior to employment. Review of the employee file for Employee #2 revealed the employee was hired on 01/04/16. There was no evidence that the Adult Caregiver Misconduct Registry check had been conducted prior to employment. Interview with the Human Resources Administrator on 02/25/16 at 3:45 PM revealed that she was responsible for conducting the required background checks on employees prior to hire. She stated she did not know why two of the employees did not have the Adult Caregiver Misconduct Registry checks performed. She further stated, I must have overlooked it. Interview with the Human Resources Branch Manager on 02/25/16 at 4:00 PM revealed that she had not identified a problem with the appropriate background checks on employees not being performed. She stated she had a check-off list that she, along with the Human Resources Administrator, uses to ensure all appropriate background checks have been conducted. She further stated she was unsure how the misconduct registry checks were missed.

Based on observation, interview, hospital record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure that the rights of five (5) of twenty-four (24) sampled residents (Residents #1, #2, #4, #5 and #6) to execute and implement advance directives related to life-sustaining treatment were protected and promoted. On [DATE], the facility transferred Resident #1 to the hospital due to shortness of breath and labored respirations. However, the facility failed to ensure Resident #1's Living Will, which directed that no life-sustaining treatments or medications be administered to the resident, was transferred with the resident to the hospital. On [DATE], Resident #1 was intubated and placed on mechanical ventilation until he/she was extubated on [DATE]. Resident #1 returned from the hospital, to the facility on [DATE]. On [DATE], the facility initiated intravenous (IV) fluids for Resident #1; however, the resident's Living Will directed the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids (Refer to F250, F279, F309, and F490). The facility admitted Resident #2 with an Advance Directive that stated the resident's Power of Attorney (POA) could refuse or withdraw consent to any type of medical care or treatment including but not limited to artificially administered nutrition or hydration. The facility failed to have a system to ensure staff was knowledgeable of residents' advance directive wishes. Staff was not aware Resident #2 had an advance directive. On [DATE], staff notified Resident #2's family member that, if after testing the resident could have nothing by mouth, the resident would require "a tube feeding, hospice, or to be discharged from the facility." (Refer to F250, F279, and F309) On [DATE], the facility transferred Resident #4 to the Emergency Department for treatment; however, according to the hospital's Emergency Department Chart the facility failed to send the resident's Living Will with the resident (Refer to F250). In addition, review of the medical records for Resident #5 and Resident #6 revealed the residents had Advanced Directives. The facility failed to ensure the Advanced Directives were in the residents' medical record and that staff was knowledgeable of the Advanced Directives (Refer to F250). The facility's failure to have an effective system in place to establish, maintain, and implement policies and procedures regarding the residents' right to execute and implement advance directives was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279), and 42 CFR 483.25 Quality of Care (F309); and, 42 CFR 483.75 Administration (F490). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE] which alleged removal of the Immediate Jeopardy on [DATE]. A Partial Extended Survey was conducted on ,[DATE]-,[DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the Scope and Severity to "E" at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.75 Administration (F490); and,42 CFR 483.25 Quality of Care (F309) Scope and Severity of a "D", while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Resident Rights, reviewed by the facility on [DATE], revealed the policy did not specifically address advance directives. Review of the facility's Advance Directives policy and procedure, reviewed by the facility on [DATE], revealed Social Services staff or others designated by the Administrator, would meet with the resident and/or legal representative and explain Advance Directives. Social Services or designees would assist residents to execute an advance directive. The facility would have an Advance Directive Committee consisting of the Administrator/Assistant Administrator, Medical Director, Director of Nursing (DON), Director of Social Services (DSS), Primary Care Nurse, Resident/Resident's Responsible Party, and Concerned Individual/Family Member that would meet and review any situation of concern related to advance directives. The policy also stated that any person may bring a situation of concern to any member of the Advance Directive Committee member, and that member would be responsible for calling a committee meeting. The facility's policy did not address how the facility would ensure that advance directives were transferred with residents to other health care facilities when the resident was transferred from the facility. In addition, the facility's policy did not address how the facility would ensure all staff was knowledgeable of the residents' advance directive wishes. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Further review revealed a Living Will Directive and Health Care Surrogate Designation formulated by Resident #1 which had been notarized and filed on [DATE]. The Living Will specified that Resident #1 chose to have life-prolonging treatment and medication withheld or withdrawn and be permitted to die naturally with only the administration of pain-alleviating medication or treatment. Review of Resident #1's Resident's Rights/Advance Directives form dated [DATE], revealed the resident had initialed and signed the form which the DSS witnessed on [DATE], indicating that the resident had executed advance directives and had a designated Power of Attorney (POA). However, review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #1 to have executed no advance directives. Review of Resident #1's initial Comprehensive Care Plan, dated [DATE], and the most recent Comprehensive Care Plan dated [DATE], revealed that although Resident #1's cardiopulmonary resuscitation (CPR) designation had been included on both care plans, the resident's Living Will Directive and Health Care Surrogate Designation, had not been included in the resident's Comprehensive Plan of Care. Review of a Nursing Note dated [DATE], at 4:42 AM, revealed Registered Nurse (RN) #1 assessed the resident to have audible wheezing throughout his/her lung fields, labored respirations, and [MEDICAL CONDITION]. RN #1 notified Resident #1's Physician, and the resident was transferred to the hospital for further evaluation and treatment. Interview with RN #1 on [DATE], at 3:40 PM, revealed at the time she transferred Resident #1 to the hospital on [DATE], she completed a facility transfer form which contained resident specific information such as vital signs at the time of transfer, weight, and [DIAGNOSES REDACTED]. This form along with a copy of the resident's "Face Sheet" and medication list was sent to the hospital with the resident. RN #1 stated she did not send a copy of Resident #1's Living Will to the hospital at the time of transfer because the only advance directive information copied and sent with a resident when transferred to another health care facility was their CPR designation. Additionally, RN #1 stated she had been unaware that Resident #1 had a Living Will when she transferred him/her to the hospital on [DATE]. Review of the resident's hospital medical record from [DATE]-[DATE], revealed the resident arrived at the Hospital emergency room via ambulance on [DATE], at 5:10 AM, with a chief complaint of shortness of breath. Review of the "Emergency Department Chart" revealed hospital staff documented that Resident #1 had no Advance Directive based on the documentation sent from the facility. Further review of the Emergency Department Chart revealed after receiving his/her initial evaluation and treatment in the Emergency Department, Resident #1 was admitted to the hospital's medical unit on [DATE] at 12:01 PM for further treatment of [REDACTED]. Review of the Physician order [REDACTED].#1 to the Intensive Care Unit (ICU). At 6:18 AM on [DATE], the Hospital Physician intubated (a tube inserted into the trachea for artificial ventilation) Resident #1 and placed the resident on mechanical ventilation. Further review of the hospital's physician's orders [REDACTED]. Further review revealed Resident #1 also received [MEDICAL TREATMENT] (a medical procedure to remove fluid and waste from the blood) on [DATE]. Resident #1 was extubated on [DATE] and returned to the facility on [DATE]. Observations of Resident #1 on [DATE], revealed the resident to be in bed, alert but with confusion, and unable to communicate effectively. Interviews with the Unit Manager for Resident #1 on [DATE], at 5:30 PM and with the Director of Nursing (DON) on [DATE], at 10:56 AM, revealed, they both stated the only information related to advance directives sent with a resident when transferred to the hospital or other health care facility was the resident's designation for cardiopulmonary resuscitation. Additionally both staff members stated they were unaware that Resident #1 had a Living Will when he/she was transferred to the hospital on [DATE]. Continued review of Resident #1's medical record revealed the facility readmitted the resident on [DATE]. Review of a Hospital Discharge Summary for Resident #1, dictated on [DATE], revealed his/her discharge [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan last reviewed by the facility on [DATE], revealed Resident #1 had a history of [REDACTED]. Review of Resident #1's Living Will Directive and Health Care Surrogate Designation, as specified above, revealed Resident #1 authorized the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids. Observation of Resident #1 on [DATE] at 1:43 PM, revealed the resident was in bed receiving intravenous (IV) fluids of 5% [MEDICATION NAME] with no added medications, infusing via roller dial with an insertion site in the resident's lower extremity. Continued observations of Resident #1 on [DATE] at 10:20 AM, 12:15 PM, and 3:06 PM; on [DATE] at 5:33 PM; and, on [DATE] at 3:10 PM revealed Resident #1 continued to receive intravenous fluids via roller clamp. Review of Physician order [REDACTED].#1, revealed the physician ordered staff on [DATE], to initiate intravenous fluids for Resident #1 due to the resident's abnormal laboratory test results. Further review of Resident #1's Physician order [REDACTED]. Interview with Resident #1's Physician on [DATE], at 10:10 AM revealed she initiated intravenous fluids for Resident #1 on [DATE], due to the resident having decreased food and fluid intake and abnormal laboratory values. However, Resident #1's Physician stated that the resident's laboratory values had been chronically abnormal and were secondary to the resident's [MEDICAL CONDITION], and would likely always be abnormal. The Physician stated she was unaware that Resident #1 had a Living Will until "approximately two weeks ago" when she was told by the facility. The Physician stated she had not read the resident's Living Will, but had been informed that Resident #1 had elected to receive no life-sustaining measures. However, the Physician stated she was not aware that the Living Will also directed the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids. Interview with Resident #1's family member on [DATE], at 4:15 PM, revealed she was not aware that Resident #1 was receiving intravenous therapy, and had never been consulted or contacted prior to the fluids being implemented for Resident #1. The family member stated that infusion of fluids would be a direct contradiction of Resident #1's wishes as specified in his/her Living Will. Interviews with the Administrator on [DATE], at 12:05 PM and 6:00 PM revealed a resident's designated CPR status was transferred with a resident when sent out to the hospital, but no other Advance Directive documents were sent, including the resident's Living Will. The Administrator stated the facility's policy did not direct staff to send a copy of Living Wills or advance directives to other health care facilities upon a resident's transfer, and it had never been a practice of the facility to do so. The Administrator stated he had been unaware that the Living Will in Resident #1's chart contained information detailing Resident #1's wishes related to life-sustaining treatment until he was notified by Resident #1's family member on [DATE]. Interview with the facility's Administrator on [DATE] at 10:53 AM revealed he had "looked" at Resident #1's Living Will when was made aware of the document on [DATE], but he had not recognized or considered the initiation of intravenous fluids for Resident #1 on [DATE], to be in conflict with the resident's Advance Directive to receive no artificially provided food, water, or fluids. Additional interview with the Administrator on [DATE] at 6:00 PM, revealed he was unaware of how many residents in the facility had formulated Advance Directives. He stated the facility did not have a system in place to readily identify this information. The Administrator stated he was also unaware of what system the facility utilized to ensure that if a resident had executed an Advance Directive, it was on the chart and accessible to staff. 2. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's Rights/Advance Directives form for Resident #2 dated [DATE], revealed the resident had executed a Durable Power of Attorney (DPOA) Advance Directive. Review of Resident #2's DPOA dated [DATE], revealed the resident's POA could consent to, refuse, or withdraw consent to any type of medical care, treatment, surgical procedure, diagnostic procedure, medication, and the use of mechanical or other procedures that affect any bodily function, including but not limited to artificial respiration, artificially administered nutrition, or hydration and cardiopulmonary resuscitation. Review of Resident #2's Dietary Progress Note, dated [DATE], revealed the Unit Manager (UM) and the Registered Dietitian (RD) had a discussion with Resident #2's family member about the results of a bedside swallow evaluation (BSE). Continued review of the Dietary Progress Notes revealed the recommendation was for the resident to be on a pureed diet with pudding-thick liquids and a Modified [MEDICATION NAME] Swallow Study (MBSS - swallowing study) was recommended. Further review of the Dietary Progress Notes revealed the family member requested to sign a waiver that he/she was aware of the risk of aspiration, but requested the resident be allowed to eat and drink other foods. Review of the Dietary Progress Notes revealed the facility's staff informed the family member that a waiver was not an option in the facility and confirmed with the Assistant Administrator that a waiver was not an option in the facility. The RD and UM notified the resident's family member that if after the swallowing study it was recommended the resident could have nothing by mouth (NPO), the options for the resident "would be a tube feeding, hospice, or to be discharged from the facility." Further review of the Dietary Progress Notes revealed Resident #2's family member gave consent for the MBSS and stated if it was recommended that the resident be NPO a Hospice service referral could be made. Review of the Dietary Progress Notes dated [DATE], revealed the recommendation from the MBSS was for the resident to have a mechanical soft diet with thin liquids. Continued review revealed staff made Resident #2's family member aware of the recommendations and the family member was agreeable to the diet. Interview on [DATE] at 1:55 PM with Resident #2's family member revealed Resident #2 did not eat a pureed diet well and would have lost weight if the facility left the resident on that diet. The interview further revealed the family member had informed the facility that the resident had a Living Will that stated he/she did not want a feeding tube. Continued interview revealed facility staff informed the family member that the Assistant Administrator had told them that if it was recommended the resident be NPO, the resident would have to have tube feedings, be on Hospice services, or be discharged from the facility. Interviews with Registered Nurse (RN) #5 on [DATE], at 4:24 PM; with RN #4 on [DATE], at 3:25 PM; and, with RN #1 on [DATE], at 3:40 PM revealed the staff was not aware Resident #2 had a Living Will. Interview on [DATE] at 3:43 PM with the RD, and on [DATE] at 3:50 PM with UM #2 revealed the UM and the RD discussed the BSE results with Resident #2's family member. The resident's family member requested to sign a waiver that he/she was aware of the risk of aspiration, but wanted the resident to be allowed to eat a diet other than a pureed diet. The RD stated that the family member did not want Resident #2 to have a pureed diet because he/she was afraid the resident would not eat well and would lose weight. The interview further revealed the RD and UM confirmed with the Assistant Administrator that the facility did not allow families to sign waivers, and that the options, if the recommendation was for the resident to be NPO, would be to have a tube feeding placed, to be placed on Hospice services, or be discharged from the facility. Continued interview with the RD and UM revealed Resident #2's family member was agreeable to the MBSS, but informed the facility staff that the resident had a Living Will and did not want a tube feeding. The staff revealed prior to the discussion with Resident #2's family member they were not aware the resident had a Living Will. Interview on [DATE] at 5:40 PM with the Assistant Administrator revealed he had discussed Resident #2 with the RD because the resident had lost weight; a feeding tube and Hospice were discussed as options. Further interview revealed staff made the resident's family member aware of the options. The Assistant Administrator stated he never informed a family member or facility staff that a waiver was not an option in the facility. He stated it was the right of the resident and/or their family to make decisions about the care they received. The Assistant Administrator stated he was not aware the resident had a Living Will at the time the discussions about tube feeding placement occurred. Interview on [DATE] at 5:58 PM with the Administrator revealed he had a discussion with the family member of Resident #2. The family member informed the Administrator that the resident had an extensive 24-page Advance Directive which stated that the resident did not wish to have a feeding tube placed. The Administrator stated the facility did not have a copy of the Advance Directive and was not aware the resident had an Advance Directive. 3. Review of Resident #4's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be thirteen (13), indicating the resident's cognition was intact. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident executed an advance directive including a Living Will. Review of the resident's Emergency Department chart, dated [DATE] at 12:28 PM, revealed the resident was sent from the facility to the local hospital. Triage charting revealed the resident was sent without his/her Advance Directive. 4. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be fourteen (14), indicating the resident's cognition was intact. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an advanced directive including a Power of Attorney (POA). review of the resident's medical record revealed [REDACTED]. Interview with the facility's administrative staff including the Administrator, Assistant Administrator, and DON on [DATE] at 5:17 PM revealed they were unaware the resident's POA information was not in the chart. Further interview, with the administrative staff revealed the facility should have been aware of the resident's POA information. 5. Review of Resident #6's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be six (6), indicating the resident's cognition was severely impaired. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had not executed a Living Will but listed a Health Care Surrogate. However, review of the resident's Physician order [REDACTED]. The physician's orders [REDACTED]." However, review of the resident's medical record revealed [REDACTED]. Interview with the facility's administrative staff including the Administrator, Assistant Administrator, and DON on [DATE] at 5:11 PM revealed they were "unsure" if the resident had an advance directive or Living Will. Further interview revealed the facility should have been aware of the Living Will and a copy should have been on the chart. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1) On [DATE], licensed nursing staff that was on duty at that time was informed immediately, by the ADON of actions to be taken, and on the proper paperwork that was to accompany Resident #1 and all other residents in the facility when they were transferred to any other facility including appointments and emergency care. This paperwork included Code Status, Living Will, POA, Guardianship papers, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive section of the resident's medical record. 2) On [DATE], the Director of Social Services, Nurse Manager, QA (Quality Assurance) Coordinator, and MDS (Minimum Data Set) Coordinator conducted an immediate review of Resident #1's medical record and confirmed that the resident's Living Will was in the chart and in the correct location. 3) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #1 after being notified of the Immediate Jeopardy. 4) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plan was reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #1's chart. 5) An emergency Interdisciplinary Care Team Conference was conducted by phone with Resident #1's Health Care Surrogate on [DATE] at 12:00 PM, and at this time, the Surrogate verified that she was indeed this person's Healthcare Surrogate and the Living Will the facility had on file reflected the resident's wishes. 6) The Interdisciplinary Care Conference Team consisting of the Administrator, Assistant Administrator, DON (Director of Nursing), ADON (Assistant Director of Nursing), Nurse Manager, Social Worker, MDS Coordinator, Clinical Dietician, and Attending Physician reviewed the resident's care plan to confirm that all components of the Living Will were included. 7) The Health Care Surrogate directed that Resident #1 be changed from "full code" (CPR) status to a "no code" (no CPR) status, which was witnessed by everyone present at the meeting. The Do Not Resuscitate form was completed and signed on [DATE] by the Nurse Manager and the Attending Physician. The Attending Physician wrote the new order and nursing staff updated the medical record to reflect the change. 8) Resident #1's care plan was confirmed on [DATE] to reflect the no code status and was determined by the Nurse Consultant to be correct. 9) On [DATE], the Attending Physician documented participating in the conference call on [DATE] with the Health Care Surrogate and discussed the current medical condition of the patient. Resident #1's intravenous (IV) fluids were discontinued on [DATE]. 10) On [DATE], the Director of Social Services, Nurse Manager, QA Coordinator, and MDS Coordinator conducted an immediate review of Resident #2's medical record and confirmed that it included a copy of a Durable Power of Attorney (DPOA) and it was located in the correct location of the medical record. 11) On [DATE], an emergency Interdisciplinary Care team that included the Administrator, Assistant Administrator, DON, ADON, Nurse unit Manager Social Worker, MDS coordinator, Clinical Dietician and Physician, conducted a meeting via telephone conference with Resident #2's Durable Power of Attorney (DPOA) and confirmed that the information the DPOA provided on admission on [DATE] was in fact correct in reflecting the current wishes of the resident. 12) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #2 after being notified of the Immediate Jeopardy. 13) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plans were reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #2's chart. 14) As of [DATE], all current residents' charts have been reviewed by the Director of Social Services or Social Worker to ensure all Advance Directives, which include: DPOA, POA (Power of Attorney), Healthcare Surrogate, Guardianship, and Living Wills were in the chart and in the proper place. 15) All residents that are their own responsible party were interviewed by Social Services beginning on [DATE] to determine their cognitive status, and those with impaired cognition had a legal representative. The residents were also asked about their code status and if they wanted any changes to their Advance Directives at that time. No residents, who were their own responsible party, were found to have changes in their cognitive status. 16) All residents or their designated representatives, except two (2), were called by Social Services, to confirm that their Advance Directive was current and up to date; and the Code Status that the facility had on file was correct. Social Services and the Assistant Administrator will continue to contact the legal representatives to confirm that the information the facility has on file is current. 17) On [DATE], through individual chart reviews, the Assistant Administrator verified that the Social Worker's Progress Notes confirmed the accuracy of the Advance Directives currently on file. The Assistant Administrator documented this in a monitoring log. 18) During this process two (2) residents had code status changes from CPR only to Full Code Status. The Full Code Status form was signed and placed in the resident's chart. The MDS Coordinators then updated the care plans on [DATE] and the face sheets were updated. 19) On [DATE], the Full Code Status Form was revised by the DON. Options of CPR only and Chemical Code were removed from the Full Code Status Form. The ADON and Charge Nurses (beginning on [DATE]) completed training on this form change. 20) The MDS Coordinators were trained on [DATE] by the Nurse Consultant to ensure proper understanding of Advance Directive Care Plans and what should be included in them. This training included assessing whether the resident had an Advance Directive, Durable Power of Attorney for Healthcare, or a Living Will. 21) Care plans will also include the resident's expressed wishes regarding care and treatment goals as outlined by the Advance Directives. Social Services staff was trained as of [DATE] by the MDS Coordinators on how to develop the Advance Directive Care Plan. 22) All resident care plans were reviewed and revised relating to Advance Directives and Code Status by the MDS Coordinators, and was completed by [DATE] 23) The MDS Coordinators will initiate the Advance Directives care plan upon admission. The Social Services Department will be responsible for maintaining and updating the Advance Directive Care Plans now and forward on all residents. 24) Beginning on [DATE], the Quality Assurance Nurse and Assistant Administrator began monitoring Social Services' care plans daily, to ensure that the residents' wishes related to advance directives were accurately reflected on their care plan and any changes in their Advance Directives had been addressed. This was accomplished by comparing the Social Services' Notes, the Advance Directive, and care plan following any reported changes to the resident's Advance Directives. In conjunction with the care plan audit, they were also monitoring whether the Advance Directives were current and in the Advance Directives section of the resident's chart. 25) On [DATE], the Administrator, Assistant Administrator, DON, and ADON, discussed what immediate action needed to be taken. At that time, the ADON began informing Charge Nurses, Licensed Staff, and Ward Clerks on duty, of the proper paperwork that is to accompany all residents being transferred to any other facility including emergency care. This information included documents such as code status, Living Wills, POA, Guardianship, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive Section of the resident's chart. 26) On [DATE] the Executive Director provided training on the State and Federal requirements. This training was provided to the Admissions Coordinator, Assistant Administrator, Assistant Director of Nursing, Social Worker and Licensed Practical Nurse (LPN) Coordinator and competency was demonstrated by a posttest on [DATE]. Beginning on [DATE], the ADON provided the same training to the Administrator, DON, Director of Social Services, and Charge Nurses, and competency was demonstrated by a posttest. 27) The ADON began training the Administrator, Assistant Administrator, DON, Charge Nurses, Licensed Staff, and Ward Clerks on [DATE] regarding additional measures needed to be taken to ensure that all resident's in

Based on observation, interview, record review, hospital records and review of the facility's policy, it was determined the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five (5) of twenty-four (24) sampled residents (Residents #1, #2, #4, #5 and #6). The facility failed to provide Resident #1, #2, #4, #5, and #6 assistance with implementing advance directives and failed to assist Resident #1 to find an alternate responsible party when the resident's Health Care Surrogate became unable to make decisions. The facility admitted Resident #1 on [DATE], and placed a copy of the resident's previously executed Living Will Directive and Health Care Surrogate Designation in his/her medical record. However, the facility failed to assist Resident #1 to implement his/her Advance Directive when it became medically necessary. On [DATE], Resident #1 was transferred to the hospital; however, the facility failed to ensure the resident's Living Will was provided to the hospital. On [DATE], while admitted to the hospital Resident #1 suffered acute respiratory distress, was intubated, and placed on mechanical ventilation until he/she was extubated on [DATE]. Additionally, the facility was aware since [DATE] that Resident #1's Health Care Surrogate was no longer able to make decisions, but failed to provide Resident #1 with assistance to determine who or how health care decisions would be made for him/her (refer to F155, F279, F309, and F490). The facility's failure to have an effective system in place to ensure resident's received medically related social services, and residents who had executed advance directives were assisted to implement those directives was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279),42 CFR 483.25 Quality of Care (F309); and, 42 CFR 483.75 Administration (F490). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. A partial extended survey was conducted on ,[DATE]-,[DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the Scope and Severity to "E" at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.75 Administration (F490); and, 42 CFR 483.25 Quality of Care (F309) Scope and Severity of a "D", while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: An interview with the Administrator on [DATE] at 10:53 AM revealed the facility did not have a specific policy and procedure that addressed medically related Social Services. Review of the facility's policy, "Advance Directives," reviewed by the facility on [DATE], revealed Social Services staff would be responsible to assist residents who elected to formulate or implement an Advance Directive. Review of the Director of Social Services' (DSS) job description revealed the DSS was responsible for overseeing the assessment and documentation of medically related social needs of residents upon admission and throughout residency; acting as a liason between staff, residents, and families on matters concerning resident needs, progress, and medical condition; ensuring social services staffs' compliance with agency policies regulating, and laws governing the agency, and methods of service delivery; and participating as a member of the Admissions Committee and Advance Directive Committee. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight (8), indicating the resident had moderately impaired cognition. Resident #1's Comprehensive Care Plan updated [DATE], revealed the resident had impaired cognition related to dementia. Further review of the medical record revealed it contained a Living Will Directive and Health Care Surrogate Designation, which Resident #1 formulated and signed on [DATE]. Review of Resident #1's Advance Directive revealed a Health Care Surrogate was designated for Resident #1; the surrogate's spouse was an alternate Health Care Surrogate, if the original Health Care Surrogate became unable to make decisions for Resident #1. Resident #1's medical record also contained a Resident Rights/Advance Directive form dated [DATE], which was signed by the Social Worker acknowledging that Resident #1 had an Advance Directive, and that facility staff would follow the terms of the Advance Directive. Interviews with the facility's DSS on [DATE] at 11:00 AM, 5:15 PM, and 5:50 PM, revealed the DSS was present when Resident #1 was originally admitted to the facility on [DATE]. After reviewing the Resident's Rights/Advance Directives form, the DSS stated he had witnessed the form on [DATE], and was aware that Resident #1 had a Living Will upon admission. However, he stated he had not read the document and was unaware that an alternate Health Care Surrogate had been designated by Resident #1 if the original Health Care Surrogate became incapacitated. The DSS stated his only role in assisting residents with advance directives was to inquire upon admission if they had formulated an advance directive. If the resident had not formulated an advance directive, the DSS would provide the resident or family with written information regarding advance directives. The DSS stated if the resident did have an advance directive, it was placed in the resident's chart, and he had no further involvement in assisting residents with implementing the advance directive. Review of a Nutritionally at Risk Ongoing Report Summary revealed on [DATE] the facility's Registered Dietitian (RD) called the telephone number listed on the chart for Resident #1's Health Care Surrogate, and was informed the Health Care Surrogate had a tracheotomy and was unable to speak. The entry indicated the facility's DSS was notified of the Health Care Surrogate's condition, and the DSS stated he would notify State Adult Protective Services. Interviews with the facility's DSS on [DATE] at 11:00 AM, 5:15 PM, and 5:50 PM, revealed he notified State Adult Protective Services (APS) "a couple of times" related to Resident #1 having no primary decision maker, but made no documentation related to the notifications. The DSS stated he also called the number listed for Resident #1's Health Care Surrogate and spoke to the spouse and daughter of the Health Care Surrogate regarding Resident #1 having no person identified to make health care decisions. However, because the DSS failed to read Resident #1's Living Will, he was unaware the spouse of the Health Care Surrogate was the alternate named in Resident #1's Living Will. The DSS stated he did not document any contact with the family member and did not recall the date the conversations took place. Interviews were conducted with the resident's Alternate Health Care Surrogate and her daughter on [DATE] at 12:27 PM and 1:18 PM; on [DATE] at 11:25 AM; on [DATE] at 4:15 PM; and, on [DATE] at 1:00 PM. The Alternate Health Care Surrogate's daughter explained that she was a health care professional with a background in geriatrics and long-term care and had routinely assisted Resident #1's Health Care Surrogate to make decisions related to Resident #1's medical care. The Alternate Health Care Surrogate's daughter stated the facility initially contacted her in [DATE] related to making health care decisions for Resident #1, when the resident's Health Care Surrogate suffered a debilitating stroke and was unable to make decisions for Resident #1. The Alternate Health Care Surrogate's daughter explained that she and the Alternate Health Care Surrogate were unaware at the time that Resident #1 had formulated a Living Will naming him/her (the Health Care Surrogate's spouse) as the alternate decision maker when they were contacted by the DSS in [DATE]. Continued interview with the Alternate Health Care Surrogate's daughter revealed the facility requested she obtain guardianship of Resident #1. She stated she was agreeable to do so and went to the courthouse on [DATE], and was instructed that "emergency guardianship" would be the most appropriate and time effective avenue to pursue. The Alternate Health Care Surrogate's daughter stated court officials told her that obtaining "emergency" guardianship would require documentation by Resident #1's physician confirming the resident's need for the emergency order. The Alternate Health Care Surrogate's daughter stated she spoke to the facility's DSS who agreed that pursuit of emergency guardianship for Resident #1 would be the most appropriate action, and would request that Resident #1's physician provide the documentation. However, according to the Alternate Health Care Surrogate's daughter she was never provided the documentation and was therefore unable to proceed with obtaining emergency guardianship of Resident #1. Further interviews with the DSS on [DATE] at 11:00 AM, 5:15 PM, and 5:50 PM, revealed he had discussed obtaining guardianship of Resident #1 with the Alternate Health Care Surrogate's daughter over the phone on various occasions, but had made no documentation of the discussions and was unable to provide any information related to dates or times. The DSS stated that the Alternate Health Care Surrogate's daughter had been agreeable to obtaining guardianship but he had not contacted Resident #1's physician and requested the documentation required for the family member to obtain emergency guardianship, because he wanted to "meet with her (the Alternate Health Care Surrogate's daughter) in person and discuss it with her." The DSS stated he wanted to ensure the family member was "serious" about obtaining guardianship of Resident #1 before contacting the resident's physician. However, there was no evidence that the DSS took any action to arrange a meeting with the Alternate Health Care Surrogates daughter. Review of the Hospital Discharge Summary for Resident #1 dictated on [DATE], revealed the facility transferred Resident #1 to the hospital on [DATE], with shortness of breath, wheezing in the lungs, and pitting edema. Review of the Emergency Department (ED) Chart for Resident #1 dated [DATE], revealed upon arrival to the ED Resident #1's history was obtained via facility documentation, and the resident had no advance directives. The Summary stated that on [DATE], while admitted to the hospital for treatment of [REDACTED].#1 went into acute respiratory distress, was intubated, and placed on mechanical ventilation. The Summary stated Resident #1 also underwent hemodialysis (a medical procedure to remove fluid and waste products from the blood) on [DATE]. Further review of the Summary revealed the hospital physician caring for Resident #1 contacted the Alternate Health Care Surrogate's daughter on [DATE], notifying her that Resident #1 had been intubated and was on mechanical ventilation. The Summary indicated that the Alternate Health Care Surrogate's daughter came to the hospital, but was not allowed to make health care decisions for Resident #1 because the Alternate Health Care Surrogate's daughter did not have a Power of Attorney or other legal designation for Resident #1. The Summary stated that eventually a "next of kin" for Resident #1 was located and contacted via telephone on [DATE]. The Next of Kin gave verbal authority to the physician to extubate Resident #1, and provide no further hemodialysis treatment. Resident #1 was extubated on [DATE] and readmitted to the facility on [DATE]. 2. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Resident's Rights/Advance Directives form for Resident #2 dated [DATE], revealed the resident had executed a Durable Power of Attorney (DPOA) Advance Directive. Review of Resident #2's DPOA dated [DATE], revealed the resident's POA could consent to, refuse, or withdraw consent to any type of medical care, treatment, surgical procedure, diagnostic procedure, medication, and the use of mechanical or other procedures that affect any bodily function, including but not limited to artificial respiration, artificially administered nutrition, or hydration and cardiopulmonary resuscitation. Review of Resident #2's clinical record revealed a Dietary Progress Note dated [DATE], which stated the Unit Manager (UM) and the Registered Dietitian (RD) had spoken with resident's family member about the resident's ability to swallow. The Progress Note stated the family member was informed the options for the resident "would be a tube feeding, Hospice, or to be discharged from the facility" if the resident could not have anything by mouth." Interview on [DATE] at 1:55 PM with Resident #2's family member revealed the family member had informed the facility that the resident had a Living Will that stated he/she did not want a feeding tube. Continued interview revealed facility staff informed the family member that the Assistant Administrator stated if it was recommended the resident be NPO, the resident would have to have tube feedings, be on Hospice services, or be discharged from the facility. Interview on [DATE] at 3:43 PM with the RD, and on [DATE] at 3:50 PM with UM #2 revealed they were not aware the resident had a Living Will until the family member informed them. Further interview with the RD and UM #2 revealed they informed the family member that the Assistant Administrator told them that if it was recommended that Resident #2 be NPO, a tube feeding would have to be placed, the resident would have to be placed on Hospice services, or the resident would be discharged from the facility. An interview with the DSS on [DATE] at 3:30 PM revealed he was not involved in the discussion regarding Resident #2's weight loss/swallowing difficulties. The DSS stated he thought the resident already had a feeding tube. Interview on [DATE] at 5:40 PM with the Assistant Administrator revealed he had discussed Resident #2's care with the RD because the resident had lost weight. He stated a feeding tube and Hospice were discussed as options. The Assistant Administrator stated he was not aware the resident had a Living Will when the discussions occurred. 3. Review of Resident #4's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident executed a Living Will. However, review of the resident's Emergency Department Chart, dated [DATE] at 12:28 PM, revealed the facility transferred the resident to the local hospital and did not send the resident's Advance Directive. 4. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the "Resident's Rights/Advance Directives" form for Resident #5, dated [DATE], revealed the resident had executed a Power of Attorney (POA). review of the resident's medical record revealed [REDACTED]. 5. Review of Resident #6's medical record revealed the facility admitted the resident on [DATE] with diagnoses, which included Dementia, Cerebrovascular Accident, Schizophrenia, Chronic Obstructive Pulmonary Disease, and Depression. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], for Resident #6 revealed the resident had a Health Care Surrogate. Review of the resident's Physician order [REDACTED]. The physician's orders [REDACTED]." However, review of the resident's medical record revealed [REDACTED]. During an interview with the facility's Director of Social Services (DSS) on [DATE] at 11:00 AM, 5:15 PM, and 5:50 PM, the DSS stated his only role with advance directives was to inquire upon admission if they had formulated an advance directive. He stated if the resident did have an advance directive, it was placed in the resident's chart, and he had no further involvement in assisting residents with implementing the advance directive. Interviews with the facility's Administrator on [DATE] at 12:05 PM and 6:00 PM revealed that the DSS was responsible to oversee and ensure that residents were assisted to execute and/or implement their Advance Directives after admission to the facility. The Administrator stated he conducted no oversight or monitoring of Advance Directives in the facility. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1) On [DATE], licensed nursing staff that was on duty at that time was informed immediately, by the ADON of actions to be taken, and on the proper paperwork that was to accompany Resident #1 and all other residents in the facility when they were transferred to any other facility including appointments and emergency care. This paperwork included Code Status, Living Will, POA, Guardianship papers, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive section of the resident's medical record. 2) On [DATE], the Director of Social Services, Nurse Manager, QA (Quality Assurance) Coordinator, and MDS (Minimum Data Set) Coordinator conducted an immediate review of Resident #1's medical record and confirmed that the resident's Living Will was in the chart and in the correct location. 3) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #1 after being notified of the Immediate Jeopardy. 4) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plan was reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #1's chart. 5) An emergency Interdisciplinary Care Team Conference was conducted by phone with Resident #1's Health Care Surrogate on [DATE] at 12:00 PM, and at this time, the Surrogate verified that she was indeed this person's Healthcare Surrogate and the Living Will the facility had on file reflected the resident's wishes. 6) The Interdisciplinary Care Conference Team consisting of the Administrator, Assistant Administrator, DON (Director of Nursing), ADON (Assistant Director of Nursing), Nurse Manager, Social Worker, MDS Coordinator, Clinical Dietician, and Attending Physician reviewed the resident's care plan to confirm that all components of the Living Will were included. 7) The Health Care Surrogate directed that Resident #1 be changed from "full code" (CPR) status to a "no code" (no CPR) status, which was witnessed by everyone present at the meeting. The Do Not Resuscitate form was completed and signed on [DATE] by the Nurse Manager and the Attending Physician. The Attending Physician wrote the new order and nursing staff updated the medical record to reflect the change. 8) Resident #1's care plan was confirmed on [DATE] to reflect the no code status and was determined by the Nurse Consultant to be correct. 9) On [DATE], the Attending Physician documented participating in the conference call on [DATE] with the Health Care Surrogate and discussed the current medical condition of the patient. Resident #1's intravenous (IV) fluids were discontinued on [DATE]. 10) On [DATE], the Director of Social Services, Nurse Manager, QA Coordinator, and MDS Coordinator conducted an immediate review of Resident #2's medical record and confirmed that it included a copy of a Durable Power of Attorney (DPOA) and it was located in the correct location of the medical record. 11) On [DATE], an emergency Interdisciplinary Care team that included the Administrator, Assistant Administrator, DON, ADON, Nurse unit Manager Social Worker, MDS coordinator, Clinical Dietician and Physician, conducted a meeting via telephone conference with Resident #2's Durable Power of Attorney (DPOA) and confirmed that the information the DPOA provided on admission on [DATE] was in fact correct in reflecting the current wishes of the resident. 12) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #2 after being notified of the Immediate Jeopardy. 13) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plans were reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #2's chart. 14) As of [DATE], all current residents' charts have been reviewed by the Director of Social Services or Social Worker to ensure all Advance Directives, which include: DPOA, POA (Power of Attorney), Healthcare Surrogate, Guardianship, and Living Wills were in the chart and in the proper place. 15) All residents that are their own responsible party were interviewed by Social Services beginning on [DATE] to determine their cognitive status, and those with impaired cognition had a legal representative. The residents were also asked about their code status and if they wanted any changes to their Advance Directives at that time. No residents, who were their own responsible party, were found to have changes in their cognitive status. 16) All residents or their designated representatives, except two (2), were called by Social Services, to confirm that their Advance Directive was current and up to date; and the Code Status that the facility had on file was correct. Social Services and the Assistant Administrator will continue to contact the legal representatives to confirm that the information the facility has on file is current. 17) On [DATE], through individual chart reviews, the Assistant Administrator verified that the Social Worker's Progress Notes confirmed the accuracy of the Advance Directives currently on file. The Assistant Administrator documented this in a monitoring log. 18) During this process two (2) residents had code status changes from CPR only to Full Code Status. The Full Code Status form was signed and placed in the resident's chart. The MDS Coordinators then updated the care plans on [DATE] and the face sheets were updated. 19) On [DATE], the Full Code Status Form was revised by the DON. Options of CPR only and Chemical Code were removed from the Full Code Status Form. The ADON and Charge Nurses (beginning on [DATE]) completed training on this form change. 20) The MDS Coordinators were trained on [DATE] by the Nurse Consultant to ensure proper understanding of Advance Directive Care Plans and what should be included in them. This training included assessing whether the resident had an Advance Directive, Durable Power of Attorney for Healthcare, or a Living Will. 21) Care plans will also include the resident's expressed wishes regarding care and treatment goals as outlined by the Advance Directives. Social Services staff was trained as of [DATE] by the MDS Coordinators on how to develop the Advance Directive Care Plan. 22) All resident care plans were reviewed and revised relating to Advance Directives and Code Status by the MDS Coordinators, and was completed by [DATE] 23) The MDS Coordinators will initiate the Advance Directives care plan upon admission. The Social Services Department will be responsible for maintaining and updating the Advance Directive Care Plans now and forward on all residents. 24) Beginning on [DATE], the Quality Assurance Nurse and Assistant Administrator began monitoring Social Services' care plans daily, to ensure that the residents' wishes related to advance directives were accurately reflected on their care plan and any changes in their Advance Directives had been addressed. This was accomplished by comparing the Social Services' Notes, the Advance Directive, and care plan following any reported changes to the resident's Advance Directives. In conjunction with the care plan audit, they were also monitoring whether the Advance Directives were current and in the Advance Directives section of the resident's chart. 25) On [DATE], the Administrator, Assistant Administrator, DON, and ADON, discussed what immediate action needed to be taken. At that time, the ADON began informing Charge Nurses, Licensed Staff, and Ward Clerks on duty, of the proper paperwork that is to accompany all residents being transferred to any other facility including emergency care. This information included documents such as code status, Living Wills, POA, Guardianship, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive Section of the resident's chart. 26) On [DATE] the Executive Director provided training on the State and Federal requirements. This training was provided to the Admissions Coordinator, Assistant Administrator, Assistant Director of Nursing, Social Worker and Licensed Practical Nurse (LPN) Coordinator and competency was demonstrated by a posttest on [DATE]. Beginning on [DATE], the ADON provided the same training to the Administrator, DON, Director of Social Services, and Charge Nurses, and competency was demonstrated by a posttest. 27) The ADON began training the Administrator, Assistant Administrator, DON, Charge Nurses, Licensed Staff, and Ward Clerks on [DATE] regarding additional measures needed to be taken to ensure that all resident's information in the Resident Transfer Packet, which included Advance Directives were being sent to the receiving facility. This training gave direction that all residents' information was sent with him or her when they were transferred out of the facility and will also be faxed to the receiving facility, copied and placed in the miscellaneous section of the chart with the fax transmission confirmation. During this time, staff was also instructed to compare the documents included in the Advance Directive Section to those listed on the resident's Face Sheet, which is generated from Point Click Care, to ensure all current documents were present. 28) Beginning on [DATE] the QA Nurse, Unit Manager, or the Assistant Administrator, started monitoring to ensure that all Advance Directives for a resident that was being transferred out of the facility were accurate and sent. This was accomplished by reviewing the resident's transfer packet that was copied, faxed, and placed in the miscellaneous section of the resident's chart. This process is being documented daily on a monitoring log; no problems have been identified at this time. 29) The facility initiated daily monitoring on [DATE] of staff training regarding resident transfer processes, faxing Advance Directives, the State and Federal requirements, Advance Directive Definitions, Sending Advance Directives during transfer, and the Advance Directives policy. The ADON or Charge Nurse was performing the monitoring through interviews with a minimum of three (3) staff per day that were previously trained. All shifts were included in this monitoring, and all shifts were being monitored within a 2-day period. 30) Beginning on [DATE], Social Services, MDS Coordinators, Admissions Coordinator, QA Coordinator, Licensed Staff, Ward Clerks, and Finance, were trained by the ADON, DON, or Charge Nurse on the advance directive definitions and the State and Federal requirements; competency was demonstrated by posttest. 31) As of [DATE], the Administrator and Assistant Administrator reviewed and revised the Advance Directive Policy to reflect that upon admission the Admission Coordinator would provide a copy of this policy and would discuss and confirm the Advance Directive status with the resident and or responsible party and would document in the individual medical record with the Resident Rights/Advance Directives form upon admission whether the resident had an Advance Directive. The resident and/or legal representative, DPOA, POA, or Guardian would date and sign a statement attesting that the Advance Directive and facility policy had been explained upon admission. 32) The Admissions Coordinator will provide copies of Advance Directive information obtained on the day of admission to Finance, LPN Supervisor, and Unit Manager or Ward Clerk. 33) LPN Supervisor/Data Entry Specialist entered all orders into the Point Click Care to include code status and advance directives on the day of admission. This information was then generated to the resident's face sheet, which was sent to the resident's nursing unit, and then placed on the resident's chart by the ward clerk, on the day of admission. 34) On [DATE], the Assistant Administrator trained the Admissions Coordinator, ADON, and Social Services on the revisions to the Advance Directive Policy, responsibilities, and processes that were in place to ensure that residents' advance directives were executed per the resident's wishes, and competency was demonstrated by a posttest. 35) Together the Assistant Administrator and ADON trained the DON, QA Coordinator, MDS Coordinators, Charge Nurses, Finance, and Unit Managers regarding the Advance Directive Policy and Procedure revision and competency was demonstrated by a post test. 36) Beginning [DATE], licensed staff and the ward clerks were trained on the changes to the Advance Directive Policy by the DON, ADON, or Charge Nurse and showed competency by test. All above-mentioned staff was trained as of [DATE] on this policy except eight (8) licensed staff and one ward clerk, who will be trained prior to returning to direct resident care. 37) Beginning on [DATE] the initial admissions portion of the Advance Directive procedure as outlined in the Advance Directive Policy was being monitored daily by the Assistant Administrator with each new admission. This will accomplished by reviewing the admissions' paperwork and confirming that any advance directives received during the admission process were in fact listed on the Resident's Rights/Advance Directive Sheet. The findings were then reported on a daily monitoring log with each new admission. No problems were identified at the time. 38) Starting on [DATE], the QA Coordinator or the Assistant Administrator checked resident charts daily to confirm that the Advance Directive section of the chart still contained all of the resident's Advance Directives. This was accomplished by comparing the Advance Directives located in the chart to their daily monitoring log. 39) The Administrator and Assistant Administrator revised the Social Services Policy on [DATE] to include the procedure for invoking a health care agent or legal representative after the resident was determined not to have decision-making capacity. This policy stated, "The assigned social worker will determine if the resident is self-responsible or if they have a POA, DPOA, or legal guardian in place. The social worker would contact them to let them know the resident has had a mental status change and can no longer make their own decisions. If the legal representative accepts responsibility, they will begin making decisions for the resident. If the resident does not have a POA, DPOA or legal guardian then social services would contact any family members who may be w

Based on observation, interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to develop a care plan for nineteen (19) of twenty-four (24) sampled residents (Residents #1, #2, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) that identified the resident's preferences regarding Advance Directives which dictated the resident's care and treatment wishes at a time when/if the resident lacked the ability to do so to ensure the resident's highest practicable psychosocial well-being. Resident #1 was admitted to the facility with an executed Advance Directive, which dictated the resident's wishes regarding life-prolonging treatment and artificially provided food, water, and fluids, to be implemented when the resident became incapacitated and unable to make decisions. However, the facility failed to develop an initial care plan which recognized or addressed the Advance Directive, and failed to periodically reassess the resident's plan of care related to Advance Directives (refer to F155, F250, F309, and F490). Medical record review of Residents #2, #4, #5, #6, #8, #10, #11, #12, #13, #15, #16, #17, #18, #19, #20, and #21 revealed the residents all had Advance Directives (Living Will, Power of Attorney, or Health Care Surrogate Designation). The facility failed to develop a care plan that included advance care planning to address residents' advance directives. Interviews with Minimum Data Set (MDS) Coordinators #1 and #2 revealed the only advance directive incorporated into a resident's plan of care was the resident's designated cardiopulmonary resuscitation status (CPR). Resident #9 and Resident #14 chose "CPR only" code status upon admission to the facility. The facility failed to ensure the residents' code status was accurately reflected on the residents' care plans. Review of the residents' care plans revealed the facility identified the residents were classified as "full code" (refer to F309). The facility's failure to have an effective system in place to ensure the process of Advance Directive care planning was ongoing; and failure to afford the resident/family the ability to implement an advance directive was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE] which alleged removal of the Immediate Jeopardy on [DATE]. A Partial Extended Survey was conducted on [DATE]-[DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the Scope and Severity to "E" at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.75 Administration (F490); and, 42 CFR 483.25 Quality of Care (F309) Scope and Severity of a "D", while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy and procedure, "Care Plans-Comprehensive," undated, revealed the resident's comprehensive care plan was designed to reflect the resident's expressed wishes regarding care and treatment goals. The policy also stated interventions would be implemented that were targeted and meaningful to the resident. Additionally, the policy stated the interdisciplinary process would require careful data gathering, proper sequencing of events, and complex clinical decision-making. Further review of the facility's policy revealed it was the responsibility of the "Care Planning/Interdisciplinary Team" to develop a comprehensive care plan and no single person was responsible. However, an interview on [DATE] at 11:45 AM with MDS Coordinators #1 and #2 revealed they were responsible for completing MDS assessments and completing care plans in the facility. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], and acknowledged upon admission that Resident #1 had executed an advance directive related to life-prolonging treatment and artificially provided food, fluids, and nutrition. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 to be moderately cognitively impaired. However, the facility failed to identify on the assessment that Resident #1 had formulated an Advance Directive, and had named a Health Care Surrogate designated to make decisions if he/she became unable to do so himself/herself. Review of Resident #1's Initial Comprehensive Care Plan dated [DATE], revealed Resident #1 had impairment with both long and short-term memory, but was able to make most decisions for himself/herself. The Care Plan did not address Resident #1's Advance Directive related to life-prolonging treatment or the administration of artificially provided food, water, or fluids. Review of Resident #1's MDS assessment completed on [DATE], revealed the facility assessed Resident #1 to be severely cognitively impaired and rarely or never able to make decisions. Review of Resident #1's Comprehensive Care Plan updated on [DATE] revealed the resident was dependent on staff related to cognitive impairment. However, the Care Plan failed to identify that Resident #1 had formulated a Living Will and would be dependent on facility staff to assist the resident with executing the Advance Directive. Review of the clinical record revealed documentation from a hospital "Emergency Department Chart" dated [DATE], which stated the facility transferred Resident #1 to the Emergency Department (ED) on [DATE], but failed to send the resident's Advance Directive. Resident #1 was admitted to the hospital. On [DATE], when the resident's health condition deteriorated, Resident #1 was intubated, placed on mechanical ventilation, and received [MEDICAL TREATMENT], which was against the resident's expressed wishes in his/her Advance Directive. Resident #1 was extubated on [DATE], and readmitted to the facility on [DATE]. Additionally, the facility infused Resident #1 intravenously (IV) with artificial fluids, from [DATE] until [DATE], which was against the resident's expressed wishes in the Advance Directive. The facility did not consult or obtain consent from Resident #1's Alternate Health Care Surrogate. Interview with Registered Nurse (RN) #1, who completed Resident #1's initial Admission MDS assessment and Comprehensive Care Plan, stated she did not recall doing the details of Resident #1's admission documentation. She stated she had never been trained or instructed to care plan any Advance Directive other than the resident's designated cardiopulmonary resuscitation (CPR) designation. 2. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was cognitively impaired. Review of the Resident's Rights/Advance Directives form dated [DATE] for Resident #2 revealed the resident had executed a Durable Power of Attorney (DPOA) Advance Directive. Review of Resident #2's DPOA dated [DATE], revealed the resident's POA could consent to, refuse, or withdraw consent to any type of medical care, treatment, surgical procedure, diagnostic procedure, medication, and the use of mechanical or other procedures that affect any bodily function including but not limited to artificial respiration, artificially administered nutrition or hydration, and cardiopulmonary resuscitation. Review of Resident #2's Plan of Care dated [DATE], revealed the facility developed a care plan related to the resident's Do Not Resuscitate (DNR) status; however, the facility failed to develop a care plan regarding the DPOA and the resident's wishes regarding health care decisions. Continued review of the resident's Plan of Care revealed the plan of care had been revised on [DATE], related to the resident not wanting to have a feeding tube placed (see F155). However, the Care Plan did not include Advance Directive care planning information to address the resident's wishes regarding health care decisions. 3. Review of Resident #4's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 13, indicating the resident's cognition was intact. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed a Living Will. Review of the Care Plan last reviewed on [DATE], revealed the resident had a "full code" status. However, the Care Plan did not include Advance Directive care planning to address the resident's Living Will information. 4. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be 14, indicating the resident's cognition was intact. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advanced Directive including a Power of Attorney (POA). Review of the Care Plan reviewed by the facility on [DATE] revealed the resident had chosen a "full code" status; however, the care plan did not include Advance Directive care planning containing the resident's POA information and Advance Directives. 5. Review of Resident #6's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be six (6), indicating the resident's cognition was severely impaired. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident listed a Health Care Surrogate. Review of the resident's Physician order [REDACTED]. Review of Resident #6's Care Plan reviewed by the facility on [DATE], revealed the facility identified the resident requested DNR code status. The Care Plan stated, "If hospitalized , send copy of the written DNR order with resident." However, the Care Plan did not include Advance Directive care planning regarding the resident's Health Care Surrogate or the resident's Living Will. 6. Review of Resident #8's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be one (1), indicating the resident's cognition was severely impaired. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive which included a Health Care Surrogate. Medical record review revealed a Living Will located in the resident's chart. Review of the Care Plan reviewed by the facility on [DATE] revealed a DNR code status, stating, "If hospitalized , send copy of the written DNR order with resident." The Care Plan did not include Advance Directive care planning regarding the resident's Living Will information. 7. Review of Resident #10's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be five (5), indicating the resident's cognition was severely impaired. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed a Living Will. Review of the resident's Care Plan, reviewed by the facility on [DATE], revealed the resident chose "Do Not Resuscitate" (DNR) for his/her code status. However, the facility failed to provide Advance Directive care planning regarding the resident's Living Will. 8. Review of Resident #11's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be five (5), indicating the resident's cognition was severely impaired. Review of the "Resident Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive including a Living Will and POA. Review of the care plan, which was reviewed by the facility on [DATE], revealed the resident's DNR code status, but the facility failed to provide advance care planning information regarding the Living Will or POA information. 9. Review of Resident #12's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be 99, indicating the resident was unable to complete the interview. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive including a Living Will. Review of the Care Plan, which was reviewed by the facility on [DATE], revealed no Advance Directive care planning regarding the Living Will information. 10. Review of Resident #13's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be 15, indicating the resident was assessed to be cognitively intact. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive which included a Living Will and POA. Review of the Care Plan, last reviewed by the facility on [DATE], revealed the resident's DNR code status was included on the care plan; however, the facility failed to include the Advance Directive care planning regarding the resident's Living Will or POA information. 11. Review of Resident #15's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be 15, indicating the resident was cognitively intact. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed his/her Advance Directive which included a Living Will and Power of Attorney. Review of the resident's Care Plan, last reviewed by the facility on [DATE], revealed there was no advance care planning regarding the resident's Living Will or POA. 12. Review of Resident #16's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS, dated [DATE], revealed the facility had assessed the resident's BIMS score to be 99, indicating the resident was unable to complete the interview. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive which included a Living Will and POA. Review of the resident's Care Plan, last reviewed by the facility on [DATE], revealed no advance care planning to include information about the resident's Living Will and POA. 13. Review of Resident #17's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be 15, indicating the resident was cognitively intact. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive which included a Living Will and designation of a Health Care Surrogate. Review of the Care Plan, last reviewed by the facility on [DATE], revealed no advance care planning to include information regarding the resident's Living Will and Health Care Surrogate. 14. Review of Resident #18's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be 99, indicating the resident was unable to complete the interview. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive including a Living Will and Durable Power of Attorney (DPOA). Review of the Care Plan, last reviewed by the facility on [DATE], revealed the resident had a "full code" status, but the facility failed to provide the Advance Directive care planning containing the resident's Living Will or DPOA information. 15. Review of Resident #19's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility had assessed the resident's BIMS score to be three (3), indicating the resident's cognition was severely impaired. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive which included a Living Will. Review of the Care Plan dated [DATE], revealed the DNR code status, stating, "If hospitalized , send copy of the written DNR order with resident." However, the facility failed to provide advance care planning regarding the resident's Living Will information. 16. Review of Resident #20's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's cognitive skills for daily decision-making to be severely impaired. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive including a Living Will and POA. Review of the Care Plan reviewed on [DATE], revealed the resident's DNR code status, but the facility failed to provide Advance Directive care planning regarding the resident's Living Will and POA. 17. Review of Resident #21's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be seven (7), indicating the resident's cognition was severely impaired. Review of the "Resident's Rights/Advance Directives" form, dated [DATE], revealed the resident had executed an Advance Directive including a Living Will and Power of Attorney. Review of the resident's Care Plan, last reviewed by the facility on [DATE], revealed the resident's DNR code status. However, the care plan did not include advance care planning regarding the resident's Living Will or POA information. 18. Review of Resident #9's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Annual MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be 15, indicating the resident was cognitively intact. Review of the resident's code status form, dated [DATE], revealed the resident had chosen "CPR only" as his/her code status. Review of the resident's Admission Physician Orders, dated [DATE], revealed a physician's orders [REDACTED]." However, further review of the Physician order [REDACTED]. Review of the resident's care plan, which the facility last reviewed on [DATE], revealed the resident was classified as "Full Code" status. Review of the clinical record revealed no documented evidence the resident's responsible party had changed the resident's code status. 19. Review of Resident #14's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's BIMS score to be three (3), indicating the resident's cognition was severely impaired. Review of the resident's code status form, dated [DATE], revealed the resident chose "CPR only" for his/her code status. However, review of the Physician order [REDACTED]. Plan, last reviewed by the facility on [DATE], revealed the resident was classified as "Full Code" status. An interview on [DATE] at 11:45 AM with MDS Coordinators #1 and #2, who were responsible for completing MDS assessments and completing care plans in the facility, revealed they did not care plan Advance Directives other than cardiopulmonary resuscitation (CPR) status for any resident in the facility. The MDS Coordinators stated it was not a facility practice to incorporate the resident choices regarding Advance Directives into the resident's current or future plan of care. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1) On [DATE], licensed nursing staff that was on duty at that time was informed immediately, by the ADON of actions to be taken, and on the proper paperwork that was to accompany Resident #1 and all other residents in the facility when they were transferred to any other facility including appointments and emergency care. This paperwork included Code Status, Living Will, POA, Guardianship papers, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive section of the resident's medical record. 2) On [DATE], the Director of Social Services, Nurse Manager, QA (Quality Assurance) Coordinator, and MDS (Minimum Data Set) Coordinator conducted an immediate review of Resident #1's medical record and confirmed that the resident's Living Will was in the chart and in the correct location. 3) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #1 after being notified of the Immediate Jeopardy. 4) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plan was reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #1's chart. 5) An emergency Interdisciplinary Care Team Conference was conducted by phone with Resident #1's Health Care Surrogate on [DATE] at 12:00 PM, and at this time, the Surrogate verified that she was indeed this person's Healthcare Surrogate and the Living Will the facility had on file reflected the resident's wishes. 6) The Interdisciplinary Care Conference Team consisting of the Administrator, Assistant Administrator, DON (Director of Nursing), ADON (Assistant Director of Nursing), Nurse Manager, Social Worker, MDS Coordinator, Clinical Dietician, and Attending Physician reviewed the resident's care plan to confirm that all components of the Living Will were included. 7) The Health Care Surrogate directed that Resident #1 be changed from "full code" (CPR) status to a "no code" (no CPR) status, which was witnessed by everyone present at the meeting. The Do Not Resuscitate form was completed and signed on [DATE] by the Nurse Manager and the Attending Physician. The Attending Physician wrote the new order and nursing staff updated the medical record to reflect the change. 8) Resident #1's care plan was confirmed on [DATE] to reflect the no code status and was determined by the Nurse Consultant to be correct. 9) On [DATE], the Attending Physician documented participating in the conference call on [DATE] with the Health Care Surrogate and discussed the current medical condition of the patient. Resident #1's intravenous (IV) fluids were discontinued on [DATE]. 10) On [DATE], the Director of Social Services, Nurse Manager, QA Coordinator, and MDS Coordinator conducted an immediate review of Resident #2's medical record and confirmed that it included a copy of a Durable Power of Attorney (DPOA) and it was located in the correct location of the medical record. 11) On [DATE], an emergency Interdisciplinary Care team that included the Administrator, Assistant Administrator, DON, ADON, Nurse unit Manager Social Worker, MDS coordinator, Clinical Dietician and Physician, conducted a meeting via telephone conference with Resident #2's Durable Power of Attorney (DPOA) and confirmed that the information the DPOA provided on admission on [DATE] was in fact correct in reflecting the current wishes of the resident. 12) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #2 after being notified of the Immediate Jeopardy. 13) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plans were reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #2's chart. 14) As of [DATE], all current residents' charts have been reviewed by the Director of Social Services or Social Worker to ensure all Advance Directives, which include: DPOA, POA (Power of Attorney), Healthcare Surrogate, Guardianship, and Living Wills were in the chart and in the proper place. 15) All residents that are their own responsible party were interviewed by Social Services beginning on [DATE] to determine their cognitive status, and those with impaired cognition had a legal representative. The residents were also asked about their code status and if they wanted any changes to their Advance Directives at that time. No residents, who were their own responsible party, were found to have changes in their cognitive status. 16) All residents or their designated representatives, except two (2), were called by Social Services, to confirm that their Advance Directive was current and up to date; and the Code Status that the facility had on file was correct. Social Services and the Assistant Administrator will continue to contact the legal representatives to confirm that the information the facility has on file is current. 17) On [DATE], through individual chart reviews, the Assistant Administrator verified that the Social Worker's Progress Notes confirmed the accuracy of the Advance Directives currently on file. The Assistant Administrator documented this in a monitoring log. 18) During this process two (2) residents had code status changes from CPR only to Full Code Status. The Full Code Status form was signed and placed in the resident's chart. The MDS Coordinators then updated the care plans on [DATE] and the face sheets were updated. 19) On [DATE], the Full Code Status Form was revised by the DON. Options of CPR only and Chemical Code were removed from the Full Code Status Form. The ADON and Charge Nurses (beginning on [DATE]) completed training on this form change. 20) The MDS Coordinators were trained on [DATE] by the Nurse Consultant to ensure proper understanding of Advance Directive Care Plans and what should be included in them. This training included assessing whether the resident had an Advance Directive, Durable Power of Attorney for Healthcare, or a Living Will. 21) Care plans will also include the resident's expressed wishes regarding care and treatment goals as outlined by the Advance Directives. Social Services staff was trained as of [DATE] by the MDS Coordinators on how to develop the Advance Directive Care Plan. 22) All resident care plans were reviewed and revised relating to Advance Directives and Code Status by the MDS Coordinators, and was completed by [DATE] 23) The MDS Coordinators will initiate the Advance Directives care plan upon admission. The Social Services Department will be responsible for maintaining and updating the Advance Directive Care Plans now and forward on all residents. 24) Beginning on [DATE], the Quality Assurance Nurse and Assistant Administrator began monitoring Social Services' care plans daily, to ensure that the residents' wishes related to advance directives were accurately reflected on their care plan and any changes in their Advance Directives had been addressed. This was accomplished by comparing the Social Services' Notes, the Advance Directive, and care plan following any reported changes to the resident's Advance Directives. In conjunction with the care plan audit, they were also monitoring whether the Advance Directives were current and in the Advance Directives section of the resident's chart. 25) On [DATE], the Administrator, Assistant Administrator, DON, and ADON, discussed what immediate action needed to be taken. At that time, the ADON began informing Charge Nurses, Licensed Staff, and Ward Clerks on duty, of the proper paperwork that is to accompany all residents being transferred to any other facility including emergency care. This information included documents such as code status, Living Wills, POA, Guardianship, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive Section of the resident's chart. 26) On [DATE] the Executive Director provided training on the State and Federal requirements. This training was provided to the Admissions Coordinator, Assistant Administrator, Assistant Director of Nursing, Social Worker and Licensed Practical Nurse (LPN) Coordinator and competency was demonstrated by a posttest on [DATE]. Beginning on [DATE], the ADON provided the same training to the Administrator, DON, Director of Social Services, and Charge Nurses, and competency was demonstrated by a posttest. 27) The ADON began training the Administrator, Assistant Administrator, DON, Charge Nurses, Licensed Staff, and Ward Clerks on [DATE] regarding additional measures needed to be taken to ensure that all resident's information in the Resident Transfer Packet, which included Advance Directives were being sent to the receiving facility. This training gave direction that all residents' information was sent with him or her when they were transferred out of the facility and will also be faxed to the receiving facility, copied and placed in the miscellaneous section of the chart with the fax transmission confirmation. During this time, staff was

Based on interview, record review, and review of the facility's policy/procedures it was determined the facility's Administration failed to ensure its resources, including policies related to Advance Directives were used effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being. The facility transferred Resident #1 to the hospital on [DATE]. The facility failed to provide the hospital with a copy of the resident's Living Will. The resident was intubated, placed on a ventilator, and received [MEDICAL TREATMENT] while at the hospital, which was not in accordance with the resident's Living Will. On [DATE], when the daughter of Resident #1's Alternate Health Care Surrogate learned the resident had a Living Will and that her Mother was listed as the Alternate Health Care Surrogate, she contacted the facility's Administrator regarding the facility's failure to ensure the resident's Living Will was provided to the hospital and wishes were honored. However, the Administrator failed to take any action to address the daughter's concern (refer to F155, F250, F279, and F309). The facility's failure to have an effective system in place to ensure the facility was administered effectively was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.25 Quality of Care (F309); and, 42 CFR 483.75 Administration (F490). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE] which, alleged removal of the Immediate Jeopardy on [DATE]. A partial extended survey was conducted on ,[DATE]-,[DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the Scope and Severity to "E" at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.75 Administration (F490); and, 42 CFR 483.25 Quality of Care (F309) at a Scope and Severity of "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Advance Directive Policy outlined in the Admission Agreement revised [DATE], revealed the facility had an Advance Directive Committee which consisted of several of the facility's Department Heads including the Administrator. The policy stated any person may bring a situation of concern to any member of the Advance Directive Committee, and that member would be responsible for calling a committee meeting. The policy stated the Advance Directive Committee would meet on an "as required basis." Review of the "Position Description" for the facility administrator revealed the administrator was responsible to ensure the protection of patients rights and for the oversight of the development of all departments policies and procedures to assure they are kept current and were followed according to State and Federal Regulations. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE]. According to admission documentation, the resident provided a copy of his/her Living Will to the facility. Review of the Living Will Directive and Health Care Surrogate Designation for Resident #1, which had been notarized and recorded on [DATE], revealed Resident #1 chose to have life-prolonging treatment withheld or withdrawn and be permitted to die naturally with only the administration of pain-alleviating medication or treatment. Review of Resident #1's medical record and hospital record revealed on [DATE], the facility transferred Resident #1 to the hospital; however, the facility failed to ensure the resident's Living Will was provided to the hospital. Because of this failure, Resident #1 received life-sustaining treatment including intubation (placement of a flexible plastic tube into the trachea to maintain an open airway), mechanical ventilation (technique through which air is moved to and from the lungs through an external device), and [MEDICAL TREATMENT] (a medical procedure to remove fluid and waste products from the blood) during the resident's hospitalization from [DATE] through [DATE]. In addition, the Administrator failed to ensure that the rights of Residents #2, #4, #5 and #6 to execute and implement advance directives related to life-sustaining treatment were protected and promoted. The Administrator failed to ensure staff was knowledgeable of their roles related to executing, care planning and implementing advance directives. He also failed to ensure staff was aware of which residents had advance directives and failed to ensure the resident's advance directives were sent with them when they were transferred to the hospital. Interview with the Administrator on [DATE] at 6:00 PM revealed he received a telephone call from Resident #1's Alternate Health Care Surrogate's daughter on [DATE]. The Administrator stated the Surrogate's Daughter was upset, because she had just learned that Resident #1 had a Living Will on file in the facility, which had not been sent with Resident #1 to the hospital on [DATE], and subsequently Resident #1 had been intubated and placed on mechanical ventilation. Continued interview with the Administrator on [DATE] at 6:00 PM, revealed that although he was made aware of the Alternate Health Care Surrogate's Daughter's concern on [DATE], he failed to conduct an inquiry into the concern, or arrange an Advance Directive Committee meeting to address the Alternate Health Care Surrogate's Daughter's concern. According to the Administrator, the facility was not under any obligation to send Living Wills with a resident when transferred to the hospital stating, "We don't do that, have never done that; it is not in our policy." **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1) On [DATE], licensed nursing staff that was on duty at that time was informed immediately, by the ADON of actions to be taken, and on the proper paperwork that was to accompany Resident #1 and all other residents in the facility when they were transferred to any other facility including appointments and emergency care. This paperwork included Code Status, Living Will, POA, Guardianship papers, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive section of the resident's medical record. 2) On [DATE], the Director of Social Services, Nurse Manager, QA (Quality Assurance) Coordinator, and MDS (Minimum Data Set) Coordinator conducted an immediate review of Resident #1's medical record and confirmed that the resident's Living Will was in the chart and in the correct location. 3) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #1 after being notified of the Immediate Jeopardy. 4) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plan was reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #1's chart. 5) An emergency Interdisciplinary Care Team Conference was conducted by phone with Resident #1's Health Care Surrogate on [DATE] at 12:00 PM, and at this time, the Surrogate verified that she was indeed this person's Healthcare Surrogate and the Living Will the facility had on file reflected the resident's wishes. 6) The Interdisciplinary Care Conference Team consisting of the Administrator, Assistant Administrator, DON (Director of Nursing), ADON (Assistant Director of Nursing), Nurse Manager, Social Worker, MDS Coordinator, Clinical Dietician, and Attending Physician reviewed the resident's care plan to confirm that all components of the Living Will were included. 7) The Health Care Surrogate directed that Resident #1 be changed from "full code" (CPR) status to a "no code" (no CPR) status, which was witnessed by everyone present at the meeting. The Do Not Resuscitate form was completed and signed on [DATE] by the Nurse Manager and the Attending Physician. The Attending Physician wrote the new order and nursing staff updated the medical record to reflect the change. 8) Resident #1's care plan was confirmed on [DATE] to reflect the no code status and was determined by the Nurse Consultant to be correct. 9) On [DATE], the Attending Physician documented participating in the conference call on [DATE] with the Health Care Surrogate and discussed the current medical condition of the patient. Resident #1's intravenous (IV) fluids were discontinued on [DATE]. 10) On [DATE], the Director of Social Services, Nurse Manager, QA Coordinator, and MDS Coordinator conducted an immediate review of Resident #2's medical record and confirmed that it included a copy of a Durable Power of Attorney (DPOA) and it was located in the correct location of the medical record. 11) On [DATE], an emergency Interdisciplinary Care team that included the Administrator, Assistant Administrator, DON, ADON, Nurse unit Manager Social Worker, MDS coordinator, Clinical Dietician and Physician, conducted a meeting via telephone conference with Resident #2's Durable Power of Attorney (DPOA) and confirmed that the information the DPOA provided on admission on [DATE] was in fact correct in reflecting the current wishes of the resident. 12) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #2 after being notified of the Immediate Jeopardy. 13) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plans were reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #2's chart. 14) As of [DATE], all current residents' charts have been reviewed by the Director of Social Services or Social Worker to ensure all Advance Directives, which include: DPOA, POA (Power of Attorney), Healthcare Surrogate, Guardianship, and Living Wills were in the chart and in the proper place. 15) All residents that are their own responsible party were interviewed by Social Services beginning on [DATE] to determine their cognitive status, and those with impaired cognition had a legal representative. The residents were also asked about their code status and if they wanted any changes to their Advance Directives at that time. No residents, who were their own responsible party, were found to have changes in their cognitive status. 16) All residents or their designated representatives, except two (2), were called by Social Services, to confirm that their Advance Directive was current and up to date; and the Code Status that the facility had on file was correct. Social Services and the Assistant Administrator will continue to contact the legal representatives to confirm that the information the facility has on file is current. 17) On [DATE], through individual chart reviews, the Assistant Administrator verified that the Social Worker's Progress Notes confirmed the accuracy of the Advance Directives currently on file. The Assistant Administrator documented this in a monitoring log. 18) During this process two (2) residents had code status changes from CPR only to Full Code Status. The Full Code Status form was signed and placed in the resident's chart. The MDS Coordinators then updated the care plans on [DATE] and the face sheets were updated. 19) On [DATE], the Full Code Status Form was revised by the DON. Options of CPR only and Chemical Code were removed from the Full Code Status Form. The ADON and Charge Nurses (beginning on [DATE]) completed training on this form change. 20) The MDS Coordinators were trained on [DATE] by the Nurse Consultant to ensure proper understanding of Advance Directive Care Plans and what should be included in them. This training included assessing whether the resident had an Advance Directive, Durable Power of Attorney for Healthcare, or a Living Will. 21) Care plans will also include the resident's expressed wishes regarding care and treatment goals as outlined by the Advance Directives. Social Services staff was trained as of [DATE] by the MDS Coordinators on how to develop the Advance Directive Care Plan. 22) All resident care plans were reviewed and revised relating to Advance Directives and Code Status by the MDS Coordinators, and was completed by [DATE] 23) The MDS Coordinators will initiate the Advance Directives care plan upon admission. The Social Services Department will be responsible for maintaining and updating the Advance Directive Care Plans now and forward on all residents. 24) Beginning on [DATE], the Quality Assurance Nurse and Assistant Administrator began monitoring Social Services' care plans daily, to ensure that the residents' wishes related to advance directives were accurately reflected on their care plan and any changes in their Advance Directives had been addressed. This was accomplished by comparing the Social Services' Notes, the Advance Directive, and care plan following any reported changes to the resident's Advance Directives. In conjunction with the care plan audit, they were also monitoring whether the Advance Directives were current and in the Advance Directives section of the resident's chart. 25) On [DATE], the Administrator, Assistant Administrator, DON, and ADON, discussed what immediate action needed to be taken. At that time, the ADON began informing Charge Nurses, Licensed Staff, and Ward Clerks on duty, of the proper paperwork that is to accompany all residents being transferred to any other facility including emergency care. This information included documents such as code status, Living Wills, POA, Guardianship, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive Section of the resident's chart. 26) On [DATE] the Executive Director provided training on the State and Federal requirements. This training was provided to the Admissions Coordinator, Assistant Administrator, Assistant Director of Nursing, Social Worker and Licensed Practical Nurse (LPN) Coordinator and competency was demonstrated by a posttest on [DATE]. Beginning on [DATE], the ADON provided the same training to the Administrator, DON, Director of Social Services, and Charge Nurses, and competency was demonstrated by a posttest. 27) The ADON began training the Administrator, Assistant Administrator, DON, Charge Nurses, Licensed Staff, and Ward Clerks on [DATE] regarding additional measures needed to be taken to ensure that all resident's information in the Resident Transfer Packet, which included Advance Directives were being sent to the receiving facility. This training gave direction that all residents' information was sent with him or her when they were transferred out of the facility and will also be faxed to the receiving facility, copied and placed in the miscellaneous section of the chart with the fax transmission confirmation. During this time, staff was also instructed to compare the documents included in the Advance Directive Section to those listed on the resident's Face Sheet, which is generated from Point Click Care, to ensure all current documents were present. 28) Beginning on [DATE] the QA Nurse, Unit Manager, or the Assistant Administrator, started monitoring to ensure that all Advance Directives for a resident that was being transferred out of the facility were accurate and sent. This was accomplished by reviewing the resident's transfer packet that was copied, faxed, and placed in the miscellaneous section of the resident's chart. This process is being documented daily on a monitoring log; no problems have been identified at this time. 29) The facility initiated daily monitoring on [DATE] of staff training regarding resident transfer processes, faxing Advance Directives, the State and Federal requirements, Advance Directive Definitions, Sending Advance Directives during transfer, and the Advance Directives policy. The ADON or Charge Nurse was performing the monitoring through interviews with a minimum of three (3) staff per day that were previously trained. All shifts were included in this monitoring, and all shifts were being monitored within a 2-day period. 30) Beginning on [DATE], Social Services, MDS Coordinators, Admissions Coordinator, QA Coordinator, Licensed Staff, Ward Clerks, and Finance, were trained by the ADON, DON, or Charge Nurse on the advance directive definitions and the State and Federal requirements; competency was demonstrated by posttest. 31) As of [DATE], the Administrator and Assistant Administrator reviewed and revised the Advance Directive Policy to reflect that upon admission the Admission Coordinator would provide a copy of this policy and would discuss and confirm the Advance Directive status with the resident and or responsible party and would document in the individual medical record with the Resident Rights/Advance Directives form upon admission whether the resident had an Advance Directive. The resident and/or legal representative, DPOA, POA, or Guardian would date and sign a statement attesting that the Advance Directive and facility policy had been explained upon admission. 32) The Admissions Coordinator will provide copies of Advance Directive information obtained on the day of admission to Finance, LPN Supervisor, and Unit Manager or Ward Clerk. 33) LPN Supervisor/Data Entry Specialist entered all orders into the Point Click Care to include code status and advance directives on the day of admission. This information was then generated to the resident's face sheet, which was sent to the resident's nursing unit, and then placed on the resident's chart by the ward clerk, on the day of admission. 34) On [DATE], the Assistant Administrator trained the Admissions Coordinator, ADON, and Social Services on the revisions to the Advance Directive Policy, responsibilities, and processes that were in place to ensure that residents' advance directives were executed per the resident's wishes, and competency was demonstrated by a posttest. 35) Together the Assistant Administrator and ADON trained the DON, QA Coordinator, MDS Coordinators, Charge Nurses, Finance, and Unit Managers regarding the Advance Directive Policy and Procedure revision and competency was demonstrated by a post test. 36) Beginning [DATE], licensed staff and the ward clerks were trained on the changes to the Advance Directive Policy by the DON, ADON, or Charge Nurse and showed competency by test. All above-mentioned staff was trained as of [DATE] on this policy except eight (8) licensed staff and one ward clerk, who will be trained prior to returning to direct resident care. 37) Beginning on [DATE] the initial admissions portion of the Advance Directive procedure as outlined in the Advance Directive Policy was being monitored daily by the Assistant Administrator with each new admission. This will accomplished by reviewing the admissions' paperwork and confirming that any advance directives received during the admission process were in fact listed on the Resident's Rights/Advance Directive Sheet. The findings were then reported on a daily monitoring log with each new admission. No problems were identified at the time. 38) Starting on [DATE], the QA Coordinator or the Assistant Administrator checked resident charts daily to confirm that the Advance Directive section of the chart still contained all of the resident's Advance Directives. This was accomplished by comparing the Advance Directives located in the chart to their daily monitoring log. 39) The Administrator and Assistant Administrator revised the Social Services Policy on [DATE] to include the procedure for invoking a health care agent or legal representative after the resident was determined not to have decision-making capacity. This policy stated, "The assigned social worker will determine if the resident is self-responsible or if they have a POA, DPOA, or legal guardian in place. The social worker would contact them to let them know the resident has had a mental status change and can no longer make their own decisions. If the legal representative accepts responsibility, they will begin making decisions for the resident. If the resident does not have a POA, DPOA or legal guardian then social services would contact any family members who may be willing to be the responsible party for the resident. If the family members are not willing, then social services will contact Adult Protective Services (APS) and request the process for obtaining a guardian to be started." 40) Social Services was trained on [DATE] by the Assistant Administrator regarding the revised Social Services Policy. 41) During the admission process, the Admissions Coordinator would determine the resident's legal representative based on information provided by the resident at the time of admission. 42) Upon admission, the resident's mental status was assessed by the Licensed Staff assigned to the resident on their unit through the nursing admission assessment form, and by the MDS Coordinators through the Brief Interview Mental Status (BIMS), which is done within seven (7) days of admission and also done quarterly with scheduled care plan meetings and with any significant change. Should any of these assessments indicate the resident was not capable of being their own decision maker, Social Services would be informed by the nursing staff during the daily morning management administrative meeting of any mental status changes that may require further assessment. 43) If a mental status change and further assessment of a resident indicated the need for a legal representative, then at that point Social Services would seek to invoke the health care agent or legal representative as outlined in the Social Services Policy. 44) The Assistant Administrator checked to ensure that any issues relating to Social Services have been followed-up on during the daily Social Services meeting. This was documented on the Daily Social Services Meeting Minutes. 45) Upon admission, the resident's assigned Social Worker would confirm Advance Directives. Furthermore, the Social Worker would review the advance directive status when requested by the resident or responsible party, upon any re-admission, quarterly with care plan meetings and after any significant change. 46) The Social Worker would assist the resident in developing a living will within twenty-four (24) hours of being requested. The Assistant Administrator would monitor this by comparing the Advance Directives to what was stated on the Resident's Rights/Advance Directive Sheet and documented in the Social Services Progress Note. 47) As of [DATE], the Assistant Administrator initiated daily meetings with the Social Worker and Director of Social Services to discuss any residents that were sent out of the facility, returned to facility, or had received any new documents concerning Advance Directives. 48) All Advance Directive care plans will be reviewed immediately upon admission or re-admission by the Social Worker and documentation of the review will be placed in the Social Worker Notes. These would also be reviewed by the MDS Coordinator and Social Worker and the rest of the interdisciplinary care plan team during scheduled care plan meetings, and then documented in the Social Services section of the clinical record as well as the Interdisciplinary Care Plan Sheets. 49) If the resident and/ or their representative were present during this care plan meeting, the Advance Directive and Code Status would be discussed to confirm that the directive continues to reflect the resident's wishes. If there was no representative present, Social Services would contact the legal representative to confirm the Advance Directive was still current. This will be completed with the Quarterly MDS review, and any change in status. 50) The Quality Assurance (QA) Nurse and Assistant Administrator were monitoring care plans relating to advance directives daily to ensure the residents' wishes expressed on the Advance Directives were outlined in the care plans as of [DATE]. 51) Beginning on [DATE], Licensed Staff and Ward Clerks were given re-enforcement training by the ADON, related to information to be included on the shift-to-shift report, and competency was proven by a post test. 52) On [DATE], the Administrator instructed the Nurse Managers and DON to begin reporting any mental status changes reported on the shift-to-shift report during the Morning Administrative Management Meeting. At that time, the team would discuss necessary changes that needed to be addressed, if any. As of [DATE], no change in any resident's mental status had been reported. This was documented daily on the Daily Morning Administrative Management Meeting Notes. 53) When a significant change, quarterly or annually assessment is conducted and a brief interview of mental status (BIMS) will be completed on each resident to determine their decision making ability by the MDS Coordinator. This will be reported to the resident's assigned Social Worker, to determine if any changes in legal representative needs to be made. 54) When a resident is admitted , readmitted , or had verbalized their desire to change their code status, the nurse will contact the Doctor and obtain a Doctor's order. At that time, a DNR or full code status form would be completed with two (2) caregiver signatures. If the code status was obtained by telephone, the same process will apply. The nurse will document the code status change in the Nurse's Notes and place the change on the shift-to-shift report. 55) Beginning on [DATE], licensed staff and ward clerks were trained on the changes to the Advance Directive Policy by the DON, ADON, or Charge Nurse and showed competency by a post test. The Advance Directive Policy included the process for contacting the legal representative with any changes in the Advance Directives. All above-mentioned staff was trained as of [DATE] on this policy, except for eight (8) licensed staff and one ward clerk, who will be trained prior to returning to direct resident care. 56) Per the revised Advance Directives Policy, Social Services or designated others will assist the residents who elect to execute an Advance Directive. Social Services will ensure all documents that belong in the Advance Directive Section are placed in the medical chart. 57) Social Services was trained on the changes to the Advance Directive Policy on [DATE] by the ADON; and competency was demonstrated by a post test. 58) A copy of the Code Status order will be given to the LPN Supervisor, who will input the order into the "Point Click Care System" and the Admission Record will be generated from this information. The Admission Record (Face Sheet) will be sent to the resident's nursing unit and placed in front of the chart by the ward clerk, on the day of the change in code status. 59) On [DATE], the Assistant Director of Nursing implemented and trained all Licensed staff and Ward Clerks on the modified existing transfer form to provide an expanded checklist that specifically listed Living Wills, Power of Attorney, Health Care Surrogate or Guardianship documents. 60) As of [DATE], compliance with the policies and processes were being verified daily by the facility's Administrative team which consists of the Administrator, Assistant Administrator, Director of Nursing, and Assistant Director of Nursing or QA Coordinator and reviewed daily during the QA Daily meeting. Any notice of non-compliance will be reported to the Administrator and a plan of action will be developed to prevent reoccurrence. 61) The Executive Adviser and the Nurse Consultant will review the minutes of the management meetings and will attend meetings at least weekly to ensure the Allegation of Compliance is being implemented and that any adjustments to the process are identified, discussed and steps implemented to correct. 62) The Executive Adviser and Nurse Consultant are in daily consultation with the Administrator since [DATE]. They are reviewing documentation, interviews and training staff to ensure the plan is being carried out as alleged. ***The SSA validated the Immediate Jeopardy was removed as follows: 1) Interviews with LPN #2 on [DATE] at 2:28 PM, LPN #1 on [DATE] at 3:23 PM and RN #2 on [DATE] at 2:56 PM revealed they were knowledgeable regarding what paper work was to be transferred with residents when sent out of the facility including all Advance Directives formulated by the resident. 2) Review of Resident #1's chart on [DATE] revealed the resident's Living Will was in the chart and in the correct location. 3) Review of Resident #1's chart on [DATE] at 1:50 PM revealed an Advance Directive Care Plan was present in the medical record. 4) Interviews with MDS Coordinator #2 on [DATE] at 3:06 PM revealed the Nurse Consultant had trained her on developing an Advance Directive care plan. Interview with the Nurse Consultant on [DATE] at 2:00 PM, revealed she had confirmed the accuracy of Resident #1's Advance Directive Care Plan. 5) Review of the Progress Notes dated [DATE], and interview with Resident #1's Health Care Surrogate on [DATE] at 3:00 PM revealed a care plan conference was conducted via telephone to discuss Resident #1. During the interview, the Health Care Surrogate stated she was making health care decisions for Resident #1. 6) Interviews on [DATE], at 4:44 PM with the Administrator; at 3:32 PM with the Assistant Administrator; and, at 4:37 PM with the DON (Director of Nursing) revealed they had all reviewed Resident #1's care plan and confirmed it contained all the Advance Directives that were included in Resident #1's Living Will. 7) Interview with Resident #1's Health Care Surrogate on [DATE] at 3:00 PM revealed she confirmed with the facility that Resident #1 was to be a DNR. Review of Resident #1's medical record on [DATE] at 1:50 PM revealed the DNR form was signed on [DATE]. Resident #1's medical record also contained a signed physician's orders [REDACTED]. 8) Review of Resident #1's chart on [DATE] at 1:50 PM revealed the resident's care plan reflected the DNR status. 9) Review of Physician Nots, dated [DATE] revealed the physician documented participating in the conference call on [DATE] with the Health Care Surrogate and discussed the current medical condition of the resident. Review of Resident #1's medical record revealed intravenous (IV) fluids were discontinued for Resident #1 on [DATE]. Observation of Resident #1 on [DATE] at 3:09 PM revealed the resident was not receiving IV fluids. 10) Review of Resident #2's medical record on [DATE] at 2:20 PM revealed it contained a copy of the resident's Durable Power of Attorney (DPOA) and it was located in the correct section of the medical record. 11) Review of the Progress Notes dated [DATE], and interview with Resident #2's DPOA on [DATE] at 3:00 PM revealed the facility confirmed the information in Resident #2's DPOA was correct and reflected the wishes of Resident #2. 12) Review of Resident #2's medical record on [DATE] at 2:20 PM revealed it contained an Advance Directive Care Plan for Resident #2. 13) Interview with MDS Coordinator #2 on [DATE] at 3:06 PM revealed the Nurse Consultant trained her on developing an Advance Directive care plan. Interview with the Nurse Consultant on [DATE] at 2:00 PM, revealed she confirmed the accuracy of Resident #2's Advance Directive Care Plan. 14) Review of a Resident Disposition form dated [DATE], and interview on [DATE] at 4:05 PM with the Director of Social Services revealed that all charts had been reviewed to ensure Advance Directives were on the chart under the designated tab. 15) Interviews on [DATE] at 3:15 PM with Resident #3 and at 3:22 PM with Resident #4 revealed they had been interviewed by the DSS and had not made changes in their code status designations. Review of Social Service Notes for Residents #20 and #23 revea

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide the necessary care and services for two (2) of twenty-four (24) sampled residents (Residents #1 and #2) to attain or maintain each of the resident's practicable physical, mental, and psychosocial well-being, in accordance with their comprehensive assessment and plan of care. The facility admitted Resident #1 on [DATE] with an advance directive, which was provided to the facility to ensure the resident's wishes were implemented regarding life-prolonging treatment and artificially provided nutrition and hydration if the resident no longer had decisional capacity. However, the facility failed to recognize and assist Resident #1 to implement his/her Advance Directive and failed to implement pertinent approaches to obtain and act on the resident's wishes to ensure the psychosocial needs of Resident #1 were met. On [DATE], the facility transferred Resident #1 to the hospital, but failed to ensure the resident's advance directive accompanied the resident. Subsequently, while hospitalized Resident #1 was intubated, placed on mechanical ventilation, and received [MEDICAL TREATMENT], all of which specifically went against Resident #1's wishes as stated in the advance directive. Resident #1 was extubated on [DATE], and returned to the facility on [DATE]. Additionally, from [DATE] through [DATE], the facility infused Resident #1 with artificial fluids via intravenous (IV) access, which again was in conflict with Resident #1's executed advance directive (refer to F155, F250, F279, and F490). In addition, the facility failed to ensure pain medications were available in a timely manner for the treatment of [REDACTED].#2. The resident had a physician's orders [REDACTED]. Resident #2 had a physician's orders [REDACTED]. The facility failed to obtain the medication from the pharmacy until four days ([DATE]) after the physician's orders [REDACTED].#2 experienced back pain on [DATE]. Further, the facility failed to reassess Resident #2 for the continued need for pain medication and the resident's pain medication was discontinued on [DATE] (refer to F282 and F425). The facility's failure to have an effective system in place to ensure residents received care and services to maintain their highest level of practicable physical, mental, and psychosocial well-being was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.75 Administration (F490). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. A partial extended survey was conducted on ,[DATE]-,[DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to "E" at 42 CFR 483.10 Resident Rights (F155), 42 CFR 483.15 Quality of Life (F250), 42 CFR 483.20 Resident Assessment (F279), 42 CFR 483.75 Administration (F490); and, 42 CFR 483.25 Quality of Care (F309) Scope and Severity of a "D", while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, "Advance Directives," reviewed by the facility on [DATE], revealed the facility would adhere to state and federal laws and regulations on advance directives. The policy also stated that facility staff would assist residents who elect to execute an advance directive. 1. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE]. Review of a Resident's Rights/Advance Directives form dated [DATE], signed by Resident #1 and the facility's Social Worker, revealed Resident #1 formulated advance directives. Further review of Resident #1's medical record revealed a Living Will directive and Health Care Surrogate Designation for Resident #1, which had been notarized and recorded on [DATE]. The Living Will specified that Resident #1 chose to have life-prolonging treatment withheld or withdrawn and be permitted to die naturally with only the administration of pain-alleviating medication or treatment. The Living Will also directed that Resident #1 authorized the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility failed to recognize the resident's formulation of advance directives when the assessment was conducted indicating the resident did not formulate an Advance Directive. Review of Resident #1's initial Comprehensive Care Plan dated [DATE], revealed the facility also failed to develop a care plan to address the resident's advance directive. Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident had moderate cognitive impairment. Review of a Significant Change MDS assessment dated [DATE], revealed the resident had a BIMS score of 99, and was severely cognitively impaired. Review of Resident #1's most recent Comprehensive Care Plan dated [DATE], revealed the resident's designated cardiopulmonary resuscitation status was care planned, but the facility failed to identify or address Resident #1's Living Will directive and Health Care Surrogate designation. Review of Nursing Notes dated [DATE], at 4:55 AM, revealed the facility transferred Resident #1 to the hospital on [DATE], due to shortness of breath, audible wheezing in the lungs, labored respirations, and [MEDICAL CONDITION]. An interview was conducted on [DATE] at 3:40 PM with Registered Nurse (RN) #1, who transferred Resident #1 to the hospital on [DATE]. RN #1 stated she completed a facility transfer form and sent it with Resident #1 to the hospital, along with the resident's medication list and resident information sheet. RN #1 stated she did not send a copy of Resident #1's Living Will to the hospital on [DATE], because she was unaware the resident had a Living Will, and the only documentation transferred to the hospital with a resident related to advance directives was the resident's designated Cardiopulmonary Resuscitation (CPR) status. Review of the Emergency Department medical record for Resident #1 dated [DATE], revealed Resident #1 presented to the Emergency Department on [DATE], at 5:10 AM via ambulance with the chief complaint being shortness of breath. The documentation further stated Resident #1's history was obtained from facility documentation, which accompanied the resident to the hospital, and included no advance directives. Interview with the facility's Administrator on [DATE], at 6:00 PM, revealed that it was the practice of the facility to send the resident's designated CPR status with them when they were transferred to the hospital, but they did not send other advance directives including Living Wills. Additionally, the Administrator stated he was aware that Resident #1 had a Living Will on file in the facility that named a Health Care Surrogate, but was unaware the Living Will documented Resident #1's wishes regarding life-sustaining treatments and medications. Further review of Resident #1's hospital record revealed after obtaining initial treatment in the Emergency Department, Resident #1 was admitted to the medical unit on [DATE], at 12:01 PM for further management and treatment for [REDACTED]. On [DATE], at 5:35 AM, Resident #1 had increased respiratory distress and decreased oxygen saturation, and was transferred to the Intensive Care Unit. At 6:18 AM on [DATE], Resident #1 was intubated and placed on mechanical ventilation. Resident #1 continued to receive mechanical ventilation, requiring bilateral wrist restraints to prevent self-extubation until [DATE], when Resident #1 was extubated. Further review of Resident #1's medical record revealed the facility readmitted Resident #1 on [DATE]. Observations of Resident #1 on [DATE] at 1:43 PM, on [DATE] at 10:20 AM, 12:15 PM, and 3:06 PM, on [DATE] at 5:33 PM, and on [DATE] at 3:10 PM revealed the resident was in bed and unable to communicate effectively. Resident #1 was also observed to be receiving intravenous fluids during each of the observations. physician's orders [REDACTED].#1 on [DATE] due to the resident having abnormal laboratory test results. Further review of Resident #1's physician's orders [REDACTED]. Interview with Resident #1's Physician on [DATE], at 10:10 AM revealed she was unaware that Resident #1 had a Living Will, which directed the withholding of artificially provided fluids, prior to initiating the intravenous infusions on [DATE]. Interview with Resident #1's Alternate Health Care Surrogate's daughter on [DATE], at 4:15 PM, revealed the Alternate Health Care Surrogate had not been consulted or contacted prior to the initiation of intravenous fluids for Resident #1 on [DATE], and would not have authorized the facility to implement the administration of fluids for Resident #1. Interviews with the Administrator on [DATE], at 12:05 PM and 6:00 PM revealed he was aware that Resident #1 had been ordered intravenous fluids, but had never contemplated or considered that the administration of the fluids were in conflict with the resident's Living Will. Interviews with the Administrator on [DATE] at 12:05 PM and on [DATE] at 10:53 AM revealed the facility did not have a specific policy related to "code status" or what steps were required to change a resident's cardiopulmonary resuscitation designation to "Do Not Resuscitate." Review of readmission Physician order [REDACTED].#1 was readmitted to the facility with a notation in the margin of the orders stating "code change to DNR (Do Not Resuscitate)." Review of a State Emergency Medical Services Do Not Resuscitate (DNR) Order form dated [DATE] revealed Resident #1's name was written on the designated signature line followed by "per living will." Interview with the Administrator on [DATE] at 6:00 PM, revealed he instructed Unit Manager (UM) #1 to fill out the form to change Resident #1's designation to DNR due to "finding out" that Resident #1 had a Living Will on file in the resident's medical record in the facility. However, review of the Living Will directive and Health Care Surrogate designation formulated by Resident #1 on [DATE], revealed the document did not indicate a designated choice for cardiopulmonary resuscitation. Interview with UM #1 on [DATE], at 5:30 PM revealed she filled out the DNR form for Resident #1 at the direction of the Administrator, and stated that she nor the nurse who signed that she "witnessed" the form had spoken to any member of Resident #1's family including the resident's designated Alternate Health Care Surrogate, prior to changing the resident's chosen cardiopulmonary resuscitation status to DNR. Interview with Resident #1's Alternate Health Care Surrogate and her daughter on [DATE] at 12:27 PM revealed that although they felt the Resident should be a DNR, the facility had never discussed changing Resident #1's code status with them on [DATE] or at any other time. 2. Review of the facility's policy titled "Pain Assessment," revised [DATE], revealed the facility had a pain management program to assess the resident's pain level and provide optimal comfort through a pain control plan, which was mutually established with the resident, family, and members of the health care team. The policy further revealed assessment of the pain management program would occur daily and would focus on the effectiveness of the program and the comfort level of the resident. Continued review of the policy revealed pain should be assessed for onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms. The policy revealed staff should determine the appropriate type of pain medication and administer the medication as ordered by the physician. If no pain medication was ordered, staff should notify the physician and obtain an order. Interview on [DATE] at 3:03 PM, with the Director of Nursing (DON) revealed residents were only placed on the pain management program if they were receiving scheduled pain medications. Review of the medical record for Resident #2 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident to have severely impaired cognition. The assessment further revealed the resident had not received any pain medication in the previous five (5) days (was at the facility for those five days), and had not "had pain or been hurting at any time in the last five days." Review of Resident #2's Admission Pain assessment dated [DATE], revealed the resident had not had pain in the five (5) days prior to the pain assessment being completed. Review of Resident #2's Plan of Care, initiated on [DATE], revealed the facility identified the resident was at risk for an alteration in comfort/pain with an intervention to administer pain medications as ordered. Interview on [DATE] at 1:55 PM with Resident #2's family member revealed the resident had been on narcotic pain medication prior to being admitted to the facility due to the resident's history [MEDICAL CONDITION], and the family member had requested the resident's pain medications be ordered at the facility. The family member stated he/she felt the resident was experiencing pain, which could possibly be the cause of the resident's decreased appetite. Review of Resident #2's Progress Notes dated [DATE], revealed the physician documented that the resident had refused his/her medication three (3) times and the physician was going to order pain medication because the resident "may be in pain" and because the resident had previously been on pain medication. Review of Resident #2's Physician order [REDACTED]." Review of Resident #2's Medication Administration Record [REDACTED]. Review of Resident #2's PRN (as needed) medication sheet dated [DATE] (one day before the narcotic pain medication was available), revealed the resident complained of back pain (no documentation of the rating of the resident's pain) and staff administered Tylenol (a non-narcotic pain medication). Continued review of the PRN medication sheet revealed the resident had no pain after administration of the Tylenol. Further review of Resident #2's MAR indicated [REDACTED]. Further review of Resident #2's PRN sheet revealed staff administered narcotic pain medication to Resident #2 on the following days and for the following complaints or symptoms: On [DATE] the resident complained of back pain, rated his/her pain a "4" on a scale of 1 to 10, and was observed to have facial grimacing; on [DATE] the resident complained of back pain with no documentation of the resident's rating of the pain; on [DATE] the resident complained of back pain and rated his/her pain a "4"; on [DATE] there was no documentation of the resident's pain rating or location of the pain; and, on [DATE] the resident was observed to have facial grimacing and rated the pain as a "4". Interview on [DATE] at 3:25 PM with Registered Nurse (RN) #4 revealed Resident #2's family requested that narcotic pain medication be ordered for the resident because the resident had been on the pain medication at home prior to admission to the facility. Further interview revealed an order was obtained from the resident's physician for narcotic pain medication to be given as needed three (3) times a day for seven (7) days. She stated the order was written on a Friday, and because the physician was aware that medications were not delivered to the facility on weekends, the physician wrote for the medication to be started when it was available because the resident did not appear to be having any pain. The interview revealed that all pain medications that were written "as needed" were ordered for a seven to fourteen-day period. Then, on the day the order for the medications ended, the order was taken off the resident's chart, placed on the Physician's "Problem List," and the Physician evaluated the need to continue the pain medication. The RN stated Resident #2 occasionally complained of pain or appeared to be in pain since the resident was admitted to the facility. Review of the Physician's Problem List (list of residents that the physician needs to see and the reason the resident needs to be seen), dated February 2015, revealed Resident #2 was not on the list to be seen by the Physician for the evaluation of the resident's continued need for narcotic pain medication. Review of the physician progress notes [REDACTED].#2's comfort level or narcotic pain medication was addressed. Review of the physician's orders [REDACTED].#2's narcotic pain medication was not reordered. Interview on [DATE] at 3:25 PM, with Licensed Practical Nurse (LPN) #3 revealed the LPN placed Resident #2's narcotic pain medication on the MAR indicated [REDACTED]. She stated she should have ensured the resident's name was placed on the Physician's Problem List so the use of narcotic pain medication could be evaluated to be discontinued or to be continued. The LPN stated Resident #2 occasionally complained of or appeared to have back pain during the time the pain medication was not available, but did not appear to be in more pain than normal. Interview on [DATE] at 11:15 AM with Resident #2's Physician revealed Resident #2's family requested the resident's narcotic pain medications be ordered by the facility because the resident had been on narcotic pain medication at home. The interview further revealed the Physician wrote the medication to start when available because the order was written on a Friday and the Physician was aware that medications were not delivered on weekends and the medication would not be received by the facility until Monday or Tuesday. The Physician stated nursing staff reported the resident was not showing signs of pain or complaining of pain. The Physician further stated the resident's pain medication was not reordered because staff did not add the resident to the Physician's "Problem List" to evaluate the resident's pain medication. Interview on [DATE] at 3:43 PM and on [DATE] at 4:25 PM, with Unit Manager (UM) #2 revealed medications needed on the weekends or the evenings should be obtained from the emergency pharmacy. The Nurse Manager stated Resident #2's pain medication was written to start when available because the resident had not complained of pain per reports of the nursing staff; however, medications should be started as soon as possible when ordered and the first doses should be obtained from the emergency pharmacy until the order for the medication was received by the regular pharmacy. The interview further revealed when medications were ordered "as needed" for seven days the order should be taken off the resident's chart and placed on the Physician's Problem List to be evaluated. The Nurse Manager revealed she had reviewed the Problem List for the month of February 2015 and Resident #2's pain medication had not been reevaluated by the Physician and the medication was discontinued because the resident's name was not added to the Physician's Problem List. Interview on [DATE] at 10:15 AM and 3:03 PM with the Director of Nursing (DON) revealed the DON talked to Resident #2's Physician and Nurse and was informed the Physician had not written a prescription so the medication could be obtained from the emergency pharmacy. The resident had not been complaining of or showed signs that he/she was experiencing pain and that the medication was ordered because the family requested the medication order. The interview further revealed the DON was not aware of the facility staff having problems obtaining medications. She stated that medications could be obtained from the emergency pharmacy, and that all medication orders should be started as soon as possible. The interview further revealed Resident #2 was not placed on the pain management program because the resident had not experienced pain during the admission assessment and the resident was not on a scheduled pain medication. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1) On [DATE], licensed nursing staff that was on duty at that time was informed immediately, by the ADON of actions to be taken, and on the proper paperwork that was to accompany Resident #1 and all other residents in the facility when they were transferred to any other facility including appointments and emergency care. This paperwork included Code Status, Living Will, POA, Guardianship papers, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive section of the resident's medical record. 2) On [DATE], the Director of Social Services, Nurse Manager, QA (Quality Assurance) Coordinator, and MDS (Minimum Data Set) Coordinator conducted an immediate review of Resident #1's medical record and confirmed that the resident's Living Will was in the chart and in the correct location. 3) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #1 after being notified of the Immediate Jeopardy. 4) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plan was reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #1's chart. 5) An emergency Interdisciplinary Care Team Conference was conducted by phone with Resident #1's Health Care Surrogate on [DATE] at 12:00 PM, and at this time, the Surrogate verified that she was indeed this person's Healthcare Surrogate and the Living Will the facility had on file reflected the resident's wishes. 6) The Interdisciplinary Care Conference Team consisting of the Administrator, Assistant Administrator, DON (Director of Nursing), ADON (Assistant Director of Nursing), Nurse Manager, Social Worker, MDS Coordinator, Clinical Dietician, and Attending Physician reviewed the resident's care plan to confirm that all components of the Living Will were included. 7) The Health Care Surrogate directed that Resident #1 be changed from "full code" (CPR) status to a "no code" (no CPR) status, which was witnessed by everyone present at the meeting. The Do Not Resuscitate form was completed and signed on [DATE] by the Nurse Manager and the Attending Physician. The Attending Physician wrote the new order and nursing staff updated the medical record to reflect the change. 8) Resident #1's care plan was confirmed on [DATE] to reflect the no code status and was determined by the Nurse Consultant to be correct. 9) On [DATE], the Attending Physician documented participating in the conference call on [DATE] with the Health Care Surrogate and discussed the current medical condition of the patient. Resident #1's intravenous (IV) fluids were discontinued on [DATE]. 10) On [DATE], the Director of Social Services, Nurse Manager, QA Coordinator, and MDS Coordinator conducted an immediate review of Resident #2's medical record and confirmed that it included a copy of a Durable Power of Attorney (DPOA) and it was located in the correct location of the medical record. 11) On [DATE], an emergency Interdisciplinary Care team that included the Administrator, Assistant Administrator, DON, ADON, Nurse unit Manager Social Worker, MDS coordinator, Clinical Dietician and Physician, conducted a meeting via telephone conference with Resident #2's Durable Power of Attorney (DPOA) and confirmed that the information the DPOA provided on admission on [DATE] was in fact correct in reflecting the current wishes of the resident. 12) On [DATE], the MDS Coordinator immediately developed an Advance Directives Care Plan for Resident #2 after being notified of the Immediate Jeopardy. 13) On [DATE], the Nurse Consultant in-serviced the MDS Coordinators on the process for developing an Advance Directive Care Plan. The Advance Directive Care Plans were reviewed by the Nurse Consultant for accuracy and determined to be correct. The Advance Directive Care Plan was then placed in Resident #2's chart. 14) As of [DATE], all current residents' charts have been reviewed by the Director of Social Services or Social Worker to ensure all Advance Directives, which include: DPOA, POA (Power of Attorney), Healthcare Surrogate, Guardianship, and Living Wills were in the chart and in the proper place. 15) All residents that are their own responsible party were interviewed by Social Services beginning on [DATE] to determine their cognitive status, and those with impaired cognition had a legal representative. The residents were also asked about their code status and if they wanted any changes to their Advance Directives at that time. No residents, who were their own responsible party, were found to have changes in their cognitive status. 16) All residents or their designated representatives, except two (2), were called by Social Services, to confirm that their Advance Directive was current and up to date; and the Code Status that the facility had on file was correct. Social Services and the Assistant Administrator will continue to contact the legal representatives to confirm that the information the facility has on file is current. 17) On [DATE], through individual chart reviews, the Assistant Administrator verified that the Social Worker's Progress Notes confirmed the accuracy of the Advance Directives currently on file. The Assistant Administrator documented this in a monitoring log. 18) During this process two (2) residents had code status changes from CPR only to Full Code Status. The Full Code Status form was signed and placed in the resident's chart. The MDS Coordinators then updated the care plans on [DATE] and the face sheets were updated. 19) On [DATE], the Full Code Status Form was revised by the DON. Options of CPR only and Chemical Code were removed from the Full Code Status Form. The ADON and Charge Nurses (beginning on [DATE]) completed training on this form change. 20) The MDS Coordinators were trained on [DATE] by the Nurse Consultant to ensure proper understanding of Advance Directive Care Plans and what should be included in them. This training included assessing whether the resident had an Advance Directive, Durable Power of Attorney for Healthcare, or a Living Will. 21) Care plans will also include the resident's expressed wishes regarding care and treatment goals as outlined by the Advance Directives. Social Services staff was trained as of [DATE] by the MDS Coordinators on how to develop the Advance Directive Care Plan. 22) All resident care plans were reviewed and revised relating to Advance Directives and Code Status by the MDS Coordinators, and was completed by [DATE] 23) The MDS Coordinators will initiate the Advance Directives care plan upon admission. The Social Services Department will be responsible for maintaining and updating the Advance Directive Care Plans now and forward on all residents. 24) Beginning on [DATE], the Quality Assurance Nurse and Assistant Administrator began monitoring Social Services' care plans daily, to ensure that the residents' wishes related to advance directives were accurately reflected on their care plan and any changes in their Advance Directives had been addressed. This was accomplished by comparing the Social Services' Notes, the Advance Directive, and care plan following any reported changes to the resident's Advance Directives. In conjunction with the care plan audit, they were also monitoring whether the Advance Directives were current and in the Advance Directives section of the resident's chart. 25) On [DATE], the Administrator, Assistant Administrator, DON, and ADON, discussed what immediate action needed to be taken. At that time, the ADON began informing Charge Nurses, Licensed Staff, and Ward Clerks on duty, of the proper paperwork that is to accompany all residents being transferred to any other facility including emergency care. This information included documents such as code status, Living Wills, POA, Guardianship, Healthcare Surrogate, Fiduciary, and any other legal documents in the Advance Directive Section of the resident's chart. 26) On [DATE] the Executive Director provided training on the State and Federal requirements. This training was provided to the Admissions Coordinator, Assistant Administrator, Assistant Director of Nursing, Social Worker and Licensed Practical Nurse (LPN) Coordinator and competency was demonstrated by a posttest on [DATE]. Beginning on [DATE], the ADON provided the same training to the Administrator, DON, Director of Social Services, and Charge Nurses, and competency was demonstrated by a posttest. 27) The ADON began training the Administrator, Assistant Administrator, DON, Charge Nurses, Licensed Staff, and Ward Clerks on [DATE] regarding additional measures needed to be taken to ensure that all resident's information in the Resident Transfer Packet, which included Advance Directives were being sent to the receiving facility. This training gave direction that all residents' information was sent with him or her when they were transferred out of the facility and will also be faxed to the receiving facility, copied and placed in the miscellaneous section of the chart with the fax transmission confirmation. During this time, staff was also instructed to compare the documents included in the Advance Directive Section to those listed on the resident's Face Sheet, which is generated from Point Click Care, to ensure all current documents were present. 28) Beginning on [DATE] the QA Nurse, Unit Manager, or the Assistant Administrator, started monitoring to ensure that all Advance Directives for a resident that was being transferred out of the facility were accurate and sent. This was accomplished by reviewing the resident's transfer packet that was copied, faxed, and placed in the miscellaneous section of the resident's chart. This process is being documented daily on a monitoring log; no problems have been identified at this time. 29) The facility initiated daily monitoring on [DATE] of staff training regarding resident transfer processes, faxing Advance Directives, the State and Federal requirements, Advance Directive Definitions, Sending Advance Direc

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to follow residents' plans of care for the treatment of [REDACTED].#2 and Resident #7). The facility developed care plans for Resident #2 and Resident #7 to address the risk for altered comfort or pain with an intervention to administer pain medication as ordered. Resident #2's physician ordered pain medication for the resident on 01/30/15. However, the facility failed to obtain and administer Resident #2's pain medication until 02/03/15 (four days after the medication was ordered). Resident #7 had an order for [REDACTED].#7. The resident missed four (4) doses of the scheduled pain medication on 03/06/15 and 03/07/15. (Refer to F309 and F425) The findings include: Review of the facility's policy titled "Using the Care Plan," not dated, revealed the policy stated the documentation of resident care should be consistent with the residents' care plans. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 01/20/15 with [DIAGNOSES REDACTED]. Review of Resident #2's Plan of Care, initiated on 01/28/15, revealed the facility identified the resident was at risk for alteration in comfort/pain with an intervention to administer pain medications as ordered. Review of Resident #2's Physician Orders, dated 01/30/15, revealed an order for [REDACTED]." However, review of Resident #2's Medication Administration Record [REDACTED]. Review of Resident #2's PRN (as needed) Medication Administration Record [REDACTED]. The PRN medication sheet stated the resident had no pain after administration of the Tylenol Interview on 03/09/15 at 3:25 PM with Registered Nurse (RN) #4 revealed Resident #2's Plan of Care should have been followed and the medication should have been administered when ordered, but the medication was not available in the facility. Further interview revealed the Physician ordered the medication to be given when available because he was aware the facility would not receive the medication until Monday or Tuesday. Interview on 03/03/15 at 3:43 PM with Unit Manager (UM) #2 revealed the resident's plan of care should have been followed and Resident #2's pain medication should have been administered timely (within a few hours of being ordered). She stated the resident's medication could have been obtained at the "backup" pharmacy. The interview further revealed the Physician ordered that the medication could be administered when it was available because the physician was aware the facility would not receive the medication until Monday or Tuesday and the resident had not complained or shown signs that he/she was experiencing pain. 2. Review of the medical record of Resident #7 revealed the facility readmitted the resident on 11/06/13 with [DIAGNOSES REDACTED]. Review of Resident #7's Plan of Care, revised on 02/18/15, revealed the facility identified the resident was at risk for an alteration in comfort/pain. Interventions included to administer pain medications as ordered. Review of Resident #7's Physician Orders, dated March 2015, revealed the resident's physician ordered [MEDICATION NAME] ([MEDICATION NAME] 10 mg/[MEDICATION NAME] 325 mg, a narcotic pain medication) three (3) times per day for pain (original order was written on 11/28/14). Continued review of Resident #7's Physician Orders, dated 03/06/15, revealed an order that stated the resident's medication could be held "until available on 03/07/15." Review of Resident #7's MAR, dated March 2015, revealed the resident missed four (4) doses of the scheduled [MEDICATION NAME] pain medication on 03/06/15 and 03/07/15. Interview on 03/11/15 at 11:59 AM with Licensed Practical Nurse (LPN) #4 revealed Resident #7 had a plan of care in place for the treatment of [REDACTED]. The interview further revealed the order for Resident #7's prescription narcotic pain medication was faxed to the pharmacy on 03/04/15; however, the facility still had not received the medication on 03/06/15. The interview further revealed the physician wrote an order for [REDACTED]. Interview on 03/11/15 at 1:37 PM with Nurse Manager #1 revealed Resident #7's Plan of Care should have been followed and the resident should not have missed doses of his/her pain medication because the facility has an emergency pharmacy available after hours and on weekends to obtain medications. Interview on 03/09/15 at 10:15 AM and at 3:03 PM with the Director of Nursing (DON) revealed Resident #2's and Resident #7's care plans should have been followed. The DON stated the residents' pain medications should have been administered timely, and no doses of medication should have been missed. The interview further revealed the medications should have been obtained from the emergency pharmacy. Interview on 03/11/15 at 5:10 PM with the Administrator revealed Resident #2's and Resident #7's Plans of Care should have been followed. The interview further revealed Resident #2's medication should have been obtained the day the order was written or at least the next day and Resident #7 should not have missed doses of the scheduled medication. The interview revealed medications that were ordered on weekends, in the evening, or medications not available due to a delivery issue could be obtained from the emergency pharmacy. The Administrator stated he was not aware residents' medications were not being obtained and administered timely.

Based on interviews, record review, review of the facility's narcotic logbook, and review of the facility's policies, it was determined the facility failed to provide pharmaceutical services to meet the needs of two (2) of twenty-four (24) sampled residents (Resident #2 and Resident #7). The facility failed to have a system to ensure narcotic medications were available for residents; and, failed to ensure that narcotics ordered after 3:30 PM on Thursday, Friday, Saturday, or Sunday were available at the facility before Monday. Resident #2 had a physician's orders [REDACTED]. Resident #2's medication was not available for administration to the resident until 02/03/15 (Tuesday), four (4)days after the order was written. Resident #7 had a physician's orders [REDACTED]. Resident #7's pain medication was not available and the resident missed four (4) doses of the pain medication on 03/06/15 and 03/07/15. (Refer to F282 and F309) The findings include: Review of the facility's policy titled "Receiving of Resident Medication From Outsource Pharmacies," with a revision date of February 2006, revealed Physician order [REDACTED]. Further review of the policy revealed medications were shipped to the facility (if obtained from the outsource pharmacy); the facility's security staff picked them up (if obtained from the emergency pharmacy) and delivered them to the facility; or, they were delivered by a Hospice courier each day as needed. Review of the facility's policy titled "Back-Up Pharmacy," dated February 2002, revealed when medications were needed, the physician's orders [REDACTED]. The policy further revealed the Charge Nurse or facility staff was required to take the physician's orders [REDACTED]. Review of the Master Agreement for Emergency Medications, dated 07/01/12, revealed the local Medical Center's pharmacy would provide emergency medications for the residents of the facility. The pharmacy agreed to provide medications to the facility when the contract pharmacy was unable to provide medications in a timely manner. Review of the Master Agreement for Pharmacy Services, dated 04/01/12, revealed the outside pharmacy should provide pharmacy services with a clinically based drug formulary specifically tailored for the special needs of the long-term care population, developed in concert with the facility. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 01/20/15 with [DIAGNOSES REDACTED]. Review of Resident #2's Physician Orders, dated 01/30/15 at 11:45 AM, revealed an order for [REDACTED]." Review of Resident #2's Medication Administration Record [REDACTED]. Review of the facility's Narcotic Prescription Logbook revealed Resident #2 had a prescription dated 01/30/15, for Hydrocodone 5 mg/325 mg three (3) times per day for seven (7) days documented on the Logbook. Continued review of the Narcotic Logbook revealed Resident #2's prescription was not faxed to the facility's contract pharmacy until 02/01/15; and the medication was not received by the facility until 02/03/15. Interview on 03/09/15 at 3:25 PM with Registered Nurse (RN) #4 revealed medication orders had to be faxed to the pharmacy Monday through Thursday before 3:30 PM to ensure medications were delivered to the facility the next day. The interview further revealed orders faxed to the pharmacy after 3:30 PM would possibly take two (2) days before they were delivered to the facility. Orders faxed to the pharmacy on Friday or on the weekend would be delivered to the facility on Monday or Tuesday. The RN stated the facility could obtain prescriptions from the emergency pharmacy; however, prescriptions for narcotic medications had to be written on a different prescription pad than was normally used by the facility, so the physician wrote an order to hold the medication until it was available because the resident was not currently experiencing any pain. The interview revealed an order and prescription (on the contract facility's prescription pad) was written by the resident's physician for narcotic pain medication to be given to Resident #2 as needed three (3) times per day for seven (7) days on a Friday; knowing the medication would not be available for several days, the physician wrote for the medication to be started when the medication was available. The interview further revealed since the order for Resident #2's pain medication was obtained on a Friday, the medication was not delivered to the facility by the pharmacy until Monday or Tuesday. Interview on 03/03/15 at 3:43 PM, and on 03/10/15 at 4:25 PM with Unit Manager #2 revealed medications needed on the weekends or the evenings could be obtained from the emergency pharmacy; however, narcotic medications had to be written on a different prescription pad than was usually used by the facility's physicians. Continued interview revealed medications should be started as soon as possible when ordered and the first doses should be obtained from the emergency pharmacy until the order for the medication was received by the contract pharmacy. 2. Review of the medical record of Resident #7 revealed the facility readmitted the resident on 11/06/13 with [DIAGNOSES REDACTED]. Review of Resident #7's Physician order [REDACTED].#7's Physician order [REDACTED]." Review of the Narcotic Prescription Logbook revealed Resident #7 had a prescription dated 03/04/15, for Norco 10 mg/325 mg three (3) times per day for seven (7) days. Continued review of the Narcotic Logbook revealed Resident #7's prescription was faxed to the facility's contract pharmacy on 03/04/15; however, the medication had not been received by the facility on 03/06/15. Review of Resident #7's MAR indicated [REDACTED]. Interview on 03/11/15 at 11:59 AM with Licensed Practical Nurse #4 revealed the order for Resident #7's prescription for narcotic pain medication was faxed to the pharmacy on 03/04/15 (Wednesday). When the facility had not received the medication as of 03/06/15, the resident's physician wrote a prescription for the narcotic pain medication to be filled at the emergency pharmacy if the resident's medications were not delivered that day (03/06/15) due to inclement weather. The Physician also wrote an order to hold the medication until the medication was available on 03/07/15. The LPN stated the facility staff obtained Resident #7's prescription from the emergency pharmacy on 03/07/15, when the resident's medications were not delivered from the contract pharmacy. Interview on 03/11/15 at 1:37 PM with Unit Manager #1 revealed the medication orders should not be written to be started when available. The interview further revealed that when medications could not be obtained from the emergency medication supply, they should be obtained from the emergency pharmacy. Continued interview revealed narcotic medication prescriptions that were to be obtained from the emergency pharmacy had to be written on a different prescription pad than used by the facility for the contract pharmacy. Interview on 03/09/15 at 11:53 AM with the Associate Director of Pharmacy (Outsource Pharmacy) revealed prescriptions received by the pharmacy by 3:30 PM Monday through Thursday were processed the same day and delivered to the facility the following day. The interview further revealed orders received on Friday, Saturday, or Sunday were delivered to the facility on Monday or Tuesday. Continued interview revealed the only time medications were not shipped to the facility timely was because at times the facility took a long time to get order clarifications. Interview on 03/09/15 at 12:09 PM with the Pharmacy Director of the emergency pharmacy revealed the facility was able to get medications from the Medical Center's retail pharmacy Monday through Saturday during business hours and was able to get emergency medications after hours from the Medical Center's In-patient Pharmacy. Continued interview revealed the Pharmacy Director was not aware of any problems obtaining medications from the emergency pharmacy. Interview on 03/11/15 at 3:03 PM with the Director of Nursing (DON) revealed Resident #2's pain medication should have been obtained from the emergency pharmacy so the medication could be started timely. She stated Resident #7 should not have missed his/her scheduled doses of pain medications due to the pharmacy not delivering the medications. The interview further revealed that narcotic pain medications could be obtained from the emergency pharmacy; however, the prescription had to be written on a different prescription pad. Interview on 03/11/15 at 5:10 PM with the Administrator revealed the facility had services available to obtain medications after hours and on weekends. He stated that the services should be used to ensure medications were administered timely and to ensure residents did not miss doses of medications. The Administrator was not aware there was a problem with getting physician prescribed medications for the residents.

Based on observation, interview, and a review of facility policy and procedure it was determined the facility failed to store, prepare, and serve food under sanitary conditions. A dietary staff person was observed to raise a lid on a trashcan and discard trash and did not wash her hands after touching the trash can lid. In addition, a contract food delivery worker was observed to enter and exit the kitchen and deliver food without wearing a head covering. Cans of food with dents on the can seam were observed stored in the dry storage area available for use. The findings include: 1. A review of the facility's Prevention of Food-Borne Illness - Personal Hygiene policy, with a revision date of 09/01/14, revealed staff should wash their hands carefully with soap and water whenever they become soiled; immediately before work in the morning; after using the bathroom; after coughing, sneezing, or blowing the nose; after touching the hair, mouth, or cigarettes; after handling raw unwashed food and dirty dishes; before touching food, clean dishes and silverware. Observation conducted on 01/13/15 at 7:25 AM revealed Dietary Staff Member #1 removed her gloves and threw them away in the garbage container while touching the top of the lid. Dietary Staff Member #1 failed to wash her hands. Interview conducted with Dietary Staff Member #1 on 01/15/15 at 5:38 PM, revealed staff should wash their hands before any contact with food and after touching the garbage container and/or lid. Further interview with Dietary Staff Member #1 revealed she should have washed her hands after making contact with the garbage container lid. 2. A review of the facility policy titled "Receiving/Inspecting Deliveries," with a revision date of 09/01/12, revealed dietary facility staff was to instruct delivery personnel where to place items and which sanitation and food safety precautions were necessary. Observation conducted on 01/13/15 at 11:22 AM, 11:24 AM, 11:28 AM, and 11:50 AM, revealed a food delivery worker was observed to make trips in and out of the kitchen delivering food supplies without wearing a hair net. Interview with the food delivery worker on 01/13/15 at 11:50 AM, revealed he was not aware that he was supposed to wear a hair net and staff had not informed him a hair net was required. 3. A review of the facility policy titled "Damaged Products," with a revision date of 09/01/12, revealed food was inspected during delivery and before being accepted. Items later found to be damaged, spoiled, or otherwise unacceptable, were set aside and credit was obtained from the vendor if possible. Further review of the policy revealed dented, bulging, or otherwise damaged canned products were included in the definition of damaged products. Observation conducted on 01/13/15 at 7:20 AM, of the facility dry food storage area revealed four #10 cans of pineapple and one #10 can of fruit cocktail, with dents on the can seams, stored on a shelf with other cans of food available for resident use. Additional observation conducted during a sanitation tour of the dry storage area on 01/15/15 at 4:10 PM revealed three #10 cans of pineapple and one #10 can of apples, with dents on the can seam, stored on a shelf with other cans of food available for resident use. An interview conducted with the Dietary Manager on 01/15/15 revealed the dented cans should have been set aside and not utilized. Additional interview revealed the Dietary Manager checked the food storage weekly and was not aware the dented cans were available for use.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure the ambient air temperature levels were maintained between 71 and 81 degrees Fahrenheit in resident room [ROOM NUMBER] and the hallway outside resident room [ROOM NUMBER]. The temperature of resident room [ROOM NUMBER] was 66 degrees Fahrenheit on 01/14/15 at 8:38 AM and the temperature of the hallway outside resident room [ROOM NUMBER] was 68 degrees Fahrenheit on 01/14/15 at 8:38 AM. The findings include: Interview with the facility Maintenance Operations Supervisor on 01/15/15 at 3:33 PM revealed the facility did not have a written policy related to air temperatures in areas occupied by residents. However, the Maintenance Operations Supervisor stated they maintained temperatures in the facility with a minimum temperature of 72 degrees Fahrenheit in winter conditions and a maximum temperature of 85 degrees Fahrenheit in summer conditions. Observation of the air temperature in resident room [ROOM NUMBER] on 01/14/15 at 8:38 AM revealed the temperature to be 66 degrees Fahrenheit next to the window and 68 degrees Fahrenheit in the middle of the room. Continued observation revealed Resident A to be sitting up in a wheelchair next to the window in room [ROOM NUMBER] eating breakfast with a hooded sweatshirt on and the hood was pulled up to cover his/her head. Observation of the air temperature in the hallway outside resident room [ROOM NUMBER] revealed the temperature to be 68 degrees Fahrenheit. A group interview was conducted on 01/13/15 at 3:08 PM with 13 alert and oriented residents. During the interview one resident complained that his/her room (room [ROOM NUMBER]) was too cold. Interview with Resident A on 01/14/15 at 8:38 AM revealed his/her room temperature was cold and uncomfortable. Resident A stated, "I've told them I'm cold and they haven't done anything about it." Interview with the Mechanical Maintenance Operations Technician on 01/14/15 at 9:00 AM revealed the facility uses Automated Logic, which is a computer-controlled automated heating and air system to set and control air temperatures throughout the facility. Further interview with the Mechanical Maintenance Operations Technician revealed the facility had the ability to set the air temperature in each individual resident room and that room [ROOM NUMBER] was set on 71 degrees Fahrenheit. The Mechanical Maintenance Operations Technician stated that sometimes the temperature in the facility does get "a little cool" until the heat kicks on. Further interview with the Mechanical Maintenance Operations Technician revealed the computerized system would alarm and let them know if any temperatures in the facility dropped 2 degrees below what the thermostat temperature was set on. Continued interview with the Mechanical Maintenance Operations Technician revealed he was not aware of any residents being too cold. Interview with the Maintenance Operations Supervisor on 01/15/15 at 3:33 PM revealed if a resident makes a request to have their room temperature changed the staff member it was reported to should notify the charge nurse. The charge nurse would notify the ward clerk who would then send a work order to the Maintenance Department. Continued interview with the Maintenance Operations Supervisor revealed he had received no reports regarding temperatures in resident room [ROOM NUMBER] or anywhere in the facility. Interview with the facility Administrator on 01/15/15 at 6:10 PM revealed he had been monitoring facility air temperatures on a regular basis using the automated computer system and he was not aware of any issues with the temperatures in the facility.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to revise the comprehensive care plan for one (1) of twenty-two (22) sampled residents. Resident #11 was noncompliant with wearing oxygen as ordered by the physician. Facility staff was aware the resident exhibited this behavior, but failed to revise the resident's care plan to address the noncompliance. The findings include: Review of the facility policy titled "Care Plans-Comprehensive," (undated) revealed the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family, or representative (sponsor), developed and maintained a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain. In addition, the policy stated assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition changed. The policy stated the Care Planning/Interdisciplinary team was responsible for the review and updating of care plans. Review of Resident #11's medical record revealed the facility admitted the resident on 09/16/05, with [DIAGNOSES REDACTED]. Review of Resident #11's January 2015 physician orders revealed an order for [REDACTED]. A review of Resident #11's care plan revealed the facility identified the resident was at risk for impaired breathing and that the resident required oxygen at 2 liters. However, observation of Resident #11 on 01/13/15 at 10:15 AM and 2:39 PM, and on 01/14/15 at 8:52 AM revealed Resident #11 was not wearing oxygen. Further observations of Resident #11 on 01/15/15 at 9:41 AM revealed the resident was not wearing oxygen while sitting in a wheelchair at the nurses' station. Interview with State Registered Nurse Aide (SRNA) #4 on 01/15/15 at 9:41 AM revealed Resident #11 was known for pulling off his/her oxygen. The SRNA stated when the resident's oxygen was off she placed the resident's oxygen back on and explained to the resident that it helped with his/her breathing. Interview with Registered Nurse (RN) #3, who was also the Unit Manager, on 01/15/15 at 10:18 AM revealed Resident #11 had physician's orders for oxygen and was aware the resident removed his/her oxygen, but there was no evidence action had been taken to revise the resident's care plan. Interview with RN #5, who was also the Minimum Data Set (MDS) Coordinator, on 01/15/15 at 10:29 AM revealed she signed off on an Interdisciplinary Team (IDT) meeting held on 12/16/14, which revealed the IDT was aware that Resident #11 removed his/her oxygen at times. However, there was no evidence the IDT revised Resident #11's care plan to include the resident's behavior. RN #5 stated, "I probably overlooked it. If I see something about a resident refusing care, then, yes I should have care planned it."

Based on observation, interview, record review, and a review of the facility's policy, it was determined the facility failed to ensure services were provided in accordance with the written plan of care for one (1) of twenty-two (22) sampled residents (Resident #16). The facility developed a care plan for Resident #16 with an intervention for oxygen at 2 liters per minute. Observation of Resident #16 on 01/15/15 revealed the resident's oxygen was at 4 liters per minute. The findings include: Review of the facility's policy titled "Using the Care Plan," undated, revealed a resident's care plan should be used in developing the resident's daily care routines. Review of Resident #16's medical record revealed the facility admitted the resident on 08/08/08, with [DIAGNOSES REDACTED]. A review of Resident #16's January 2015 physician orders [REDACTED]. A review of Resident #16's care plan dated 11/11/14 revealed the facility identified that the resident required oxygen at 2 liters per nasal cannula. Observation of Resident #16 on 01/15/15 at 1:18 PM and 3:31 PM revealed Resident #16 was wearing oxygen at 4 liters per minute via nasal cannula, not at the physician-ordered 2 liters per minute. Interview with Resident #16 on 01/15/15 at 1:18 PM revealed State Registered Nurse Aide (SRNA) #1 increased Resident #16's oxygen after breakfast because Resident #16 was "smothering." Interview with SRNA #1 on 01/15/15 at 1:50 PM revealed after Resident #16 finished his/her breathing treatment, she increased Resident #16's oxygen to 3 liters per minute via nasal cannula. An interview with the Director of Nursing (DON) on 01/15/15 at 5:43 PM revealed Unit Managers and Nurses should be monitoring to ensure care plans were implemented.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of twenty-two (22) sampled residents (Residents #11 and #16) received oxygen at the prescribed/care planned rate. Residents #11 and #16 had physician's orders [REDACTED]. Resident #11 often removed his/her oxygen; however, the facility failed to revise the resident's care plan to address the resident's behavior. Observation of Resident #16 revealed the resident's oxygen was being administered at 4 liters per minute. The findings include: Review of the facility's policy, "Oxygen Administration - Monitoring Clients Receiving Oxygen," (undated) revealed facility staff was required to check physician's orders [REDACTED]. 1. A review of Resident #11's medical record revealed the facility admitted the resident on 09/16/05, with [DIAGNOSES REDACTED]. A review of Resident #11's January 2015 physician orders [REDACTED]. A review of Resident #11's care plan revealed the facility identified the resident was at risk for impaired breathing and the resident required oxygen at 2 liters. However, observations of Resident #11 on 01/13/15 at 10:15 AM and 2:39 PM, and on 01/14/15 at 8:52 AM revealed Resident #11 was not wearing oxygen. Additional observations of Resident #11 on 01/15/15 at 9:41 AM revealed the resident was sitting in a wheelchair at the nurses' station not wearing oxygen. An interview with State Registered Nurse Aide (SRNA) #4 on 01/15/15 at 9:41 AM, and with Registered Nurse (RN) #3, who was also the Unit Manager, on 01/15/15 at 10:18 AM, revealed they were aware Resident #11 often removed his/her oxygen, but there was no evidence action had been taken to revise the resident's care plan. Interview with RN #5, who was also the Minimum Data Set (MDS) Coordinator, on 01/15/15 at 10:29 AM and a review of the Interdisciplinary Team (IDT) notes for Resident #11 dated 12/16/14, revealed the IDT was aware that Resident #11 removed his/her oxygen at times. However, there was no evidence the IDT revised Resident #11's care plan to include the resident's behavior. RN #5 stated, "I probably overlooked it. If I see something about a resident refusing care, then, yes I should have care planned it." 2. A review of Resident #16's medical record revealed the facility admitted the resident on 08/08/08, with [DIAGNOSES REDACTED]. A review of Resident #16's January 2015 physician orders [REDACTED].#16 was required to received oxygen at 2 liters per minute per nasal cannula. Observations of Resident #16 on 01/15/15 at 1:18 PM and 3:31 PM revealed the resident was wearing oxygen at 4 liters per minute via nasal cannula, not at the physician-prescribed 2 liters per minute. Interview with Registered Nurse (RN) #3, who was also the Unit Manager, on 01/15/15 at 10:18 AM revealed nurses were required to check residents' oxygen liter flow every shift. Further interview with RN #3 revealed she completed random room checks every morning and at random times during the day to ensure that residents were getting proper care, which included checking to ensure oxygen was being administered at the correct rate. Interview with the Director of Nursing (DON) on 01/15/15 at 5:43 PM revealed nurses were required to review residents' physician orders, Medication Administration Records (MAR), and Treatment Administration Records (TAR) every shift and were required to document that residents were receiving oxygen at the correct liter flow. Further interview with the DON revealed all department heads were assigned to do random room checks daily to ensure proper care, including that oxygen was being provided.

Based on observation, interview, and policy review it was determined the facility failed to maintain effective infection technique in a manner to prevent the development and transmission of disease and infection for one (1) of twenty-two (22) sampled residents (Resident #8). On 01/13/15 at 3:30 PM, a State Registered Nurse Aide was observed to provide incontinence care for Resident #8. While wearing the soiled gloves used to provide incontinence care, the SRNA was observed to obtain items from the resident's closet and adjust Resident #8's Bi-Pap mask. The SRNA was observed to also place the soiled personal brief in the resident's wheelchair, which was a potential for the transmission of bacteria. The findings include: Review of the facility policy, "Nursing Assistant Textbook of Skills Manual Policy," (revision date July 2011) revealed hands should be washed with soap and water when there was contact with a resident. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/01/14, revealed the resident required extensive assistance for bed mobility and total assistance for toileting. Review of the MDS further revealed the resident was frequently incontinent of bowel and bladder. On 01/13/15 at 3:30 PM, State Registered Nurse Aide (SRNA) #5 was observed to don gloves and provide incontinence care to Resident #8. After providing incontinence care the SRNA, while still wearing soiled gloves, obtained supplies from the resident's closet and adjusted Resident #8's Bi -Pap mask. The SRNA was also observed to place the soiled personal brief on Resident #8's wheelchair prior to properly disposing of the brief. The SRNA did not remove her soiled gloves and wash her hands until right before leaving Resident #8's room. Interview conducted with SRNA #5 on 01/13/15 at 3:45 PM, revealed she had been trained to wash her hands with soap and water, and change gloves after contact with a resident. The SRNA stated she should have washed her hands and changed gloves prior to adjusting the resident's Bi-Pap mask. She also stated the soiled brief should not have been placed in the wheelchair. Interview with Unit Manager (UM) #2 on 01/15/15 at 4:30 PM revealed routine in-services were provided to all staff regarding infection control procedures, proper hand washing, and glove changing procedure. Unit Manager #2 also stated that staff was observed performing appropriate hand washing during her "rounds" and skill check-offs were completed without concerns. According to UM #2, skill competency evaluations were completed with SRNA staff annually and no problems had been identified related to lack of appropriate handwashing and glove changes. Interview with the Director of Nursing (DON) on 01/15/15 at 5:04 PM, revealed administrative staff was responsible for monitoring and conducting skill check-offs with staff, and staff should have changed gloves and washed hands after care was provided for the resident. The DON also stated the SRNA should have not placed the soiled personal brief in the wheelchair.

Based on observation, interview, record review, and review of the facility's investigation and policy and procedures, it was determined the facility's investigation failed to include resident interviews related to an allegation of abuse for one (1) of three (3) sampled residents (Resident #4). A review of the facility investigation revealed a State Registered Nurse Aide (SRNA) had locked Resident #4 in the "smoke room" after the resident did not exit the room when asked. A review of the facility investigation revealed Resident #4 was interviewed about the incident; however, the facility had failed to interview other residents who utilize the smoke room to determine if they had witnessed or been affected by similar violations. The findings include: A review of the facility policy titled "Abuse Prevention Program," revision date 07/16/12, revealed involuntary seclusion is defined as separation of a resident from other residents against the resident's will. The initial investigation should include interviews of witnesses including but not limited to the following: assigned caregiver, caregivers in the immediate area, potential witnesses such as visitors, family, roommates, and the alleged perpetrator. A review of the medical record for Resident #4 revealed the facility readmitted the resident on 11/27/13 with [DIAGNOSES REDACTED]. A review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the resident to be assessed to have a Brief Interview for Mental Status (BIMS) score of 10 which revealed the resident is moderately cognitively impaired. A review of the five-day final report of the facility investigation, dated 10/28/14, revealed the facility Social Worker (SW) observed SRNA #1 standing outside the facility smoke room by the pool table on 10/21/14. The SRNA informed the SW he/she was unable to get Resident #4 to leave the smoke room. Continued review of the investigation revealed SRNA #1 informed the SW that the SRNA had told Resident #1 if the resident did not come out of the smoke room the SRNA was going to lock the door. The SW then informed the SRNA she would get Resident #4 to come out. Further review of the investigation revealed when the SW went to the smoke room door, she observed Resident #4 inside the smoke room, and the door to the smoke room was locked. Review of the investigation revealed the SW informed SRNA #1 she should never lock a resident in a room or threaten to lock a resident in a room. SRNA #1 told the SW she had called the resident's bluff and locked the door because the resident would not come out of the smoke room. Further review of the investigation revealed Resident #4 did not appear to be in any distress when the smoke room door was opened. A review of the investigation revealed Resident #4 and staff that worked with the resident were interviewed; however, the investigation had no documented evidence that other residents that smoke were interviewed as part of the investigation. Further review of the investigation revealed SRNA #1 was immediately removed from the floor and resident care. Interview on 11/10/14 at 1:35 PM with Resident #4 revealed the only problem the resident had in the smoke room was when a worker locked the resident in there one day for a few minutes. The resident denied that he/she was "bothered" by the incident because the resident was able to finish his/her cigarette. A review of a witness statement written by SRNA #1 on 10/22/14 revealed on 10/21/14 at approximately 1:30 PM, SRNA #1 had informed all residents the smoke break was over and the residents needed to exit the smoke room. All of the residents had left the room except for Resident #4. The witness statement further revealed SRNA #1 informed the resident several times the smoke break was over and the resident needed to leave the smoke room but the resident continued to sit in the smoke room. SRNA #1 revealed she stated to Resident #4, "You better come out or I will lock the door," and Resident #4 stated to the SRNA, "You won't do it." The witness statement revealed SRNA #1 left the smoke room, locked the door, and assisted another resident in a wheelchair around the corner. Further review of the witness statement revealed SRNA #1 had no intentions of leaving the resident in the smoke room and did not mean any harm to the resident. Interview on 11/10/14 at 3:45 PM with the SW revealed she was walking toward the smoke room and observed SRNA #1 standing by the pool table. The SRNA informed the SW he/she was unable to get Resident #4 to come out of the smoke room. The interview further revealed SRNA #1 informed the SW that the SRNA had told Resident #4 if he/she did not come out of the smoke room the SRNA was going to lock the door. The SW informed SRNA #1 she would get the resident to come out. Continued interview revealed when the SW went to the smoke room door she observed Resident #4 inside the smoke room and the door to the room was locked. The SW revealed the smoke room door was unlocked by SRNA #1 and the resident came out of the smoke room and did not appear to be in any distress. The interview further revealed the SW informed SRNA #1 that staff should never lock or threaten to lock a resident in a room. Continued interview revealed the SW immediately reported the incident to the Director of Nursing (DON) and the SRNA was removed from the floor. The interview revealed the SW conducted the investigation of the incident and denied interviewing other residents related to the allegation because the allegation obviously happened and the SRNA admitted to locking the door of the smoke room. Interviews on 11/10/14 at 4:55 PM with the Administrator, DON, and Assistant Administrator revealed the administrative staff reviewed all investigations and did not find a problem with the investigation related to Resident #4. The interview further revealed the administrative staff felt the investigation was "an open and shut case" because SRNA #1 had reported locking Resident #4 in the smoke room. The administrative staff acknowledged that other residents that use the smoke room should have been interviewed as part of the investigation.