Every finding on record at Pioneer Trace Group LLC

Based on interview, record review, and review of the facility's document and polices, the facility failed to protect the residents' right to be free from mental and verbal abuse for 3 of 7 sampled residents, Resident (R) 1, R7, and R11. Resident (R) 2 had a history of verbal and physical outburst behaviors. Residents observed R2 throwing objects, physically hitting staff, and attempts were made to hit other residents and staff. This caused the residents psychosocial harm in which they made statements of being afraid, scared, walking on eggshells, and fear for their safety when R2 was around.Immediate Jeopardy (IJ) was identified on 05/21/2026 in the area of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation and was determined to exist on 05/13/2026. Substandard Quality of Care (SQC) was also determined to exist. The facility submitted an acceptable IJ Removal Plan on 05/27/2026. The immediacy was determined to be removed on 05/27/2026, prior to exit.The findings include:Review of the facility's policy titled, Reporting Abuse to Facility Management, dated 12/2023, revealed abuse was defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.Review of the facility's policy titled, Abuse Prohibition, dated 01/12/2017, revealed the facility would provide each resident with an environment free from any type of abuse. It further revealed the facility would not condone any form of resident abuse and would continually monitor response to the facility's policies, procedures, training programs, and system to prevent resident abuse from occurring. 1. Review of R2's admission Record revealed the facility admitted the resident on 12/03/2024 with diagnoses of mood (affective) disorder, persistent mood disorder, genetically related intellectual disability, anxiety disorder, moderate intellectual disabilities, developmental disorder of scholastic skills, conduct disorders, and mild dementia.Review of R2's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/10/2026 revealed the facility assessed R2 to have a Brief Interview for Mental Status [BIMS] score of nine of 15, indicating moderate cognitive impairment. Review of the facility's document Long Term Care Facility - Self-Reported Incident Form, dated 01/08/2026, revealed R1 and R2 were involved in a resident-to-resident altercation. According to witness interviews conducted by the facility, R2 told R1, I hate you, and I'm not going to talk to you, and I'm going to kill you. The report revealed staff separated the residents, initiated 1:1 supervision, and R2 was sent to the emergency room for evaluation, returning to the facility the same day. Further review of the facility's investigation revealed R1 stated he did not feel safe at the facility due to R2.Review of R2's undated Care Plan revealed the facility identified verbally abusive behaviors related to moderate intellectual disability, mood disorder, aggressive behavior, and developmental delay. The care plan focus was initiated on 12/10/2024 and documented incidents, including becoming verbally abusive toward a roommate, striking a visitor, yelling and cursing at staff, yelling profanities at residents, behavioral outbursts in the dining room related to seating arrangements on 01/19/2026, yelling and cursing while hitting a handrail on 01/30/2026, yelling and cursing on 02/01/2026, and becoming upset with another resident in the dining room on 02/05/2026. Interventions initiated on 12/10/2024 included analyzing triggers and circumstances associated with behaviors, assessing coping skills, evaluating medication side effects, providing positive feedback for appropriate behaviors, obtaining psychiatric consultation as indicated, redirecting the resident, and removing the resident from situations when behaviors escalated. Additional interventions included offering diversion activities, initiated on 04/06/2026, and utilizing noise-reduction earphones, initiated on 05/14/2026, after the 05/13/2026 incident with R1.Further review of R2's undated Care Plan further revealed the facility identified physical aggressive behaviors related to moderate intellectual disability, mood disorder, aggressive behavior, and developmental delay. The care plan focus was initiated on 12/10/2024 and documented incidents in which R2 struck a visitor on 12/06/2024, struck an employee on 04/16/2025, struck a staff member on 05/09/2025, and struck a staff member on 10/31/2025. Interventions included 15-minute monitoring initiated on 01/09/2026, monitoring and reporting danger to self and others, identifying triggers, providing redirection, and removing the resident from situations when behaviors escalated. Continued review revealed an additional behavior focus was initiated on 02/03/2026 after R2 slammed a bedroom door, kicked a footboard, thrashed in bed, threatened to break her glasses, repeatedly yelled profanities, and stated, I'm going to wring my neck. Interventions included one-to-one supervision, physician notification, family notification, transfer to the emergency room for evaluation, and assist the resident in identifying safer coping mechanisms.Further review of R2's undated Care Plan revealed a behavior focus initiated on 02/19/2026, after the resident became agitated when asked to move to allow another resident access through an area, yelled and cursed, hit and kicked a wall and closet, threw items in her room, and made statements of self-harm. Interventions included one-to-one supervision, physician notification, family notification, psychiatric consultation, and allowing the resident to calm down in her room. Continued review revealed an additional behavior focus was initiated on 03/10/2026 for poor impulse control, yelling and cursing at others when she did not get her way, becoming easily agitated, anxious, and upset. Interventions initiated on 03/10/2026 included assisting the resident in developing appropriate coping mechanisms, identifying triggers, de-escalating behaviors, removing the resident from situations as necessary to protect the rights and safety of others, offering diversion activities, redirecting the resident to her room, and removing the resident to a quieter area when upset.Further review of R2's undated Care Plan revealed a behavior focus was initiated on 04/13/2026, after the resident became agitated and combative with staff and others. Interventions included 15-minute checks, psychiatric consultation, maintaining the resident in view of the staff, and redirecting the resident to her room. Continued review revealed a behavior focus was initiated on 05/13/2026, after the resident cursed and spat at another resident. Interventions included 1:1 supervision, redirection, encouraging involved residents to sit apart in the dining room, changing 1:1 supervision to 15-minute checks, and separating residents in the dining room.Review of a Physician Note, dated 01/27/2026, revealed the resident had recently been sent for psychiatric evaluation in the local (ED) Emergency department after a resident cut in line in the cafeteria line in front of her, and R2 began threatening the other resident and stating, I will kill you, you bitch. Documentation revealed the resident was transferred to the emergency room to be evaluated by psychiatric services and discharged back to the facility that day. The physician further documented the facility would closely monitor the resident and seek to avoid similar situations. Review of R2's Progress Notes, dated 01/30/2026 at 3:04 PM and written by Licensed Practical Nurse (LPN) 6 revealed R2 became agitated while sitting at the nurses' station when another resident attempted to pass through the area. Documentation stated R2 leaned forward and then threw herself backward in her wheelchair while yelling, I hate you bitch. The note further documented R2 continued yelling profanities until staff redirected her to her room and turned on the television.Review of R2's Progress Notes, dated 01/30/2026 at 3:15 PM and written by Registered Nurse (RN) 2, revealed R2 was yelling, I hate you bitch. Documentation stated R2 threw items from her bedside table, removed and threw her eyeglasses across the room, kicked, threw herself backward into her wheelchair, and punched the side rail of her bed. The note documented staff attempted redirection and interventions for safety; however, R2 continued cursing, screaming at staff, and punching the bed rail.Review of R2's Progress Notes, dated 02/03/2026 at 11:01 AM and written by RN2, stated R2 slammed her bedroom door, kicked the footboard of her bed, thrashed in bed, threatened to break her glasses, and repeatedly yelled profanities. Per the note, R2 stated, I'm going to wring my neck, while pulling covers over her face. Staff attempted redirection; however, R2 remained agitated. RN2 further documented R2 was sent to the emergency department (ED) of a local hospital for an evaluation.Review of R2's Progress Notes, dated 02/17/2026 at 5:20 PM and written by RN2, revealed R2 became upset when staff was assisting her roommate to bed. The note stated R2 pulled the privacy curtain, slammed the room door, and screamed profanities while propelling herself in a wheelchair up and down the hallway in the unit.Review of R2's Progress Notes, dated 02/19/2026 at 6:49 AM and written by LPN1, stated R2 became upset when staff requested she move to allow another resident access to the nurses' station. Per the note, R2 was punching the wall with her fist, yelling profanities as she propelled herself down the hallway, and stated, I will kill myself. Review of R2's Progress Notes, dated 02/19/2026 at 1:39 PM and written by LPN1, revealed R2 propelled herself in her wheelchair toward her room while shouting profanities, including I hate you bitches and I'm never coming back. The note revealed once R2 entered her room, she kicked her closet door off track, punched the heater, and threw personal belongings throughout the room. Review of a psychiatric Progress Note, from an inpatient psychiatric hospital dated 02/20/2026 at12:45 PM, revealed the nursing facility staff reported increased aggressive behaviors toward others. The note stated R2 engaged in self-injurious behaviors, including bruising herself during behavioral outbursts, and had a history of verbal aggression, yelling, cursing, and making statements suggestive of self-harm. It further revealed that R2 had moments of anger due to feeling ignored or overlooked.Review of R2's Progress Note, dated 02/28/2026 at 3:05 PM and written by LPN9, revealed LPN9 notified the Medical Director of R2's increased behaviors with no new orders documented in the progress note. Review of R2's Progress Notes, dated 03/12/2026 at 3:22 PM and written by RN2, revealed other residents had politely asked R2 to allow them to pass her in the hallway when she began screaming profanities and punching and kicking the walls as she propelled herself down the hallway to her room. Review of R2's Progress Notes, dated 04/13/2026 at 4:46 PM and written by LPN9, revealed R2 became upset in the dining room when another resident sat at a table she believed was her seat. Per the note, R2 attempted to spit on other residents, spit on staff multiple times, threw a water bottle at staff, screamed profanities, attempted to throw her wheelchair, struck multiple staff members in the back and legs, attempted to kick at a resident who was sitting in the hallway, and hit LPN9 in the buttocks. The note described R2 as very combative and un-redirectable. Physician notification occurred, and orders were obtained to send R2 for further evaluation.Review of R2's Progress Note, dated 04/26/2026 at 1:20 PM and written by LPN9, revealed R2 was positioned in the hallway when another resident attempted to pass through the area. Per the note, staff asked R2 to move back so the other resident could pass. The note documented R2 attempted to back her wheelchair but bumped into another resident's leg. R2 became upset and stated, You're making me mad, I'm going to go off, and I hate it here. Documentation further revealed R2 propelled her wheelchair down the hallway, grabbed a meal tray from a dietary cart, threw it onto the floor, threw her glasses, and began swinging at Certified Nursing Assistants (CNA) who were attempting to shield other residents in the hallway from her punches. The note further stated R2 screamed profanities, including calling others whores and bitches, attempted to throw a wheelchair, overturned a wheelchair, and swung a wheelchair armrest at staff. Per the note, R2 entered another resident's room, slammed the door, kicked and struck the door, and then returned to her room where she continued screaming, slamming items, and exhibiting aggressive behaviors. Review of R2's Progress Note, dated 05/13/2026 at 1:34 PM and written by the Director of Nursing (DON), revealed R2 started screaming while in her room. Documentation indicated the Social Worker, DON, and Unit Manager responded. R2 attempted to slam her door but became upset when a curtain interfered with the door closing. Staff redirected R2, provided sips of water, and administered Tylenol for pain. Documentation indicated R2 was later observed sitting calmly on the side of her bed.Review of R2's Progress Note, dated 05/13/2026 at 1:38 PM and written by the DON, revealed R2 was observed in the hallway attempting to pick up and throw her wheelchair. Documentation indicated the wheelchair tipped backward; however, anti-tip devices prevented it from overturning. Per the note, the DON responded and offered to take R2 outside to the courtyard. Review of R2's Progress Note, dated 05/13/2026 at 4:40 PM and written by LPN6, revealed R2 became agitated while seated with other residents in the dining room during supper and began cursing at another resident. Documentation indicated staff separated the residents and moved them to different tables. The note identified the precipitating factor as another resident making faces at R2.Review of R2's Progress Note, dated 05/13/2026 at 4:47 PM and written by LPN6, revealed the Medical Doctor (MD) was notified of R2's behaviors. Documentation revealed the MD agreed for R2 to be placed on 15-minute checks related to behaviors.Review of the facility's investigation Long Term Care Facility-Self Reported Incident Form, completed and signed by the Administrator, dated 05/13/2026 at 4:33 PM, revealed R1 and R2 were involved in a verbal altercation in the dining room prior to supper. Further review revealed R2 became increasingly agitated, verbally threatened R1, and spit at R1 during the altercation. The investigation revealed staff witnessed R2 spit at R1 and acknowledged the residents had prior verbal altercations before the incident. 2. Review of R1's admission Record revealed the facility admitted the resident to the facility on [DATE] with diagnoses of cerebral infarction, vascular dementia, and generalized anxiety. Review of R1's quarterly MDS, with an ARD of 02/23/2026, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, which indicated R1 was cognitively intact.During an interview on 05/19/2026 at 3:00 PM, R1 stated she did not feel safe in the facility due to R2's outbursts. Review of a Grievance/Complaint Form, filed by R7 and dated 04/13/2026, revealed R7 reported not feeling safe in the facility due to R2's behaviors, including hitting, kicking, and spitting at staff and other residents. The Administrator documented in the grievance resolution that residents were provided a handout What To Do If You See Another Resident Having Behaviors, which instructed residents, to avoid engaging with residents exhibiting behaviors, seek a safe place (your room, dining room, or near staff), loudly say, 'I need help!,' take deep breathes, notify staff of what happened when it is safe, and remember staff were here to help keep everyone safe.3. Review of R7's admission Record revealed the facility admitted R7 on 11/15/2023 with diagnoses of chronic obstructive pulmonary disease (COPD), anxiety disorder, and depression. Review of R7's quarterly MDS, with an ARD of 04/20/2026, revealed the facility assessed R7 to have a BIMS score of 15 out of 15, which indicated R7 was cognitively intact.During an interview on 05/19/2026 at 11:05 AM, R7 stated he did not feel safe around R2, and he had previously informed the facility's administration he believed R2 would eventually hurt someone. R7 stated he avoided the dining room due to R2's behaviors and would go to other residents' rooms to protect them during R2's outbursts of behavior. R7 stated he felt he had to walk on eggshells when around R2. He further stated he was fearful that R2's behavior would cause him to beat the hell out of R2 to protect himself and other residents. R7 further stated she had observed R2 throw wheelchairs in the hallway and observed other aggressive and disruptive behaviors that involved R2 hitting staff so hard with her fist that staff had fallen to the floor. 4. Review of R11's admission Record revealed the facility admitted R11 on 06/21/2024 with diagnoses of chronic inflammatory demyelinating polyneuritis and anxiety disorder. Review of R11's quarterly MDS, with an ARD of 04/07/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated R11 was cognitively intact.During an interview on 05/20/2026 at 3:00 PM, R11 stated she hid behind the wall in her room when she heard R2 screaming because she was afraid R2 would hurt her. During an interview on 05/21/2026 at 2:30 PM, Licensed Practical Nurse (LPN) 6 stated staff attention was frequently redirected to R2 to prevent behavioral outbursts which prevented staff from meeting the needs of other residents. LPN 6 further stated the facility could not meet R2's needs, and the facility was not an appropriate placement for R2. In an additional interview, on 05/20/2026 at 4:00 PM, R11 stated she did not feel safe around R2. R11 stated she was wheelchair dependent and feared R2 would hurt her. R11 stated when R2 became upset, screamed, or exhibited behaviors, she would hide in her room because she was afraid of R2. R11 stated she altered her routes within the facility to avoid R2 and would not remain alone with R2. R11 further stated she observed R2 become upset, scream, and throw items, which caused her to discontinue a therapy session because she was nervous and unable to continue participation.During an interview with CNA9 on 05/18/2026 at 4:32 PM, CNA9 stated R2 had physically assaulted her on multiple occasions. CNA 9 stated R2 had struck her while she was positioning herself between R2 and other residents to protect the residents from being hit. CNA9 stated R2 had thrown items at her, hit her, and struck her with a closed fist to her chest, arms, and back. CNA 9 further stated R2 frequently threw items, including meal trays and wheelchairs, during behavioral episodes and expressed concern for the safety of other residents when R2 became agitated.During an interview on 05/21/2026 at 3:00 PM, CNA 1 stated R2 became upset when care was delayed and preferred that staff remain near her during care. CNA1 stated R2 became upset when she did not get her way.During an interview on 05/21/2026 at 3:25 PM, LPN6 stated multiple residents had reported they did not feel comfortable or safe around R2 following the incident with R1 on 05/13/2026. LPN6 further stated R2 required significant staff attention and supervision. LPN 6 stated R2's care needs frequently required staff intervention and, at times, affected staff's ability to provide care to other residents.During an interview with the Social Worker (SW) on 05/18/2026 at 2:30 PM, the SW stated the facility had not attempted to identify or secure an alternative placement for R2 despite ongoing concerns regarding R2's behaviors and reports from other residents that they did not feel safe in the facility. The SW stated no referrals had been made to other facilities, and no placement efforts had been initiated.During an interview with the Administrator on 05/21/2026 at 4:45 PM, she stated staff frequently contacted her for assistance in calming R2 during behavioral outbursts. The Administrator stated she believed R2 would benefit from a smaller group setting and had observed the dining room environment to be overstimulating for R2, frequently resulting in behavioral outbursts. The Administrator further stated, It is not my expectation for any of the residents to hide or live in fear in their home.During an interview with the Medical Director on 05/27/2026 at 2:30 PM, he stated his expectation was that residents should feel safe in the facility and not be fearful of other residents. The Medical Director stated he believed R2 would benefit from more focused, individualized care. He stated R2 might experience fewer behavioral outbursts if staff members were able to provide more attention to address her needs.The facility submitted an acceptable IJ Removal Plan on 05/27/2026, alleging removal of the IJ on 05/27/2026 as follows verbatim: Root cause of the immediate jeopardy:The facility failed to implement interventions to protect the residents' right to be free from abuse byResident #2.Resident(s) affected by the IJ:-Resident #2 has been attending day program 2x a week since 4/7/2026. Resident #2 attends this outpatient activity program from Approx. 8am to 430pm on the scheduled days. Beginning the 1st week of June the resident will go to the day program 3x a week. She attends this outpatient activity program from approx 8am to 430pm on the scheduled daysResident #2 had a verbal altercation with Resident #1 on 5/13/26 in the dining room and was observed to spit on Resident #1.-Resident #2 was placed on 1:1 then Q 15 min. checks on 5/13/26 to 5/15/2026-Resident #2 was placed on 1:1 when out of room and on 15 minute checks when in room starting on 5/21/2026.-A medication review was completed by the attending MD with the addition of increasing Rexulti to 2mg started on 5/16/2026, with noted improvement as of 5/21/2026.Resident(s) the facility identified at risk for IJ:-All residents are at risk for the cited deficiency-All interviewable residents were interviewed on 5/22/2026 by the Social Worker, with the question: Do you feel a sense of safety and security in facility. Residents interviewed had a BIMS 8 or greater with a total number of 46 residents interviewed by Social Worker on 5/22/2026 and a total number of 49 interviewed on 5/25/2026 by Administrator. All residents excluding 4 indicated they did not have any safety concerns in the last 7 days. 1 out of 4 residents baseline is feeling of fear unrelated to facility, 2 out of 4 residents stated they felt safe with exceptions and 1 out 4 residents state noise makes her nervous. 3 out of 4 residents declined interventions with 1 out of 4 residents with intervention in place and felt like intervention worked. R1 was offered a stop sign for door and declined and stated understanding that staff were for assistance. R7 currently has stop sign for door and states is effective. R11 declined stop signfor [sic] door for interview compelted [sic] on 5/22/2026. All residents interviewed on 5/25/2026 felt safe in the facility excluding one resident who's [sic] baseline is fearful.-Uninterviewable residents were assessed with a OV PHQ9 on 5/26/2026 by the Social Worker, Unit Nurse managers and Wound nurse. OV PHQ9 assessments completed on 24 residents with no concerns noted.Training:All staff have received in-serviced education on the regulatory requirements for F600 including but not limited to: the need to monitor, intervene and immediately report residents who demonstrate behaviors that present a risk to themselves or other residents; to immediately report all allegations of abuse; and to protect residents involved in an allegation of abuse from further abuse as completed by Administrator, Social worker, DON, Unit Nurse Coordinators, MDS and Wound Nurse by 5/24/2026. All staff members employed by Pioneer Trace have received in-service. Human Resources will be responsible for training of new hires and agency if facility were to use agency staff. Facility will continue to do bi-annually abuse and prevention education and testing as preformed by the social worker. Facility compelted inservice education to staff on 5/24/2026. Daily polling of staff to be completed by Administrator or DON to verify competency starting 5/25/2026. Questions will be asked: What do you do when you witness a resident having behaviors, what are some examples of Deescalation strategies, when do you report abuse.Systems Implemented:-The resident continues on Rexulti 2 mg with noted continued improvement in behaviors.-Resident #2 is still on 1:1 when out of room and 15min. Checks when in room.-Resident #2 ordered noise reduction earphones as tolerated implemented on 5/14/2026-The facilities Social Worker contacted the resident's day program on 5/22/2026 to determine the types of activities the resident is engaging in, and has added a selection of these to the facility activity program for the resident.-The facilities Social Worker contacted the PASSR agency on 5/22/2026 to determine if any other services are available for the resident.-An Ad Hoc QAPI meeting on 5/22/2026 was conducted with Medical Director, DON and Administrator. The meeting was held to discuss findings, interventions and impleme11tation related to the citation for abuse and care plans.Monitoring:-The QAPI audit tool for the monitoring of compliance with the F 600 requirements including but not limited to protecting residents from abuse, immediately reporting of abuse allegations, and implementation of care plan interventions for residents with behaviors that may pose a risk of abuse to others.-Interviewable resident will be interviewed daily during IJ period, regarding any-safety concerns in the facility and then every 2 weeks for 1 month, then monthly for 2 months, and then quarterly to determine if there are any resident behavior or other potential risks for abuse that need to be addressed as completed by Social Worker or Administrator. Social Worker or Administrator will be responsible for reporting results.-During IJ period Administrator or Social Worker to interview residents with the question: Do you feel a sense of safety and security in facility. Interviews will be conducted on a period of Mondays -Fridays starting on 5/25/2026 and will conclude after IJ period and review with QAPI agrees.-Facility to complete daily AD HOC QAPI meetings daily starting 5/25/2026 during IJ period.Alleged removal date:5/27/2026

Based on interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure residents' care plans were revised to include interventions needed to provide person-centered care related to supervision and monitoring to ensure safety for 1 of 28 sampled residents, Resident (R) 5.Interviews with staff revealed that on 05/02/2026 at approximately 5:55 PM, staff observed the resident exiting the facility and they were able to intervene and return the resident back to the facility. However, the facility failed to revise the resident's care plan to include interventions that would increase the resident's supervision and/or monitoring. Review of the facility's investigation revealed R5 eloped from the facility on 05/02/2026 at approximately 8:11 PM and was found outside near the back facility entrance roadway by Dietary Aide 1 who was taking out trash. The investigation revealed R5 traveled approximately 286 feet from the facility's entrance, in her wheelchair over an uneven surface, without staff awareness or supervision. Immediate Jeopardy (IJ) was identified on 05/21/2026 in the area of 42 CFR 483.21 Comprehensive Person-Centered Care Plans and was determined to exist on 05/02/2026. The facility submitted an acceptable IJ Removal Plan on 05/27/2026. The immediacy was determined to be removed on 05/27/2026, prior to exit. Refer to F689The findings include:Review of the facility's policy titled, Care Plans - Comprehensive, undated, revealed areas of concern identified during resident assessments were to be evaluated using specific assessment tools before interventions were added to the care plan. The review further revealed assessments were ongoing, and care plans were to be revised as information about the resident and the resident's condition changed. The policy further revealed the interdisciplinary team (IDT) was responsible for reviewing and updating care plans when there was a significant change in the resident's condition, when the desired outcome was not met, when the resident was re-admitted to the facility after a hospital stay, and at least quarterly.Review of R5's admission Record revealed the facility admitted the resident on 11/04/2025 with diagnoses including Wernicke's encephalopathy (caused mental status changes and confusion) and agitation.Review of R5's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/29/2026, revealed the facility assessed R5 to have a Brief Interview for Mental Status [BIMS] score of nine out of 15, indicating moderate cognitive impairment.Review of R5's MDS Ancillary Assessment, dated 11/11/2025, 02/02/2026, 04/29/2026, and 05/04/2026 revealed R5 was assessed as high risk for wandering/elopement. Review of R5's undated Care Plan Report revealed a focus area for wandering/exit-seeking behaviors. The care plan documented exit-seeking behaviors on 11/09/2025, 01/06/2026, 02/16/2026, and 04/10/2026. The care plan noted R5 was easily redirected and frequently verbalized wanting to go home. The care plan revealed interventions including monitoring every shift and application of a WanderGuard bracelet initiated on 11/09/2025. Additional interventions initiated on 01/29/2026 included scheduled hydration one hour prior to bedtime, assisting R5 to bed immediately on second shift if pacing or exit-seeking behaviors continued, providing care in a calm and reassuring manner, reorientation to surroundings and environment, and reminding R5 frequently to notify staff with needs. Fifteen-minute location checks were implemented following documented exit-seeking behaviors. Further review revealed the interventions for scheduled hydration, assisting R5 to bed immediately on second shift if pacing or exit-seeking behaviors continued, providing care in a calm and reassuring manner, reorientation to surroundings and environment, reminding R5 frequently to notify staff with needs, and fifteen-minute location checks were marked as resolved. The care plan did not identify dates these interventions were resolved. The ongoing interventions identified in the care plan were monitoring every shift and use of a WanderGuard bracelet. The care plan continued to document exit-seeking behaviors on 01/06/2026, 02/16/2026, and 04/10/2026.Review of R5's Physician's Orders, dated 11/09/2025 revealed an order for a WanderGuard bracelet related to wandering behaviors.Review of the facility's investigation form Long Term Care Facility Self-Reported Incident Form, completed and signed by the Administrator, dated 05/02/2026 at 8:12 PM, revealed R5 was found near the back facility entrance roadway by Dietary Aide 1 while taking out trash at approximately 8:11 PM. During an interview with the Administrator on 05/20/2026 at 4:00 PM, she stated when she documented the investigation of the incident that occurred on 05/02/2026 at 8:11 PM, she was unaware of the resident's exit seeking behaviors or prior attempts on that day, 05/02/2026.During an interview on 05/18/2026 at 7:58 AM, Certified Nursing Assistant (CNA) 2 stated she was aware R5 had been exhibiting exit-seeking behaviors. CNA2 further stated day shift staff had reported that R5 and another resident had been discussing ways to leave the facility earlier that day. During an interview on 05/21/2026 at 2:00 PM, CNA3 stated R5 had a history of attempting to leave the facility. CNA3 stated R5 made multiple attempts to exit the facility on 05/02/2026 and was determined to leave the facility. She stated the nurses working at the time were aware of the incident.During an interview on 05/20/2026 at 12:41 PM, CNA1 stated R5 tailgated visitors through the facility's front entrance at approximately 5:55 PM on 05/02/2026. CNA1 stated R5 exited the facility in her wheelchair through the front entrance doors and traveled approximately 60 feet from the facility's entrance before staff intervened and returned R5 to her unit near the nurses' station. She stated the nurses working at the time were aware of the incident.Further review of R5's undated Care Plan Report revealed no documented evidence to suggest the facility revised the resident's care plan to include the resident's attempt to elope at 5:55 PM on 05/02/2026. Review of Licensed Practical Nurse (LPN) 3's Health Status Progress Note, dated 05/02/2026 at 8:56 PM, revealed R5 eloped from the facility and was found by dietary staff at 8:11 PM. The note further revealed administration was notified at 8:12 PM, and R5 was placed on 1:1 supervision.During an interview on 05/20/2026 at 11:21 AM, LPN3, the nurse assigned to R5 at the time of 05/02/2026 attempted elopement at 5:55 PM and the elopement at 8:11 PM, stated day shift staff had not communicated to her that R5 had exhibited exit-seeking behaviors on their shift on 05/02/2026. She stated she had not implemented additional interventions related to R5's elopement risk behavior on 05/02/2026 at 5:55 PM. She stated she was not aware R5 was exit seeking prior to the elopement and had not been told by the CNAs about the tailgating incident at 5:55 PM.During an interview on 05/21/2026 at 1:00 PM, the Minimum Data Set (MDS) Coordinator stated when a resident began demonstrating exit-seeking behaviors, new interventions should be immediately implemented and added to the care plan. The MDS Coordinator stated 1:1 supervision and 15-minute checks would have been appropriate interventions following R5's exit-seeking behaviors and attempts to leave the facility on 05/02/2026 prior to the actual elopement. The MDS Coordinator further stated all licensed nurses were able to enter new interventions into the care plan and were responsible for updating the care plan when new interventions were implemented. During an interview with the Director of Nursing (DON) on 05/20/2026 at 12:11 PM, she stated the nurse working at the time of an exit-seeking incident was expected to immediately implement interventions. She stated then, the interdisciplinary team (IDT), whose members included the Administrator, herself (DON), the Unit Managers, the MDS Coordinator, and the Dietary Manager, would review the resident's care plan the following day to determine whether additional interventions were needed.During continued interview with the Administrator on 05/20/2026 at 4:00 PM, she stated staff was expected to identify exit-seeking behaviors and immediately implement interventions to prevent residents from leaving the facility unsupervised and to ensure resident safety. The Administrator stated interventions should be initiated as soon as exit-seeking behaviors were observed. The facility provided an acceptable IJ Removal Plan on 05/27/2026 which alleged removal of the IJ on 05/27/2026 as follows verbatim:Root cause of the immediate jeopardy: The facility failed to review/revise the care plan for Resident #5 related to wander risk behaviors. MDS and DON reviewed Resident #5 careplan on 5/21/2026 for appropriate interventions, intervention of 15min checks to remain continuously. Resident(s) affected by the IJ:Resident #5 exited the facility on 5/2/26.-The resident was returned into the facility on 5/2/26 and received a head-to-toe skin assessment with no injuries noted. Vitals within normal range. Vitals and assessments completed by resident's nurse, the resident was placed 1:1 until bedtime and 15-minute checks were initiated and continuous. Resident #5 care-plan was revised to include interventions of 1:1 until bedtime and 15-minute check continuously.Resident(s) the facility identified at risk for IJ:All residents identified with wander risk behaviors had the potential to be affected. 100 % audit was completed by unit nurse coordinators for the last 30 days of charted wandering/exit seeking behaviors, 21 residents identified. Care-plans were reviewed/revised with any indicated interventions, completed by unit nurse managers and MOS on 5/22/2026 for all 21 residents identified with wander/exit seeking behaviors. Floor nurses are responsible for adding care-plans on residents with exit seeking behaviors to include interventions which may include increased supervision.Training:All staff have received in-service education on the facility policy/protocol for wander risk management including but not limited to:-Consistent implementation of resident specific care plan interventions for the monitoring and prevention of residents exiting the facility unsupervised.-All staff in-serviced on the procedure for checking outside of a door when the alarm system sounds and for completing a head count to determine that all residents are accounted for.-The increased monitoring process for residents that demonstrate exit seeking behaviors.-All Staff in-serviced on the importance of notifying the DON/Nurses Management/Administrator if wander risk interventions are not effective or if any new wander risk behavior residents are identified so that care plans may be reviewed and revised as needed.-Disciplinary actions that will be implemented for staff that fail to follow the facility protocol for response to door alarms.-Education on care planning, reporting incidents per chain of command and documenting.This training was provided by Administrator, Social worker, DON, Unit Nurse Coordinators, MDS and Wound Nurse by 5/24/2026. All staff members employed by Pioneer Trace have received inservice.Human Resources will be responsible for training of new hires and agency if facility were to use agency staff. Facility completed inservice education to staff on 5/24/2026. Daily polling of staff to be completed by Administrator or DON to verify competency starting 5/25/2026. Questions will be asked: When should you implement an intervention related to exit seeking, When do you implement a care-plan related to exit seeking, what are some examples of interventions for exit seeking.Systems implemented-100 % audit was completed by unit nurse managers and MDS for the last 30 days of charted wandering/exit seeking behaviors. Care-plans were reviewed/revised with any indicated interventions, completed by unit nurse managers and MDS on 5/22/2026.-Disciplinary action was implemented for immediate staff involved the day of the elopement for failure to notify and implement interventions.-Ad Hoc QAPI meeting on 05/22/2026 conducted with Medical Director, DON and Administrator. The meeting was held to discuss interventions and implementation related to elopement and care planning.Monitoring:-Unit nurse managers will audit care-plan documentation for residents identified with wander risk/ behaviors weekly x 4 weeks to determine any need for revisions and will then utilize the QAPI audit tool as outlined below.-Unit nurse managers to review progress notes every morning from the previous day Monday - Friday (weekends to be reviewed following Monday) to identify any wander risk behaviors and will determine that they have been addressed on the care plan.-Facility to complete daily AD HOC QAPI meetings daily starting 5/25/2026 during IJ periodAlleged Removal Date: 5/27/26

Based on observation, interview, record review, review of the website https://www.localconditions.com, review of the facility's investigation, and review of the facility's policies, the facility failed to have an effective system in place to ensure each resident received adequate supervision and monitoring. The facility failed to implement interventions and adequate supervision for 1 of 20 sampled residents to prevent unsafe wandering and elopement, Resident (R) 5.Review of the facility's investigation revealed R5 eloped from the facility on 05/02/2026 at approximately 8:11 PM and was found outside near the back facility entrance roadway by Dietary Aide 1, who was taking out trash. The investigation revealed R5 traveled approximately 286 feet from the facility entrance, in her wheelchair, over an uneven surface, without staff awareness or supervision.Immediate Jeopardy (IJ) was identified on 05/21/2026 in the area of 42 CFR 483.25 Quality of Care and was determined to exist on 05/02/2026. Substandard Quality of Care (SQC) was also determined to exist. The facility submitted an acceptable IJ Removal Plan on 05/27/2026. The immediacy was determined to be removed on 05/27/2026, prior to exit. The findings include: Review of the facility's policy titled, Wander Monitoring System, undated, revealed staff was required to promptly respond to door alarms, redirect residents away from alarmed areas, and reset alarms only after determining the area was clear. Review of the facility's policy titled, Wander Monitoring System-Sounding, undated, revealed staff was required to immediately respond when the alarm sounded, identify the source of the alarm, search the area of the activated door, and complete a resident head count if the source of the alarm could not be identified. Review of the facility's policy titled, Elopements, undated, revealed staff was required to promptly report a resident suspected of being missing, initiate a search of the building and premises, and notify administration. Review of the local weather conditions at https://www.localconditions.com, dated 05/02/2026, revealed at approximately 8:00 PM the outdoor temperature of 47 degrees Fahrenheit, with wind gusts up to 10.7 miles per hour. 1. Review of R5's admission Record revealed the facility admitted R5 on 11/04/2025 with diagnoses including Wernicke's encephalopathy, lack of coordination, muscle weakness, and age-related physical debility. Review of R5's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/29/2026, revealed the facility assessed R5 to have a Brief Interview for Mental Status [BIMS] score of nine of 15, indicating moderate cognitive impairment. Review of R5's undated Care Plan Report revealed a focus area for wandering/exit-seeking behaviors. The care plan documented exit-seeking behaviors on 11/09/2025, 01/06/2026, 02/16/2026, and 04/10/2026. The care plan noted R5 was easily redirected and frequently verbalized wanting to go home. The care plan revealed interventions including monitoring every shift and application of a WanderGuard bracelet initiated on 11/09/2025. Additional interventions initiated on 01/29/2026 included scheduled hydration one hour prior to bedtime, assisting R5 to bed immediately on second shift if pacing or exit-seeking behaviors continued, providing care in a calm and reassuring manner, reorientation to surroundings and environment, and reminding R5 frequently to notify staff with needs. Fifteen-minute location checks were implemented following documented exit-seeking behaviors. Further review revealed the interventions for scheduled hydration, assisting R5 to bed immediately on second shift if pacing or exit-seeking behaviors continued, providing care in a calm and reassuring manner, reorientation to surroundings and environment, reminding R5 frequently to notify staff with needs, and fifteen-minute location checks were marked as resolved. The care plan did not identify dates these interventions were resolved. The ongoing interventions identified in the care plan were monitoring every shift and use of a WanderGuard bracelet. The care plan continued to document exit-seeking behaviors on 01/06/2026, 02/16/2026, and 04/10/2026. Review of R5's Elopement/Wander Risk Evaluation, dated 11/11/2025 at 12:10 PM and completed by Licensed Practical Nurse (LPN) 8, revealed R5 scored 16, which identified the resident as a mild risk for elopement if the score was between 15 and 18. Documentation identified the resident had a history of exit-seeking behavior, cognitive impairment, and impaired safety awareness. Review of R5's Elopement/Wander Risk Evaluation, dated 05/04/2026 at 3:07 PM and completed by the Minimum Data Set (MDS) Coordinator, revealed R5 scored 16, which identified the resident as mild risk for elopement. However, review of R5's MDS Ancillary Assessment, dated 11/11/2025, 02/02/2026, 04/29/2026, and 05/04/2026 revealed R5 was assessed as high risk for wandering/elopement. Review of R5's Physician's Orders, dated 11/09/2025 at 2:43 PM, revealed the physician ordered, Secure wander alert to left ankle. Monitor every day and night. Review of the facility's investigation form Long Term Care Facility Self-Reported Incident Form, completed and signed by the Administrator, dated 05/02/2026 at 8:12 PM, revealed R5 was found near the back facility entrance roadway by Dietary Aide 1 while taking out trash at approximately 8:11 PM. The investigation revealed R5 traveled approximately 286 feet from the facility entrance, in her wheelchair, over an uneven surface, without staff awareness or supervision. Further investigation revealed at least two residents, including a resident who wore a WanderGuard bracelet, knew the code to silence the WanderGuard door alarms. Staff interviews further revealed the WanderGuard alarms frequently sounded during evening hours, and alarms were not always immediately responded to if staff was providing resident care. The investigation further revealed the facility was experiencing increased visitor traffic due to the local high school prom, and the facility's door alarms frequently sounded between 6:00 PM and 8:30 PM due to resident smoking times and shift change activities. Review of R5's Progress Notes, dated 05/02/2026 at 8:56 PM and written by LPN3, revealed R5 eloped the building and was found at 8:11 PM the same evening.During an interview on 05/20/2026 at 12:41 PM, Certified Nursing Assistant (CNA) 1 stated R5, who wore a WanderGuard bracelet (a device worn by residents to prevent elopement that caused the door with an alarm to sound when the resident exited the door) tailgated visitors out the facility door on two occasions at approximately 5:55 PM on 05/02/2026. CNA1 stated during the second attempt, R5 exited the facility in her wheelchair and traveled approximately 60 feet from the front entrance before staff intervened and returned R5 to her Unit near the nurses' station.During an interview on 05/20/2026 at 5:05 PM, LPN5 stated she responded to the facility door alarm at approximately 7:45 PM on 05/02/2026 and observed another resident coming through the door. LPN5 stated she entered the code to reset the alarm and did not look outside because she assumed the resident coming through the door had activated the alarm. During an interview on 05/19/2026 at 2:30 PM, Dietary Aide 1 stated while taking trash from the building on 05/02/2026, he discovered R5 outside near the facility's roadway. Observation on 05/19/2026 at 2:30 PM with the Maintenance Director and Dietary Aide 1 revealed the distance from the facility's front entrance to the location where R5 was found measured approximately 286 feet. During an interview with R5 on 05/18/2026 at 3:00 PM, she stated she could not recall the elopement event. Observation of R5 on 05/18/2026 at 10:00 AM, 12:15 PM, 2:15 PM, and 5:30 PM revealed she remained near the facility's front entrance and close to the exit door. During an interview on 05/18/2026 at 5:39 PM, CNA21 stated R6 and R7 knew the facility's front door access code and independently utilized the code to enter and exit through the facility's front entrance prior to the elopement incident. CNA21 stated the facility door access code was changed following R5's elopement incident. 2. Review of R6's electronic health record (EHR) revealed the resident was wearing a WanderGuard bracelet due to an elopement risk. During an interview on 05/19/2026 at 2:00 PM, the Administrator stated the facility's Quality Assessment and Performance Improvement (QAPI) committee and administration was aware residents knew the facility's front door access code prior to the elopement incident. She stated the two residents (R6 and R7) heard staff telling someone else the code to get in and started using it. The Administrator further stated the facility was unable to independently change the code, and the door access company was not contacted to change it until after R5's elopement. The Administrator stated no additional monitoring of the entrance doors or residents was implemented prior to the elopement incident despite the facility's awareness that residents knew the front door access code. During an interview on 05/20/2026 at 12:41 PM, CNA1 stated, on 05/02/2026 at approximately 5:55 PM, R5 exited the facility through the front entrance by tailgating visitors. She stated staff then observed R5 approximately 60 feet from the entrance and redirected her back inside the facility. CNA1 further stated the facility did not increase R5's monitoring. During an interview with Housekeeper 22 on 05/20/2026 at 12:20 PM, she stated R5 had a smoking break on 05/02/2026, which began around 6:50 PM and ended at approximately 7:20 PM. She stated she routinely assisted residents outside during these times and saw R5 near the front entrance during the evening smoking break. She stated staff often did not respond to door alarms during these periods. 3. During an interview on 05/19/2026 at 7:00 PM, R7 stated, on the evening of 05/02/2026, the facility door alarm sounded for an extended time without staff response. R7 stated he told LPN3 he would check the alarm and saw LPN5 enter the code to silence it without verifying the exterior. R7 stated he routinely signed himself out and accessed the facility grounds independently for smoking breaks and, therefore, knew the front entrance door code. During an interview on 05/20/2026 at 4:37 PM, CNA5 stated between 7:00 PM and 8:00 PM on 05/02/2026, she heard the facility door alarm but did not respond, assuming the nursing staff had already addressed it.During an interview on 05/20/2026 at 5:05 PM, LPN5 stated, at approximately 7:45 PM on 05/02/2026, she responded to the facility door alarm by entering the code to reset it but did not check outside to determine the cause of the alarm activation. During an interview on 05/20/2026 at 11:21 AM, LPN3 stated on 05/02/2026, R7 informed her he was going to check the alarm and later told her another nurse had reset it. During continued interview on 05/19/2026 at 2:00 PM, the Administrator stated staff was expected to immediately respond to door alarm activations, determine the cause of the activation, inspect the exterior area, and complete a resident count if the cause of the alarm could not be determined. The Administrator stated, once a resident with a WanderGuard bracelet exited the door, the alarm would continue sounding until staff entered the code to reset the system. During an interview on 05/27/2026 at 2:10 PM, the Medical Director stated he expected all staff, regardless of department, to immediately respond to door alarm activations. The Medical Director stated the facility needed to gain control of the front entrance door system to prevent residents at risk for elopement from leaving the facility. The facility submitted an acceptable IJ Removal Plan on 05/27/2026 alleging IJ removal on 05/27/2026 as follows verbatim:Root cause of the immediate jeopardy:The facility failed to implement interventions to prevent Resident #5 from exiting the facility without supervision. All residents who have exit seeking behaviors are at risk.Resident(s) affected by the IJ:Resident #5 exited the facility on 5/2/26.The resident was returned into the facility on 5/2/26 and received a head-to-toe skin assessment with no injuries noted. Vitals within normal range. Vitals and assessments completed by resident's nurse, the resident was placed 1:1 until bedtime and 15-minute checks were initiated and continuous.Resident(s) the facility identified at risk for IJ:All residents identified with wander risk behaviors had the potential to be affected. 100 % audit was completed by unit nurse coordinators for the last 30 days of charted wandering/exit seeking behaviors, 21 residents identified. Care-plans were reviewed/revised with any indicated interventions, completed by unit nurse managers and MDS on 5/22/2026 for all 21 residents identified with wander/exit seeking behaviors. Floor nurses are responsible for adding care-plans on residents with exit seeking behaviors to include interventions which may include increased supervision.Training:-The Facility provided re-education for all staff on elopement and wandering, responding to door alarms as well as completing a headcount and area search, on 5/4/2026 - 5/8/26 and again beginning 5/22/26 and was completed on 5/24/2026. Staff in serviced that only staff may have knowledge of Door Alarm code on 5/8/2026 and completed again on 5/24/26. Staff educated that if door code is shared with any non-employed staff of Pioneer Trace, that employee would face disciplinary actions up to termination.Education was completed 5/24/2026. This training was provided by Administrator, Social worker, DON, Unit Nurse Coordinators, MDS and Wound Nurse by 5/24/2026. All staff members employed by Pioneer Trace have received inservice. Human Resources will be responsible for training of new hires and agency if facility were to use agency staff. Facility completed inservice education to staff on 5/24/2026. Daily polling of staff to be completed by Administrator or DON to verify competency starting 5/25/2026.Questions will be asked: When should you respond to a door alarm, should you check outside when responding to a door alarm, what do you do if you do not locate a resident when responding to a door alarm.Systems implemented-The Facility did a complete accounting for all residents, all residents in the building and or accounted for, this occurred on 5/2/2026. Completed by floor staff on shift.-Polling of residents completed on 5/2/2026. Questions related to asking residents if they wanted to go outside, would they know what to do and questions related to asking residents if it is hard to stay inside or ask for help when they want to go somewhere. Residents who expressed not knowing were educated, no other concerns noted. Completed by facility nurses.-All residents received an updated assessment for elopement on 5/4/2026 (Resident #5 previously identified as elopement risk and continues to be at risk). Completed by nursing management.-Maintenance Director contacted door alarm company to change master door code on 5/4/2026, door alarm company responded to facility on 5/5/2026 at 8am and successfully changed master door code and the secondary door code.-On 5/4/2026 all keypads were updated with signage for staff use only completed by the Administrator.-On 5/4/2026 important safety notice was given to residents explaining keypads are to be used by staff only and to ask for assistance when needing to use doors. Facility Administrator wrote safety notices and activities department delivered to residents.-On 5/4/2026 important safety notice to all visitors was posted on the front doors, notice will be kept up for four weeks and then moved to guest sign in area. Administrator wrote safety notice and placed it on front door.-Ad Hoc QAPI meeting on 5/5/26 conducted with Medical Director, DON and Administrator. The meeting was held to discuss interventions and implementation related to elopement.-On 5/21/26 the facility initiated a second staff member to assist with all smoke breaks. This process also included that when all smoke breaks are completed, smoking assisting staff will notify nurses on duty that smoke break have concluded to eliminate the confusion on door alarms associated with smoke breaks.Monitoring:-The Facility conducted an elopement drill on 5/6/2026 and again on 5/22/26 with no concerns noted, completed by Maintenance Director. Facility to conduct elopement drills 2x a day for both shifts daily starting Monday 5/25/2026 and continue while facility is in IJ period, will conclude after IJ period and review with QAPI agrees. Elopement drills will be conducted by Administrator, Maintenance Director or DON.-Facility to complete daily AD HOC QAPI meetings daily starting 5/25/2026 during IJ period.

Based on observation, interview, review of the facility's job descriptions, and review of the facility's documents and policy, the facility failed to ensure that food was stored in a manner that minimized the risk of foodborne illness for all 78 current facility residents. Observation on 01/07/2026 and review of the facility's Food Temperature logs for 01/01/2026, 01/04/2026, 01/05/2026, and 01/06/2026 revealed the temperature in the facility's walk-in refrigerator/cooler was greater than 41 degrees Fahrenheit (F), the upper limit for the acceptable temperature.The findings include:Review of the undated policy titled, Preventing Foodborne Illness - Food Handling, revealed the functioning of the refrigerator and food temperatures were to be monitored at designated intervals throughout the day and documented according to state-specific requirements. Further review revealed federal standards required that refrigerated food be stored below 41 degrees Fahrenheit (F).Review of the Job Description for the Cook, signed 11/01/2016, revealed duties included inspection of all equipment for proper functioning and safety before and during use; to follow established safety and infection control procedures; to plan, direct, and supervise the food service program including food storage, inspection of all equipment and systems regularly for proper functioning and safety; and to notify maintenance immediately of repair needs. Review of the undated Job Description for the Dietary Manager revealed duties included having knowledge of supplies and equipment used by the department and the care of that equipment. It also revealed the Dietary Manager followed and assured that those dietary personnel followed established safety and infection control procedures. Per the job description, the Dietary Manager planned to ensure education and new training would be implemented and would follow up on that. Review of the poster Hazard Analysis Critical Control Points [HACCP], posted in the kitchen, revealed foods in cold storage should be held at a temperature of 41 degrees F or less. Review of the Food Temperature logs, dated 01/01/2026 to 01/06/2026, revealed printed references for staff to follow. The references stated the expected internal temperature of the walk-in refrigerator was 32 to 41 degrees F, and, in writing, staff was expected to tell the Dietary Manager immediately if temperatures in any area were not in the appropriate range. Further review of entries, dated 01/01/2026 through 01/06/2025, revealed the walk-in refrigerator temperatures were greater than 41 degrees F on 01/01/2026, 01/04/2026, 01/05/2026, and 01/06/2026.Observation on 01/07/2026 at 9:12 AM, during the initial tour of the kitchen, revealed the internal temperature of the walk-in refrigerator, according to the analog thermometer located on the inside shelf near the door, was 48 degrees F. The State Survey Agency (SSA) Surveyor advised the cook of the observation and requested a better placement of the thermometer for a more accurate reading. The SSA Surveyor told the Dietary Manager immediately afterward for her follow-up.Additional observation on 01/07/2026 at 11:15 AM revealed the analog thermometer had been repositioned to the back of the refrigerator, the thermometer had been replaced, but the temperature remained at 48 F. Further observation revealed at that time, the Dietary Manager was in the kitchen, and staff disposed of all refrigerated foods. No food from the refrigerator was used for the midday meal.During an interview on 01/07/2026 at 3:07 PM, the Dietary Manager stated she let the maintenance staff know of the problem, and there had never been a temperature issue with the refrigerator in the past. She stated the refrigerator, freezer, dishwasher, and food temperatures were checked daily by the cooks.During an interview on 01/07/2026 at 3:15 PM, [NAME] 3 stated she checked the refrigerator and freezer temperatures on 01/05/2026 and again on 01/06/2026. She stated the acceptable temperature for the walk-in refrigerator was 44 degrees F to 45 degrees F. She stated if food in the refrigerator was not kept cold enough, it could spoil and potentially cause a resident to become ill. She stated she did not inform the Dietary Manager of the temperature that had been obtained on either date. [NAME] 3 stated she had seen the poster HACCP that was posted in the kitchen. However, she stated she did not recall the temperatures that were listed.During an interview on 01/07/2026 at 3:35 PM, the Maintenance Director stated he was made aware of the concern related to the refrigerator temperature, and the repair company he reached out to would be there as soon as possible.During an interview on 01/08/2026 at 9:30 AM with the Registered Dietitian, she stated she performed a monthly audit of sanitation, food tray temperatures, and refrigerator/freezer temperatures for accuracy. She stated she had no previous concerns with any of her findings.During an interview on 01/08/2026 at 11:32 AM with [NAME] 2, he stated an acceptable refrigerator temperature was 32 degrees F to 45 degrees F. He stated if those temperatures were not adhered to, food could go bad and could cause mold or even cause resident illness. He stated if the temperatures were out of range or if there was any concern about temperatures or a need to repair something, he knew to go to the Dietary Manager or Maintenance staff. He stated the temperature he documented on the dinner temperature log on 01/06/2026 was 43 degrees F. [NAME] 2 stated he did not inform anyone about that finding or place a maintenance work order. During an interview on 01/08/2026 at 12:37 PM with [NAME] 4, she stated the temperature in the walk-in refrigerator should be 34 degrees F or lower. She stated she did not notify the Dietary Manager, Maintenance, or any authority, of her documented readings greater than 41 degrees F on 01/01/2026 and 01/04/2026. She stated the risk of foods not kept at the appropriate temperatures was they could go bad, but if they didn't smell bad, it would be okay. She stated she recalled seeing the poster HACCP that was hanging in the kitchen. When reviewing the information regarding the safe temperature of refrigerated foods, she stated she thought the temperature reading was for the freezer. During an interview on 01/08/2026 at 2:40 PM with the Administrator, she stated she was made aware of the temperature readings of the walk-in refrigerator, and the food had to be thrown out. She stated the risk of foods kept at temperatures outside of the safe parameters would be that residents could get sick.

Based on observation, interview, review of the facility's job descriptions, and review of the facility's documents and policy, the facility failed to ensure essential kitchen equipment was maintained and in safe operating condition for all 78 of the facility's current residents.The findings include:Review of the undated policy titled, Preventing Foodborne Illness - Food Handling, revealed the functioning of the refrigerator and food temperatures were to be monitored at designated intervals throughout the day and documented according to state-specific requirements. Further review revealed federal standards required that refrigerated food be stored below 41 degrees Fahrenheit (F).Review of the Job Description for the Cook, signed 11/01/2016, revealed duties included inspection of all equipment for proper functioning and safety before and during use; to follow established safety and infection control procedures; to plan, direct, and supervise the food service program including food storage, inspection of all equipment and systems regularly for proper functioning and safety; and to notify maintenance immediately of repair needs. Review of the undated Job Description for the Dietary Manager revealed duties included having knowledge of supplies and equipment used by the department and the care of that equipment. Review of the Food Temperature logs, dated 01/01/2026 to 01/06/2026, revealed printed references for staff to follow. The references stated the expected internal temperature of the walk-in refrigerator was 32 to 41 degrees F, and, in writing, staff was expected to tell the Dietary Manager immediately if temperatures in any area were not in the appropriate range. Further review of entries, dated 01/01/2026 through 01/06/2025, revealed the walk-in refrigerator temperatures were greater than 41 degrees F on 01/01/2026, 01/04/2026, 01/05/2026, and 01/06/2026.Review of an invoice from an outside contractor, dated 06/20/2025, revealed the walk-in cooler/refrigerator was running warm and was found to have clogged condenser coils. The invoice stated repairs were made and checked for effectiveness, and no further problems were identified.Review of an invoice from an outside contractor, dated 01/07/2026, revealed the walk-in cooler was warm, and the condenser coils were frozen. The defrost timer was also inconsistent. Per the invoice, the cause of frozen coils was listed as a likely prolonged exposure related to an opened cooler door. Observation on 01/07/2026 at 9:12 AM, during the initial tour of the kitchen, revealed the internal temperature of the walk-in refrigerator, according to the analog thermometer located on the inside shelf near the door, was 48 degrees F. The State Survey Agency (SSA) Surveyor advised the cook of the observation and requested a better placement of the thermometer for a more accurate reading. The SSA Surveyor told the Dietary Manager immediately afterward for her follow-up.Additional observation on 01/07/2026 at 11:15 AM revealed the analog thermometer had been repositioned to the back of the refrigerator, the thermometer had been replaced, but the temperature remained at 48 F. Further observation revealed at that time, the Dietary Manager was in the kitchen, and staff disposed of all refrigerated foods. No food from the refrigerator was used for the midday meal.During an interview on 01/07/2026 at 3:07 PM, the Dietary Manager stated she told maintenance staff the refrigerator was not staying cool enough. She stated the door consistently failed to close well, and staff had to try to keep it closed. She stated the last time she reported that to anyone to evaluate or repair was to a former maintenance man over two years ago, but no repairs were ever made. She stated she did not complete a work order or report the concern to the current Maintenance Director or the Administrator. She stated she did recall, during the past summer, there was a service call for the walk-in cooler/refrigerator for freon or fan repair, but the temperature was never an issue. She stated she could not recall how it was determined there was an issue if the temperature had not been identified as a concern.During an interview on 01/07/2026 at 3:15 PM, [NAME] 3 stated she was aware staff had to make a concerted effort to shut the door to the walk-in cooler. She stated, with heavy use at mealtimes, the door could stay open more than intended.During an interview on 01/07/2026 at 3:35 PM, the Maintenance Director stated he previously had not been made aware of issues concerning the walk-in cooler door. He stated a call was made to an outside contractor for repair, and the contractor would be at the facility as soon as possible, adding that it was most often the same day.During an interview on 01/08/2026 at 12:57 PM with [NAME] 4, she stated the door to the walk-in cooler required staff to make sure that it shut correctly. She stated she was not aware of it ever being looked at.During additional interview on 01/08/2026 at 2:04 PM with the Maintenance Director, he stated the problem was identified as a frozen coil because of leaving the walk-in refrigerator door open for a prolonged period of time, possibly overnight. He stated the refrigerator's functions, other than the door, were in good order. He stated he planned to follow up with the Administrator regarding the door and a possible solution. During an interview on 01/08/2026 at 2:40 PM with the Administrator, she stated she was made aware of the walk-in cooler door issue, and the Dietary Manager had staff throw away food that was inside. She stated the Maintenance Director and the service contractor would work toward a solution so there would not be a problem in the future. She stated she expected the dietary staff to let her or the Dietary Manager know if there was any concern, and contact numbers were posted throughout the building. She stated she would make sure staff was educated and given any additional training if needed.

Based on interview, record review, and review of the facility's policies, the facility failed to ensure a resident was free from abuse due to misappropriation or exploitation for 1 of 38 sampled residents, Resident (R) 2. The findings include:Review of the facility's policy titled, Controlled Substances, revised date 12/2011, revealed nursing staff must count controlled drugs at the end of each shift. The policy stated the nurse coming on duty and the nurse going off duty must make the count together and must document and report any discrepancies to the Director of Nursing Services.Review of the facility's policy titled, Controlled Medication Storage, dated [DATE], revealed at each shift change, a physical inventory of all controlled medication(s), including the emergency supply, was conducted by two licensed nurses and was documented on the controlled medication accountability record per facility procedure.Review of the facility's policy titled Abuse Prevention, revised [DATE], revealed that misappropriation of resident property was defined as deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of the resident's belongings without the resident's consent.Review of R2's Face Sheet revealed the facility initially admitted the resident on [DATE] with diagnoses of moderate protein - calorie malnutrition, dementia, and adult failure to thrive. Further review of R2's electronic medical record (EMR) revealed he had a gastric tube (g-tube), which was used to administer his medications. Per the record, on [DATE] R2's g-tube became occluded and was replaced on [DATE] at the local hospital, and he returned to the facility on [DATE]. Further review revealed Hospice was consulted on [DATE], and orders for lorazepam (an anti-anxiety agent) and morphine (an opioid pain reliever) were given to provide comfort during end-of-life care. Per the record, R2 expired at the facility on [DATE].Review of the facility's initial Incident Report, dated [DATE], revealed documentation that R2's Brief Interview for Mental Status [BIMS] score was zero (0), indicating severe cognitive impairment. It further revealed not all of his narcotic medication was accounted for, and an internal investigation had been initiated. Review of R2's Controlled Drug Administration Record revealed the last dose of lorazepam 0.5 milligrams (mg) was administered on [DATE] at 5:02 PM.Review of the facility's Daily Staffing Sheet, dated [DATE], revealed Licensed Practical Nurse (LPN) 7, LPN1, and State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) 3 were on the schedule as working during the time of the incident.During an interview on [DATE] at 5:19 PM with SRNA/KMA3, she stated the Hospice nurse, Registered Nurse (RN) 3, on [DATE], went to get the medications from the contracted pharmacy for R2 and immediately returned with them in her possession. She stated she was told by LPN1 that LPN1 and the Hospice nurse had counted 15 lorazepam 0.5 mg tablets that were contained in a bottle. She stated she personally recounted with LPN1 before locking them in the narcotic drawer of the medication cart. She stated she was aware that LPN1 gave one tablet, in addition to one dose of morphine, via g-tube, later that day. She stated there had been a call-in that evening, and it was hectic. She stated at shift change at 6:00 PM, she told the oncoming nurse, LPN7, about the bottle of lorazepam, that it was not in a blister pack skid, as were most narcotics received from the pharmacy. She stated LPN7 just shut the drawer and did not count the pills. SRNA/KMA3 stated that upon her return in the morning, she failed to count the bottle of Lorazepam with the night shift nurse, LPN7, before accepting the keys for the cart. She stated she had no reason for not doing it, but just did not, although she knew it was the policy to do so. SRNA/KMA3 stated later in the shift, LPN1 asked her if she had given any lorazepam to R2, and she told LPN1 she had not because she was not allowed to give medications by g-tube. She stated LPN1 told her five lorazepam tablets were missing. She stated she and LPN1 attempted to find the Director of Nursing (DON) and were unsuccessful. She stated because of the DON's absence, they reported the missing tablets to the A Hall Unit Manager, RN2. SRNA/KMA3 stated both she and LPN1 were immediately suspended pending further investigation.The State Survey Agency (SSA) Surveyor attempted to interview LPN7 by telephone on [DATE] at 5:38 PM. However, LPN7 did not answer, and LPN7's voice mailbox was full.During an interview on [DATE] at 5:49 PM with LPN1, she stated on [DATE], she worked on the day shift and was assigned to R2. She stated he went into Hospice care that day, and the Hospice nurse obtained narcotics for him from the contracted pharmacy. She stated the Hospice nurse brought a brown pill bottle from the pharmacy for R2. She stated the Hospice nurse gave the bottle to her and SRNA/KMA3, and she counted 15 Lorazepam 0.5 mg tablets, created a narcotic count sheet, and locked them in the narcotic drawer of the medication cart. LPN1 stated she did administer a dose later that day, so there were 14 tablets left when she counted them. She stated that was the only dose she gave him. She stated, later that night, SRNA/KMA3 had the cart and would have counted with the oncoming nurse, LPN7. She stated the next morning ([DATE]), SRNA/KMA3 received the same cart from the same night nurse she had given keys to the previous evening, LPN7. She stated later in the day, she went to the cart to give R2 a dose of the lorazepam and found only nine pills, instead of 14, with five tablets missing. LPN1 stated she asked SRNA/KMA3 to do a recount with her, and the same number of pills was counted. She stated she and SRNA/KMA3 attempted to report it immediately to the DON, but the DON was not in her office. Therefore, she stated she and SRNA/KMA3 told the Unit Manager of A-Hall, RN2. She stated other medication carts and Medication Administration Records (MAR) were reviewed for accuracy, and no further discrepancies were found. She stated she and SRNA/KMA3 were sent home, pending investigation. She stated the following week, the DON called and told them they could come back to work. LPN1 stated the DON gave an in-service on counting all narcotics regardless of the type of container. During an interview on [DATE] at 5:34 PM with the Pharmacist from the contracted pharmacy, he stated there were 15 lorazepam 0.5 mg tablets picked up by the Hospice nurse, RN3, on [DATE] at 12:57 PM. He stated they were packaged in a clear brown pharmacy bottle.During an interview on [DATE] at 5:14 PM with the responding officer from the local police department, he stated he received the first call from the Administrator on [DATE] at 5:44 PM. He stated the staff member he needed to interview had left the state on a planned trip, other relevant staff had been sent home, and the timing of the holidays delayed the initiation of the investigation. He stated he planned to begin the investigation the following week, and he had been in communication with the facility Administrator. He stated there was currently no police report.During an interview on [DATE] at 6:00 PM with RN2, she stated on [DATE], the Hospice nurse had asked LPN1 to give a dose of lorazepam to Resident 2. RN2 stated when the medication was retrieved, LPN1 saw that the count was not correct. She stated both SRNA/KMA3 and LPN1 brought this information to her, the A Hall Unit Manager. She stated she took the medication bottle of lorazepam and the accompanying signature sheets. She stated the DON suspended SRNA/KMA3, LPN1, and LPN7.During an interview with the DON on [DATE] at 6:50 PM, she stated she expected the clinical staff to count all narcotics when accepting the medication cart, regardless of the type of storage container. She stated she also expected that would occur during their breaks as well.During an interview with the Administrator on [DATE] at 6:53 PM, she stated she expected the narcotics to be thoroughly counted before anyone accepted a medication cart. She also stated that education would be done. She stated she did not expect she would need to make any policy changes but would continue to reinforce the existing one.

Based on interview, record review, and review of the facility's document and policy, the facility failed to ensure appropriate coordination, oversight, communication, and continuity of care related to dialysis services for 1 of 38 sampled residents, Resident (R29). The facility failed to maintain an active contract with the dialysis provider and failed to ensure required dialysis communication was completed, sent, reviewed, and returned to the medical record to support continuity of care and monitor the resident's condition before and after dialysis treatments. This failure placed the resident at risk for unmet medical needs and complications related to dialysis services.The findings Include:Review of the facility's policy titled, Hemodialysis Access Care, revised September 2010, revealed the general medical nurse was expected to document in the resident's medical record every shift and obtain and maintain reports from the dialysis nurse post-dialysis. The facility was unable to provide evidence of an active contract or written agreement with the dialysis provider for R29, who was actively receiving off-site dialysis services.Review of R29's Face Sheet revealed the facility initially admitted the resident on 12/25/2022 with diagnoses including end-stage renal disease, type II diabetes mellitus, hypertension, and dependence on renal dialysis.Review of R29's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/02/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 of 15, indicating the resident was cognitively intact. Review of R29's Care Plan, revised 11/06/2025, revealed R29 attended off-site dialysis three days per week and had a left upper arm arteriovenous (AV) fistula.Review of the facility's document Dialysis and Nursing Home Handoff Communication Tool, undated, revealed the section to be completed by the nursing home and sent with the resident for each dialysis treatment was incomplete for 12/29/2025, 12/31/2025, 01/02/2026, and 01/05/2026. However, further review revealed the dialysis center sent those forms back to the facility with R29, with their section completed. During an interview on 01/08/2026 at 4:00 PM, Registered Nurse (RN) 1 stated she forgot to complete the nursing home section of the dialysis communication form for 01/02/2026 that was sent to the dialysis center. She further stated it was important to communicate with dialysis staff to be aware of any changes or complications. During an interview on 01/08/2026 at 4:30 PM, Licensed Practical Nurse (LPN) 3 stated she forgot to complete and send the dialysis communication form on 12/31/2025 with R29. She stated it was important to complete the nursing home section to update the dialysis center of any changes that could impact treatment. During an interview on 01/08/2026 at 3:00 PM, the Director of Nursing (DON) stated she expected nursing staff to complete the nursing home section of the dialysis communication form and ensure the dialysis section was completed and reviewed upon the resident's return from each dialysis treatment to support continuity of care and ensure the facility was aware of the resident's status during and after dialysis.During an interview on 01/08/2026 at 2:00 PM, the Administrator stated the dialysis contract had been misplaced by the nursing facility and the dialysis provider. The Administrator further stated the facility should have an active contract when a resident was receiving dialysis services. The Administrator stated nursing staff should complete dialysis communication forms to ensure effective communication and continuity of care between the facility and the dialysis provider.

Based on interview and review of the facility's policy, the facility failed to ensure all residents had the right to send and receive mail on Saturdays. The findings include: Review of the facility's policy titled, Residents Rights, revised 07/01/2014 revealed the resident had the right to privacy in written communications, including the right to send and promptly receive mail. During the Resident Council meeting on 10/01/2024 at 10:00 AM, Resident (R) 46 stated residents did not receive or send mail on Saturdays at the facility. R46 stated he did receive packages unopened the day they were delivered to the facility. The rest of the resident attendees confirmed there was no Saturday mail delivery. In an interview with the Business Office Manager (BOM) on 10/03/2024 at 12:21 PM, she stated she was unaware it was against residents' rights not to have their mail being delivered on Saturdays. The BOM stated her work schedule was Monday through Friday 7:30 AM to 4:00 PM, and she was not on the campus during the weekends to sort the mail and give it to the Activities Department. In an interview with Activities 1 on 10/03/2024 at 12:35 PM, she stated only department heads had keys to the mailbox which required a key to retrieve the mail. Activities 1 stated packages delivered by carriers were given to the resident as soon as they were delivered to the facility. Activities 1 stated the only time a resident would receive an opened box was if it was a delivery error by the carrier or if a resident asked for a staff member to help them open the package. In an interview with the Director of Nursing (DON) on 10/03/2024 at 1:45 PM, she stated the mailbox was checked by the BOM. The DON stated the BOM got the mail from the mailbox and sorted out the business mail from the residents' mail. The DON stated the Activities Department was at the facility seven days a week, and they gave the residents the mail everyday, including on Saturdays. The DON stated packages were given to residents the day they were delivered to the facility from the carrier. She stated her expectations for staff was to respect residents. In an interview with the Administrator on 10/03/2024 at 12:15 PM, she stated the BOM was responsible for getting the mail, sorting it, and distributing it to department heads. The Administrator stated the Activities Department would distribute the mail to the residents. The Administrator stated that the department heads only worked Monday through Friday, and they were the only ones who had the keys to the mailbox. The Administrator stated a few residents had subscriptions to the newspaper, and they gave those to residents as soon as they were delivered to the facility.

Based on interview and review of the facility's policies, the facility failed to establish written standards, policies, and procedures for a documented water management program based on nationally accepted standards for all residents (census 76). The facility did not have a water management program that included a description of the building's water systems where Legionella and other opportunistic waterborne pathogens could grow and spread, flow diagrams, measures to prevent growth, testing protocols, acceptable ranges, and established ways to intervene when control limits were not met. The findings include: Review of the facility's policy titled, Infection Control Policy, dated 02/02/2021, revealed the policy's purpose is to prevent, detect, investigate, and control infections in the facility and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and general public. Review of the facility's policy titled, Prevention of Legionella Growth and Exposure, dated 06/2017, revealed the facility had an established water management program in an effort to prohibit and/or reduce the exposure to Legionella. Further review revealed a text and diagram model of the facility's water system would be maintained and the facility would implement and monitor control measures that might include but was not limited to environmental rounds to identify areas that might promote water stagnation or biofilm, water temperature monitoring, and lab testing of residents with healthcare associated pneumonia. Review of the facility's policy titled, Infection Preventionist, revised 03/2017, revealed the Infection Preventionist was responsible for coordinating the implementation and updating of the facility's established infection prevention and control policies and practices. Review of the facility's Infection Preventionist Job Description, undated, revealed the infection preventionist conducted oversight of the infection prevention and control program including maintaining a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services and following accepted national standards. Review of the facility's . Maintenance Director Job Description, undated, revealed duties and responsibilities included following established safety and infection control procedures and actively participating in the facility's Quality Assurance/Continuous Quality Improvement program to assure departmental activities were conducted in a manner consistent with local, state, and federal regulations. In an interview with the Maintenance Director on 10/03/2024 at 9:10 AM, he stated he had been maintenance director for just a few months and prior to that he worked in maintenance at an apartment building. He stated he was not able to speak to information related to the facility's water management system and had not received training for anything that related to Legionella. The Maintenance Director stated he was unsure if the facility performed chlorine testing. He further stated he had not performed any chlorine tests on the water. The Maintenance Director stated he did not have a description or diagram of the building's water flow system and was not aware that one existed. In an interview with the Administrator on 10/03/2024 at 10:22 AM, she stated she was not aware of a schematic or description of the facility's water flow system. She further stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) shared the responsibility of Infection Preventionist. In an interview with the ADON on 10/03/2024 at 11:57 AM, she stated as part of her Infection Preventionist (IP) responsibilities, she reviewed policies and reported disease outbreaks that included, but was not limited to influenza, COVID, and bed bugs. She stated the facility's infection control and prevention policies were reviewed yearly and as needed. The ADON stated she was not involved in the facility's water management system and believed it was maintenance's responsibility. She further stated, if cases of Legionella were identified in the facility, it was her responsibility to track those cases. In an interview on 10/03/2024 at 12:14 PM with the DON, she stated she assumed the role of DON and IP approximately 17 months ago and shared IP duties with the ADON. The DON stated the Maintenance Director worked with the local water department regarding the water system. She further stated the IP reported and tracked communicable diseases such as Legionella. The DON stated since she started at the facility, she had not reported any cases of Legionella. The DON stated she did not know if the facility conducted chlorine testing on the water. She further stated it was important to monitor the water to prevent sickness and spread of potential diseases. During an interview with the Administrator on 10/03/2024 at 2:18 PM, she stated there was not a current facility water management system in place, and it was not something that had been discussed in their Quality Assessment and Performance Improvement (QAPI) meetings. She further stated it was important to monitor the facility's water system to prevent pathogens like Legionella from entering the facility in efforts to protect residents, staff, and visitors. The Administrator stated she was not aware of any reported cases of Legionella. She further stated tracking and surveillance of potential disease outbreaks were the responsibility of the IP, but she was ultimately responsible as well.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to prepare food safely to prevent cross-contamination. Dietary Aide (DA) 2 was observed on 10/01/2024 preparing a puree brownie with gnats flying around the uncovered blender and gnats were observed flying in and around the trash can in the dining area. The deficiency had the potential to affect all residents that received meals from the kitchen. The findings include: Review of the facility's policy titled, Resident Rights, revised on 08/01/2013, revealed the facility must care for its residents in a manner and in an environment that promoted maintenance or enhancement of each of the resident's quality of life. Review of the facility's policy titled, Food and Preparation and Service, revised 07/01/2014, revealed the food services employees shall prepare and serve food in a manner that complied with safe preparation and handling. Review of the facility's policy titled, Pest Control, revised 05/01/2008 revealed the facility shall maintain an effective pest control program. Per the policy, the facility maintained an on-going pest control program to ensure the building was kept free of insects and rodents. Review of the facility's Commercial Pest Control Agreement revealed it was dated 10/23/2006. Observation on 10/01/2024 at 11:35 AM, revealed DA2 was preparing puree brownie with gnats flying around the uncovered blender. Observation on 10/01/2024 at 11:49 AM, revealed there was a heavy presence of gnats flying in and around the trash can sitting inside the dining room with residents present for lunch. In an interview on 10/03/2024 at 8:56 AM with DA3, she stated she had received training in the kitchen. DA3 stated she had been educated on cross contamination. DA3 stated she had not seen any gnats, bugs, or rodents. She stated if she saw any gnats, bugs, or rodents she would notify the Dietary Manager (DM). In an interview with DA1 on 10/03/2024 at 9:02 AM, she stated she was educated on cross contamination. DA1 stated she had seen gnats around the trash can, and when she did, she changed the trash bag and cleaned the trash cans. DA1 stated she had not seen nearly as many as she did during the hot humid days of summer. DA1 stated she normally worked the morning shift, and she reported issues to the Dietary Manager (DM) or PM [NAME] , who were always on shift. In an interview with the PM [NAME] on 10/03/2024 at 11:57 AM, he stated cross contamination was taught to him at the facility. He stated gnats were in the kitchen. He stated he reported the issue to maintenance, and people came out and sprayed. He stated if a gnat got into the food, it was cross contamination. In an interview with the DM on 10/03/2024 at 9:03 AM, she stated she trained new staff on cross contamination. The DM stated when she was not working or out of the building, the cooks were responsible for the kitchen. The DM stated she had seen gnats in the building. The DM stated having gnats in the kitchen caused cross contamination, and the food could not be served and would need to be discarded if gnats were in the food. In an interview with Housekeeping Aide (HA) 1 on 10/03/2024 at 8:01 AM, she stated gnats were an issue in the building. HA1 stated she mostly saw the gnats around the residents' sinks. HA1 stated housekeeping sprayed bleach in the sinks, and she reported the sighting of gnats to maintenance. In an interview with Maintenance 1 on 10/03/2024 at 8:21 AM, he stated commercial pest control company came to the facility on ce a month. Maintenance 1 stated the last visit was last Tuesday, September 24, 2024, to spray the building for spiders and rodents, but not for gnats. Maintenance 1 stated he had not had any reports of gnats reported to him at the time of the campus visit made by the pest control company. Maintenance stated Housekeeping 1 told him this morning she had a sighting of gnats. He stated he had not received any reports of gnats being in the kitchen. In an interview with the Director of Nursing (DON) on 10/03/2024 at 1:45 PM, she stated she did see gnats in the building, in the generalized areas. She stated there was a resident in the facility that ate snacks up and down the hallway, dropping food. The DON stated housekeeping would clean up after the residents, as her [NAME] was, We work in their home, and it needed always to be clean. She stated she reported any sighting of gnats to the Administrator or the Maintenance Department. The DON stated her expectations for staff in the facility was to respect residents and follow safety guidelines. In an interview with the Administrator on 10/03/2024 at 12:15 PM, she stated she did see gnats in the building, but the pest control company was at the facility last week to spray. She stated she would call for a revisit from the company and have them visit more often. The Administrator stated she had the expectation for staff to follow all the policies and procedures while they were working inside the facility. The Administrator stated she wanted all staff to treat the residents with respect, love, and dignity as this was their home and needed to be treated as such, as soon as staff entered the facility.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to protect residents from physical abuse for two (2) of four (4) sampled residents, Resident #1 and #2. On 05/18/2021, Resident #1 was observed to be standing outside Resident #2's room when both started yelling at each other. Before staff could intervene, both residents were observed to slap at each other's arms. There were no assessed injuries to either resident. The findings include: Review of the facility's policy titled, Abuse Prevention, reviewed and revised on 01/12/17, defined physical abuse as hitting, slapping, punching, kicking, and controlling behavior through corporal punishment. Continued review revealed the facility would provide each resident an environment free from any type of abuse, and any violations would be reported to the Office of the Inspector General within twenty-four (24) hours of the initial report, or two (2) hours if significant injury or death had occurred. Review of the facility's investigation, dated 05/18/2021, revealed an allegation of physical abuse was observed, on 05/18/2021 at 10:58 AM, by Social Worker #1. The report revealed Resident #1 was observed to be standing outside Resident #2's room when both started yelling at each other. Before staff could intervene, both residents were observed to slap at each other's arms. The report stated there were no assessed injuries to either resident, and all required notifications were made and orders obtained for supervision levels for both residents. Per the report, both residents were placed on one-to-one (1:1) supervision until they went to bed and then placed on fifteen (15) minute checks throughout the night. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility, on 05/04/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #2, in a Quarterly Minimum Data Set (MDS) Assessment, dated 04/21/2021, as a nine (9) out of fifteen (15) on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of Resident #2's medical record revealed Resident #2 was admitted to the facility, on 08/22/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #2, in a Annual MDS Assessment, dated 03/03/2021, as a six (6) out of fifteen (15) on the BIMS, indicating severe cognitive impairment. Review of the skin assessments for Resident #1 and Resident #2, dated 05/18/2021, after the incident, revealed no injury to Resident #1 or Resident #2. Interview with Resident #1, on 06/09/2021 at 1:15 PM, revealed he/she had no memory of the incident and stated he/she felt safe living at the facility. Interview with Resident #2, on 06/09/2021 at 1:21 PM, revealed he/she stated, through yes/no questions, that Resident #1 sometimes made fun of his/her speech disabilities but that he/she felt safe living at the facility, and staff did a good job of keeping residents safe. Interviews with Resident #3 and Resident #4, on 06/09/2021 at 1:25 PM and 1:31 PM, respectively, revealed they felt safe living at the facility and also felt staff did a good job protecting the residents. Interview with Social Worker #1, on 06/09/2021 at 9:32 AM, revealed she observed Resident #1 standing outside Resident #2's doorway and witnessed both residents begin yelling and slapping at each other before she could get to the room. Further interview revealed she separated both residents and made appropriate notifications. Interview with the Director of Nursing (DON), on 06/10/2021 at 12:47 PM, revealed she was notified of the incident and both residents were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview revealed she expected staff to be able to protect residents of the facility from abuse to the best of his/her ability. She stated if staff knew two (2) residents did not like each other, the residents would be kept apart and surveilled more closely. The DON stated both Resident #1 and Resident #2 ambulated with wheelchairs, and staff had been alerted to monitor them for any further aggressive behaviors. Interview with the Administrator, on 06/10/2021 at 1:07 PM, revealed protecting residents from abuse was a priority. He stated he expected residents not to be abused or neglected. Further, he stated, following the incident, both residents were immediately separated, assessed, and placed on increased supervision, as was facility protocol. The Administrator stated both residents had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the interview, he stated both residents appeared to have forgotten about the incident and were interacting positively a few days later. The Administrator concluded by stating there was usually consistent staff working on the hall shared by Resident #1 and Resident #2, who was knowledgeable about both residents and what their reactions might be, and he would expect them to be alert to any signs of tension or aggression in the future to prevent a reoccurrence.

Based on interview, record review, and review of facility policy, it was determined the facility failed to protect residents from physical abuse for one (1) of five (5) sampled residents (Resident #2). On 06/11/2020 at 9:30 PM, Resident #1 struck Resident #2 during an altercation, resulting in a skin tear. The findings include: Review of the facility Abuse Prevention Policy, revised 01/12/17, revealed physical abuse was defined as hitting, slapping, punching, kicking, and controlling behavior through corporal punishment. Continued review revealed the facility would provide each resident an environment free from any type of abuse, and any violations would be reported to the Office of the Inspector General within twenty-four (24) hours of the initial report, or two (2) hours if significant injury or death had occurred. Review of the facility Investigation, dated 06/16/2020, revealed an allegation of physical abuse occurred on 06/11/2020 at 9:30 PM. Per the Investigation, State Registered Nurse Aide (SRNA) #8 heard Resident #1 yelling, went to his/her room, and observed Resident #1 and Resident #2 hitting each other. Continued review revealed Resident #2 had followed Resident #1 into his/her room to get food, resulting in an altercation in which Resident #2 sustained a skin tear to his/her right arm. Both residents were placed on one-on-one (1:1) supervision until they went to bed, then placed on fifteen (15) minute checks throughout the night. Review of the Skin Assessment for Resident #1 and Resident #2, dated 06/11/2020, revealed no injury to Resident #1, and a skin tear to Resident #2's right forearm. Review of Resident #1's medical record revealed the facility admitted the resident on 08/22/19 with [DIAGNOSES REDACTED]. The facility assessed Resident #1 in a Significant Change Minimum Data Set (MDS) Assessment, dated 04/20/2020, as having a Brief Interview for Mental Status (BIMS) score of (3) out of fifteen (15), indicating severe cognitive impairment. Further, the facility assessed the resident as having behaviors of rejecting care. Review of Resident #1's Comprehensive Care Plan, initiated 09/11/19, revealed the resident was at risk for behavior/actions that place resident at risk for altercation with other residents related to impaired cognition, with a goal that the resident would interact safety within environment and respond to staff intervention as evidenced by no negative interactions with fell ow residents. Interventions included one on one (1:1) when agitated, or anxious, provide diversional activity, provide meaningful activity, redirect to safe area when wandering and remove from stimulating environment and allow time for rest and reflection. All interventions were initiated 09/11/19. The Care Plan was revised on 06/11/2020 related to the altercation with Resident #2, with new interventions to prevent further occurrence. Review of Resident #2's medical record revealed the facility admitted the resident on 05/04/17 with [DIAGNOSES REDACTED]. The facility assessed Resident #2, in Quarterly Minimum Data Set (MDS) Assessment, dated 06/02/2020, as having a Brief Interview for Mental Status (BIMS) of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Further, the facility assessed the resident as having no behaviors. Review of Resident #2's Comprehensive Care Plan initiated 09/09/14, revised 12/28/17, revealed the resident had Behavioral Symptoms and would exhibit behavior related to verbal taunts to instigate altercations with other residents; makes noises while in hallway; repeats other resident's words, and also [MEDICATION NAME] and sings to disrupt environment. The goal stated the resident would have a decrease in behavioral episodes and be free from injury related to non-compliant behaviors through next review. The interventions included consult with Psyche Services as needed; document episodes of non-compliant behavior; educate resident on outcome of non-compliant behaviors; if taunting other residents, ask him/her to please not do so, and medications as ordered. Review of Resident #2's Progress Note, dated 06/11/2020, signed by Licensed Practical Nurse (LPN) #3, revealed staff heard yelling, and found Resident #2 in another resident's room, in an altercation over food. Further, Resident #2 had a skin tear to his/her right forearm 3 centimeters (cm) x 2 cm, and the Director of Nursing (DON) and Nurse Practitioner were notified. Continued review revealed attempts were made to notify Resident #2's family. Per the Note, a new order for treatment to Resident #2's skin tear was obtained. Resident #2's Comprehensive Care Plan was revised on 06/11/2020 related to the altercation with Resident #1, with new interventions to prevent further occurrence. Interview with Resident #2, on 06/22/2020 at 10:40 AM, revealed he/she and another resident got into it , and he/she had a healing skin tear to his/her right forearm. Resident #2 could not recall what the argument was about. Further interview revealed Resident #2 could not recall any previous incidents in which he/she was abused or harmed by residents or staff. When questioned if he/she felt safe at the facility, Resident #2 stated he/she would leave if he/she didn't feel safe. Interview with SRNA #8, on 06/23/2020 at 1:11 PM, revealed he was on his way to the shower room where the linen carts were kept to get some sheets for another resident, when he heard smacking. SRNA #8 stated he followed the sounds to Resident #1's room, and saw Resident #1 and Resident #2 sitting in their wheelchairs, smacking at each other. SRNA #8 stated he pulled Resident #2 out of Resident #1's room, and alerted Licensed Practical Nurse (LPN) #3. SRNA #8 stated he sat with Resident #2 until he/she went to bed. Per interview, Resident #2 told SRNA #8 he/she wanted some of Resident #1's snack crackers and had stuck his/her hand in the box even though Resident #1 didn't want to share. SRNA #8 stated he had never known either resident to act that way, and described the conflict as out of the ordinary for them. Interview with SRNA #4, on 06/22/2020 at 2:12 PM, revealed Resident #1 informed her about the incident that occurrence on 06/11/2020 between Resident #1 and Resident #2. She stated per her conversation with Resident #1, Resident #1 shared some of his/her snack crackers with Resident #2, and they got into an argument when Resident #2 went to get more without asking. She stated she wasn't able to make out anything else Resident #1 was trying to say, but since the incident she had not noticed any changes in either Resident #1's or Resident #2's behaviors. She stated Resident #1 had some trouble communicating, and would sometimes get agitated when he/she could not be understood. Interview with LPN #3, on 06/23/20 at 3:08 PM, revealed he had spoken with Resident #2 and attempted to speak with Resident #1 after the incident. Per interview, he determined Resident #2 had observed Resident #1 eating some snack crackers and followed him/her into his/her room to talk and eat some snack crackers. When Resident #2 reached to get some crackers without asking, Resident #1 struck him/her in the arm. LPN #3 stated he had assessed both residents, with no injury to Resident #1 and a skin tear to Resident #2's right forearm. LPN #3 described Resident #2 as good-hearted; however, stated other residents didn't always understand his/her social behaviors, and therefore he tried to keep Resident #2 where he could see him/her. LPN #3 stated there had not been any problems between the two (2) residents since the incident. The DON was on leave and unavailable for interview during the Survey. Interview with the Assistant Director of Nursing (ADON), on 06/23/2020 at 2:25 PM, revealed it was her expectation staff would protect residents from abuse to the best of their ability. She stated both Resident #1 and Resident #2 ambulated with wheelchairs, and staff had been alerted to monitor them for any further aggressive behaviors. The ADON stated after the incident, Resident #1 and Resident #2 were observed sharing a shack and talking in front of the nurse's station. Interview with the Administrator, on 06/23/20 at 3:18 PM, revealed protecting residents from abuse was a priority. He stated it was his expectation residents not to be abused or neglected. Per interview, following the altercation between Residents #1 and #2, both residents were immediately separated and assessed, and were placed on increased supervision, as per facility protocol. The Administrator stated both residents had a history of [REDACTED]. Further, both residents appeared to have forgotten about the incident, and were interacting positively a few days later. The Administrator concluded by stating there was usually consistent staff on the hall shared by Resident #1 and Resident #2, who were knowledgeable about both residents and what their reactions might be, and he would expect them to be alert to any signs of tension or aggression in the future to prevent reoccurrence.

Based on observation, interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement a person centered Comprehensive Care Plan (CCP) for each resident to meet a resident's medical, and nursing needs identified in the comprehensive assessment for one (01) of nineteen (19) sampled residents (Resident #69). Resident #69 had pressure ulcers/injuries to his/her right ankle and left heel, and the CCP, dated 10/23/19, revealed an intervention to provide heel protection. However, observation on 11/12/19, 11/13/19 and 11/14/19, revealed Resident #69 was in bed without heel protection. The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #69's clinical record revealed the facility admitted the resident on 09/10/19, and readmitted the resident on 10/23/19, with [DIAGNOSES REDACTED]. Review of Resident #69's Admission Minimum Data Set (MDS) Assessment, dated 09/17/19, revealed the facility assessed the resident as having a Brief Status for Mental Status (BIMS) score of twelve (12) indicating moderately impaired cognition. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (02) staff with bed mobility, transfers, ambulation, toileting, personal hygiene, and dressing. Further review revealed the resident was at risk for pressure ulcers/injuries and had no unhealed pressure ulcers. Continued review revealed the resident was assessed as having receiving pressure-reducing devices for his/her bed. Review of the Comprehensive Care Plan, dated 10/23/19, revealed the resident was readmitted from the hospital with a Stage I Pressure area to the left heel. The goal stated the Stage I Pressure area to the left heel would heal with no signs of symptoms of infection. The interventions included, but were not limited to: monitor for signs and symptoms of infection, dated 10/23/19; provide pressure relief to area as ordered, dated 10/23/19; treatments and medications as ordered and monitor for effectiveness and for adverse side effects, dated 10/23/19; and heel protection, dated 10/23/19. Review of the Monthly Physician Order's for (MONTH) 2019, revealed an order to Cleanse Stage I Pressure injury to the left heel with Normal Saline, pat dry and apply skin prep every day for skin management, dated 10/23/19. Further, there was no documented evidence of an order for [REDACTED].>Continued review of the Monthly physician's orders [REDACTED]. Review of the Weekly Wound Assessment, dated 11/11/19, revealed Resident #69 had a right ankle, Pressure ulcer with measurements 1.2 centimeters (cm) length by 1.3 cm width, with 0.01 cm depth. Additionally, the date of onset was 11/11/19. Further, pressure relief device included float heels. Observation of Resident #69, on 11/12/19 at 3:17 PM, revealed the resident was in bed, lying on his/her back in semi fowler position under a sheet. The outline of the resident's lower extremities was noted and the resident had no devices on his/her feet. The resident's left heel was resting flat on the mattress/sheet and his/her right outer ankle was resting flat on the mattress/sheet. The resident's eyes were closed and he/she did not wake to verbal stimuli. Review of the Weekly Wound Assessment, dated 11/13/19, revealed Resident #69 had a left heel, Stage I Pressure ulcer with measurements 3.0 cm length by 3.0 cm width, with no depth. Additionally, the date of onset was 10/23/19. Further, pressure relief device included float heels. Observation of Resident #69, on 11/13/19 at 9:29 AM, revealed he/she was in bed, lying on his/her back in semi fowler position under a sheet. The resident's bilateral feet were uncovered and the resident's left heel was resting flat on the mattress/sheet and his/her right outer ankle was resting flat on the mattress/sheet. The resident stated he/she had wounds to his/her feet that were treated by the nurse daily. Additionally, Resident #69 stated he/she did not like wearing heel boots; however. he/she wore them when staff prompted and assisted with applying them. Observation of Resident #69's wound care and assessment, on 11/14/19 at 9:20 AM, revealed the resident was lying in bed on his/her back in semi fowlers position under a sheet, with feet uncovered. The resident's left heel was resting flat on the mattress/sheet and his/her right outer ankle was resting flat on the mattress/sheet. No heel boots were noted. Additionally, the resident's right outer ankle had a hydro-cellular dressing in place with no date or initials to indicate placement. When the dressing was removed from the resident's right outer ankle wound, the wound bed was pink with macerated edges and there was a moderate amount of yellow exudate noted prior to wound cleansing. Further, the resident's left heel skin was intact, dry and peeling. During this observation of wound care, Registered Nurse (RN) #1 stated the resident should have had bilateral heel boots/protection on his/her feet to decrease the risk for further skin breakdown. Further, during this observation Resident #69 stated he/she would wear the heel boots if someone would put them on. Interview with Licensed Practical Nurse (LPN) #2, on 11/14/19 at 10:12 AM, revealed she had worked at the facility for one (01) year and four (04) months, and was working on Resident #69's hallway for the day/shift. Per interview, heel protection meant heel boots for Resident #69. Additionally, Resident #69 was to wear heel boots to protect his/her heels from skin breakdown and to promote healing of the wounds on his/her heel/ankle. However, LPN #2 stated the resident refused to wear them at times. Continued interview revealed the CCP was used by all nursing staff as a guide in providing care to each resident and following/implementing the CCP was essential to ensure the residents' needs were met. Further, per the CCP Resident #69 should have heel boots on to decrease the risk for further skin breakdown. Interview with State Registered Nursing Assistant (SRNA) #1, on 11/14/19 at 4:00 PM, revealed she had worked at the facility for twenty (20) years. Per interview, she implemented the care plan to provide necessary care to residents. Additionally, Resident #69 wore heels boots because he/she had ulcers on his/her feet. Further, it was important for Resident #60 to wear heel boots to protect his/her heels from further skin breakdown. Interview with the Director of Nursing (DON), on 11/14/19 at 4:16 PM, revealed it was her expectation RAI Manual Guidelines were to be followed related to implementation of the CCP. Additionally, if a resident was care planned for heel protection, she expected nursing staff to ensure the CCP was followed unless the resident refused the intervention. Further, it was important for the CCP to be implemented to ensure the Interdisciplinary team provided necessary care to residents to prevent complications such as skin breakdown. Interview with the Administrator, on 11/14/19 at 4:30 PM, revealed he expected the interventions developed on the CCP to be implemented per RAI guidelines. Further interview revealed it was important to ensure CCP interventions such as heel boots were implemented to prevent skin breakdown and to provide safe care to meet residents' needs.

Based on observation, interview, record review, review of the facility policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for one (1) of nineteen (19) sampled residents (Resident #35). Resident #35 had a Physicians Order; dated 07/19/19 for heel boots when in bed; however, there was no documented evidence the CCP was revised to include the heel boots. Further, observations on 11/13/19 revealed the resident was in bed for approximately one (01) hour without heel boots on his/her feet. The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. Review of Resident #35's clinical record revealed the facility admitted the resident on 07/11/19 with [DIAGNOSES REDACTED]. Review of Resident #35's Physician's Orders, dated (MONTH) 2019, revealed an order for [REDACTED]. Review of the Comprehensive Care Plan (CCP), revised 09/20/19, revealed Resident #35 had impaired skin integrity and was at risk for further impairment related to decreased mobility, required assistance with turning and repositioning; admitted to facility with two (02) Stage II pressure ulcer to buttocks; and an Unstageable pressure ulcer on right heel acquired on 07/02/19. The goal revealed the resident would exhibit signs and symptoms of healing without signs of symptoms of infection and have no further open areas. The interventions included, but were not limited to: pressure reduction mattress to bed, dated 07/11/19; dietitian consult as needed for recommendations, dated 07/15/19; turn and reposition every two (02) hours, dated 07/11/19; weekly wound assessment, dated 07/11/19; and treatments as ordered and monitor wound for any signs and symptoms of infection/deterioration, dated 08/01/19. However, there was no documented evidence the CCP was revised to include heel boots in bed ordered on [DATE]. Review of Resident #35's Quarterly Minimum Data Set (MDS) Assessment, dated 10/07/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (04) indicating severe cognitive impairment. Further, the facility assessed the resident as requiring extensive assistance or total assist of two (02) staff for bed mobility. Additional review revealed the resident ambulated in his/her room with limited assistance of two (2) staff and was independent with setup for locomotion in the wheelchair. Per the MDS Assessment, the resident had unsteady balance, and was only able to stabilize with staff assistance during transition from surface to surface. Continued review revealed the resident was at risk of pressure ulcers/injuries and had two (02) stage II pressure injuries and an Unstageable pressure ulcer/injury. Further, the resident was receiving pressure ulcer/injury care and had a pressure-reducing device for the bed. Observation of Resident #35, on 11/13/19 at 10:15 AM, revealed the resident was attempting to self-transfer to bed from wheelchair. Continued observation revealed the wheelchair alarm sounded and State Registered Nurse Aide (SRNA) #2 responded. The resident stated he/she wanted to lay down in bed. Resident #35 was assisted to bed; however, heel boots were not placed on the resident's feet after his/her shoes were removed. Additional observation, on 11/13/19 at 11:02 AM, revealed the resident remained in bed with no heel boots on his/her feet; and his/her bilateral heels were lying on the mattress. Observation of Resident #35 during wound care and assessment, on 11/14/19 at 10:12 AM, revealed the resident was lying in bed without heel boots on prior to wound care. Further observation revealed State Registered Nursing Assistant (SRNA) #1 brought heel boots into the resident's room from central supply. Interview with Licensed Practical Nurse (LPN) #2, on 11/14/19 at 10:12 AM, revealed she had worked at the facility for one (01) year and four (04) months, and usually worked on B side, Resident #35's hallway. Per interview, Resident #35 wore heel boots to protect his/her heels from skin breakdown and to promote healing of the wound on his/her right heel. Additionally, the CCP was used by all nursing staff to provide guidance related to residents' care needs. Per interview, all nurses could revise the care plan to include preventative interventions such as heel boots. Continued interview revealed residents who wore heel boots had Physician's orders to do so, and the CCP should include the intervention for heel boots as per the Physician's order. Further, Resident #35 should have had heel boots on while in bed on 11/13/19 at 10:15 AM, and prior to wound care on 11/14/19, as per physician orders. Interview with SRNA #1, on 11/14/19 at 4:00 PM, revealed she had worked at the facility for twenty (20) years. Per interview, she used the care plan as a guide for providing care to residents. Additionally, the CCP should be accurate related to residents' needs and should include devices they such as heel boots. Further, it was important for Resident #35 to wear heel boots to protect his/her heels from further skin breakdown and he/she should have been wearing heel boots while in bed on 11/13/19 and 11/14/19. Interview with the Director of Nursing (DON), on 11/14/19 at 4:16 PM, revealed it was her expectation for the RAI Manual Guidelines to be followed related to revision of the CCP. Additionally, if a resident had an order for [REDACTED]. Interview with the Administrator, on 11/14/19 at 4:30 PM, revealed he expected the CCP to be revised with interventions as necessary per RAI guidelines. Further interview revealed it was important to ensure the CCP was revised to include preventative interventions such as heel boots to prevent skin breakdown and to provide safe care to meet residents' needs.

Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical and nursing needs that are identified in the comprehensive assessment for one (1) of five (5) sampled residents (Resident #1). Although Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 02/04/19, revealed the facility assessed the resident to require the assistance of two (2) staff for transfers; and the Certified Nursing Assistant (CNA) Care Plan dated 02/2019 specified the resident required two (2) staff and a Hoyer Lift (mechanical lift) for transfers; the Comprehensive Care Plan was not developed with interventions for two (2) staff to transfer the resident per Hoyer Lift. On 02/16/19, a State Registered Nurse Assistant (SRNA) transferred Resident #1 from the wheelchair to the bed independently and without the Hoyer Lift. After the transfer, Resident #1 was holding his/her right leg up behind his/her knee; and was whimpering, crying out and moaning. On 02/17/19, Resident #1 continued to show signs of pain, and the resident's right upper thigh was assessed to be red and swollen. Resident #1 was transferred to the local Hospital emergency roiagnom on [DATE], and diagnosed with [REDACTED]. Subsequently, Resident #1 was transferred to a University hospital on [DATE], due to the need for higher care related to the Femoral Fracture and underwent a Right Above the Knee Amputation, on 02/20/19. (Refer to F-689) The findings include: Review of the facility's Policy, titled Care Plans, revealed each resident will have individualized care plans completed timely and serve as a guide to staff for the type of care needed. An SRNA (State Registered Nurse Aide) care plan indicates the care needed for ADLs (activities of daily living) including the amount of assistance needed. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #1's clinical record revealed the facility admitted the resident on 03/29/16 with [DIAGNOSES REDACTED]. Review of the Activities of Daily Living (ADLs) Comprehensive Care Plan (CCP), with initiation date of 09/26/16, revealed the resident had ADL/ Self-care Deficit due to decline and was at risk for further decline related to weakness and confusion. The goal revealed the resident would have needs met per staff through next review date. The interventions included: extensive to total assistance of one (1) to two (2) staff for ADLs; and consistent approach amongst caregivers. Review of the Falls (CCP), with an initiation date of 04/02/17, revealed the resident was at high risk for falls due to: confusion, poor safety awareness; impaired mobility/balance; often propelled wheelchair without noticing where he/she was going and had a history of [REDACTED]. The goal revealed, the resident would be free of falls. The interventions included: straight back cushion to wheelchair for proper positioning; may be in gerichair for mobility and comfort; mat to right side of bed; bed in lowest position; and pull tab alarm when in bed for safety. However, there was no documented evidence the CCP included interventions for the resident to be transferred with two (2) staff members and the Hoyer Lift (mechanical lift). Review of Resident #1's CNA (Certified Nursing Aide) Care Plan, dated (MONTH) 2019, revealed the resident required two (2) staff for bed mobility; did not ambulate; and required two (2) staff and a Hoyer Lift for transfers. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having both short term and long term memory loss. Further review revealed the facility assessed the resident as requiring extensive assist of two (2) staff for transfers; and as ambulation not occurring. Continued review revealed the facility assessed the resident as not steady and only able to stabilize with staff assistance when moving from seated to standing position and during surface to surface transfers (surface between bed and chair or wheelchair). Additional review of the MDS Assessment, revealed the facility assessed the resident as having Functional Limitation in Range of Motion of both lower extremities; and as requiring a wheelchair for mobility. Review of the Progress Notes, dated 02/16/19 at 7:30 PM, completed by Registered Nurse (RN) #1, revealed she was called to Resident #1's room by SRNA #2 who informed her that while the resident was being turned and changed, he/she was moaning as if in pain. Per the Note, the resident was holding his/her right knee bent and would moan as SRNA #1 and SRNA #2 continued to turn and change him/her. Further review of the Note, revealed there was no bruising or swelling of the right knee noted. The subsequent Note dated 02/16/19 at 7:35 PM, revealed the resident received Tylenol 1000 milligrams (pain medication). The subsequent Note, dated 02/16/19 at 8:05 PM, completed by RN #1, revealed, Resident resting with eyes closed, no moaning at present time. Review of Resident #1's Progress Note, dated 02/17/19 at 6:20 AM, completed by Licensed Practical Nurse (LPN) #1, revealed Resident #1 was complaining of right leg pain; and the resident's right leg was noted to appear larger than the left leg, appeared to have redness and was warm to touch. Per the Note, the resident had a positive pedal pulse, a popliteal pulse could not be palpated, and the resident was continuously moving back and forth, while holding the right leg still. The subsequent Note, dated 02/17/19 at 6:50 AM, revealed the Physician was notified and orders were obtained to send the resident to the Hospital emergency room for evaluation and treatment. Review of the local Hospital Emergency Department (ED) Note, dated 02/17/19 at 7:37 AM, revealed the patient presented with pain, swelling and tenderness, and complaints which affected the right quadriceps. The patient had an injury of unknown cause and the patient was non-weight bearing, and bedbound until transferred to the wheelchair. According to the Note, at 9:22 AM, interpretation of X-Ray results, revealed distal Femur Fracture just proximal to the knee. Continued review revealed the patient would be transferred to another hospital related to higher care needed for Femoral Fracture. Review of the University Hospital Emergency Department General Note, dated 02/17/19 at 9:56 AM, revealed the patient presented for evaluation of Right Femur Fracture, and the Nursing Home reported patient was at baseline yesterday, and this morning resident was complaining of right leg pain. There was no trauma or falls reported. Review of the University Hospital Consultation Note for Surgery and Orthopedics, dated 02/19/19 at 3:47 PM, revealed the Physician had a long discussion with the family regarding the treatment options. Per the Note, the family wanted to proceed with transfemoral amputation (above the knee) to limit the risk of hardware and bone healing related complications and the plan was to proceed with the operation, on 02/20/19. Review of Resident #1's University Hospital Operative Report, dated 02/20/19, at 1:40 PM, revealed the patient underwent a total hip as as well as total knee in the past, and had severe Dementia as well as multiple comorbidities. Due to the patient's overall medical status, the risks, benefits, and alternatives of non-operative verses open reduction and internal fixation versus above knee amputation were discussed with the patient's family, who ultimately decided to proceed with above the knee amputation. Continued review revealed the procedure for the right above-knee amputation was performed, on 02/20/19. Review of the facility's Event Report, dated 02/18/19, completed by the Director of Nursing (DON), revealed LPN #1 reported Resident #1 was assessed to have swelling and redness to his/her right leg. According to the Report, the facts observed at the scene, revealed about 6:00 AM on 02/17/19, the nurse noted redness to the resident's right leg and the resident complained of pain. Continued review revealed a physician's orders [REDACTED]. Further review revealed the Root Cause of injury, was Resident #1 was manually transferred from the wheelchair to the bed to prevent a fall on 02/16/19, around 7:30 PM. Interview with SRNA #1, on 02/28/19 at 2:25 PM, revealed on 02/16/18 at approximately 7:30 PM, when she entered Resident #1's room, she observed the resident sitting in the wheelchair near the bed. She stated Resident #1 was leaning forward with the safety seatbelt in place, but the seat belt appeared to be loose. Per interview, she thought Resident #1 was going to tip forward in the wheelchair, so she placed her body against the resident and placed her arms around his/her underarms. She stated she then unhooked the safety seatbelt and lifted the resident from the wheelchair to the side of the bed. SRNA #1 further stated she then placed one (1) arm around the resident's shoulder and one (1) arm behind his/her knees and assisted the resident into a lying position. Continued interview with SRNA #1, revealed after the resident was in bed, she went to ask SRNA #2 to help change the resident's clothes. Per interview, when she and SRNA #2 started to undress the resident and remove his/her pants, they realized the resident started whimpering like he/she was in pain and SRNA #2 immediately went to find the nurse. Further interview revealed RN #1 assessed Resident #1 and administered pain medication. Per interview, during the night of 02/16/19 and the morning of 02/17/19, when she and SRNA #2 provided care for the resident, he/she did not appear to be in pain. Additional interview with SRNA #1, revealed she was familiar with Resident #1's CNA Care Plan and knew Resident #1 required the assistance of two (2) staff and a Hoyer lift for transfers prior to her transferring the resident independently, on 02/16/18. However, she stated since the resident was light weight, she thought she could transfer the resident by herself. Post exit phone interview with the MDS Coordinator, on 03/11/19 at 11:03 AM, revealed the Comprehensive Care Plan (CCP) was derived from the MDS Assessment, and therefore if Resident #1's MDS Assessment was coded as the resident requiring two (2) staff for transfers, this should have been reflected on the CCP. Further interview revealed if the CNA Care Plan indicated the resident required two (2) staff and a Hoyer Lift for transfers, this should have been reflected on the CCP as an intervention. The MDS Coordinator, revealed the CCP should be individualized and specific for each resident in order for staff to be able to implement the necessary care for the residents. Interview on 03/01/19 at 10:36 AM, and post exit interview on 03/11/19 at 11:09 AM, with the Director of Nursing (DON), revealed the transfer technique and how many staff were required to transfer a resident, including any equipment needed for the transfer, should be on the CCP. Per interview, the CCP was generated from the MDS Assessment and should be individualized and specific; however, she acknowledged Resident #1's CCP did not specify Resident #1 was to be transferred with the assistance of two (2) staff and the Hoyer Lift. She stated she ensured the CNA Care Plan was updated monthly with specific interventions for each resident. She further stated, it was her expectation the SRNAs follow the SRNA CCP as it was a guide to providing care for the residents and included the transfer technique, how many staff were required to transfer residents, and any devices needed for the transfer. Further interview revealed Resident #1's CNA Care Plan had an intervention for two (2) staff for transfers with the Hoyer lift; however, the facility investigation concluded Resident #1 was transferred independently from the bed to the wheelchair, by SRNA #1 on 02/16/19. Interview with the Administrator, on 03/01/19 at 10:45 AM, revealed the CCP should have specific and individualized interventions and the CCP and the CNA Care Plan should be used as a guide in providing care. Further, a resident who was assessed as requiring more than one (1) person's assistance and a Hoyer Lift for transfers should not be transferred with just one (1) person without the Hoyer Lift.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (1) of five (5) sampled residents (Resident #1). Resident #1 was assessed by the facility to require the assistance of two (2) staff for transfers according to the Annual Minimum Data Set (MDS) Assessment, dated 02/04/19; however, the Comprehensive Care Plan did not specify the transfer technique and how many staff were required to transfer the resident. The Certified Nurse Assistant (CNA) Care Plan, dated 02/2019 did specify the resident required two (2) staff and a Hoyer Lift (mechanical lift) for transfers. On 02/16/19, a State Registered Nurse Assistant (SRNA) transferred the resident from the wheelchair to the bed independently and without the Hoyer Lift. Staff interviews and record review revealed Resident #1 showed signs of pain after the transfer and was holding his/her right leg up behind his/her knee; and was whimpering, crying out and moaning, when staff attempted to move the resident's right leg. The next morning, on 02/17/19, Resident #1 continued to hold his/her right leg up from behind the knee, and the resident's right upper thigh was assessed to be red and swollen. Resident #1 was transferred to the local Hospital emergency roiagnom on [DATE], where the resident was diagnosed with [REDACTED]. Resident #1 was then transferred to a University hospital on [DATE], due to the need for higher care related to the Femoral Fracture. The [MEDICAL CONDITION] resulted in the resident undergoing a Right Above the Knee Amputation, on 02/20/19. (Refer to F-656) The findings include: Review of the facility Accidents Policy, revised 07/30/15, revealed the purpose of the Policy was to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The procedure includes: Identify hazards and risks; Evaluate and analyze hazards and risks; Implement interventions to reduce hazards and risks; and Monitor effectiveness and modify interventions when necessary. Review of Resident #1's medical record revealed the facility admitted the resident on 03/29/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Activities of Daily Living (ADLs) Comprehensive Care Plan (CCP), with initiation date of 09/26/16, revealed the resident had ADL/ Self-care Deficit due to decline and was at risk for further decline related to weakness and confusion. The goal stated the resident would have needs met per staff through next review date. There were several interventions which included: extensive to total assistance of one (1) to two (2) staff for ADLs; and consistent approach amongst caregivers. Review of Resident #1's Falls (CCP), with an initiation date of 04/02/17, revealed the resident was at high risk for falls due to: confusion, poor safety awareness; impaired mobility/balance; often propelled wheelchair without noticing where he/she was going and had a history of [REDACTED]. The goal stated the resident would be free of falls. There were several interventions including: straight back cushion to wheelchair for proper positioning; may be in gerichair for mobility and comfort; mat to right side of bed; bed in lowest position; and pull tab alarm when in bed for safety. However, there was no documented evidence Resident #1's CCP included interventions for the resident to be transferred with two (2) staff members or the method required for transfer (Hoyer Lift). (Refer to F-656) Review of Resident #1's CNA (Certified Nursing Aide) Care Plan, dated (MONTH) 2019, revealed the resident required two (2) staff for bed mobility. Further review revealed the resident did not ambulate; and required two (2) staff and a Hoyer Lift (mechanical lift) for transfers. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having both short term and long term memory loss. Further review revealed the facility assessed the resident as requiring extensive (resident involved in activity, staff provide weight bearing support) assist of two (2) staff for transfers; and as ambulation not occurring. Continued review revealed the facility assessed the resident as not steady and only able to stabilize with staff assistance when moving from seated to standing position and during surface to surface transfers (surface between bed and chair or wheelchair). Additional review of the MDS Assessment, revealed the facility assessed the resident as having Functional Limitation in Range of Motion of both lower extremities; and as requiring a wheelchair for mobility. Review of the MDS Ancillary Assessments, dated 02/04/19, under the Bed Safety Section, revealed the resident was non-ambulatory, had a history of [REDACTED]. The Fall Risk Assessment Section, revealed the resident had one (1) to two (2) falls in the last six (6) months; received [MEDICAL CONDITION] medications; had poor memory and recall ability; had impaired vision; was totally incontinent; was confined to chair and disoriented; was unable to independently come to a standing position; and required hands on assistance to move from place to place. There was no fall risk scale to reference, and there was no score given related to this resident's fall risk. However, the Assessment stated the resident was at high risk for falls. Review of the Progress Notes, dated 02/16/19 at 7:30 PM, completed by Registered Nurse (RN) #1, revealed she was called to Resident #1's room by SRNA #2 who stated while the resident was being turned and changed, he/she was moaning as if in pain. Per the Note, the nurse checked the resident and noted he/she was holding the right knee bent and would moan as SRNA #1 and SRNA #2 continued to turn and change him/her. No bruising or swelling of the right knee was noted. A subsequent Note dated 02/16/19 at 7:35 PM, revealed the resident received Tylenol (medication for pain relief) 1000 milligrams. Review of Resident #1's (MONTH) 2019, Electronic Medication Administration Record [REDACTED]. Review of Resident #1's Progress Note, dated 02/16/19 at 8:05 PM, completed by RN #1, revealed, Resident resting with eyes closed, no moaning at present time. Review of the Progress Note, dated 02/17/19 at 6:20 AM, completed by Licensed Practical Nurse (LPN) #1, revealed Resident #1 complained of right leg pain. Per the Note, the resident's right leg was assessed and was noted to appear larger than the left leg, and appeared to have redness and was warm to touch. Per the Note, the resident had positive pedal pulse and the nurse was unable to palpate a popliteal pulse. According to the Note, the resident was continuously moving back and forth, but holding the right leg still. The subsequent Note, dated 02/17/19 at 6:50 AM, revealed the Physician was notified and orders were received to send the resident to the Hospital emergency room for evaluation and treatment. Interview with SRNA #1, on 02/28/19 at 2:25 PM, revealed on 02/16/18 at approximately 7:30 PM, she entered Resident #1's room and observed him/her sitting in the wheelchair near the bed. Per interview, the resident was leaning forward in the seatbelt with the safety seatbelt in place, but the seat belt appeared to be loose. SRNA #1 stated she thought Resident #1 was going to tip forward in the wheelchair, so she placed her body against the resident and placed her arms around Resident #1's underarms, then unhooked the safety seatbelt and lifted the resident from the wheelchair to the side of the bed. SRNA #1 further stated she then placed one (1) arm around the resident's shoulder and one (1) arm behind the resident's knees and assisted the resident into a lying position. Further interview with SRNA #1, revealed she then went to get help from SRNA #2 to help change the resident's clothes for bed. Per interview, when she and SRNA #2 started to undress Resident #1 and take off his/her pants, they noticed he/she was whimpering like he/she was in pain and SRNA #2 immediately asked the nurse to come assess the resident. Continued interview with SRNA#1, revealed RN #1 assessed the resident and administered pain medication. Per interview, during the night of 02/16/19 and the morning of 02/17/19, when she and SRNA #2 provided care for the resident, the resident did not appear to be in any pain. Additional interview with SRNA #1, revealed she was familiar with Resident #1's CNA Care Plan and knew Resident #1 required the assistance of two (2) staff and a Hoyer lift for transfers prior to her transferring the resident independently on 02/16/18. However, she stated the resident was light weight and she thought she could transfer the resident by herself. Interview with SRNA #2, on 02/28/19 at 4:12 PM, revealed she was assisting SRNA #1 with dressing Resident #1 on the night of 02/16/19, and when they attempted to move resident's right leg, the resident would cry out and moan, like in pain. Per interview, after dressing the resident for bed, she went to alert the nurse that the resident was acting like he/she was in pain. Interview with Registered Nurse (RN) #1, on 02/28/19 at 10:58 AM, revealed on 02/16/19, SRNA #2 alerted her Resident #1 was in pain and she immediately went to assess the resident. She stated the resident was holding his/her right leg up behind his/her knee. RN#1 stated, per her assessment there was no redness or swelling and no signs of anything abnormal. RN#1 further stated she assumed the resident may be having arthritic pain or pain from his/her prior knee replacement,and she administered Tylenol for pain. Further interview revealed the Tylenol was effective because when she checked on the resident afterward, the resident appeared to be resting comfortably in bed, and to her knowledge had slept well through the night. Interview with SRNA #8, on 03/01/19 at 8:12 AM, revealed she assisted Resident #1 with dressing on the morning of 02/17/19 around 6:30 AM with the assistance of SRNA #9. Per interview, Resident #1 was holding his/her right leg in the air and would not bend his/her right leg in order for the SRNAs to dress the resident in pants. SRNA#9 stated she was able to get a stretchy pair of pants on the resident. Further interview revealed SRNA #8 and SRNA #9 transferred the resident from the bed to the wheelchair with the Hoyer lift without issue. Further interview revealed after Resident #1 was transferred to the wheelchair, the resident was holding his/her right leg up in the wheelchair and this was abnormal behavior for the resident. Per interview, when she asked the resident why he/she was holding his/her leg up, the resident stated, it's broke. SRNA #8 stated she then went to get Licensed Practical Nurse (LPN) #1 to assess the resident. The State Agency Representative attempted to contact SRNA #9 via phone, on 03/01/19 at 9:30 AM, and a message was left. The phone call was not returned. Interview with LPN #1, on 02/28/19 at 10:50 AM, revealed when she received report from RN #1 on the morning of 02/17/19, she was told Resident #1 had complained of pain and Tylenol was administered and was effective. Per interview, at about 6:20 AM that morning, SRNA #8 requested her to assess Resident #1's right leg. LPN #1 stated when she assessed Resident #1, she observed the resident's right thigh to be somewhat swollen and red. She stated she assessed the resident's right lower extremity pedal pulse, which was present, but faint and it was difficult to assess the popliteal pulse as the resident was holding his/her right leg up from behind the knee. Per interview, after the assessment, she contacted the physician and obtained orders to send the resident to the Hospital emergency room (ER) for evaluation. LPN #1 stated she attempted to notify the resident's family of the transfer at 7:05 AM, and at 7:08 AM she called report to the ER. Further interview revealed at 7:25 AM, Emergency Medical Services transferred the resident to the Hospital. Interview with SRNA #3 and SRNA #4, on 02/28/19 at 11:30 AM, revealed if a staff member needed to know how a resident was to be transferred, they were to check the nurse aide care plan book at each nurse's station. Per interview, there was also a sticker located on the foot board of each resident's bed which stated the transfer assistance needed and what method of transfer was required. Further interview revealed they would never transfer a resident by themselves if that resident required two (2) staff for transfers, as this would be dangerous for the resident and staff. Review of the local Hospital Emergency Department (ED) Note, dated 02/17/19 at 7:37 AM, revealed the patient presented with pain, swelling and tenderness, and complaints affected the right quadriceps. Further review revealed the patient had an injury of unknown cause and the patient was non-weight bearing, and bedbound until transferred to wheelchair. Per the Note, at 9:22 AM, interpretation of X-Ray results, revealed distal Femur Fracture just proximal to the knee. Pain medication [MEDICATION NAME] 30 milligrams (mg) given Intramuscular (IM) and pain decreased. Continued review revealed the patient would be transferred to another hospital related to higher care needed for Femoral Fracture. Review of the University Hospital Emergency Department General Note, dated 02/17/19 at 9:56 AM, revealed the patient presented for evaluation of Right Femur Fracture. Nursing Home reports patient was at baseline yesterday, and this morning resident was complaining of right leg pain. No trauma or falls reported. Further review of the Note, revealed the Nursing Home reported patient had severe dementia at baseline, was wheelchair bound and nonvocal. Review of the University Hospital Consultation Note for Surgery and Orthopedics, dated 02/18/19 at 11:26 AM, revealed per the patient's past medical history, he/she had bilateral knee replacements four (4) years ago and a right hip replacement three (3) years ago after a fall. Further review revealed, will discuss case at conference and have conversation with the patient and family regarding best management for fracture; operation versus non-operative treatment. Review of the University Hospital Consultation Note for Surgery and Orthopedics, dated 02/19/19 at 3:47 PM, revealed the Physician had a long discussion with the family regarding treatment options. The family would like to proceed with transfemoral amputation (above the knee) to limit the risk of hardware and bone healing related complications. Plan to proceed with operation, on 02/20/19. Review of Resident #1's University Hospital Operative Report, dated 02/20/19, at 1:40 PM, revealed the patient presented to the ED from the Nursing Home, and the patient was minimally communicative and non-weight bearing with significant flexion contracture of the right hip. Patient underwent a total hip as as well as total knee in the past. Patient has severe Dementia as well as multiple comorbidities. Due to patient's overall medical status, the risks, benefits, and alternatives of non-operative verses open reduction and internal fixation versus above knee amputation were discussed with the family, who ultimately decided to proceed with above the knee amputation. Further review revealed the procedure for the right above-knee amputation was performed, on 02/20/19. Review of the facility's Event Report dated 02/18/19, completed by the Director of Nursing (DON), revealed LPN #1 reported Resident #1 was assessed to have swelling and redness to the right leg. Per the Report, the facts observed at the scene, revealed about 6:00 AM on 02/17/19, the nurse noted redness to the resident's right leg and the resident complained of pain. Further review revealed a physician's orders [REDACTED]. Additional review revealed the Root Cause of injury, was Resident #1 was manually transferred from the wheelchair to the bed to prevent a fall on 02/16/19 around 7:30 PM. Review of the facility's Investigation of Unexplained Injury, dated 02/20/19, signed by the DON, Administrator, and the Social Services Director, revealed SRNA #1 stated during interview 02/17/19 at 7:30 PM, that on 02/16/19 about 7:30 PM, when she entered Resident #1's room, the resident was leaned over significantly forward in the wheelchair and SRNA #1 feared the resident was going to tip the wheelchair forward. The wheelchair was parked next to the bed so SRNA #1 put her arms around the resident's upper torso and released the seatbelt, and then transferred the resident from the wheelchair to the bed. SRNA #1 stated the transfer was not difficult and no incident occurred. Shortly after transfer, Resident #1 complained of right leg pain and was given Tylenol that seemed effective for the rest of the night, and the resident did not complain again, until 02/17/19 at 6:00 AM. Review of the Physician's Progress Note dated 02/26/19, completed by Resident #1's Attending Physician, revealed Resident #1 was discharged from the hospital related to a Distal Right Femur Fracture. Further review revealed there were no reports of witnessed fall or trauma by the nursing staff. No distress noted. Wound stable to AKA (above the knee amputation). Interview with the Resident #1's Attending Physician on 03/01/19 at 10:05 AM, revealed Resident #1 was frail and had a [DIAGNOSES REDACTED]. Per interview, the resident was elderly and had a low body mass index, and [MEDICAL CONDITION], which made him/her susceptible to a Fracture. Further interview revealed with an improper transfer, anything could happen, but she could not say for sure that Resident #1's improper transfer with just one (1) staff member on 02/16/19, could have caused the resident's fracture because the resident did not weight much and and it should be easy to transfer the resident with just one (1) person. Interview with the Physical Therapist, on 02/28/19 at 2:35 PM, revealed a resident who was non-weight-bearing and required the assistance of two (2) staff and the Hoyer lift should never be transferred with just one (1) person. Further interview revealed this type of transfer could cause severe harm to the resident such as bruising and even broken bones, as well as causing injury to staff. Interview with the Director of Nursing (DON), on 03/01/19 at 10:36 AM, revealed it was her expectation staff follow facility policies and procedures related to preventing accidents for the residents' well being. Per interview, it was her expectation the SRNAs follow the SRNA CCP as it was a guide for staff to provide care for the residents and included the transfer technique and how many staff were required to transfer residents. Per interview, injuries could occur to both residents and staff if residents were improperly transferred. Further interview revealed Resident #1's CNA Care Plan had an intervention for two (2) staff for transfers with the Hoyer lift; however, the facility investigation concluded on 02/16/19 Resident #1 was transferred independently from the bed to the wheelchair, by SRNA #1. Continued interview revealed Resident #1 complained of pain after the transfer and complained of pain the next morning, and was diagnosed with [REDACTED]. The DON stated the resident should have been transferred as per the SRNA CCP on 02/16/19 by SRNA #1. Post exit interview with the DON, on 03/11/19 at 11:09 AM, revealed the transfer technique and how many staff were required to transfer a resident, and any equipment needed for the transfer should be on the CCP. Per interview, the CCP was generated from the MDS Assessment and should be individualized and specific. Interview with the Administrator, on 03/01/19 at 10:45 AM, revealed it was his expectation staff were knowledgeable of how to provide care for each resident. Per interview, the CCP should have specific and individualized interventions and the CCP and the CNA Care Plan should be used as a guide in providing care. Per interview, a resident who was assessed as requiring more than one (1) person's assistance for transfers should not be transferred with just one (1) person. Further interview revealed staff should be aware of the need for specific devices such as a Hoyer Lift for transfer of individual residents, in order to prevent injuries to residents and staff.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to provide nourishing snacks to residents at bedtime, and failed to have juice available on request. Interview during Group Interview, conducted by the State Agency Representative on 9/12/18, revealed Residents #20, #29, #38, #51, #53, #60, and #66 complained the facility failed to offer bedtime snacks and did not have juice available when requested. In addition, observation and interview with staff and Residents #12, #23, #36, and #57, on the evening of 9/13/18, revealed the facility failed to offer bed time snacks. The findings include: Review of the facility Hydration and Nutrition Policy, revised 9/25/15, revealed snacks are offered between meals and at bedtime according to resident desire or need, and fluids are always available to residents. 1. Group Interview conducted by the State Survey Agency Representative on 9/12/18 at 10:59 AM, revealed Resident #20, #29, #38, # 51, #53, #60, and #66 were not being offered bedtime snacks at night, and would enjoy being offered nourishments and fluids other than water at bedtime. The residents also expressed during Group Interview the facility did not have juice available which used to be offered in the daytime and at bedtime. Further Group Interview revealed they had not expressed these concerns to the facility. Review of Resident #20's medical record revealed the facility assessed the resident in a Quarterly Minimum Data Set ((MDS) dated [DATE], as having a Brief interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #29's medical record revealed the facility assessed the resident in an Annual MDS assessment dated [DATE], as having a BIMS of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Review of Resident #38's medical record revealed the facility assessed the resident in a Quarterly MDS assessment dated [DATE], as having a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Resident #51 had a facility assessed BIMS score of fourteen (14) out of fifteen (15), on the Annual Minimum Data Set (MDS) assessment dated [DATE], indicating the resident to be cognitively intact. Resident # 53 had a facility assessed BIMS score of twelve (12) out of fifteen (15), on the Annual Minimum Data Set ((MDS) dated [DATE], indicating moderate cognitive impairment. Resident #60 had a facility assessed BIMS score of thirteen (13) out of fifteen (15), on the Quarterly Minimum Data Set ((MDS) dated [DATE], indicating the resident to be cognitively intact. Resident #66 had a facility assessed BIMS score of fifteen (15) out of fifteen (15), on the Admission Minimum Data Set ((MDS) dated [DATE], indicating the resident to be cognitively intact. 2. Review of Resident #36's medical record revealed the facility assessed the resident as having a BIMS score of eleven (11) out of fifteen (15) per the Quarterly MDS assessment dated [DATE], indicating moderate cognitive impairment. Observation on 9/12/18 at 8:00 PM, revealed Resident #36 was sitting in a chair in his/her room. Interview with the resident at the time of observation, revealed if he/she asked for snacks at bedtime staff would say they did not have any. Per interview he/she had stopped asking for snacks from the facility and his/her family would bring in snacks for him/her. 3. Resident #57 had a facility assessed BIMS score of thirteen (13) out of fifteen (15), on the Quarterly Minimum Data Set ((MDS) dated [DATE], indicating the resident was cognitively intact. Observation on 9/12/18 at 8:06 PM, revealed Resident #57 was in his/her room lying in bed. Interview with the resident during the observation revealed staff never offered snacks at bedtime. Per interview, he/she would occasionally like to have snacks at bedtime. 4. Review of Resident #13's medical record revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) on the Annual Minimum Data Set ((MDS) dated [DATE], indicating the resident was cognitively intact. Observation on 9/12/18 at 8:11 PM, revealed Resident #13 was lying in bed in his/her room on Hall A. Interview with the resident during the observation revealed snacks were never offered at anytime, and definitely not offered at bedtime. Per interview, the facility used to offer juice several times a day and now never offered juice. Resident #13 stated he/she would like to have juice and snacks offered to him/her at bedtime and at other times of the day. Continued interview revealed when the facility did have snacks the only snacks available were cheese and crackers which were not offered, but staff would get them if requested. 5. Review of Resident #23's medical record revealed the facility assessed the resident as having a BIMS score of ten (10) out of fifteen (15) on the Annual Minimum Data Set ((MDS) dated [DATE], indicating moderate cognitive impairment Observation on 9/12/18 at 8:13 PM, revealed, Resident #23 was sitting in his/her room. Interview with Resident #23 during the observation, revealed nursing staff did not offer snacks at bedtime or anytime. Per interview, he/she would ask for snacks; however, staff did not offer them. Per interview, staff never offered any nutrition or fluids between meals other than ice and water. Observation of staff on 9/12/18 from 8:00 PM- 9:00 PM, on A Hall and B Hall, revealed staff did not offer snacks or nourishments to residents other than passing ice and water. Observation on 9/12/18 at 8:15 PM, of the A Hall refrigerator, and at 8:45 PM, of the B Hall refrigerator, revealed cranberry juice, sandwiches and assorted labeled resident drinks. The Nurse's station for both A and B Hall had peanut butter and cracker, cheese crackers, and graham crackers as well as assorted condiments. Interview with Licensed Practical Nurse (LPN) #5, on 9/13/18 at 8:15 PM, revealed she was assigned to the A Unit. Per interview, she did not offer bedtime snacks to all residents routinely each night. Continued interview she would give snacks to the residents known to want night snacks and she would give snacks to certain residents during medication pass. Per interview, if resident's asked for snacks she would obtain a snack per resident request. However, LPN #5 stated she did not ask the State Registered Nursing Assistants (SRNA) if they had passed snacks at night and did not know if they offered snacks to all residents. Per interview, all resident's should be offered a bedtime snack because some residents may want a snack and not ask for it, and some residents were unable to ask for a snack due to cognitive impairment. Per interview, there were sandwiches as well as cheese and crackers from the kitchen which were always available on the unit. Interview with SRNA #8, on 9/13/18 at 8:40 PM, revealed she sometimes offered bedtime snacks to residents, but not every evening. Per interview, snacks were available at the nursing station in the nourishment refrigerator and cabinet. Continued interview revealed the facility did not have a snack cart to make rounds or a list indicating each resident's diet orders in order to provide snacks to each resident. Interview with SRNA #9, on 9/13/18 at 8:45 PM, revealed she was aware of some residents' preferences for bedtime snacks and delivered these residents snacks, but she did not offer each resident a bedtime snack. Further interview revealed there was no snack and hydration cart or list to indicate the residents' diet in order to offer each resident a snack in the evenings. Per interview, SRNAs or nurses should be offering a bedtime snack to all residents each night to help ensure adequate nutrition and hydration and for resident enjoyment. Interview with the Assistant Director of Nursing (ADON), on 9/13/18 at 11:50, revealed all residents should be offered a bedtime snack. Per interview, it was important for staff to offer snacks because all residents may not voice or be able to voice being hungry or thirsty, but may enjoy a snack at bedtime. Further interview revealed it was important staff ensured residents with a [DIAGNOSES REDACTED]. Continued interview revealed there may be times when residents may not have eaten much at dinner and that would make offering a bedtime snack even more important. Interview with the Dietary Manager, on 9/13/18 at 3:00 PM, revealed the dietary department did send snacks to the unit to stock the nourishment refrigerators, but the kitchen did not individually label snacks with the residents' name. Per interview, there was no unit snack lists. Interview with the Director of Nursing (DON), on 09/13/18 at 4:45 PM, revealed all residents if allowed PO (by mouth) food and fluids should be offered snacks at bedtime to maintain optimal nutrition. Per interview, the facility maintained snacks for the residents at the nurse's station. Further interview revealed the time period after supper until breakfast was the longest period between meals, and the SRNAs should be offering nutrition and hydration upon nightly rounds. Interview with the Administrator, on 09/13/18 at 5:50 PM, revealed all residents if allowed PO dietary nutrition should be offered snacks at bedtime each evening. Per interview, this was important to maintain nutrition, hydration, satisfaction, and quality of life for the residents. Per interview, the facility needed to put a quality assurance plan in place as a priority to give residents options in snacks at bedtime.

Based on interview, and review of facility Policy, it was determined the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) Policy included a written Quality Plan that describes the process for conducting QAPI activities such as identifying and correcting quality deficiencies as well as opportunities for improvement. The findings include: Review of the facility Quality and Assurance Performance Improvement Policy, dated 08/01/14, revealed parameters for the development and operation of a QAPI Committee. However, there was no documented evidence of a QAPI Plan describing the process for identifying and correcting quality deficiencies including tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underling causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities. Interview with the Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN), on 09/13/18 at 1:05 PM, revealed she was also the Director of QAPI. She stated the team met monthly; however, there was no established Quality Plan inclusive of performance measurement, goals, data analysis, or interventions based on reported outcomes. Interview with the Director of Nursing (DON), on 09/13/18 at 4:18 PM, revealed the QAPI Committee was the responsibility of the ADON. She further stated she was not aware of a Quality Plan with written policies and protocols . Further interview revealed there were no active quality initiatives other than monitoring of call light responses on the date of the interview. She stated a Quality Program was important for the facility to ensure residents achieved optimal outcomes. Interview with the Administrator, on 09/13/18 at 5:29 PM, revealed the Quality Plan should have written standards for collection of data, guidance for measurement of data, and assessment of the effectiveness of interventions. Per interview, the facility's current QAPI Policy did not contain a Quality Plan with additional policies and protocols. He stated the ADON was responsible for the Quality Program and all staff had a role in quality improvement. He further stated a well established quality plan was the structure for providing optimal resident outcomes.

Based on interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable disease and infections. There was no documented evidence of written policies and procedures which included a system of surveillance designed to identify possible communicable diseases before transmission to others; and when and how isolation should be used for a resident; including, but not limited to the type and duration of the isolation, and the least restrictive possible isolation for the resident. Also, review of the Facility Infection Control Risk Assessment, dated 11/17/17, revealed an assessment of the facility's infection control risks was completed; however, there was no written analysis or summary connecting the Assessment to written infection control and surveillance policies and procedures for the facility. In addition, observation on 09/12/18, revealed Resident #13 had no signage related to contact isolation, no Personal Protective Equipment (PPE) at the entry to the resident's room, and no biohazard receptacle in the resident's room. However, the resident had a Physician's Order for contact isolation related to Extended Spectrum Beta Lactamase (ESBL) in the Urine. Observation of a catheterization procedure on 09/12/18, for Resident #13, revealed the nurse did not follow contact precautions related to wearing a gown, and disposing of used supplies per a biohazard container. Furthermore, Resident #68 did not have a Physician's Order for isolation; however, PPE and signage was on the resident's door. Review of Resident #68's Microbiology Report revealed a wound culture was reported on 08/30/18, revealing the sacral wound culture showed [MEDICAL CONDITION] (MRSA). The findings include: 1. Review of the Centers for Disease Control (CDC) recommendations, revealed one (1) to three (3) million infections occur in long-term facilities annually. The National Healthcare Safety Network (NHSN), a part of CDC, recommends long-term facilities track infections in a systematic way to improve care and decrease costs. Review of the Facility Infection Control Risk Assessment, dated 11/17/17, revealed an assessment of the facility's infection control risks was completed; however, there was no system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases based upon the facility Assessment. Review of the facility Unit B Antibiotic Tracking Log dated 03/26/18 through 09/10/18, revealed six (6) of twenty-eight residents did not have the antibiotic start date recorded; twenty-six (26) of twenty- eight (28) residents treated with antibiotics did not have a pathogen/organism identified; ten (10) of twenty -eight (28) residents did not have an antibiotic discontinue date; and two (2) of twenty- eight (28) residents did not have the antibiotic treatment documented. Thus, the facility lacked information to ensure resident safety from transmission of infections acquired at the facility. Also, the facility did not have written standards, policies, or procedures defining the surveillance system designed to identify possible communicable diseases before transmission to others when requested. Furthermore the facility did not have written standards, policies, or procedures defining how isolation should be used for a resident; including, but not limited to the type and duration of the isolation, and the least restrictive possible isolation for the resident, nor was there evidence the Infection Control Risk Assessment was included in policies and procedures. Interview with the Assistant Director of Nursing (ADON) (who also served as the Infection Control Preventionist) on 09/13/18 at 11:21 AM, revealed she did not track residents with infections or antibiotics over time. She stated she reviewed antibiotic orders each day but did not access laboratory reports until the end of the month to see what infections were present in the facility. Per interview, she did not maintain the information to establish any infection control risks for residents. Further interview revealed the facility had no written standards, policies, or procedures for management of infections acquired within the facility. Interview with the Director of Nursing (DON) on 09/13/18 at 4:18 PM, revealed the ADON had overall responsibility for the Infection Control Program. The DON stated it was important to review laboratory work associated with infections to enable the facility to establish common infections and implement preventive measures to protect residents and staff from disease transmission. 2. Review of the facility's Contact Precautions Policy, dated 2007, revealed general guidelines were provided for contact isolation. Per Policy, gloves were required for entry into residents' rooms and gowns were required if clothing came into contact with the resident, environmental surface, or items in the resident's room; if the patient was incontinent; or if there was wound drainage not contained by a dressing. No other policies related to transmission precautions were submitted for review. Review of the Centers for Disease Control (CDC), Management of Multi-Drug-Resistant-Organisms in Healthcare Setting, 2006, last updated (MONTH) 15, (YEAR), revealed once multi-drug resistant organisms (MDROs) were introduced into a healthcare setting, transmission and persistence of the organism was dependent on prevention efforts. Further review revealed recommendations for contact precautions (gown and gloves) when in contact with draining wounds. Continued review revealed educational interventions should intensify when MDROs were identified within the facility. Review of Resident #13's medical record revealed the facility admitted the resident on 05/07/18 with [DIAGNOSES REDACTED]. Review of Resident #13's Acute Care Plan with problem onset date of 03/26/18, revealed a problem of strong odor in urine upon in/out catheterization. The goal stated the resident would be symptom free by review date with target date of 10/25/18. Interventions include antibiotics as ordered, offer and encourage fluids, provide proper peri care, and contact precautions related to Extended Spectrum Beta Lactamase (ESBL) in the Urine. Review of Resident #13's Annual Minimum Data Set (MDS) Assessment, dated 07/14/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Review of Resident #13's (MONTH) (YEAR) Order Summary Report, revealed an active Physician's Order for Contact Precautions, with an original order date of 5/17/18. Further review of Resident #13's (MONTH) (YEAR) Order Summary Report, revealed Physician's Orders dated 06/12/18, with start date of 06/24/18, for [MEDICATION NAME] (antibiotic) 10 Milligrams one (1) by mouth one (1) time a day for Urinary Tract Infection [MEDICAL CONDITION] for three (3) months until 09/24/18. Observation on 09/12/18 at 4:15 PM, revealed there was no signage on the door related to isolation precautions or to see a nurse before entering. In addition there was no PPE noted on the door or at the entrance to the resident's room. Licensed Practical Nurse (LPN) #2 was observed to enter the resident's room without donning PPE. LPN #2 was further observed to perform In and out urinary catheterization on Resident #13 using sterile technique. LPN #2 then disposed of the used catheter in the resident's trash can beside the bed, emptied the urine from the catheterization into the resident's commode, and discarded the urine container and gloves in Resident #13's roommate's trash can. There was no biohazard receptacle in the room. LPN #2 then performed hand hygiene, donned gloves and continued to care for the resident. Interview on 09/12/18 4:50 PM with LPN #2, revealed she received infection control education in facility orientation, and had worked as a nurse for a year. Per interview if a resident was on contact precautions there would be signage on the door to warn staff and visitors to see the nurse before entering the resident's room and there would be a caddy on the door containing PPE. She stated when a lab report came back indicating the need for contact precautions the nurse would call the physician for an order for [REDACTED]. LPN #2 further acknowledged she did not utilize isolation precautions for Resident #13 as there was no indication the resident was on isolation precautions. Interview on 09/13/18 at 10:20 AM, with State Registered Nurse Aide (SRNA) #7, revealed if a resident was on contact precautions staff would receive this information during report at the beginning of the shift and there would be pockets on the resident's door containing gowns, gloves, and masks. Per interview, if a resident was on contact precautions the resident's linens will be placed in a special bag, and biohazard trash would be discarded into a red bag in the resident's room. Further interview revealed she had taken care of Resident #13 for three (3) years and the resident had not been on isolation precautions. Interview on 09/13/18 10:30 AM with LPN #5, revealed if a resident was on contact precautions staff would be informed during shift report, and there would be a yellow basket on the resident's door containing PPE. She further stated staff would put the resident's clothes and linens in a washable bag that dissolved in the wash, and biohazard trash would be placed in a red bag. Per interview, the facility did not use signage to inform visitors or staff of the need to see the nurse before entering the room. LPN #5 stated she had taken care Resident #13 a few times a month for the last two (2) to three (3) years and the resident had not been on contact precautions. Interview on 09/13/18 at 10:00 AM, with Resident #13, revealed staff wore gloves when they are provided care for him/her, but not gowns. He/she stated it had been a while since anyone had worn a gown while providing care for him/her. Further interview revealed staff usually discarded the used catheters in the beside trash can and the urine container in the bathroom trash can. 3. Review of Resident #68's medical record revealed the facility admitted the resident on 06/07/18 with [DIAGNOSES REDACTED]. Review of Resident #68's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the Resident as having a BIMS score of nine (09) out of fifteen (15) indicating moderate cognitive impairment. Review of Resident #68's Acute Care Plan, revised 08/16/18, revealed the resident was readmitted with an unstageable sacral pressure ulcer infected [MEDICAL CONDITION] according to hospital records. The goal stated the wound would show signs of healing. However, there were no interventions for contact precautions. Review of Resident #68's Microbiology Report, revealed a wound culture was collected on 08/27/18 with report date of 08/30/18, indicating the sacral wound culture showed [MEDICAL CONDITION] (MRSA) (Mutidrug Resistant Organism). Review of Resident #68's (MONTH) (YEAR) Order Summary Report revealed no Physician's orders related to isolation precautions. However, observation on 09/12/18 at 5:00 PM, revealed signage on Resident #68's door which stated to see the nurse before entering. In addition, there was PPD hanging on the door including gowns and gloves. Continued interview on 9/13/18 11:21 AM with the ADON/ICP, revealed staff were educated on isolation precautions during orientation and as needed. She stated if a resident was on contact precautions there would be signage on the resident's door to see the nurse before entering as well as a caddy containing PPE. She further stated biohazard bags would be kept in the room for biohazard waste; however, she was not sure who picked up those bags to be discarded. Per interview, staff also passed information in shift report related to isolation precautions. Further interview revealed if the signage and the PPE was removed from the resident's door, staff could assume the resident was no longer in isolation. Continued interview on 09/13/18 4:18 PM with the DON, revealed education for nursing staff related to isolation precautions was provided by the ADON and the DON during orientation and per computer training. The DON stated if there was a Physician's Order for contact precautions, the order should be followed to prevent the transmission of disease and infection to residents and staff. Further interview revealed there should be Physician's Orders related to isolation for any resident on contact precautions for MDROs. Interview with the Administrator on 09/13/18 at 5:29 AM, revealed it was his expectation for the Nursing Department to take the lead on infection control actions. He stated the ADON had overall responsibility for the program. He further stated it was important to track, trend, and manage infectious diseases to enable the facility to prevent disease transmission among staff and residents. Continued interview revealed it was important the facility had written written infection control and surveillance policies to identify communicable diseases. Further interview with the Administrator, revealed communication of infection control issues such as the need for isolation precautions was the most important aspect in prevention of disease and infection. The Administrator stated adhering to isolation precautions and protocols was of high importance to prevent transmission of infection to residents and staff.

Based on interview, record review, review of Policies utilized by the facility, and review of the Centers for Disease Control (CDC), The Core Elements of Antibiotic Stewardship in Nursing Homes, it was determined the facility failed to have an Antibiotic Stewardship Program that was developed and implemented based on written protocols for antibiotic use in order to monitor antibiotic usage; optimize the treatment of [REDACTED]. Review of the facility Antibiotic Tracking Log and interview with the Assistant Director of Nursing (ADON)/Infection Control Nurse (ICN), revealed no antibiotic prescribing protocols were in place nor evidence of laboratory results to support antibiotic usage. Twenty six (26) of twenty-eight (28) residents did not have a culture collected to support correct antibiotic prescribing, dosing, and duration in order to reduce the development of antibiotic-resistant organisms. In addition, the Antibiotic Tracking Log was incomplete with no pathogen identified for twenty six (26) of twenty eight (28) residents on antibiotics; no start date for antibiotics for nine (9) of twenty eight (28) residents; and no antibiotic stop dates for ten (10) of twenty eight (28) residents. The findings include: Review of the Antibiotic Stewardship-Staff and Clinician Training and Roles Policy, 2001 Med Pass, Inc., revised (MONTH) (YEAR), utilized by the facility, revealed nursing assistants, licensed nursing staff, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Consultant Pharmacist would receive training in antibiotic stewardship. However, there were no protocols present in the policy regarding antibiotic prescribing, review of prescribing practices, protocols for optimizing the treatment of [REDACTED]. Review of the Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, Policy dated 11/27/17, revealed the Infection Preventionist should review all antibiotic starts within forty -eight (48) hours of antibiotic therapy. However, no antibiotic use protocols for consistent review of laboratory reports were included in the policy. Review of the Centers for Disease Control (CDC), The Core Elements of Antibiotic Stewardship in Nursing Homes, undated, recommended facility-specific treatment recommendations, based on national guidelines and local susceptibilities and formulary options to optimize antibiotic selection and duration. The CDC further stated residents who were unnecessarily exposed to antibiotics were placed at risk for serious adverse events with no clinical benefit. Review of the facility Antibiotic Tracking Log for Unit B, 03/26/18 through 09/10/18, revealed antibiotics were prescribed for residents; however, no prescribing protocols were in place nor evidence of laboratory results to support antibiotic usage. Further review revealed twenty six (26) of twenty-eight (28) residents did not have a culture collected to support correct antibiotic prescribing, dosing, and duration to reduce the development of antibiotic-resistant organisms. In addition, the tracking log was incomplete with no pathogen identified for twenty six (26) of twenty eight (28) residents, no start date for antibiotics for nine (9) of twenty eight (28) residents, and no antibiotic stop dates for ten (10) of twenty eight (28) residents. Review of the facility Agenda for Quality Assurance (QA) Meeting Minutes, undated, revealed pharmacy was expected to attend meetings; however, no agenda item for antibiotic stewardship was included. Further review of the Quality Assurance/Performance Improvement Committee Agenda and Minutes sign in sheet, dated 09/13/18, revealed pharmacy did not attend the meeting. Interview with the Assistant Director of Nursing (ADON), Infection Control Nurse, on 09/13/18 at 11:21 AM, revealed she was responsible for the Antibiotic Stewardship Program. She stated she did not review laboratory reports, but she reviewed physician's orders [REDACTED]. The ADON stated she did not receive an antibiogram or any other information from the laboratory. She further stated during Quality Assurance and Performance Improvement Committee meetings the pharmacist reviewed how many antibiotics were prescribed to residents, but no other antibiotic stewardship information was presented. Interview with the Director of Nursing (DON), on 09/13/18 at 4:18 PM, revealed the ADON was responsible for the Antibiotic Stewardship Program. She stated it was important to track all infections to identify patterns and implement interventions to prevent the transmission of infectious disease. She further stated she realized some residents in the facility were on antibiotics for extended time periods. The DON stated the staff used an SBAR form (Form used to communicate medical concerns from the nurse to providers. The acronym means Situation, Background, Assessment and Recommendation) to notify providers of new signs and symptoms of resident infections. Per interview, the nurse then recorded residents on antibiotics on the Antibiotic Tracking Log. She stated she was unaware of any prescribing protocols to optimize antibiotic usage. She was also unaware of the lack of culture results to support antibiotic use for twenty six (26) of twenty eight (28) residents. Interview with the Administrator, on 09/13/18 at 5:29 PM, revealed protocols for antibiotic prescribing were not included in the policies utilized by the facility for antibiotic stewardship as these were older policies. He stated the Antibiotic Stewardship Program was important to the facility to ensure residents were treated for [REDACTED]. He further stated the ADON was responsible for the organization and function of the Antibiotic Stewardship Program, and the Medical Director's role was to assist with inappropriate antibiotic usage although he did not recall any time when that had been necessary. Further interview revealed the facility's QA was not effectively tracking infections and antibiotic usage. The Administrator acknowledged the facility did not have an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use.

Based on interview, record review and review of facility policy, it was determined the facility failed to have an effective system in place to ensure the Physician and/or legal representatives were notified when there was a significant change in the resident's physical status or a need to alter treatment significantly for two (2) of nine (9) sampled residents (Residents #2 and #9). Resident #2 did not meet his/her Estimated Fluid Need (EFN) on [DATE], [DATE], [DATE], [DATE], and [DATE], and on [DATE] at 5:16 PM, Resident #2 spiked a fever of 101.1 degrees Farenheit (F). The Physician was notified and the resident was started on [MEDICATION NAME] (antibiotic medication) for an Upper Respiratory Infection. On [DATE] between 8:00 PM and 10:00 PM the resident was assessed to have a further increased temperature of 102 degrees F; however, there was no documented evidence the Physician was notified of the 102 degree temperature. Staff interviews revealed Resident #2 who was a heavy wetter and normally incontinent of urine every two (2) hours; had no urinary output during rounds on [DATE] at 1:00 AM, 3:00 AM, and 5:00 AM. Additionally, the resident was receiving routine [MEDICATION NAME] (a medication to increase the excretion of water from the body) [MEDICATION NAME] (diuretic) forty (40) milligrams (mg's) twice a day for Essential Hypertension. Staff interviews further revealed Resident #2 was showing signs and symptoms of dehydration including decreased or no urine output, dry chapped lips, fever, weakness, and limited food and liquid intake. However, there was no documented evidence the resident was closely monitored and no documented evidence the physician was notified of the resident's signs and symptoms of dehydration. On [DATE], at approximately 6:00 AM, Resident #2 was observed to be unresponsive, in respiratory distress with a temperature of one 102.2 degrees F, axillary. Resident #2 was transferred to the hospital emergency room (ER), on [DATE] at 6:57 AM and on arrival had a rectal temperature of 106.7 degrees F, was unresponsive, had mottled skin (blood vessel changes in the skin that cause a patchy appearance), agonal respirations (gasping labored breathing), capillary refill time of eight (8) seconds, laboratory values which indicated severe dehydration, and his/her soft palate and uvula were like sand paper Resident #2 was admitted to the Critical Care Unit (CCU) at the Hospital and placed on a ventilator due to [DIAGNOSES REDACTED]. Resident #2 expired on [DATE]. Additionally, although the facility faxed the Physician related to Resident #9 having [MEDICAL CONDITION] to his/her right leg on [DATE], after the resident's Power of Attorney (POA) told nurses she was concerned about the resident's leg (on [DATE] and [DATE]), there was no documented evidence the facility called the physician to follow up on the fax. On [DATE], the resident's POA notified the Physician of the resident's right leg [MEDICAL CONDITION]. An Echo/Vascular Ultrasound was completed on [DATE], which revealed Resident #9 was positive for a [MEDICAL CONDITIONS], blood clot. The facility's failure to have an effective system in place to ensure the Physician and legal representatives were notified when there was a significant change in the resident's physical status or a need to alter treatment significantly has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy, on [DATE], as alleged prior to exit on [DATE], with remaining non-compliance in the area of 42 CFR 483.10 Resident Rights, F-157 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic change. The findings include: Review of the facility's policy, titled Notification of Change in Residents' Condition, revised on [DATE], revealed, staff should immediately inform the resident, consult with the resident's physician, and if known: notify the resident's legal representative when there was a change in the resident's status/condition. Continued review revealed, in the event of a resident's status change, the nurse would assess the situation, notify the attending physician, provide necessary care, notify the responsible party, document in the resident's medical record and follow up as indicated. 1. Review of Resident #2's medical record revealed, the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan revised [DATE], revealed Resident #2 had the potential for fluid deficit related to diuretic use with a goal stating the resident would be free of symptoms of dehydration and maintain moist mucous membranes, and good skin turgor. The interventions included; monitoring vital signs as ordered/per protocol and record, notify the Physician of significant abnormalities, monitor/document/report to Physician signs and symptoms of dehydration: i.e. decreased urine output, cracked lips, fatigue/weakness, fever, dry/sunken eyes and furrowed tongue. Review of the Nutrition Risk Assessment, dated [DATE], completed by the facility's Dietitian revealed Resident #2's estimated fluid needs (EFN) were two thousand and fifty (2050) to two thousand, four hundred and sixty (2460) cubic centimeters (cc) per day. Review of the Follow-Up Question Report (form used to total fluid intakes), revealed Resident #2 did not meet the estimated fluid needs (EFN) of two thousand and fifty to (2050) to two thousand and four hundred and sixty (2460) milliliters (ml's) per day on [DATE], [DATE], [DATE], [DATE]; and, on [DATE]. The resident's total fluid intakes were as follows: [DATE] - 1940 cc, [DATE] - 1680 cc, [DATE] - 2205 cc, [DATE] - 1220 cc, and [DATE] - 1500 cc. Although, the resident did not have three (3) consecutive days without meeting the EFN in order for staff to notify the Physician of the resident's hydration status as per policy, staff interviews revealed the resident was having changes in nutrition/hydration status and they were having difficulty getting the resident to eat and drink. However, there was no documented evidence the resident's Physician was notified of the resident change in condition. Interview on [DATE] at 1:40 PM, with Certified Nursing Assistant (CNA) #5, revealed the week prior to the resident's hospitalization , she observed the resident had a dry mouth, sores on the outside of his/her mouth which she soaked with warm water and a washcloth to clean the stuff off the resident's lips. Interview on [DATE] at 10:50 AM, with CNA #4 revealed the resident was cheeking (pocketing) food, had complaints of mouth pain, and the resident's lips were dried and chapped. CNA #4 stated he notified Registered Nurse (RN) #4 of these changes with Resident #2. Interview with CNA #3, on [DATE] at 10:50 AM, revealed he worked the week Resident #2 became sick, [DATE] through [DATE]. He stated he observed the resident was more combative than normal and it was difficult to feed him/her, also the resident did not want to eat and it was difficult to get fluids in him/her. CNA #3 stated the resident would cheek his/her food and would not swallow. Interview on [DATE] at 1:00 PM with the resident's POA revealed he had informed RN# 4 on [DATE] and [DATE] that they were concerned about the resident not eating and drinking well; and, looking like he/she felt bad and he wanted the Physician to see Resident #2. Review of the facility's Twenty-Four (24) Hour Report dated [DATE], revealed a note stating the resident's son, who was the POA wanted the Physician to assess the resident. However, review of the Nurse's Notes dated [DATE] and [DATE] revealed no documented evidence the resident's Physician was notified of the family's request to contact the physician. Interview on [DATE] at 1:01 PM, with RN #4 revealed she had written the notation on the twenty-four (24) hour report; however, she had failed to ensure the Physician was contacted. Review of the Nurse's Notes dated [DATE] at 5:16 PM, completed by RN #4, revealed Resident #2 had a fever of 101.1 F, and crackles (abnormal lung sounds) were noted in the lungs. Per the Note, the Physician was notified and orders were received for [MEDICATION NAME] (antibiotic medication). On [DATE] at 12:35 AM, staff documented on the Vital Sign Log, Resident #2 had a temperature of 102 F. Interview with CNA #10 on [DATE] at 5:11 PM, and CNA #11 on [DATE] at 8:27 AM revealed they worked with CNA #9 the evening of [DATE] and thought CNA #9 obtained the vital signs. CNA #9 and CNA #11 stated the vital signs were usually obtained between 8:00 PM and 10:00 PM. However, interview with CNA #9 on [DATE] at 4:43 PM revealed he could not recall if he obtained the vital signs the evening of [DATE]. Staff interviews revealed it was unclear what time the resident's vital signs were obtained on the evening of [DATE]. Interview with Certified Nursing Assistant (CNA) #7, on [DATE] at 3:44 PM, revealed Resident #2 was not eating or drinking and had only taken in about five-hundred and sixty (560) cc from 2:00 PM on [DATE] through [DATE] at 6:00 AM, for the two (2) shifts in which she worked. She stated Licensed Practical Nurse (LPN) #1 was informed of the resident's decreased fluid intake. However, record review revealed no documented evidence the resident's Physician was notified of the resident's decreased fluid intake. Interview with CNA #10, on [DATE] at 5:11 PM, revealed she worked the night of [DATE] from 2:00 PM until 10:00 PM. She stated she helped CNA #8 with changing Resident #2 and the resident did not have much urine output that shift. She stated the resident was a heavy wetter, and low urine output was not normal for him/her. Further interview revealed, the resident was not combative or fighting with her when she went to change him/her which was unusual. CNA #10 stated it was almost like the resident, did not have much fight left in (him/her). CNA #10 stated she reported these changes to LPN #1, but she did not know if LPN #1 assessed the resident. Review of Resident #2's Flowsheet, revealed on [DATE], Resident #2 had not urinated at the 1:00 AM, 3:00 AM or 5:00 AM rounds. Interview on [DATE] at 3:40 PM, with CNA #7, revealed she reported to LPN #1 that the resident was not urinating and wasn't making any noise, was stiff and difficult to roll over, pale, and had sunken cheeks. However, there was no documented evidence LPN #1 continued to monitor and/or assess the resident on [DATE] and no documented evidence the Physician was notified of the resident's increased temperature of 102 degrees F and signs and symptoms of dehydration even though the nurse was informed the resident was not urinating, was pale, weak and had sunken cheeks. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 5:50 PM, revealed on [DATE], she was given the resident's vital signs which indicated he/she had a temperature of 102 degrees F. LPN #1 stated she gave the resident two (2) 500 milligram (mg) of Tylenol. She stated she checked the resident's temperature again at approximately 12:30 AM, on [DATE], and his/her temperature was 99.0 F. However, LPN #1 stated she did not check on the resident anymore until [DATE] at approximately 6:00 AM, when she noticed the resident had no movement and was found mottled. Per interview, LPN #1 stated had not been notified by the CNAs that the resident had not urinated throughout the night; she found out through shift report. LPN #1 stated the resident was having signs and symptoms of dehydration; however, she missed it and failed to notify the Physician. Further interview on [DATE] at 10:50 AM with CNA #3 revealed at approximately 6:30 AM on [DATE], he took the resident's temperature under the resident's arm and it was 102.2 degrees F. CNA #3 stated the resident was found to be in respiratory distress, and was sweating. Record review revealed Emergency Services was called and the resident was transferred to the local Hospital. Review of Resident #2's emergency room Notes, dated [DATE], revealed upon arrival at the emergency room (ER), the resident was assessed to have a rectal temperature of 106.7 degrees F, respiratory rate of sixty-eight (68) breaths per minute, was unresponsive, had mottled skin, (changes in the blood vessels under the skin that causes a patchy appearance) agonal respirations, (an abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, accompanied by strange vocalizations). Further review, revealed the resident had a capillary refill time of eight (8) seconds, (normal capillary refill time less than two (2) seconds and prolonged capillary refill time may be a sign of shock which could indicate dehydration and decreased peripheral perfusion). Review of the laboratory values upon presentation to the ER, revealed; sodium 174 (reference range ,[DATE]), Potassium 4.1 (reference range 3XXX,[DATE].0) Blood Urea Nitrogen (BUN) 75 (reference range ,[DATE] test to measure the amount of nitrogen in the blood in order to evaluate kidney function), Creatinine 4.0 (reference range 0XXX,[DATE].2 -test to evaluate kidney function). The resident was admitted to the Cardiac Care Unit (CCU) for treatment and monitoring for [DIAGNOSES REDACTED]. On [DATE], the resident was referred to Hospice and expired on [DATE]. Interview on ,[DATE] at 8:30 AM, with the ER Physician, revealed the resident had severe dehydration. Further interview, revealed the resident had a rectal temperature of 106.7 degrees F and looked septic and dehydrated. The ER Physician stated the resident suffered brain damage which was multifaceted related to [MEDICAL CONDITION], dehydration and increased temperature which he stated was completely avoidable. The ER Physician stated if the resident's Physician had been contacted when the resident's temperature was 102 degrees F, then an increase in temperature could have been avoided. Interview on [DATE] at 11:40 AM with the On-call Physician for Resident #2 on the evening of [DATE] and [DATE], revealed he had received no phone call regarding Resident #2's increased temperature. He stated if he had been notified he could have most likely prevented the temperature from going up by transferring Resident #2 to the ER for further evaluation and to have blood work drawn. Interview on [DATE] at 10:30 AM with Resident #2's Physician revealed he considered a 102 degree F temperature a change in condition and the physician should have been notified. He stated the resident's high temperatures contributed to the resident's dehydration and cerebral injury. He further revealed if he had been notified of the increased temperature, the resident would have been sent to the ER. Continued interview with the Physician revealed the cerebral injury was partially related to the fever and this could have been prevented if the Physician been notified when the resident's temperature was noted to have increased to 102 degree F. Interview on [DATE] at 3:59 PM with the Staff Development Coordinator (SDC) revealed if a resident had decreased fluid intake and signs and symptoms of dehydration, the Physician should be notified of the change. She further stated, if a resident had an increased temperature, decreased fluids and decreased urine output the physician would need to be notified immediately. Interview on [DATE] at 4:23 PM with the Assistant Director of Nursing (ADON) revealed her expectation was when a resident had an increased temperature, decreased fluid intake and decreased urination, staff would contact the physician and send the resident to the ER. She stated, an increased temperature did increase the risk for dehydration and by not contacting the Physician she felt the situation with Resident #2 was neglect. Also, she stated LPN #1 should have further informed the Physician that Resident #2 needed to be sent to the ER. The ADON stated she considered a 102 degrees F temperature to be a significant change of condition in a resident. Interview on [DATE] at 5:27 PM, with the Director of Nursing (DON) revealed she considered a temperature of 102 degrees F a significant change of a resident's condition and her expectation was for the resident's Physician to be notified and the resident's responsible party to be notified of any change in condition as well. Interview on [DATE] at 6:46 PM, with the Administrator revealed he would expect with a change of condition the nurses should have monitored closely and contacted the physician with the change in the resident's condition. 2. Review of Resident #9's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to score three (3) out of fifteen (15) on the Brief Interview for Mental Status (BIMS), indicating the resident was severely cognitively impaired. Review of the Nurse's Note completed by RN #5, dated [DATE] at 6:48 PM, revealed the Resident's Daughter was concerned about the resident's right leg, particularly his/her calf. The Note stated there was two (2) plus [MEDICAL CONDITION] from the right ankle to the mid-thigh and measured thirty-nine (39) centimeters (cms) in circumference at the Anterior Tibial Tuberosity. Per the Note, the Daughter stated she had noticed the resident's leg was swollen for a few days but that today it was obviously bigger. Further review of the Note, revealed the nurse completed an assessment on the resident while he/she was in the bed. The Note stated, the Physician was faxed and the oncoming nurse was given a full report, will continue to monitor. Review of the Facsimile (fax) Transmission to Resident #2's Primary Care Physician (PCP), dated [DATE], revealed the resident had two (2) plus (+) [MEDICAL CONDITION] to the right leg from the ankle to the mid thigh. Continued review of the fax, revealed it was documented that this was abnormal for the resident. Further review of the Fax Transmission revealed there was no redness noted and although it was not warm, it was warmer than the left leg. Review of the Nurse's Note completed by LPN #9, dated [DATE] at 10:16 PM, revealed Resident #9 continued to have three (3) plus (+) [MEDICAL CONDITION] to the right leg. Per the Note, the resident had complaints of pain when deep pressure was applied. According to the Note, Tylenol was given at bedtime to ease discomfort. Further review of the Note, revealed the fax was on the board for the Physician. Review of the Nurse's Note, completed by RN #5, on [DATE] at 2:39 PM, revealed the resident was assessed (this morning) before getting out of bed. Per the Note, the resident's right leg still had two (2) plus (+) [MEDICAL CONDITION] with shiny skin and slight warmth. Further review of the Note, revealed the On-call Physician ordered a doppler ultrasound. Continued review of the Note revealed staff was awaiting for a call back to schedule the procedure. The Note stated the family was in the front lobby, and the nurse would continue to monitor. Review of the Ultrasound Echo/Vascular Form, dated [DATE], revealed Resident #9 was positive for a [MEDICAL CONDITIONS], blood clot. Review of the Nurse's Note completed by RN #5, on [DATE] at 4:41 PM, revealed there was an order for [REDACTED]. Observation of Resident #9, on [DATE] at 4:36 PM, revealed the resident was sitting in the hallway in his/her Gerichair, with lego pieces in front of him/her on his/her lap table. Interview with Resident #9's Daughter/Power of Attorney (POA), on [DATE] at 9:15 AM, revealed she had concerns about Resident #9's right leg being swollen and she had notified Licensed Practical Nurse (LPN) #8, on [DATE]. She stated LPN #8 told her that they would watch the leg. However, there was no documented evidence in the Nurse's Notes, the POA had expressed concern related to the resident's right leg. Continued interview with the resident's POA revealed she talked to RN #5, on [DATE], the next day. She stated she was informed by RN #5, that there was nothing in the Nurse's Notes related to the POA expressing concern about the resident's leg, but she told her, We will watch it. Resident #9's POA stated she thought her loved one might have had a blood clot, so she was persistent about alerting staff about his/her condition. The POA stated the resident did not see a Physician until [DATE]. She stated, another Primary Care Physician (PCP) #25 was in the facility to see other residents and she (POA) approached PCP #25 to assess the resident. Continued interview with Resident #9's POA, revealed the resident had a blood clot and was now on blood thinners to resolve it. Resident #9's POA reported she felt the staff was unconcerned about the needs of her loved one. Interview with Certified Nursing Assistant (CNA) #10, on [DATE] at 6:27 PM, revealed she worked with Resident #9. CNA #10 stated Resident #9's family visited the facility often. CNA #10 further revealed she saw the resident's POA tell LPN #8 and RN #5, she thought something was different with the resident's leg. She further stated, LPN #8 stated she would document the family had a concern and LPN #8 asked staff to reposition the resident. Per interview, CNA #10 stated she recalled RN #5 taking measurements because the resident's daughter was still concerned about the resident's leg. Further interview with CNA #10, revealed she heard the daughter say to staff and to another family member that she thought the resident had a blood clot. CNA #10 stated she thought this had been reported to the Physician. Interview with RN #5, on [DATE] at 11:39 AM, revealed the resident's family informed her the resident's leg was swollen more than normal. She stated the resident's POA asked her if she knew about her concern, since she reported it to LPN #8 the day before, on [DATE]. RN #5 stated she had not, adding LPN #8 quit the job. RN #5 reported she measured the resident's leg, when the POA asked her about the resident's leg, and both of his/her legs looked swollen. RN #5 stated she told the nursing staff to monitor and watch the resident's leg. She further stated she faxed the concern to the resident's PCP, and passed on the information to LPN #9. She stated the system was for the nurse to fax the concern to the Physician and put the copy of the Fax on the board at the nurse's station, and the subsequent shift was to follow up and call the Physician if there was no reply from the physician per fax. RN #5 stated she would have thought the oncoming nurse, LPN #9, would have called the resident's PCP if she had not heard from the PCP. Continued interview with RN #5 revealed if left undetected, a blood clot could lead to death. Interview with LPN #9, on [DATE] at 12:33 PM, revealed RN #5 relayed the information to her, regarding the resident's leg. LPN #9 stated she would notify the PCP for any changes in the resident's condition, but the primary communication was to Fax the physician. She stated, the information was already reported to the resident's PCP, via Fax, thus she did not have to call the PCP. Attempted interview with LPN #8, on [DATE] at 12:34 PM, a message was left with no returned call. Interview, on [DATE] at 5:27 PM and [DATE] at 1:44 PM, with the Director of Nursing (DON) revealed staff had communicated with the PCP by way of Fax since she has been the DON. She stated the concern with communicating by Fax, was that if the PCP office was closed or if staff was off for a day or two (2), then the staff who completed the original Fax would need to contact the physician. The DON stated she had educated the staff on calling the physician if there was any change of condition with the residents. She stated she was working with the physicians to devise an updated way of communication between the nurses and the physicians in order to ensure the Physicians were aware of the needs of the residents. Interview on [DATE] at 6:46 PM, with the Administrator revealed his expectations was for the nurse to follow the Notification of Change in Residents' Condition policy. Interview further revealed he would expect with a change of condition the nurses would monitor closely and contact the physician. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Administrator and Medical Director created the Abnormal Vital Signs policy, which instructed staff on the definition of abnormal vital signs, actions nurses should take when abnormal vital signs were obtained, and when to notify the physician, resident, and/or responsible party/Power of Attorney (POA). 2. On [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse reviewed facility policies regarding change in resident status, notification of change, documentation, hydration, charting, and care plans for compliance of Federal regulations to ensure thorough understanding and knowledge prior to education of staff. It was determined, facility policy had been followed regarding notification of change related to Resident #2's fluid intake on [DATE]. The facility policy Notification of Change was updated to include facility requirements when notification of change was to occur and who staff was to notify on [DATE] by the Administrator. The Administrator and DON determined the facility Charting and Care Plan policies were in compliance with Federal Regulations. It was identified, the facility had three (3) policies governing hydration; all policies were reviewed and the Administrator and DON determined one (1) of the policies met federal regulations compliance. The Hydration and Nutrition updated on [DATE], by the Administrator, would be used as the facility's only policy on hydration. 3. Twenty-four (24) out of twenty-six (26) nurses were educated on updated Notification of Change the new Abnormal Vital Signs, Hydration and Nutrition, and Charting policies on dates [DATE] through [DATE] by the DON, ADON, Staff Development Coordinator, and QAPI nurse. Additionally, education also included following the residents' plan of care related to signs and symptoms of dehydration, documentation regarding hydration and nutrition, and contacting physician with change in status (for example abnormal vital signs, signs and symptoms of dehydration). Certified Nurse Aides (CNAs) were not involved in this training even though they may obtain vital signs, it was solely the nurses' responsibility to monitor and assess the residents vital signs and hydration status. Education was conducted in small group sessions with open conversation and question and answer period at the end to test knowledge and understanding of the policies. The nurses that did not receive education would not provide direct care until education on Abnormal Vital Signs policy and Notification of Change policy had been received. Furthermore, these policies had been added to the facility's orientation program which was conducted prior to new nurses providing direct care in the facility beginning with next orientation on [DATE]. On [DATE] and [DATE], the Staff Development Coordinator made rounds through the facility daily, including weekends, and on all shifts to question all nurses about the Notification of Change and Resident Status Changes,Abnormal Vital Signs, Residents' Plan of Care, and Hydration policies. These rounds also included communicating with the facility during night shift and asking staff questions regarding notification of change, abnormal vital signs, and residents' plan of care. 4. Beginning the night of [DATE] and ending on [DATE], the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator, and (QAPI) Nurse audited one-hundred (100) percent of resident clinical records pertaining to notification of change. No evidence was found that any other residents were adversely affected by notification of change. 5. Beginning the night of [DATE] and ending [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse audited one-hundred (100) percent of resident clinical records pertaining to care plan interventions related to dehydration/fluid volume deficit. Evidence revealed all current resident care plans implemented correctly related to dehydration. MDS staff reviewed the plan of care for all current residents and updated to include the daily estimated fluid need for each resident. On [DATE], the DON added question to Electronic Medication Administration Record [REDACTED]? 6. Beginning the night of [DATE] and ending on [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse audited one-hundred (100) percent of the residents clinical records daily, including weekends, to ensure staff was compliant with the Charting policy and accurate clinical documentation. 7. Starting [DATE], and ongoing the DON with the assistance from the ADON, Staff Development Coordinator, QAPI Nurse, MDS staff, and Charge Nurses, began auditing one-hundred (100) percent nurse documentation daily, including weekends, to monitor staff compliance with facility policy regarding notification of changes in resident status, abnormal vital signs, documentation of physician notification, hydration and nutrition logs and care plan interventions. This audit would continue until Immediate Jeopardy abated. All issues identified with regards to these policies would be immediately addressed with individual staff responsible. 8. On [DATE], and ongoing the DON began auditing one-hundred (100) percent of the residents' charts daily, including weekends, to ensure plan of care related to dehydration and notification of change was followed for residents who triggered on the Nutrition and Hydration Log. The DON audited, with the help from the ADON, Staff Development Coordinator, QAPI Nurse, MDS Staff, and Charge Nurses, included inspection of Hydration and Nutrition logs, vital signs obtained, lab values obtained which was checked against nurse documentation if abnormal vital signs or lab values obtained and/or change of resident hydration status noted. The audit would continue until Immediate Jeopardy was abated. The DON would immediately address all issues regarding staff compliance with resident plan of care with individual staff and present audit findings to QAPI Committee for review and process improvement if necessary. The Nutritionally at Risk (NAR) Committee would review all residents that trigger for nutritionally at risk for hydration status weekly and would make appropriate interventions as necessary. The NAR Committee consists of the DON, ADON, MDS Coordinator, Dietary Manager, Staff Deve

Based on interview, record review and review of facility policy, it was determined the facility failed to have an effective system to ensure services were provided in accordance with each resident's written Comprehensive Plan of Care for (1) of nine (9) residents (Resident #2). The facility developed a care plan for Resident #2 stating the resident had the potential for fluid volume deficit related to diuretic use with a goal stating the resident would be free of dehydration. The interventions included monitor/document/report to the Physician as needed for signs/symptoms of dehydration. However, there was no documented evidence the care plan was followed for Resident #2 related to monitoring vital signs and notifying the Physician of significant abnormalities, and monitoring, documenting and reporting to the Physician signs and symptoms of dehydration. Interview and record review revealed the facility assessed Resident #2 to have an elevated temperature on [DATE] at 5:15 PM of 101.1 degrees Fahrenheit (F); and, on [DATE] between 8:00 PM and 10:00 PM of 102 degrees F. Further review of the clinical record revealed Resident #2, who was normally a heavy wetter had no urinary output during rounds on [DATE] at 1:00 AM, 3:00 AM, and 5:00 AM. Although the resident was having increased temperatures and staff interviews revealed the resident was showing signs and symptoms of dehydration including decreased or no urine output, dry chapped lips, fever, weakness, and limited food and liquid intake, there was no documented evidence staff provided ongoing assessments of the resident in order to monitor for signs and symptoms of dehydration; and, there was no documented evidence the physician was notified of the signs and symptoms of dehydration as per the Care Plan. On [DATE], at approximately 6:00 AM, Resident #2 was assessed to have a temperature of 102.2 degrees F axillary and was unresponsive, and in respiratory distress. The resident was transferred to the hospital on [DATE] and arrived at 6:57 AM. Resident #2 presented with a rectal temperature of 106.7 degrees F, was unresponsive, had mottled skin (blood vessel changes in the skin that cause a patchy appearance), agonal respirations (gasping labored breathing), laboratory values which indicated severe dehydration, and his/her soft palate and uvula were like sand paper. Resident #2 was admitted to the Critical Care Unit (CCU) at the local Hospital and placed on a ventilator with [DIAGNOSES REDACTED]. Resident #2 expired on [DATE] related to complications of increased temperature, dehydration, [MEDICAL CONDITION]. The facility's failure to provide services by qualified persons in accordance with each resident's written plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged, on [DATE], prior to exit on [DATE], with remaining non-compliance in the area of 42 CFR 483.20 Resident Assessment, F-282 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic change. The findings include: Review of the facility's policy titled Resident Care Plan, revised [DATE], revealed the services provided or arranged by the facility will meet professional standards. Qualified persons will provide services in accordance with each resident's written plan of care. Review of the facility's policy, titled Dietary Intake Log, reviewed [DATE], revealed the purpose of the policy was to track residents' nutrition and hydration. Continued review of the policy revealed there was a record kept daily (completed on night shift) of those residents who did not meet their daily fluid requirements. Once the resident was on the list for three (3) consecutive days the physician must be notified. When notifying the physician; staff should include the resident;s symptoms, poor skin turgor, dry mucous membranes, concentrated urine, and decreased urine output. Review of Resident #2's clinical record revealed, the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Plan of Care, revised [DATE], revealed the resident had the potential for fluid deficit related to diuretic use with a goal stating the resident would be free of symptoms of dehydration and maintain moist mucous membranes, and good skin turgor. The interventions included monitoring vital signs as ordered/per protocol and record, notify the Physician of significant abnormalities, and monitor/document/report to the Physician signs and symptoms of dehydration: decreased urine output, cracked lips, fatigue/weakness, fever, dry/sunken eyes and furrowed tongue. Review of the Nutrition Risk Assessment, dated [DATE], completed by the facility's Dietitian revealed Resident #2's estimated fluid need (EFN) was two thousand and fifty (2050) to two thousand, four hundred and sixty (2460) cubic centimeters (cc) per day. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated severe cognitive impairment. Further review of the MDS revealed the facility assessed the resident as requiring extensive assistance of two (2) for bed mobility, transfer, ambulation, dressing, toilet use and personal hygiene. Further review of the MDS, revealed the facility assessed the resident as requiring supervision and assistance of one (1) person for eating; and, as frequently incontinent of bowel and bladder. Review of the physician's orders [REDACTED]. Further review revealed Resident #2 was ordered [MEDICATION NAME] forty (40) mgs once a day on [DATE]; and, an order was received to increase the [MEDICATION NAME] to forty (40) mgs twice a day on [DATE]. Review of the Follow-Up Question Report (form used to total fluid intakes), revealed Resident #2 did not meet his/her estimated fluid needs (EFN) of 2050 to 2460 cc per day on [DATE], [DATE], [DATE], [DATE], and [DATE]. The fluid intakes were recorded as follows: [DATE] -1940 cc, [DATE] - 1680 cc, [DATE] - 2205 cc, [DATE] - 1220 cc, and [DATE] - 1500 cc. Although, Resident #2 did not have three (3) consecutive days without meeting the EFN in order for staff to notify the Physician of the resident's hydration status, staff interviews revealed the resident was having changes in nutrition/hydration status and, they were having difficulty getting the resident to eat and drink. Additionally, staff interviews revealed the resident was having behavior changes, weakness and was showing signs and symptoms of dehydration including dry mouth, and dried and chapped lips. Further record review and staff interview revealed the resident was having little or no urine output and increased body temperatures on [DATE] and [DATE]. Interview on [DATE] at 10:50 AM, with Certified Nursing Assistant (CNA) #4 revealed on [DATE] Resident #2 was cheeking food, had complaints of mouth pain, and the resident's lips were dried and chapped. CNA #4 stated he notified Registered Nurse (RN) #4 of these changes with Resident #2. However, there was no documented evidence the Physician was notified and no documented evidence the resident was monitored for signs and symptoms of dehydration, as per the Care Plan. Interview with CNA #8, on [DATE] at 4:15 PM, revealed she noticed a decline in Resident #2 when she worked the 2:00 PM to 10:00 PM shift on [DATE]. She stated the resident was refusing to eat and drink, which the resident would never do, adding (He/She) drank and ate pretty well. CNA #8 stated, she notified Licensed Practical Nurse (LPN) #1. Interview with CNA #11, on [DATE] at 8:27 AM, revealed the resident had gotten to the point were he/she stopped eating and drinking and within the last week prior to hospitalization , was pocketing his/her food. She stated the resident was normally pretty independent with his/her liquids, but had gotten to the point where staff needed to hold the resident's cup for him/her. CNA #11 stated she reported these changes to Registered Nurse (RN) #4, who told her to keep an eye on the resident and make sure he/she got fed. Interview with CNA #3, on [DATE] at 10:50 AM, revealed he worked the week the resident became sick, [DATE] through [DATE]. He stated Resident #2 was more combative than normal and was difficult to feed. CNA #3 stated the resident did not want to eat and it was difficult to get fluids in him/her. CNA #3 further stated he reported this to the Speech Language Therapist (SLP) and RN #4. Interview on [DATE] at 10:11 AM, with the SLP revealed on [DATE] while assisting Resident #2 with lunch in the dining room, the SLP noticed the resident was leaned over in the chair and looked as if he/she did not feel well. Further interview revealed the SLP informed RN #4 of the resident's condition. Review of the Nurse's Notes, dated [DATE] at 5:16 PM, completed by RN #4, revealed Resident #2 had a fever of 101.1 F, and crackles (abnormal lung sounds) were noted in the resident's lungs and the physician was notified, and orders were received for [MEDICATION NAME] (antibiotic medication). However, there was no documentation of the resident's decreased fluid intake. Interview on [DATE] at 5:20 PM, with RN #4 revealed on [DATE], she observed the resident had not felt well; she had not reviewed the resident's fluid intake because no one had reported any issues. However, interview with the CNAs revealed they had reported a change in the resident's fluid intake to RN #4. Per interview, RN #4 obtained Resident #2's temperature around 5:00 PM and discovered he/she had a fever, she contacted the Physician and obtained orders. However, the RN failed to notify the Physician of the resident's decreased fluid intake. On [DATE] at 12:35 AM, staff documented on the Vital Sign Log, Resident #2 had a temperature of 102 degrees F. Interview with CNA #10 on [DATE] at 5:11 PM, and CNA #11 on [DATE] at 8:27 AM revealed they worked the evening of [DATE] and they thought CNA #9 obtained the vital signs, stating vital signs were usually obtained between 8:00 PM and 10:00 PM. Interview with CNA #9 on [DATE] at 4:43 PM revealed he could not recall if he obtained the vital signs the evening of [DATE]. Staff interviews revealed it was unclear exactly what time the resident's vital signs were obtained on the evening of [DATE]. Interview with CNA #7, on [DATE] at 3:44 PM, revealed Resident #2 became a feeder earlier that week because the resident was not eating or drinking and had only taken in 500 ccs from 2:00 PM to 10:00 PM on [DATE], and sixty (60) ccs from 10:00 PM to 6:00 AM [DATE] through [DATE]. However, there was no documented evidence the Physician was notified of the fever, or of the resident's decreased fluid intake, as per the Care Plan. Interview with CNA #10, on [DATE] at 5:11 PM, revealed she worked the night of [DATE] from 2:00 PM until 10:00 PM and assisted CNA #8 with Resident #2's incontinence care, stating the resident did not have much urine output during that shift. CNA #10 stated it was almost like the resident, did not have much fight left in (him/her). CNA #10 stated she reported this to LPN #1, but she did not know if LPN #1 assessed the resident afterwards. Review of Resident #2's record Flowsheet, revealed on [DATE], Resident #2 had not voided at the 1:00 AM, 3:00 AM or 5:00 AM rounds. Interview on [DATE] at 3:40 PM, with CNA #7, revealed she reported to LPN #1 that the resident wasn't making any noise, was stiff and difficult to roll over, pale and had sunken cheeks. review of the resident's medical record revealed [REDACTED].#1 continued to monitor and/or assess the resident on [DATE]. There was no documented evidence the Physician was notified of the resident's increased temperature of 102 degrees F, and/or the signs and symptoms of dehydration, even though the nurse was informed the resident was not urinating, was pale, weak and had sunken cheeks, per the resident's plan of care. Interview with LPN #1, on [DATE] at 5:50 PM, revealed on [DATE] she was given the resident's vital signs which indicated he/she had a temperature of 102 degrees F and she administered two (2) 500 milligram (mg) of Tylenol. LPN #1 stated she checked the resident's temperature again at approximately 12:30 AM, on [DATE], and it was 99.0 degrees F. LPN #1 further stated she did not check on the resident anymore until [DATE] at approximately 6:00 AM, when she noticed the resident had no movement. LPN #1 further stated she was not told the resident had not urinated throughout the night by the CNAs and only found out the resident had not urinated during the two (2) hour rounds when the subsequent shift reported to her the resident had not urinated. She stated it would have been important to have known the resident had little to no urine output because she would have monitored and assessed the resident more closely. She stated she was aware the resident was on the list for decreased fluids and his/her blood sugar was high. Further interview revealed the facility did not advise her of the resident's care plan, therefore she did not know she needed to follow the care plan. Further interview on [DATE] at 10:50, with CNA #3 revealed on [DATE] at approximately 6:30 AM, he took the resident's temperature under his/her arm and the temperature was 102.2 degree F. CNA #3 stated the resident was in respiratory distress, and was sweating. Review of the Nurse's Note completed by LPN #3, dated [DATE] at 6:40 AM, revealed Resident #2 was found in distress, and unresponsive. According to the Note, the resident's skin was clammy, cool to touch and there was mottling to the bilateral lower and upper extremities, chest, neck and ears. Emergency Services (911) was called to transfer the resident to the hospital emergency room . Review of Resident #2's emergency room Notes, dated [DATE], revealed upon arrival at the emergency room (ER), the resident presented with a rectal temperature of 106.7 degrees F. The resident's laboratory values were documented as: Sodium 174 (reference range ,[DATE]), Potassium 4.1 (reference range 3XXX,[DATE].0) Blood Urea Nitrogen (BUN) 75 (reference range ,[DATE] test to measure the amount of nitrogen in the blood in order to evaluate kidney function), Creatinine 4.0 (reference range 0XXX,[DATE].2 -test to evaluate kidney function). The resident was admitted to the Cardiac Care Unit for treatment and monitoring with [DIAGNOSES REDACTED]. Review of the Electroencephalogram (EEG), dated [DATE], revealed Resident #2 had severe generalized slowing, suggesting diffuse cerebral dysfunction. On [DATE], Resident #2's family made the decision to consult Hospice for comfort measures. The resident expired on [DATE]. Interview on [DATE] at 11:40 AM with the On-call Physician for Resident #2 on the evening of [DATE] and [DATE], revealed he did not receive a phone call regarding Resident #2's increased temperature and if he had been notified he would have transferred the resident to the ER for further evaluation and to have blood work drawn. Interview on [DATE] at 10:30 AM, with Resident #2's Physician, revealed a 102 degree F temperature was a change in condition and the physician should have been notified, per the plan of care. Interview with the Minimum Data Set Coordinator (MDS), on [DATE] at 2:48 PM, revealed the care plan was important for staff to follow so they would know how to work with residents. She stated if the residents should have a concern, the care plan assists the staff with addressing any problems and how to monitor for those problems. The MDS Coordinator stated Resident #2 was care planned for Potential Fluid Deficient, related to his/her medications of diuretics. She stated, if the resident was showing signs and symptoms of dehydration, then the Physician should have been notified per the resident's plan of care. She stated staff should not wait three (3) consecutive days of being on the Hydration Log before contacting the physician if the resident was showing signs and symptoms of dehydration. Additionally, the MDS Coordinator reported the resident's care plan related to dehydration was not followed, but should have been. Interview on [DATE] at 4:23 PM, with the Assistant Director of Nursing (ADON) revealed when a resident had an increased temperature, decreased fluid intake and decreased urination staff should contact the physician per the plan of care. Interview on [DATE] at 5:27 PM, with the Director of Nursing (DON), revealed LPN #1 should have re-assessed the resident and called the physician. Further interview revealed her expectation was for staff to follow the resident's care plans. She stated, That's why we have care plans, and if the nurse did not contact the physician when Resident #2 had a significant change in temperature, then LPN #1 was not following the care plan. Interview on [DATE] at 6:46 PM, with the Administrator revealed he would expect with a change of condition the nurses should have monitored more closely and contacted the physician with the change in Resident #2's condition. Further interview revealed the care plan was not followed related to the physician not being notified concerning Resident #2's increased temperature and signs and symptoms of dehydration. He stated staff should follow the care plan, adding it's their plan of care. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Administrator and Medical Director created the Abnormal Vital Signs policy, which instructed staff on the definition of abnormal vital signs, actions nurses should take when abnormal vital signs were obtained, and when to notify the physician, resident, and/or responsible party/Power of Attorney (POA). 2. On [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse reviewed facility policies regarding change in resident status, notification of change, documentation, hydration, charting, and care plans for compliance of Federal regulations to ensure thorough understanding and knowledge prior to education of staff. It was determined, facility policy had been followed regarding notification of change related to Resident #2's fluid intake on [DATE]. The facility policy Notification of Change was updated to include facility requirements when notification of change was to occur and who staff was to notify on [DATE] by the Administrator. The Administrator and DON determined the facility Charting and Care Plan policies were in compliance with Federal Regulations. It was identified, the facility had three (3) policies governing hydration; all policies were reviewed and the Administrator and DON determined one (1) of the policies met federal regulations compliance. The Hydration and Nutrition updated on [DATE], by the Administrator, would be used as the facility's only policy on hydration. 3. Twenty-four (24) out of twenty-six (26) nurses were educated on updated Notification of Change the new Abnormal Vital Signs, Hydration and Nutrition, and Charting policies on dates [DATE] through [DATE] by the DON, ADON, Staff Development Coordinator, and QAPI nurse. Additionally, education also included following the residents' plan of care related to signs and symptoms of dehydration, documentation regarding hydration and nutrition, and contacting physician with change in status (for example abnormal vital signs, signs and symptoms of dehydration). Certified Nurse Aides (CNAs) were not involved in this training even though they may obtain vital signs, it was solely the nurses' responsibility to monitor and assess the residents vital signs and hydration status. Education was conducted in small group sessions with open conversation and question and answer period at the end to test knowledge and understanding of the policies. The nurses that did not receive education would not provide direct care until education on Abnormal Vital Signs policy and Notification of Change policy had been received. Furthermore, these policies had been added to the facility's orientation program which was conducted prior to new nurses providing direct care in the facility beginning with next orientation on [DATE]. On [DATE] and [DATE], the Staff Development Coordinator made rounds through the facility daily, including weekends, and on all shifts to question all nurses about the Notification of Change and Resident Status Changes,Abnormal Vital Signs, Residents' Plan of Care, and Hydration policies. These rounds also included communicating with the facility during night shift and asking staff questions regarding notification of change, abnormal vital signs, and residents' plan of care. 4. Beginning the night of [DATE] and ending on [DATE], the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator, and (QAPI) Nurse audited one-hundred (100) percent of resident clinical records pertaining to notification of change. No evidence was found that any other residents were adversely affected by notification of change. 5. Beginning the night of [DATE] and ending [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse audited one-hundred (100) percent of resident clinical records pertaining to care plan interventions related to dehydration/fluid volume deficit. Evidence revealed all current resident care plans implemented correctly related to dehydration. MDS staff reviewed the plan of care for all current residents and updated to include the daily estimated fluid need for each resident. On [DATE], the DON added question to Electronic Medication Administration Record [REDACTED]? 6. Beginning the night of [DATE] and ending on [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse audited one-hundred (100) percent of the residents clinical records daily, including weekends, to ensure staff was compliant with the Charting policy and accurate clinical documentation. 7. Starting [DATE], and ongoing the DON with the assistance from the ADON, Staff Development Coordinator, QAPI Nurse, MDS staff, and Charge Nurses, began auditing one-hundred (100) percent nurse documentation daily, including weekends, to monitor staff compliance with facility policy regarding notification of changes in resident status, abnormal vital signs, documentation of physician notification, hydration and nutrition logs and care plan interventions. This audit would continue until Immediate Jeopardy abated. All issues identified with regards to these policies would be immediately addressed with individual staff responsible. 8. On [DATE], and ongoing the DON began auditing one-hundred (100) percent of the residents' charts daily, including weekends, to ensure plan of care related to dehydration and notification of change was followed for residents who triggered on the Nutrition and Hydration Log. The DON audited, with the help from the ADON, Staff Development Coordinator, QAPI Nurse, MDS Staff, and Charge Nurses, included inspection of Hydration and Nutrition logs, vital signs obtained, lab values obtained which was checked against nurse documentation if abnormal vital signs or lab values obtained and/or change of resident hydration status noted. The audit would continue until Immediate Jeopardy was abated. The DON would immediately address all issues regarding staff compliance with resident plan of care with individual staff and present audit findings to QAPI Committee for review and process improvement if necessary. The Nutritionally at Risk (NAR) Committee would review all residents that trigger for nutritionally at risk for hydration status weekly and would make appropriate interventions as necessary. The NAR Committee consists of the DON, ADON, MDS Coordinator, Dietary Manager, Staff Development Coordinator, and QAPI Nurse. The DON would address all issues related to hydration and nutrition, care plans, documentation, and notification of changes with staff immediately and present audit findings to the QAPI Committee monthly. 9. Results of audits (nurse documentation and staff compliance with residents' plan of care) would be addressed daily with individual staff and audit findings would be presented to the QAPI Committee for review and process improvement at least monthly as necessary. The QAPI Committee consists of the Administrator, DON, ADON, Social Worker, Maintenance Director, Medical Director, Activizes Director, Housekeeping/Laundry Supervisor, and Dietary Manager. The QAPI Committee meets monthly with the Medical Director attending the QAPI meeting quarterly. The next QAPI meeting was scheduled for [DATE]. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the Abnormal Vital Signs, created [DATE], revealed there were parameters set, regarding a resident's blood pressure, pulse, and temperature in which the physician should be notified to due a change in the resident's change in condition. Interview with the Administrator, on [DATE] at 1:44 PM, revealed the Medical Director (MD) stopped by his office on [DATE] to discuss the concern regarding Resident #2. The Administrator revealed he acknowledged to the Physician the facility did not have a policy to address when the physician should be notified regarding a change in resident's condition. He revealed, in regards to a resident's temperature, staff would obtain the resident's temperature rectally and would notify the physician if out of the set parameters. The Administrator reported the Physician agreed with the policy. Interview with the Physician, on [DATE] at 11:00 AM, revealed he discussed Resident #2's case with the Administrator. The Physician revealed he thought the physician should have been notified with a temperature of one-hundred and two (102) and it warranted an emergency room (ER) visit, especially since the resident was on antibiotics. He reported he came up with some reasonable numbers, through his expertise and practice, that would assist the staff with notifying the physician. 2. Review of the facility's policies revealed the facility kept the Charting revised [DATE], Care Plan reviewed [DATE], and Notification of Change, dated [DATE], policies. The facility added a cheat sheet to go along with the Notification of Change in Residents' Condition. The cheat sheet was titled, Notification of Change When to Document?, created [DATE]. Interview with the Administrator, DON, and ADON on [DATE] at 1:44 PM, revealed, when he and the staff reviewed the policies, they thought the policies they had in place complied with the Federal Regulations. Continued interview with the Administrator revealed they, thought it would be helpful to have a cheat sheet to go along with the Notification of Change in Residents' Condition to assist the staff with knowing what to look for when there was a change in a residents' condition. Interview with the SDC, on [DATE] at 3:49 PM, revealed she was part of assisting with the policy review and new updated policies. Review of the facility's Hydration and Nutrition Policy, revised [DATE] revealed there was no change from the original policy provided. Interview with the Administrator, DON, and ADON on [DATE] at 1:44 PM revealed the facility had three (3) policies related to Hydration. The Administrator reported he was not aware of the three (3) different policies. Continued interview with the Administrator revealed they have removed the other two (2) polices and added a revision date to the Hydration and Nutrition policy because this one superceded the other policies. 3. Review of the In-Service Training Sheet, dated [DATE], [DATE], and [DATE], revealed staff signed they were in-serviced on Abnormal vital signs, Hydration, Documentation, Notifying Physician and Power Of Attorney (POA) of changes in condition, Notifying physician of any Significant Changes, following the care plan, and educated staff on the F-Tags the facility received. Review of the Nurses Training Manual, revised [DATE], revealed the updated policies were added for orientation of new hires. Interviews with Registered Nurse (RN) #1 on [DATE] at 8:30 PM, RN #5 on [DATE] at 11:40 AM, Licensed Practical Nurse (LPN) #6 on [DATE] at 7:07 PM, LPN #2 on [DATE] at 9:50 AM, and LPN #7 on [DATE] at 10:50 AM, revealed they were all in-serviced on the Abnormal Vital Signs policy, Hydration, Documentation, Notification of the Physician and Power of Attorney of changes of condition. Additionally, they added the information was stored at the nurses station for their reference. Review of the documentation provided by the Staff Development Coordinator revealed she provided staff with follow-up questions, on [DATE], [DATE], and [DATE], to what was in-serviced to the staff. The Staff Development Coordinator had a series of questions in which she asked staff about the required information. Interviews with Registered Nurse (RN) #1 on [DATE] at 8:30 PM, RN #5 on [DATE] at 11:40 AM, Licensed Practical Nurse (LPN) #2 on [DATE] at 9:50 AM, and LPN #7 on [DATE] at 10:50 AM, revealed they were asked questions from the Staff Development Coordinator regarding what they were in-serviced on. Interview with the SDC, on [DATE] at 3:49 PM, revealed she took all of the information from the policies and created a questionnaire in which she asked staff how much they knew about Hydration, Care Plans, Notification, Change in a Resident's Condition, Documentation, and the F-Tags cited. She stated she did not have a sign-in sheet, but documented the names and times of the individuals she spoke with. The SDC stated she questioned staff on every shift, including weekends. The SDC revealed the auditing would be ongoing and reported the Hydration for the residents have improved, adding there were less residents on the Hydration List. 4. Review of the auditing tools used to audit one-hundred (100) percent of the residents clinical records were reviewed and the records were reviewed from [DATE] through [DATE]. Interview with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) on [DATE] at 1:44 PM, revealed reports were pulled from the Point Click Care (PCC) system which provided them information on each resident. The information contained were critical labs and abnormal vital signs. The DON revealed she reviewed the information and contacted the physician when residents were triggered for critical labs. The Administrator added the nurses notes were also reviewed to see if they added anything regarding the lab results. Additionally, the DON revealed she looked at al

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure each resident was assessed and monitored after a change in condition. This failure affected two (2) of nine (9) sampled residents (Residents #2 and #9). On [DATE],the facility assessed Resident #2 to have a fever of 101.1 degrees Farenheit (F) and physician's orders [REDACTED]. According to the Medication Administration Record (MAR), the resident was administered one (1) 250 milligram (mg) dose tablet of [MEDICATION NAME] at 5:00 PM on [DATE]; however, there was no documented evidence Tylenol (pain reliever and fever reducer) was administered for the fever as per standing order. Staff interviews revealed on [DATE] between 8:00 PM and 10:00 PM the resident had a fever of 102.0 degrees F; however, there was no documented evidence the resident received Tylenol until [DATE] at 12:38 AM, over two (2) hours later. Review of the Nurse's Notes dated [DATE] at 12:38 AM, revealed Tylenol was administered, the resident had Rhonchi and wheezes (abnormal lung sounds) and the nurse would continue to monitor for any changes. Interviews also revealed the resident was normally incontinent of urine and a heavy wetter; however, the resident had no urinary output during the times of 1:00 AM, 3:00 AM, and 5:00 AM, on [DATE], and the nurse was notified. However, there was no documented evidence the resident was continuously monitored with ongoing nursing assessments and no documented evidence the physician was notified of the increased temperature or the lack of urine output. On [DATE], at approximately 6:00 AM, Resident #2 was noted to have a temperature of 102.2 degrees F axillary, was unresponsive, and in respiratory distress. The resident was transferred to the hospital on [DATE] and arrived at 6:57 AM and was assessed with [REDACTED]. Resident #2 was admitted to the Critical Care Unit (CCU) at the local Hospital and placed on a ventilator with [DIAGNOSES REDACTED]. Resident #2 expired on [DATE] related to complications of his/her increased temperature, dehydration, [MEDICAL CONDITION]. In addition, there was no documented evidence in the Nurse's Notes, that Licensed Practical Nurse (LPN) #8 documented Resident #9's Power of Attorney's (POA) concern related to the resident's right leg [MEDICAL CONDITION] and no documented evidence LPN #8 assessed the resident's leg after the resident's POA notified her of the [MEDICAL CONDITION] on [DATE]. Although the facility faxed notification to the Physician related to Resident #9's [MEDICAL CONDITION] to the right leg on [DATE], the facility failed to call the physician and follow up. On [DATE], the resident's POA, notified the Physician of the resident's right leg [MEDICAL CONDITION]. An Echo/Vascular Ultrasound completed on [DATE], revealed the resident had a [MEDICAL CONDITIONS], blood clot in the right leg. The facility's failure to provide the necessary care and services related to the resident's change in medical status, has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged, on [DATE], prior to exit on [DATE], with remaining non-compliance in the area of 42 CFR 483.25 Quality of Care, F-309 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Notification of Change in Residents' Condition, revised [DATE], revealed in an event of a significant change in the resident's physical, mental or psychosocial status, or a need to alter treatment the nurse would assess the situation, notify the attending physician, provide necessary care, notify the responsible party, document in the resident's medical record and follow- up as indicated. Review of the facility's policy, titled Cardinal Symptoms, revised [DATE], revealed staff was to notify the charge nurse if there were any elevations in temperature or notable change in rate of pulse or respirations, or if there were any unusual variations in blood pressure. Further review revealed if staff was in doubt of the accuracy of the reading, staff should ask the charge nurse to check the vital signs. Review of Resident #2's clinical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated severe cognitive impairment. Review of Resident #2's Speech Therapy Treatment Note, dated [DATE] revealed, the Speech Language Pathologist (SLP) fed the resident lunch and noted the resident did not feel well today, the resident had a cough throughout the meal and the nurse reported to the SLP the resident had the cough all day. Further review revealed Resident #2 did not respond to verbal cues to take drinks in between bites of food. Per the Note, the SLP fed the resident both food and drink. Interview with the SLP, on [DATE] at 10:11 AM, revealed, on [DATE], while assisting the resident with lunch in the dining room, the SLP noticed a change in Resident #2. She reported the resident was leaned over in the chair and looked as if he/she did not feel well. Further interview with the SLP revealed, she informed Registered Nurse (RN) #4 of the resident's condition, and RN #4 replied she did not think he/she felt well. Review of the Nurses' Notes dated [DATE] at 5:16 PM completed by RN #4, revealed the resident had a fever of 101.1F, and crackles (abnormal lung sounds) were noted in the lungs. The physician was notified and orders were received for [MEDICATION NAME] (antibiotic medication). Review of the physician's orders [REDACTED]. Interview with RN #4, on [DATE] at 5:20 PM, revealed on [DATE] she noticed the resident had not felt well all that day. RN #4 stated she took Resident #2's temperature at 5:00 PM, on [DATE], because he/she was coughing and discovered the resident had a fever. She stated she contacted the Physician and obtained orders to administer [MEDICATION NAME] for Upper Respiratory Symptoms and Coughing. RN #4 stated she would normally give Tylenol for a temperature of 99 degrees F; however, there was no documented evidence Tylenol was administered for the temperature. On [DATE] at 12:35 AM, staff documented on the Vital Sign Log that the resident had a fever of 102 degrees F; however, interviews revealed this temperature was obtained between 8:00 PM and 10:00 PM on [DATE]. Interview with Certified Nursing Assistant (CNA) #11, on [DATE] at 8:27 AM, revealed she was the floater on the night of [DATE]. She stated she thought CNA #9 took the vitals for the resident the evening of [DATE] because the vitals were completed by the time she had gotten to the unit to assist CNA #9 between 9:00 PM and 9:30 PM. Interview with CNA #9, on [DATE] at 4:43 PM, revealed he worked 2:00 PM to 10:00 PM, on [DATE]. CNA #9 stated the nurses assign the CNAs the vital signs which were normally completed by 10:00 PM, but added he normally completed his vitals between 8:00 PM and 9:00 PM. He stated he would document the resident's vital signs on a piece of paper before handing it off to the nurse who would add the information into the computer. CNA #9 revealed he would also report any abnormal vital signs to the nurse. Further interview with CNA #9 revealed on the night of [DATE], he did not recall obtaining Resident #2's vital signs, adding, he could have, but did not recall. Interview with CNA #10, on [DATE] at 5:11 PM, revealed she worked [DATE] from 2:00 PM until 10:00 PM and CNA #9 did obtain the vitals for the residents that night. She stated she assisted with changing Resident #2 and reported the resident did not have much output that night. She reported the resident was a heavy wetter, and was not voiding much which was not normal for him/her. Additionally, she stated the resident was not combative or fighting with her when she went to change him/her, which was unusual for the resident. CNA #10 stated it was almost like the resident, did not have much fight left in him/her. CNA #10 reported she told Licensed Practical Nurse (LPN) #1, but did not know if LPN #1 assessed the resident. Review of LPN #1 Nurse's Note, dated [DATE] at 12:38 AM, revealed the resident was placed on antibiotics for an upper respiratory infection and the resident had a temperature of 102 degrees F with Tylenol given for the elevated temperature. Continued review of the Note revealed the resident had wheezes and rhonchi (abnormal lung sounds) noted to bilateral lungs, no adverse reactions were noted and she would continue to observe for any changes. Additionally, on [DATE] at 1:20 AM, per the Vital Sign Log, the resident's temperature was taken again and was noted to ninety-nine (99) orally. Interview on [DATE] at 3:44 with CNA #7, revealed she told LPN #1, when she checked on the resident on [DATE] at 1:00 AM, 3:00 AM, and 5:00 AM, the resident had not urinated, which was unusual for Resident #1. She stated, when she checked on the resident at 5:00 AM, she could not reposition the resident and he/she was hard to roll over. Continued interview with CNA #7 revealed the resident was sweaty and pale with his/her cheeks sunken in. CNA #7 further revealed she reported this to LPN #1, whom to her knowledge, did not address the concern. Record review revealed no further documented evidence of continued monitoring of the resident or assessment by LPN #1 on [DATE] even though the nurse was informed the resident was not urinating, was pale, and had sunken cheeks. Interview with LPN #1, on [DATE] at 5:50 PM, revealed she was told on [DATE], during shift report at approximately 6:00 PM, the resident was on an antibiotic for respiratory issues. She stated she had staff obtain the resident's vitals on [DATE] and would normally receive the vitals around 9:30 PM or 10:00 PM. Continued interview revealed she was given the resident's vital signs which indicated he/she had a temperature of 102 degrees F and she gave the resident two (2) 500 milligram (mg) of Tylenol; however, per documentation the Tylenol was not administered until 12:38 AM. Further interview with LPN #1, revealed between 12:30 AM and 1:00 AM she checked the resident's temperature again and the temperature had come down. LPN #1 stated she did not check on the resident again until approximately 6:00 AM, when she noticed the resident had no movement and was mottled. The LPN (#1) stated she was not notified the resident had not voided throughout the night by the CNAs; however, interviews with CNA #10 and CNA #7, confirmed they informed LPN #1 about the resident's decreased urine output observed throughout the two (2) hour bed changes/checks. LPN #1 stated she only found out about the resident's lack of urine output on [DATE] at approximately 6:00 AM; however, she could not remember which CNA told her. She stated this would have been important to know because she would have monitored and assessed the resident more closely through the night had she known the resident was not urinating. Interview on [DATE] at 10:50 CNA #3 revealed Resident #2 was a heavy wetter and was often wet ninety (90) percent of the time when changing him/her. CNA #3 reported he did a walk through the morning of [DATE] and noted the resident's eyes were closed and his/her head was elevated. CNA #3 reported, at approximately 6:30 AM, the nurses went in to Resident #2's room, although he could not remember which nurses. He recalled he took the resident's temperature under his/her arm and the temperature was 102.2 degrees F. CNA #3 stated the resident was in respiratory distress, was mottled, and observed to have been sweating. Interview with LPN #3, on [DATE] at 6:20 PM, who received report from LPN #1 on the morning of [DATE], revealed LPN #1 did not report to her during the shift report, that the resident had decreased urine output, and/or a fever throughout the night of [DATE] and the morning of [DATE]. Review of LPN #3's Nurse's Note, dated [DATE] at 6:40 AM, revealed the resident was found in distress, and was unresponsive. Per the Note, the resident's respirations were fifty-six (56) (normal ,[DATE]) labored, pulse was one-hundred and thirteen (113) (normal ,[DATE]), blood pressure was seventy over thirty-eight (,[DATE]) (normal range-,[DATE]), and temperature was 102.2 axillary (normal 98.6). The resident's oxygen saturation was seventy-two percent (72%) (normal range ,[DATE]%). Further review revealed the resident's skin was clammy, cool to touch, and there was mottling to the bilateral lower and upper extremities, chest, neck, and ears. Emergency services (911) was called to transport the resident to the hospital's emergency room . Review of Resident #2's emergency room Notes dated [DATE], revealed the resident arrived at 6:57 AM and upon arrival at the emergency room (ER), the resident was found to have a rectal temperature of 106.7 degrees F, respiratory rate of 68 breaths per minute, was unresponsive, had mottled skin, and agonal respirations, (an abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, accompanied by strange vocalizations). Record review further revealed the resident had a capillary refill time of eight (8) seconds, (normal capillary refill time reference range of less than two (2) seconds) (prolonged capillary refill time may be a sign of shock which could indicate dehydration and decreased peripheral perfusion). The laboratory values obtained at the hospital on [DATE] at 8:10 AM, revealed a sodium (NA) level of 174 (reference range ,[DATE]), Blood Urea Nitrogen (BUN) level of 75 (reference range of ,[DATE]) and Creatinine level of 4.0 (reference range of 0XXX,[DATE].3). Continued review of the ER hospital record, revealed the resident was found to have a big white pill stuck in his/her throat which the ER Physician had to remove prior to the resident being intubated (a procedure by which a tube was inserted through the mouth down into the trachea, the large airway from the mouth to the lungs). Further review revealed, shortly after arrival to the ER the resident's blood pressure (B/P) was seventy-two over thirty-nine (,[DATE]) and medication was administered Intravenously (IV) to increase the resident's B/P. Further review of the hospital record revealed the resident was admitted to the Cardiac Care Unit for treatment and monitoring with [DIAGNOSES REDACTED]. On [DATE], Resident #2 had an Electroencephalogram (EEG), the report stated it was abnormal because of severe generalized slowing, suggesting diffuse cerebral dysfunction. On [DATE], the resident's family made the decision to consult Hospice for comfort measures. Resident #2 was removed from the ventilator and expired on [DATE]. Interview with the emergency room (ER) Physician, on [DATE] at 11:50 AM, revealed Resident #2 was unresponsive, mottled head to toe, his/her extremities were cold, he/she had irregular respirations noted, the back of his/her soft palate and uvula were like sand paper. Additionally, one big white pill was observed stuck on his/her pharynx; however, the medication was not identified. Further interview revealed brain damage was multifaceted related [MEDICAL CONDITION], dehydration, and a rectal core temperature of 106.7 degrees F. Continued interview with the ER Physician revealed Resident #2's condition could have been avoided. He stated, if the resident's Primary Physician would have been contacted when the resident's temperature was 102 degrees F, then an increase in temperature could have been avoided. Interview on [DATE] at 11:40 AM, with the On-call Physician for Resident #2 on the evening of [DATE] and [DATE], revealed he had received no phone call regarding Resident #2's increased temperature. Per interview, he could have most likely prevented the resident's temperature from going up, and would have sent Resident #2 to the ER for further evaluation and to have blood work completed. Interview further revealed the On-call Physician evaluated Resident #2 on [DATE] at the hospital and there was not much response. Interview, on [DATE] at 10:30 AM, with Resident #2's Physician, revealed if he had been notified of the increased temperature the resident would have been sent to the ER. Continued interview with the Physician revealed he felt the continued increase in the resident's temperature could have been avoided. The Physician stated the cerebral injury was partially related to the fever and could have been prevented had the Physician been notified at 12:35 AM on [DATE], when the resident's temperature was noted to be 102 degrees F. Interview with the Staff Development Coordinator (SDC)/LPN, on [DATE] at 3:59 PM, revealed, if a resident had a fever, decreased fluid intake, and decreased urine output the physician should have been notified immediately. The SDC further revealed she educated the nurses to check vital signs every two (2) hours if there was an observed fever. She further revealed if the fever continued to worsen, staff was to give the resident an as needed (PRN) Tylenol and notify the physician, responsible party, write a Nurse's Note, sign the Medication Administration Record (MAR), and check the resident again within one (1) hour, after administering the Tylenol, to assess the effectiveness. Further interview with the SDC revealed it would be her expectation for staff to document all interventions taken. However, record review revealed staff failed to follow this protocol. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 4:23 PM, revealed it was her expectation LPN #1 would have notified the physician when Resident #2's temperature reached 102 degrees F. Additionally, she reported LPN #1 should have further informed the physician, Resident #2 needed to be sent to the ER. Interview with the Director of Nursing (DON), on [DATE] at 5:27 PM, revealed it was her expectation that the as needed (PRN) Tylenol, would have been given with Resident #2's change in condition. She stated the resident should have been re-assessed and a call should have been made to the resident's physician. Additionally, she stated the resident should have been monitored with the increased temperature every one (1) hour with documentation of the assessment in the Nurse's Notes. Interview with the Administrator, on [DATE] at 6:46 PM, revealed his expectation was for the nurse to follow the Notification of Change in Residents' Condition policy. Further interview with the Administrator, revealed he would expect with a change in a resident's condition the nurses would monitor more closely and contact the physician. 2. Review of Resident #9's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as scoring a three (3) out of fifteen (15) on the Brief Interview for Mental Status (BIMS), indicating the resident was severely cognitively impaired. Review of the Nurse's Note written by RN #5, dated [DATE] at 6:48 PM, revealed Resident #9's daughter was concerned about the resident's right leg, particularly his/her calf. The Note revealed, the resident had two (2) plus [MEDICAL CONDITION] from the ankle to the mid-thigh and the leg measured thirty-nine (39) centimeters (cm) in circumference at the Anterior Tibial Tuberosity. According to the Note, the resident cried out when touched but when asked the resident stated he/she had pain only in his/her big toe. Further review of the Note, revealed the resident was currently taking twenty (20) milligrams of [MEDICATION NAME] (diuretic medication) daily. Per the Note, the resident's daughter stated she she had noticed the resident's leg was swollen for a few days, but today the leg was obviously bigger. Continued review of the Note, revealed RN #5 completed an assessment of the resident while he/she was in the bed. The Note stated, the Physician was faxed and the oncoming nurse was given a full report. Review of the Fax Transmission to Resident #2's Primary Care Physician (PCP), dated [DATE], revealed Resident #9 had two (2) plus (+) [MEDICAL CONDITION] to his/her right leg from the ankle to the mid thigh. Further review revealed, this was abnormal for this resident. The Fax Transmission revealed there was no redness noted and although the leg was not warm, it was warmer than the left leg. Review of the Nurse's Note written by LPN #9, dated [DATE] at 10:16 PM, revealed Resident #9 continued to have three (3) plus (+) [MEDICAL CONDITION] to his/her right leg. Further review of the Note, revealed the right leg was tight to the touch and the skin was shiny. The Note stated, the resident had complaints of pain when deep pressure was applied and Tylenol was given at bedtime to ease discomfort. The Note stated, the Fax was on the board for the Physician. Review of the Nurse's Note, written by RN #5, on [DATE] at 2:39 PM, revealed the resident was assessed that morning before getting out of bed. According to the Note, the right leg still had two (2) plus (+) [MEDICAL CONDITION] with shiny skin and slight warmth. Continued review of the Note, revealed the on call Physician ordered a doppler ultrasound and staff was awaiting call back to schedule the procedure. Review of the Ultrasound Echo/Vascular Form, dated [DATE], revealed Resident #9 was positive for a [MEDICAL CONDITIONS], blood clot. Review of the Nurse's Note written by RN #5, on [DATE] at 4:41 PM, revealed there was an order for [REDACTED]. Review of physician's orders [REDACTED]. Interview with Resident #9's Daughter/Power of Attorney (POA), on [DATE] at approximately 9:15 AM, revealed she had concerns related to Resident #9's right leg being swollen and she had notified Licensed Practical Nurse (LPN) #8, on [DATE]. She stated, she had reported this to LPN #8, who told her they would watch the leg. However, review of the Nurse's Notes revealed there was no documented evidence of the resident's POA being concerned about the resident's leg. Also, there was no documented evidence LPN #8 assessed the resident's leg. Further interview with the resident's POA revealed she talked to Registered Nurse (RN) #5, on [DATE], the next day. The POA explained she was informed by RN #5, there was no documentation in the medical record related to the POA expressing concern about the resident's leg, but she again told her, We will watch it. Resident #9's POA further explained, she thought her loved one might have had a blood clot, so she was persistent about alerting staff about his/her condition. Continued interview with the POA, revealed it was not until Sunday, [DATE], when the resident was able to see a doctor. She stated another Primary Care Physician (PCP) #25 was in the facility to see other residents and she (POA) approached PCP #25 to assess her loved one. Resident #9's POA revealed Resident #9 had a blood clot and was now on blood thinners to resolve it. Resident #9's POA further revealed she felt the staff was unconcerned about the needs of her loved one. Interview with Certified Nursing Assistant (CNA) #10, on [DATE] at 6:27 PM, revealed she overheard the resident's POA tell LPN #8 and RN #5, she thought something was different with the resident's leg. She further stated, LPN #8 told the POA that she would document the family had a concern and then she (LPN #8) asked staff to reposition Resident #9. CNA #10 further revealed RN #5 took measurements of the resident's leg because the resident's Daughter was still concerned about the resident's leg. She stated she heard the Daughter say to staff and to another family member, she thought the resident had a blood clot. CNA #10 stated she thought this had been reported to the Physician. Interview with RN #5, on [DATE] at 11:39 AM, revealed Resident #9's family informed her the resident's leg was swollen more than normal, and asked her if she was aware of her concern, since she reported it to LPN #8 the day before, on [DATE]. RN #5 stated LPN #8 had not told her about the POA's concern, adding LPN #8 quit without documenting any Nurse's Notes related to Resident #9's leg. RN #5 further stated she measured the resident's leg, adding both of his/her legs looked swollen. Continued interview, revealed she told the nursing staff to monitor and watch the resident's leg. RN #5 further stated she faxed the concern to the resident PCP, passed on the information to LPN #9, and would have thought the oncoming nurse, LPN #9, would have called the resident's PCP if she had not heard from the PCP. RN #5 explained, if left undetected, a blood clot could lead to death. Interview with LPN #9, on [DATE] at 12:33 PM, revealed RN #5 conveyed the information to her, regarding the resident's leg. LPN #9 stated she would notify the PCP for any changes in the resident's condition, but added the primary communication was to fax the physician and to call the physician with any signification changes. She stated the information was already reported to the physician, via fax, thus she did not have to contact the PCP. LPN #9 stated, the resident's POA never made any complaints to her. Attempted interview per phone with LPN #8, on [DATE] at 12:34 PM, a message was left with no returned call. Interview, on [DATE] at 5:27 PM, and [DATE] at 1:44 PM, with the Director of Nursing (DON) revealed staff had communicated with the PCP by way of fax since she had been the DON at the facility. She stated the concern was, if the PCP's office was closed or if staff was off for a day or two, the staff who completed the original fax would need to contact the physician. The DON stated, she had educated the staff on calling the physician if there was any change of condition with the residents and was working with the physicians to devise an updated way of communication with the physicians to communicate the needs of the residents. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Administrator and Medical Director created the Abnormal Vital Signs policy, which instructed staff on the definition of abnormal vital signs, actions nurses should take when abnormal vital signs were obtained, and when to notify the physician, resident, and/or responsible party/Power of Attorney (POA). 2. On [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse reviewed facility policies regarding change in resident status, notification of change, documentation, hydration, charting, and care plans for compliance of Federal regulations to ensure thorough understanding and knowledge prior to education of staff. It was determined, facility policy had been followed regarding notification of change related to Resident #2's fluid intake on [DATE]. The facility policy Notification of Change was updated to include facility requirements when notification of change was to occur and who staff was to notify on [DATE] by the Administrator. The Administrator and DON determined the facility Charting and Care Plan policies were in compliance with Federal Regulations. It was identified, the facility had three (3) policies governing hydration; all policies were reviewed and the Administrator and DON determined one (1) of the policies met federal regulations compliance. The Hydration and Nutrition updated on [DATE], by the Administrator, would be used as the facility's only policy on hydration. 3. Twenty-four (24) out of twenty-six (26) nurses were educated on updated Notification of Change the new Abnormal Vital Signs, Hydration and Nutrition, and Charting policies on dates [DATE] through [DATE] by the DON, ADON, Staff Development Coordinator, and QAPI nurse. Additionally, education also included following the residents' plan of care related to signs and symptoms of dehydration, documentation regarding hydration and nutrition, and contacting physician with change in status (for example abnormal vital signs, signs and symptoms of dehydration). Certified Nurse Aides (CNAs) were not involved in this training even though they may obtain vital signs, it was solely the nurses' responsibility to monitor and assess the residents vital signs and hydration status. Education was conducted in small group sessions with open conversation and question and answer period at the end to test knowledge and understanding of the policies. The nurses that did not receive education would not provide direct care until education on Abnormal Vital Signs policy and Notification of Change policy had been received. Furthermore, these policies had been added to the facility's orientation program which was conducted prior to new nurses providing direct care in the facility beginning with next orientation on [DATE]. On [DATE] and [DATE], the Staff Development Coordinator made rounds through the facility daily, including weekends, and on all shifts to question all nurses about the Notification of Change and Resident Status Changes,Abnormal Vital Signs, Residents' Plan of Care, and Hydration policies. These rounds also included communicating with the facility during night shift and asking staff questions regarding notification of change, abnormal vital signs, and residents' plan of care. 4. Beginning the night of [DATE] and ending on [DATE], the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator, and (QAPI) Nurse audited one-hundred (100) percent of resident clinical records pertaining to notification of change. No evidence was found that any other residents were adversely affected by notification of change. 5. Beginning the night of [DATE] and ending [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse audited one-hundred (100) percent of resident clinical records pertaining to care plan interventions related to dehydration/fluid volume deficit. Evidence revealed all current resident care plans implemented correctly related to dehydration. MDS staff reviewed the plan of care for all current residents and updated to include the daily estimated fluid need f

Based on interview, record review and review of facility policy, it was determined the facility failed to have an effective system in place to ensure residents were provided with sufficient fluid intake to maintain proper hydration and health for one (1) of nine (9) residents (Resident #2). Review of the [DATE] Fluid Totals revealed Resident #2 did not meet his/her Estimated Fluid Need (EFN) on [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review revealed on [DATE] at 5:16 PM, Resident #2 had a fever of 101.1 degrees Fahrenheit (F); on [DATE] between 8:00 PM and 10:00 PM the resident had a temperature of 102 degrees F; and, on [DATE], at approximately 6:00 AM, the resident was assessed to have a temperature of 102.2 degrees F axillary. Interview revealed Resident #2 who was a heavy wetter and normally incontinent of urine every two (2) hours; however, Resident #2 had no urinary output during rounds on [DATE] at 1:00 AM, 3:00 AM, and 5:00 AM. In addition, the resident was receiving routine [MEDICATION NAME] (a medication to increase the excretion of water from the body); forty (40) milligrams (mgs) twice a day for Essential Hypertension. Staff interviews revealed Resident #2 was showing signs and symptoms of dehydration including decreased or no urine output, dry chapped lips, fever, weakness, and limited food and liquid intake. However, there was no documented evidence staff provided ongoing monitoring of the resident to assess for the signs and symptoms of dehydration and no documented evidence the physician was notified of the resident's signs and symptoms of dehydration. On [DATE], at approximately 6:00 AM, the resident was found unresponsive and in respiratory distress. Resident #2 was transferred to the hospital on [DATE] and arrived at 6:57 AM and presented with a rectal temperature of 106.7 degrees F, was unresponsive, had mottled skin (blood vessel changes in the skin that cause a patchy appearance), agonal respirations (gasping labored breathing), capillary refill time of eight (8) seconds, labs which indicated severe dehydration, and his/her soft palate and uvula were like sand paper. Resident #2 was admitted to the Critical Care Unit (CCU) at the local Hospital and placed on a ventilator with [DIAGNOSES REDACTED]. Resident #2 expired on [DATE] related to complications of his/her increased temperature, dehydration, [MEDICAL CONDITION]. The facility's failure to provide each resident with sufficient fluid intake to maintain proper hydration has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged, on [DATE], prior to exit on [DATE], with remaining non-compliance in the area of 42 CFR 483.25 Quality of Care, F-327 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic change. The findings include: Review of the facility's policy, titled Hydration and Nutrition, reviewed [DATE], revealed the purpose of the policy was to maintain close optimal level as possible the nutritional and hydration status of each resident. Further review of the policy revealed an ongoing assessment of the ability to consume and assimilate food by the resident was conducted by the nursing personnel and the assessment would include the ability of the resident to chew, drink, swallow, and signs of dehydration. Continued review of the policy revealed the physician would be notified of changes in nutrition and hydration status as they occurred. Review of the facility's policy, titled Hydration, revised [DATE], revealed it was the policy of the facility to provide adequate hydration to all residents. Continued review of the policy revealed the residents would be assessed by the dietitian for estimated fluid needs (EFN) in a twenty-four (24) hour period. Staff would provide a minimum of one-thousand (1000) cubic centimeters (cc) in a twenty-four (24) hour period. The remainder was to be provided per nursing, medication aides, and the activity department. All residents were to have a water pitcher in their room and receive fresh water and ice three (3) times a day. Review of the facility's policy, titled Dietary Intake Log, reviewed [DATE], revealed the purpose of the policy was to track resident's nutrition and hydration. Continued review of the policy revealed there was a record kept daily (completed on night shift) of those residents who did not meet their daily fluid requirements. Once the resident was on the list for three (3) consecutive days the physician must be notified. When notifying the physician, staff should include poor skin turgor, dry mucous membranes, concentrated urine, and decreased urine output. Review of Resident #2's medical record revealed, the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. a day for Essential Hypertension. Further review revealed the resident was ordered [MEDICATION NAME] forty (40) mg's once a day on [DATE] and an order was received to increase the [MEDICATION NAME] to forty (40) mg's twice a day on [DATE]. Review of the Comprehensive Care Plan revised [DATE], revealed the resident had the potential for fluid deficit related to diuretic use with a goal stating the resident would be free of symptoms of dehydration and maintain moist mucous membranes, and good skin turgor. The interventions included; monitoring vital signs as ordered/per protocol and record, notify the Physician of significant abnormalities, monitor/document/report to Physician signs and symptoms of dehydration: decreased urine output, cracked lips, fatigue/weakness, fever, dry/sunken eyes and furrowed tongue. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status Status (BIMS) of a thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed the resident a requiring extensive assist of two (2) persons for bed mobility, and toilet use, as requiring extensive assist of one (1) person for transfers, and personal hygiene. Continued review revealed the facility assessed the resident as requiring supervision and set-up help for eating and as frequently incontinent of urine and occasionally incontinent of bowel. Review of the Nutrition Risk Assessment, dated [DATE], completed by the facility's Dietitian revealed Resident #2's estimated fluid needs (EFN) was two thousand and fifty (2050) to two thousand, four hundred and sixty (2460) cubic centimeters (cc) per day. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a had a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated severe cognitive impairment. Further review of the MDS revealed the facility assessed the resident as requiring extensive assistance of two (2) for bed mobility, transfer, ambulation, dressing, toilet use and personal hygiene. Further review of the MDS, revealed the facility assessed the resident as requiring supervision and assistance of one (1) person for eating and as frequently incontinent of bowel and bladder. Review of the Hydration/Nutrition list (list in which resident's were placed on daily if they did not meet their minimum EFN) revealed Resident #2 was on the daily log eleven (11) times from [DATE] till [DATE] for not meeting the daily EFN for one (1) twenty-four (24) hour period. However, review of Physician Fax Transmissions revealed only one (1) transmission from [DATE] till [DATE] concerning Resident #2's not meeting the EFN for three (3) consecutive days as per policy. The physician was notified on [DATE] per fax that the resident had triggered on the Hydration List for three (3) consecutive days and fluids had been encouraged. However, the fax did not address if the resident was having signs or symptoms of dehydration as per policy. Review of the Follow-Up Question Report (form used to total fluid intake), revealed Resident #2 did not meet the estimated fluid needs (EFN) of two thousand and fifty to (2050) to two thousand and four hundred and sixty (2460) cc per day on [DATE], [DATE], [DATE], [DATE], and [DATE]. The fluid intake was as follows: on [DATE] -1940 cc; on [DATE] - 1680 cc; on [DATE] - 2205 cc; on [DATE] - 1220 cc; and, on [DATE] - 1500 cc. Although, the resident did not have three (3) consecutive days without meeting the EFN in order for staff to notify the Physician of the resident's hydration status as per policy, staff interviews revealed the resident was having changes in nutrition/hydration status and they were having difficulty getting the resident to eat and drink. Also, the resident was having behavior changes, weakness and was showing signs and symptoms of dehydration including dry mouth, and dried and chapped lips. In addition, the resident was having little or no urine output and was having fevers on [DATE] and [DATE]. Interview on [DATE] at 1:40 PM with Certified Nursing Assistant (CNA) #5 revealed the week prior to the resident's hospitalization , the resident had a dry mouth, sores on the outside of his mouth which she soaked with warm water, and a washcloth to clean the stuff off his/her lips. Interview on [DATE] at 10:50 AM, with CNA #4, revealed on [DATE] he assisted Resident #2 on day shift and noticed changes with the resident. The resident was more combative and it was really difficult to get him/her to take fluids. Further interview revealed the resident was cheeking (pocketing) food, had complaints of mouth pain, and the resident's lips were dried and chapped. Further interview revealed CNA #4 had notified Registered Nurse (RN) #4 of these changes with Resident #2. However, there was no documented evidence in the Nurse's Notes of an assessment on [DATE] related to the resident pocketing food. Review of the Nurse's Notes dated [DATE] at 1:58 AM, completed by LPN #1 revealed the resident refused supper stating his/her gums were sore, but she did not observe any areas. Review of the Dietary Notes, completed by the Dietician, dated [DATE] at 12:43 PM, revealed the resident was a feeder as of [DATE] to promote increased intakes, had ill fitting dentures but resident did not want new ones per Nursing. Further review revealed the resident was non compliant with Nectar Thick Liquids, significant weight loss of 5.7 percent in one month and may consider appetite stimulant. Interview with CNA #8, on [DATE] at 4:15 PM, revealed she noticed a decline in Resident #2. CNA #8 reported she worked 2:00 PM to 10:00 PM on [DATE]. She reported the resident was refusing to eat and drink, which the resident would never do, adding he/she drank and ate pretty well. According to CNA #8, she notified Licensed Practical Nurse (LPN) #1. However, there was no documentation in the Nurse's Notes by LPN #1 on [DATE] related to the resident refusing to eat and drink on the 2:00 PM to 10:00 PM shift on [DATE]. Interview with CNA #3, on [DATE] at 10:50 AM revealed he worked the week Resident #2 became sick, [DATE] through [DATE]. He stated the resident was more combative than normal and it was difficult to feed him/her. CNA #3 revealed the resident did not want to eat and it was difficult to get fluids in him/her. CNA #3 stated he told the Speech Therapist and Registered Nurse (RN) #4. CNA #3 further revealed he noticed the resident would cheek his/her food and would not swallow. Continued interview with CNA #3 revealed the resident would complain that his/her mouth hurt and his/her lips were chapped and was a little crusted. Review of Resident #2's Speech Therapy Treatment Encounter Notes dated [DATE], revealed the Speech Language Pathologist (SLP) fed resident lunch and noted resident did not feel well today, had a cough throughout the meal and that his/her nurse reported to the SLP the patient had the cough all day. Further review revealed Resident #2 did not respond to verbal cues to take drinks in between bites of food. Continued review revealed the SLP fed the resident both food and drink. Interview on [DATE] at 10:11 AM, with the SLP revealed on [DATE] while assisting Resident #2 with lunch in the dining room, the SLP noticed a change in Resident #2. She stated the resident was leaned over in the chair and looked as if he/she did not feel well. Further interview revealed the SLP informed RN#4 of resident's condition, and RN #4 replied she didn't think he/she felt well. Review of the Nurses' Notes dated [DATE] at 5:16 PM, completed by RN #4, revealed the resident had a fever of 101.1 degrees F, and crackles (abnormal lung sounds) were noted in the lungs. The physician was notified and orders were received for [MEDICATION NAME] (antibiotic medication). Interview on [DATE] at 5:20 PM, with RN #4 revealed on [DATE] she noticed the resident had not felt well but she had not reviewed the resident's fluid intake because no one had reported any issues. However, interviews with CNAs revealed they had reported to RN #4 the resident was complaining of mouth pain and it was difficult to get the resident to take fluids. Continued interview with RN #4 revealed around 5:00 PM she took the resident's temperature because of coughing and discovered he/she had a fever and she contacted the Physician and obtained orders. On [DATE] at 12:35 AM, staff documented on the Vital Sign Log, Resident #2 had a temperature of 102 degrees F, and interviews revealed this temperature was obtained between 8:00 PM and 9:00 PM on [DATE]. Interview with CNA #7, on [DATE] at 3:44 PM, revealed she worked [DATE] from 2:00 PM until [DATE] at 6:00 AM; a double shift. She revealed Resident #2 became a feeder earlier that week because the resident was not eating or drinking and the resident had only taken in about five-hundred and sixty (560) cc on the two shifts she worked, five-hundred (500) cc from 2:00 PM to 10:00 PM on [DATE]; and sixty (60) cc from 10:00 PM to 6:00 AM, [DATE] through [DATE]. She stated, she told LPN #1, who tried to get staff to encourage fluids to the resident, but recalled the resident refused the extra liquids. Further interview with CNA #7 revealed the resident was normally combative but during her double shift, the resident was not fighting with staff. Interview with CNA #11, on [DATE] at 8:27 AM, revealed she was the floater on the night of [DATE]. CNA #11 revealed she had noticed a decline with Resident #2 within the last week because the resident had stopped fighting and looked drained. CNA #11 revealed the resident had gotten to the point were he/she stopped eating and drinking. Continued interview with CNA #11 revealed the resident, within the last week, was pocketing his/her food. She stated the resident was pretty independent with his/her liquids, but had gotten to the point were staff needed to hold his/her cup for him/her. CNA #11 stated she did not recall staff telling her to encourage more fluids to the resident. CNA #11 revealed she was not aware the resident was at risk for dehydration and that information would have assisted her with the resident's care. Further interview with CNA #11 revealed the resident sweated a lot and without additional fluids, it could increase the resident's risk for dehydration. Further interview revealed CNA #11 reported these changes to RN #4 who told her to keep an eye on the resident and make sure he/she got fed. Interview with CNA #10, on [DATE] at 5:11 PM, revealed she worked the night of [DATE] from 2:00 PM until 10:00 PM. She stated she assisted CNA #8 with changing Resident #2 and stated the resident did not have much output that night. She revealed the resident was a heavy wetter, and not voiding much which was not normal for him/her. Additionally, she stated the resident was not combative or fighting with her when she went to change him/her. CNA #10 stated it was almost like the resident, did not have much fight left in him/her. CNA #10 reported she told LPN #1, but did not know if LPN #1 assessed the resident. Review of LPN #1 Nurse's Note, dated [DATE] at 12:38 AM, revealed the resident was placed on antibiotics for upper respiratory infection and the resident had a temperature of 102 degrees F with Tylenol administered for the elevated temperature. Continued review of the Note revealed the resident had wheezes and rhonchi (abnormal lung sounds) noted to bilateral lungs, no adverse reactions noted, and she would continue to observe for any changes. Interview with LPN #1, on [DATE] at 5:50 PM, revealed she was told on Friday, on [DATE], during shift report that the resident was on an antibiotic for respiratory issues. LPN #1 revealed she gave the resident a Mighty Shake at around 7:00 PM on [DATE], which was sugar free. which he/she drank without difficulty. Continued interview with LPN #1, revealed she had staff obtain the resident's vitals on [DATE] and revealed she would normally receive the vital signs around 9:30 PM or 10:00 PM. Per interview, she was given the resident's vital signs which indicated he/she had a temperature of 102 degrees F and she gave the resident two (2) 500 milligram (mg) Tylenol. Further interview revealed she was not notified by the CNAs of any change in the resident's mental status or of the resident not drinking. However, per facility policy the nurses were to monitor the fluid and inform the CNAs when fluids needed to be encouraged. Further review of Resident #2's record Flowsheet, revealed on [DATE], there was recorded incontinent episodes which occurred at 12:16 AM, 2:05 AM and 4:05 AM. Interview on [DATE] at 3:40 PM, with CNA #7, revealed she reported to LPN #1, Resident #2 had not voided at the 1:00 AM, 3:00 AM or 5:00 AM rounds on [DATE]. She stated the resident was calm and let her remove his/her dentures, wasn't making any noise, was stiff and difficult to roll over, pale and had sunken cheeks which CNA #7 brought to LPN #1's attention. However, she stated, to her knowledge LPN #1 did not address her concerns. Further interview revealed CNA #7 could only get Resident #2 to drink sixty (60) cc of fluid during the time period from 10 PM on [DATE] until 6:00 AM on [DATE]. Review of the medical record revealed there was no documented evidence LPN #1 continued to monitor and/or assess the resident on [DATE] and no documented evidence the Physician was notified of the resident's increased temperature of 102 degrees F and signs and symptoms of dehydration even though the nurse was informed the resident was not urinating, was pale, was weak and had sunken cheeks. Further interview with LPN #1, on [DATE] at 5:50 PM, revealed she checked the resident's temperature again at approximately 12:30 AM, on [DATE], and it was 99.0 degrees F. LPN #1 revealed she did not check on the resident anymore until [DATE] at approximately 6:00 AM, when she noticed the resident had no movement. She stated the resident moved constantly by having a [DIAGNOSES REDACTED]. LPN #1 stated the resident was found mottled. LPN #1 revealed she was not told the resident had not urinated throughout the night by the CNAs. LPN #1 stated she only found out the resident had not urinated during the two hour rounds when the subsequent shift reported to her the resident had not urinated. She stated it would have been important to have known the resident had little to no urine output because she would have monitored and assessed the resident more closely. She revealed she was aware the resident was on the list for decreased fluids and his/her blood sugar was high, which showed an infection. LPN #1 stated these were some of the signs and symptoms of dehydration, but she missed it, adding she had a lot of paper work to complete that night. Further interview on [DATE] at 10:50 with CNA #3 revealed Resident #2 was a heavy wetter and was often wet ninety (90) percent of the time when changing him/her. CNA #3 reported he did a walk through the morning of [DATE] and noted the resident's eyes were closed and his/her head was elevated. CNA #3 reported that at approximately 6:30 AM, the nurses went in to Resident #2's room, CNA #3 could not recall the name of the nurses, but recalled he took the resident's temperature under his/her arm and the temperature was 102.2 degrees F. CNA #3 reported the resident was found to be in respiratory distress and was sweating. Interview on [DATE] at 6:20 PM, with LPN #3, revealed she had received shift report on [DATE] at 6:00 AM from LPN #1 who did not mention Resident #2 had decrease urine output, decrease in fluid intake, or a fever. Continued interview revealed LPN #3 would have been very concerned with a decrease in fluid intake because Resident #2 usually drank three (3) to four (4) glasses of fluids with each meal, and if the resident's fluid intake had decreased the Physician should have been contacted. Further interview revealed LPN #3 was not familiar with the facility's hydration policy. Review of LPN #3's Nurse's Note, dated [DATE] at 6:40 AM, revealed Resident #2 was found in distress and unresponsive. Per the Note, the resident's respirations was fifty-six (56) (normal ,[DATE]) labored, pulse was one-hundred and thirteen (113) (normal ,[DATE]), blood pressure was seventy over thirty-eight (,[DATE]) (normal range ,[DATE]), and temperature was 102.2 degree F axillary (normal 98.6). The resident's oxygen saturation was seventy-two percent (72%) (normal range ,[DATE]%). Per the Note, the resident's skin was clammy, cool to touch and there was mottling to the bilateral lower and upper extremities, chest, neck and ears. Emergency services (911) was called to transport the resident to the hospital emergency room . Interview on [DATE] at 10:30 AM, with the Paramedic revealed upon arrival at the facility to assess Resident #2 she observed the resident was in respiratory distress, unresponsive and mottled. Continued interview revealed the Paramedic, who was also a Phlebotomist, attempted an Intravenous (IV) Line placement but was unsuccessful, adding it was more difficult getting IV access when a person was dehydrated. Review of Resident #2's emergency room Notes, dated [DATE], revealed the resident was found to have a rectal temperature of 106.7 degrees F, respiratory rate of 68 breaths per minute, was unresponsive, had mottled skin, and agonal respirations. Further review revealed the resident had a capillary refill time of eight (8) seconds, (normal capillary refill time less than two (2) seconds and prolonged capillary refill time may be a sign of shock which could indicate dehydration and decreased peripheral perfusion). The residents laboratory values were as follows: sodium 174 (reference range ,[DATE]), Potassium 4.1 (reference range 3XXX,[DATE].0) Blood Urea Nitrogen (BUN) 75 (reference range ,[DATE], test to measure the amount of nitrogen in the blood in order to evaluate kidney function), and Creatinine 4.0 (reference range 0XXX,[DATE].2, test to evaluate kidney function). Resident #2 was admitted to the Cardiac Care Unit for treatment and monitoring with [DIAGNOSES REDACTED]. The resident expired on [DATE]. Interview on ,[DATE] at 8:30 AM, with the ER Physician, revealed upon arrival at the ER, when the ER physician attempted intubation the resident's soft palate and uvula were like sandpaper. The ER Physician revealed the resident's laboratory values indicated severe dehydration. Continued interview revealed the resident had a rectal temperature of 106.7 degrees F and looked septic along with the dehydration. He stated the resident sustained [REDACTED]. Interview on [DATE] at 10:30 AM, with Resident #2's Physician revealed he felt the resident's high temperatures contributed to the resident's dehydration and cerebral injury. Interview on [DATE] at 3:59 PM with the Staff Development Coordinator (SDC) revealed if a resident had decreased fluid intake and signs and symptoms of dehydration, the Physician should be notified of the change. Continued interview revealed if a resident had an increased temperature, decreased fluids and decreased urine output the physician would need to be notified immediately. Interview with the Dietitian, on [DATE] at 8:15 PM, revealed the residents Estimated Fluid Needs (EFN) was calculated and based on the residents body weight in kilograms (kg) times (x) twenty-five (25) to thirty (30) cubic centimeters (cc). Continued interview with the Dietitian revealed Resident #2 should have had, at a minimum, two-thousand and fifty (2050) cc. Continued interview with the Dietitian revealed staff did not have to notify her when the resident did not meet his/her fluid needs; however, the Physician should have been notified if the resident was experiencing decreased fluid intake and was not properly voiding. Interview on [DATE] at 4:23 PM with the Assistant Director of Nursing (ADON) revealed she had not been informed of Resident #2's increased swallowing difficulties or pocketing/cheeking food and would have expected this information to be in documented in a Nurse's Note. Further interview revealed her expectation when a resident had an increased temperature, decreased fluid intake, and decreased urination was for staff to contact the physician and send the resident to the ER. Continued interview revealed an increased temperature did increase the risk for dehydration and by not contacting the physician she felt the situation with Resident #2 was neglect. Interview with the Director of Nursing (DON), on [DATE] at 5:27 PM, revealed it was her expectation, the as needed (PRN) Tylenol, should have been administered on [DATE] when the resident was noted to have a temperature. Additionally, she reported the resident should have been monitored with the increased temperature every one (1) hour with documentation of the assessments in the Nurse's Notes. Interview on [DATE] at 6:46 PM, with the Administrator revealed he would expect with a change of condition the nurses should have monitored more closely and contacted the physician with the change in the resident's condition. Additionally, he revealed it would have been his expectation, if a resident had decreased fluids with a noted temperature that staff would encourage more fluids to the resident. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Administrator and Medical Director created the Abnormal Vital Signs policy, which instructed staff on the definition of abnormal vital signs, actions nurses should take when abnormal vital signs were obtained, and when to notify the physician, resident, and/or responsible party/Power of Attorney (POA). 2. On [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse reviewed facility policies regarding change in resident status, notification of change, documentation, hydration, charting, and care plans for compliance of Federal regulations to ensure thorough understanding and knowledge prior to education of staff. It was determined, facility policy had been followed regarding notification of change related to Resident #2's fluid intake on [DATE]. The facility policy Notification of Change was updated to include facility requirements when notification of change was to occur and who staff was to notify on [DATE] by the Administrator. The Administrator and DON determined the facility Charting and Care Plan policies were in compliance with Federal Regulations. It was identified, the facility had three (3) policies governing hydration; all policies were reviewed and the Administrator and DON determined one (1) of the policies met federal regulations compliance. The Hydration and Nutrition updated on [DATE], by the Administrator, would be used as the facility's only policy on hydration. 3. Twenty-four (24) out of twenty-six (26) nurses were educated on updated Notification of Change the new Abnormal Vital Signs, Hydration and Nutrition, and Charting policies on dates [DATE] through [DATE] by the DON, ADON, Staff Development Coordinator, and QAPI nurse. Additionally, education also included following the residents' plan of care related to signs and symptoms of dehydration, documentation regarding hydration and nutrition, and contacting physician with change in status (for example abnormal vital signs, signs and symptoms of dehydration). Certified Nurse Aides (CNAs) were not involved in this training even though they may obtain vital signs, it was solely the nurses' responsibility to monitor and assess the residents vital signs and hydration status. Education was conducted in small group sessions with open conversation and question and answer period at the end to test knowledge and understanding of the policies. The nurses that did not receive education would not provide direct care until education on Abnormal Vital Signs policy and Notification of Change policy had been received. Furthermore, these policies had been added to the facility's orientation program which was conducted prior to new nurses providing direct care in the facility beginning with next orientation on [DATE]. On [DATE] and [DATE], the Staff Development Coordinator made rounds through the facility daily, including weekends, and on all shifts to question all nurses about the Notification of Change and Resident Status Changes,Abnormal Vital Signs, Residents' Plan of Care, and Hydration policies. These rounds also included communicating with the facility during night shift and asking staff questions regarding notification of change, abnormal vital signs, and residents' plan of care. 4. Beginning the night of [DATE] and ending on [DATE], the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator, and (QAPI) Nurse audited one-hundred (100) percent of resident clinical records pertaining to notification of change. No evidence was found that any other residents were adversely affected by notification of change. 5. Beginning the night of [DATE] and ending [DATE], the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse audited one-hundred (100) percent of resident clinical records pertaining to care plan interventions related to dehydration/fluid volume deficit. Evidence revealed all current resident care plans implemented correctly related to dehydration. MDS staff reviewed the plan of care for all current residents and updated to include the daily estimated fluid need for each resident. On [DATE], the DON added question to Electronic Medication Administration Record [REDACTED]? 6. Beginning the night of [DATE] and ending on [DATE], the Administrat

Based on interview, record review and review of facility policy, it was determined the facility failed to have an effective system to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete; accurately documented; readily accessible; and systematically organized for three (3) of nine (9) sampled residents residents (Resident #1, #2 and #9). Interview and record review revealed Resident #2 had an elevated temperature on 09/11/15 of 101.1 degrees Fahrenheit (F); on 09/11/15 between 8:00 PM and 10:00 PM the resident had a fever of 102 degrees F; and, on 09/12/15, at approximately 6:00 AM, the resident had a fever of 102.2 degrees F axillary. Staff interviews revealed Resident #2 was a heavy wetter and was normally incontinent of urine every two (2) hours; however, the resident had no urinary output during rounds on 09/12/15 at 1:00 AM, 3:00 AM, and 5:00 AM. Review of the September 2015 Fluid Totals revealed Resident #2 did not meet his/her Estimated Fluid Need (EFN) on 09/03/15, 09/05/15, 09/07/15, 09/09/15, and 09/11/15. Staff interviews revealed the resident was showing signs and symptoms of dehydration from 09/07/15 through 09/12/15 including dry chapped lips, fever, weakness, limited food and liquid intake and decreased or no urine output. and the resident's family requested the facility contact the Physician on 09/06/15 and 09/08/15 related to concerns with the resident's health. However, there was no documented evidence the physician was notified of the increased temperature of 102 degrees F obtained on 09/11/15, notified of the signs and symptoms of dehydration, or notified of the family's request for the Physician to contact them. On 09/12/15, at approximately 6:00 AM, Resident #2 was found unresponsive and in respiratory distress. The resident was transferred to the hospital on [DATE] and arrived at 6:57 AM and presented with a rectal temperature of 106.7 degrees F, was unresponsive, had mottled skin (blood vessel changes in the skin that cause a patchy appearance), agonal respirations (gasping labored breathing), capillary refill time of eight (8) seconds, labs which indicated severe dehydration, and his/her soft palate and uvula were like sand paper. Resident #2 was admitted to the Critical Care Unit (CCU) and placed on a ventilator with [DIAGNOSES REDACTED]. Additionally, on 09/24/15, Resident #9's Power of Attorney (POA), notified Licensed Practical Nurse (LPN) #8 of the resident's right leg [MEDICAL CONDITION]. However, there was no documented evidence in the Nurse's Notes, LPN #8 assessed the resident's leg after the resident's POA notified her of the [MEDICAL CONDITION]. Resident #1 was placed in the hallway until his/her room could be cleared for bed bugs; however, the resident remained in the hallway for approximately two (2) days without a call light, with only a sectional (curtain on wheels) for privacy, although the resident complained to staff about not having a room during this time. Per the the Director of Nursing's (DON) interview the resident was placed in the hallway on 08/28/15 at 5:00 PM and was still in the hall way on 08/31/15 at 5:00 AM when she arrived at the facility. The resident was then moved to another room, other than his/her own room on 08/31/15 per the DON's direction. However there was no documented evidence this event occurred, and no documented evidence of the room change. The facility's failure to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete; accurately documented; readily accessible; and systematically organized has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/24/15, and was determined to exist on 09/11/15. The facility was notified of the Immediate Jeopardy on 09/24/15. The facility provided an acceptable credible Allegation of Compliance (AOC) on 10/02/15 with the facility alleging removal of the Immediate Jeopardy on 09/30/15. The State Survey Agency validated removal of the Immediate Jeopardy as alleged, on 09/30/15, prior to exit on 10/02/15, with remaining non-compliance in the area of 42 CFR 483.75 Administration, F-514 at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic change. The findings include: Review of the facility's policy, titled Charting, revised 07/30/15 revealed, the resident's medical record was a concise account of treatment, care, signs, symptoms and progress of the resident's condition. Further review revealed it was also necessary to include data needed for identification and communication with physician, responsible party and family. A complete history of past and present illnesses was desirable. The Rules for Charting included: all charting was to be done, it was important to note any changes in conditions: mental or physical, behaviors, voice, skin, persistent cough, bleeding, nausea, vomiting, bruises, lethargy and abnormal vital signs, elimination habits were to be watched and recorded, always use correct spelling, and all medication and treatments were to be recorded. Review of the facility's policy, titled Notification of Change in Resident's Condition, revised 08/03/15 revealed, the purpose of the policy was to immediately inform the resident, consult with the resident's physician, and if known: notify the resident's legal representative when there was a change in resident status/condition. In the event of a resident status change, the nurse would assess the situation, notify the attending physician, provide necessary care, notify the responsible party, document in the resident's medical record and follow up as indicated. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 02/10/15 with [DIAGNOSES REDACTED]. Review of the Nutrition Risk Assessment, dated 02/20/15, completed by the facility's Registered Dietitian revealed Resident #2's estimated fluid needs (EFN) was two thousand and fifty (2050) to two thousand four hundred and sixty (2460) cubic centimeters (cc) per day. Review of the Follow-Up Question Report (form used to total fluid intake), revealed Resident #2 did not meet the estimated fluid needs (EFN) of two thousand and fifty to (2050) to two thousand and four hundred and sixty (2460) cc per day for 09/03/15, 09/05/15, 09/07/15, 09/09/15, and 09/11/15. Interview on 09/16/15 at 1:00 PM with the resident's responsible party revealed he had informed Registered Nurse (RN)# 4 on 09/06/15 and 09/08/15 the family was concerned about the resident not eating and drinking well and looking like he/she felt bad and wanted Resident #2 to see the Physician. Record review of the Twenty-Four (24) Hour Report dated 09/08/15, revealed a notation stating the resident's son, who was the responsible party wanted the Physician to assess Resident #2. However, review of the Nurse's Notes dated 09/06/15 and 09/08/15 revealed there was no documented evidence the physician was notified of the family's request to contact the physician. Interview on 09/24/15 at 1:01 PM, with RN #4 revealed she had written the notation on the Twenty-Four (24) Hour Report; however, she had not contacted the Physician or ensured the subsequent nurse contacted the Physician. Review of the Nurses' Note dated 09/11/15 at 5:16 PM, completed by RN #4, revealed Resident #2 had a fever of 101.1 degrees F, and crackles (abnormal lung sounds) were noted in the lungs. Per the Note, the physician was notified and orders were received for [MEDICATION NAME] (antibiotic medication). Review of the Standing Orders for Resident #2 revealed an order for [REDACTED]. However, there was no documented evidence in the Nurse's Notes or on the Medication Administration Record [REDACTED]. Interview on 09/16/15 at 5:20 PM, with RN #4 revealed on 09/11/15 around 5:00 PM she took Resident #2's temperature because of coughing and discovered he/she had a fever and then contacted the Physician and obtained orders. Further interview revealed, she would normally give Tylenol for a temperature of 99 degrees F; however, there was no documented evidence Tylenol was administered for the temperature. Review of LPN #1 Nurse's Note, dated 09/12/15 at 12:38 AM, revealed Resident #2 was receiving antibiotics for an upper respiratory infection and the resident had a temperature of 102 degrees F with Tylenol administered for the elevated temperature. Per the Note, the resident had wheezes and rhonchi (abnormal lung sounds) noted to bilateral lungs, no adverse reactions noted, and she would continue to observe for any changes. Review of Resident #2's record Flowsheet, revealed on 09/12/15, Resident #2 had not voided at the 1:00 AM, 3:00 AM or 5:00 AM rounds on 09/12/15 and this was reported to LPN #1. Continued review of the medical record revealed there was no documented evidence LPN #1 continued to monitor and/or assess the resident on 09/12/15 and no documented evidence the Physician was notified of the resident's increased temperature of 102 degrees F and signs and symptoms of dehydration. Further interview with LPN #1, on 09/24/15 at 5:50 PM, revealed she checked Resident #2's temperature again at approximately 12:30 AM, on 09/12/15, and it was 99.0 degrees F. She stated, she did not check on the resident anymore until 09/12/15 at approximately 6:00 AM. LPN #1 further revealed she was not told the resident had not urinated throughout the night by the CNAs and only found out the resident had not urinated during the two hour rounds when the subsequent shift reported to her the resident had not urinated. Review of LPN #3's Nurse's Note, dated 09/12/15 at 6:40 AM, revealed the resident was found in distress and unresponsive. According to the Note, the resident's respirations was fifty-six (56) (normal 12-16) labored, pulse was one-hundred and thirteen (113) (normal 60-100), blood pressure was seventy over thirty-eight (70/38) (normal range 120/80), and temperature was 102.2 degree F axillary (normal 98.6). Further review revealed the resident's oxygen saturation was seventy-two percent (72%) (normal range 95-100%). The Note stated, the resident's skin was clammy, cool to touch and there was mottling to the bilateral lower and upper extremities, chest, neck and ears. Emergency services (911) was called to transfer the resident to the hospital emergency room . Review of Resident #2's emergency room Notes, dated 09/12/15, revealed the resident had a rectal temperature of 106.7 degrees F. The resident was admitted to the Cardiac Care Unit for treatment and monitoring with [DIAGNOSES REDACTED]. Interview with the Staff Development Coordinator (SDC), on 09/24/15 at 3:59 PM, revealed , if a resident had a fever, decreased fluid intake, and decreased urine output the physician should have been notified immediately and document all interventions taken. 2. Review of Resident #9's record revealed the resident was admitted by the facility on 05/15/13 with [DIAGNOSES REDACTED]. Interview with Resident #9's daughter/Power of Attorney (POA), on 10/01/15 at approximately 9:15 AM, revealed she had concerns about Resident #9's right leg being swollen and had notified Licensed Practical Nurse (LPN) #8, on 09/24/15. She revealed she had reported this to LPN #8, who told her they would watch the leg. However, there was no documented evidence in the Nurse's Notes of the resident's POA being concerned about the resident's leg. In addition, there was no documented evidence LPN #8 assessed the resident's leg. Interview with Certified Nursing Assistant (CNA) #10, on 10/01/15 at 6:27 PM, revealed she saw the resident's POA tell LPN #8 she thought something was different with the resident's leg. She further stated, LPN #8 told the POA she would document the family had a concern and then LPN #8 asked staff to reposition the resident. CNA #10 revealed she heard the daughter say to staff and to another family member that she thought the resident had a blood clot. CNA #10 stated she thought this had been reported to the Physician. Attempted interview with LPN #8, on 10/02/15 at 12:34 PM, a message was left with no returned call. Continued interview with the resident's POA, on 10/01/15 at approximately 9:15 AM, revealed she talked to Registered Nurse (RN) #5 the next day, on 09/25/15. The POA stated, she was informed by RN #5 that there was no documented evidence in the medical record related to the POA expressing concern about the resident's leg. Interview with RN #5, on 10/02/15 at 11:39 AM, revealed Resident #9's family informed her the resident's leg was swollen more than normal, and asked her if she knew about her concern, since she reported it to LPN #8 the day before, on 09/24/15. RN #5 further stated LPN #8 had not told her about the POA's concern, adding LPN #8 quit without documenting any Nurse's Notes related to the resident's leg. Review of Nurse's Note written by RN #5, dated 09/25/15 at 6:48 PM, revealed the resident's daughter was concerned about resident's right leg, particularly his calf. The Note, revealed Physician was faxed and the oncoming nurse was given a full report. The Note stated, would continue to monitor. Review of the Fax Transmission to Resident #2's Primary Care Physician (PCP), dated 09/25/15, revealed Resident #9 had two (2) plus (+) [MEDICAL CONDITION] to the right leg from the ankle to the mid thigh. Further review revealed, this was abnormal for the resident. The Fax Transmission revealed there was no redness noted and although it was not warm, it was warmer than the left leg. Review of the Ultrasound Echo/Vascular Form, dated 09/28/15, revealed Resident #9 was positive for [MEDICAL CONDITIONS], blood clot. 3. Review of Resident #1's clinical record revealed the resident was admitted by the facility on 03/28/15, with [DIAGNOSES REDACTED]. Review of the letter provided by the city, regarding Bed Bug Infestation, dated 08/29/15, revealed the Code Enforcement Office was notified on 08/28/15, bed bugs were found in Resident #1's room and the room was completely stripped. Continued review, revealed the follow-up inspection was performed by the city's Code Enforcement Inspector and all resident's were cleared to return to their rooms on 08/29/15. Interview with Resident #1, on 09/16/15 at 4:30 PM, and 09/17/15 at 3:46 PM, revealed the resident was placed at the end of the hallway for about a day and a half. Interview with CNA #15, on 09/17/15 at 3:10 PM, revealed she worked Sunday night, 08/30/15 on third shift, 10:00 PM to 6:00 AM and she talked to the resident who reported to her, he/she had been in the hallway since Saturday, 08/29/15. CNA #15 stated she asked Registered Nurse (RN) #1 why the resident was not in one of the empty beds. CNA #15 further revealed, she assisted with moving the resident to a different room during her shift. Interview with Registered Nurse (RN) #1, on 09/18/15 at 7:00 AM, revealed she could not remember the date of the incident, due to the incident not being documented; however, she was told by Licensed Practical Nurse (LPN) #2, Resident #1 had bed bugs in his/her room and they were to remove the resident and his/her roommate from their room. Interview with the Social Service Director, on 09/18/15 at 3:04 PM, revealed staff should document any room changes and should have documented the room change with Resident #1. Interview with the Director of Nursing (DON), on 09/18/15 at 3:53 PM, revealed, Resident #1 was placed in the hallway on 08/28/15, at approximately 5:00 PM. The DON further stated the incident should have been documented and she was working with staff with documentation concerns. Interview with the Administrator, on 09/18/15 at 4:19 PM, revealed staff was to notify the resident's Physician and Power of Attorney (POA), when there was a change in the residents' rooms. He further stated, staff should have documented the room changes and documented the incident, adding, documentation was very important. The facility provided an acceptable credible Allegation of Compliance (AOC) on 10/02/15, which alleged removal of the IJ effective 09/30/15. Review of the AOC revealed the facility implemented the following: 1. On 09/21/15, the Administrator and Medical Director created the Abnormal Vital Signs policy, which instructed staff on the definition of abnormal vital signs, actions nurses should take when abnormal vital signs were obtained, and when to notify the physician, resident, and/or responsible party/Power of Attorney (POA). 2. On 09/24/15, the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse reviewed facility policies regarding change in resident status, notification of change, documentation, hydration, charting, and care plans for compliance of Federal regulations to ensure thorough understanding and knowledge prior to education of staff. It was determined, facility policy had been followed regarding notification of change related to Resident #2's fluid intake on 09/11/15. The facility policy Notification of Change was updated to include facility requirements when notification of change was to occur and who staff was to notify on 09/25/15 by the Administrator. The Administrator and DON determined the facility Charting and Care Plan policies were in compliance with Federal Regulations. It was identified, the facility had three (3) policies governing hydration; all policies were reviewed and the Administrator and DON determined one (1) of the policies met federal regulations compliance. The Hydration and Nutrition updated on 09/25/15, by the Administrator, would be used as the facility's only policy on hydration. 3. Twenty-four (24) out of twenty-six (26) nurses were educated on updated Notification of Change the new Abnormal Vital Signs, Hydration and Nutrition, and Charting policies on dates 09/24/15 through 09/29/15 by the DON, ADON, Staff Development Coordinator, and QAPI nurse. Additionally, education also included following the residents' plan of care related to signs and symptoms of dehydration, documentation regarding hydration and nutrition, and contacting physician with change in status (for example abnormal vital signs, signs and symptoms of dehydration). Certified Nurse Aides (CNAs) were not involved in this training even though they may obtain vital signs, it was solely the nurses' responsibility to monitor and assess the residents vital signs and hydration status. Education was conducted in small group sessions with open conversation and question and answer period at the end to test knowledge and understanding of the policies. The nurses that did not receive education would not provide direct care until education on Abnormal Vital Signs policy and Notification of Change policy had been received. Furthermore, these policies had been added to the facility's orientation program which was conducted prior to new nurses providing direct care in the facility beginning with next orientation on 09/28/15. On 09/25/15 and 09/27/15, the Staff Development Coordinator made rounds through the facility daily, including weekends, and on all shifts to question all nurses about the Notification of Change and Resident Status Changes,Abnormal Vital Signs, Residents' Plan of Care, and Hydration policies. These rounds also included communicating with the facility during night shift and asking staff questions regarding notification of change, abnormal vital signs, and residents' plan of care. 4. Beginning the night of 09/24/15 and ending on 09/25/15, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator, and (QAPI) Nurse audited one-hundred (100) percent of resident clinical records pertaining to notification of change. No evidence was found that any other residents were adversely affected by notification of change. 5. Beginning the night of 09/24/15 and ending 09/25/15, the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse audited one-hundred (100) percent of resident clinical records pertaining to care plan interventions related to dehydration/fluid volume deficit. Evidence revealed all current resident care plans implemented correctly related to dehydration. MDS staff reviewed the plan of care for all current residents and updated to include the daily estimated fluid need for each resident. On 09/25/15, the DON added question to Electronic Medication Administration Record [REDACTED]? 6. Beginning the night of 09/24/15 and ending on 09/25/15, the Administrator, DON, ADON, Staff Development Coordinator, and QAPI Nurse audited one-hundred (100) percent of the residents clinical records daily, including weekends, to ensure staff was compliant with the Charting policy and accurate clinical documentation. 7. Starting 09/25/15, and ongoing the DON with the assistance from the ADON, Staff Development Coordinator, QAPI Nurse, MDS staff, and Charge Nurses, began auditing one-hundred (100) percent nurse documentation daily, including weekends, to monitor staff compliance with facility policy regarding notification of changes in resident status, abnormal vital signs, documentation of physician notification, hydration and nutrition logs and care plan interventions. This audit would continue until Immediate Jeopardy abated. All issues identified with regards to these policies would be immediately addressed with individual staff responsible. 8. On 09/25/15, and ongoing the DON began auditing one-hundred (100) percent of the residents' charts daily, including weekends, to ensure plan of care related to dehydration and notification of change was followed for residents who triggered on the Nutrition and Hydration Log. The DON audited, with the help from the ADON, Staff Development Coordinator, QAPI Nurse, MDS Staff, and Charge Nurses, included inspection of Hydration and Nutrition logs, vital signs obtained, lab values obtained which was checked against nurse documentation if abnormal vital signs or lab values obtained and/or change of resident hydration status noted. The audit would continue until Immediate Jeopardy was abated. The DON would immediately address all issues regarding staff compliance with resident plan of care with individual staff and present audit findings to QAPI Committee for review and process improvement if necessary. The Nutritionally at Risk (NAR) Committee would review all residents that trigger for nutritionally at risk for hydration status weekly and would make appropriate interventions as necessary. The NAR Committee consists of the DON, ADON, MDS Coordinator, Dietary Manager, Staff Development Coordinator, and QAPI Nurse. The DON would address all issues related to hydration and nutrition, care plans, documentation, and notification of changes with staff immediately and present audit findings to the QAPI Committee monthly. 9. Results of audits (nurse documentation and staff compliance with residents' plan of care) would be addressed daily with individual staff and audit findings would be presented to the QAPI Committee for review and process improvement at least monthly as necessary. The QAPI Committee consists of the Administrator, DON, ADON, Social Worker, Maintenance Director, Medical Director, Activizes Director, Housekeeping/Laundry Supervisor, and Dietary Manager. The QAPI Committee meets monthly with the Medical Director attending the QAPI meeting quarterly. The next QAPI meeting was scheduled for 10/02/15. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the Abnormal Vital Signs, created 09/21/15, revealed there were parameters set, regarding a resident's blood pressure, pulse, and temperature in which the physician should be notified to due a change in the resident's change in condition. Interview with the Administrator, on 10/02/15 at 1:44 PM, revealed the Medical Director (MD) stopped by his office on 09/21/15 to discuss the concern regarding Resident #2. The Administrator revealed he acknowledged to the Physician the facility did not have a policy to address when the physician should be notified regarding a change in resident's condition. He revealed, in regards to a resident's temperature, staff would obtain the resident's temperature rectally and would notify the physician if out of the set parameters. The Administrator reported the Physician agreed with the policy. Interview with the Physician, on 10/08/15 at 11:00 AM, revealed he discussed Resident #2's case with the Administrator. The Physician revealed he thought the physician should have been notified with a temperature of one-hundred and two (102) and it warranted an emergency room (ER) visit, especially since the resident was on antibiotics. He reported he came up with some reasonable numbers, through his expertise and practice, that would assist the staff with notifying the physician. 2. Review of the facility's policies revealed the facility kept the Charting revised 07/30/15, Care Plan reviewed 01/06/15, and Notification of Change, dated 08/03/15, policies. The facility added a cheat sheet to go along with the Notification of Change in Residents' Condition. The cheat sheet was titled, Notification of Change When to Document?, created 09/25/15. Interview with the Administrator, DON, and ADON on 10/02/15 at 1:44 PM, revealed, when he and the staff reviewed the policies, they thought the policies they had in place complied with the Federal Regulations. Continued interview with the Administrator revealed they, thought it would be helpful to have a cheat sheet to go along with the Notification of Change in Residents' Condition to assist the staff with knowing what to look for when there was a change in a residents' condition. Interview with the SDC, on 10/02/15 at 3:49 PM, revealed she was part of assisting with the policy review and new updated policies. Review of the facility's Hydration and Nutrition Policy, revised 09/25/15 revealed there was no change from the original policy provided. Interview with the Administrator, DON, and ADON on 10/02/15 at 1:44 PM revealed the facility had three (3) policies related to Hydration. The Administrator reported he was not aware of the three (3) different policies. Continued interview with the Administrator revealed they have removed the other two (2) polices and added a revision date to the Hydration and Nutrition policy because this one superceded the other policies. 3. Review of the In-Service Training Sheet, dated 09/24/15, 09/25/15, and 09/29/15, revealed staff signed they were in-serviced on Abnormal vital signs, Hydration, Documentation, Notifying Physician and Power Of Attorney (POA) of changes in condition, Notifying physician of any Significant Changes, following the care plan, and educated staff on the F-Tags the facility received. Review of the Nurses Training Manual, revised 06/05/15, revealed the updated policies were added for orientation of new hires. Interviews with Registered Nurse (RN) #1 on 10/01/15 at 8:30 PM, RN #5 on 10/02/15 at 11:40 AM, Licensed Practical Nurse (LPN) #6 on 10/01/15 at 7:07 PM, LPN #2 on 10/02/15 at 9:50 AM, and LPN #7 on 10/02/15 at 10:50 AM, revealed they were all in-serviced on the Abnormal Vital Signs policy, Hydration, Documentation, Notification of the Physician and Power of Attorney of changes of condition. Additionally, they added the information was stored at the nurses station for their reference. Review of the documentation provided by the Staff Development Coordinator revealed she provided staff with follow-up questions, on 09/25/15, 09/26/15, and 09/27/15, to what was in-serviced to the staff. The Staff Development Coordinator had a series of questions in which she asked staff about the required information. Interviews with Registered Nurse (RN) #1 on 10/01/15 at 8:30 PM, RN #5 on 10/02/15 at 11:40 AM, Licensed Practical Nurse (LPN) #2 on 10/02/15 at 9:50 AM, and LPN #7 on 10/02/15 at 10:50 AM, revealed they were asked questions from the Staff Development Coordinator regarding what they were in-serviced on. Interview with the SDC, on 10/02/15 at 3:49 PM, revealed she took all of the information from the policies and created a questionnaire in which she asked staff how much they knew about Hydration, Care Plans, Notification, Change in a Resident's Condition, Documentation, and the F-Tags cited. She stated she did not have a sign-in sheet, but documented the names and times of the individuals she spoke with. The SDC stated she questioned staff on every shift, including weekends. The SDC revealed the auditing would be ongoing and reported the Hydration for the residents have improved, adding there were less residents on the Hydration List. 4. Review of the auditing tools used to audit one-hundred (100) percent of the residents clinical records were reviewed and the records were reviewed from 09/24/15 through 10/02/15. Interview with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) on 10/02/15 at 1:44 PM, revealed reports were pulled from the Point Click Care (PCC) system which provided them information on each resident. The information contained were critical labs and abnormal vital signs. The DON revealed she reviewed the information and contacted the physician when residents were triggered for critical labs. The Administrator added the nurses notes were also reviewed to see if they added anything regarding the lab results. Additionally, the DON revealed she looked at all of the resident's vital signs manually to see if there were any residents with abnormal vital signs. The DON reported she checked the nursing documentation and ensured the physician was notified on the results. No issues were identified. 5. Review of Resident's Charts, Resident's #3, #4, #5, #6, #7, #8, Unsampled Resident's A and B, revealed their care plans were updated to dehydration/fluid volume deficit. The resident's Estimated Fluid Need(EFN) was added to the resident's care plan with interventions in place. Resident #1 was out of the facility, thus his/her chart was not updated. Interview with the Administrator, DON, and ADON, on 10/02/15 at 1:44 PM, revealed the Minimum Data Set Coordinator (MDS) reviewed all of the residents care plans to make sure their EFN numbers were updated. Additionally, the DON reported she added a question to the resident's Electronic Medication Administration Record [REDACTED]. She revealed if the resident had not, then this would prompt nurse to document interventions made to ensure the resident reached his/her EFN. Interview with the MDS Coordinator, on 10/02/15 at 4:10 PM, revealed she updated the resident's care plan to include EFN. She revealed the residents were already care planned for risk of dehydration and how to recognize the signs and symptoms of dehydration. 6. Review of resident's charts, Resident's #3, #4, #5, #6, #7, #8, Unsampled Resident's A and B, revealed no issues were noted. Interview with the Administrator, on 10/02/15 at 1:44

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the Comprehensive Care Plan was developed related to residents' Advance Directives and code status for twelve (12) of twelve (12) sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12) to ensure the resident's code status was honored and Cardiopulmonary Resuscitation (CPR) was provided as requested when Resident #2 was found unresponsive on [DATE]. Resident #2's Responsible Party signed a document on [DATE], requesting to have CPR provided in the event of cardiac or [MEDICAL CONDITION]. However, review of Resident #2's Comprehensive Care Plan revealed no documented evidence of a care plan developed regarding the resident's requested Full Code Status (a Full Code status indicates in the event of cardiac or [MEDICAL CONDITION], life-saving measures would be initiated) with interventions to address his/her code status. At approximately 4:50 AM on [DATE], Registered Nurse (RN) #1 entered Resident #2's room, found the resident unresponsive, checked for a pulse and respirations and did not obtain any; however, RN #1 failed to initiate CPR according to the resident's wishes as indicated on the Advance Directives form. The facility's failure to ensure residents' Comprehensive Care Plans were developed to include their requested code status with interventions in place to ensure their code status was honored has caused or is likely to cause serious injury harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Resident Care Plan, dated [DATE], revealed the purpose of the policy was to develop a Comprehensive Care Plan for each resident which included measurable objectives and timetables to meet the needs identified. Per the Policy, the nursing care plan would be initiated within twenty-four (24) hours of admission. Continued review revealed the resident's care plan would reflect the specific needs of each resident to include physical, social, and emotional problems and concerns. The Policy revealed the services provided or arranged by the facility would meet professional standards, and qualified persons would provide services in accordance with each resident's written plan of care. 1. Record review revealed the facility admitted Resident #2 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Admit/Readmit Screener assessment, dated [DATE], revealed Resident #2 had provided the information for the assessment, and was noted to be alert to person and verbally appropriate. Review of the physician's orders [REDACTED].#2's Responsible Party, revealed the Responsible Party requested and consented to the use of cardiac compressions or artificial ventilation to resuscitate the resident in the event of death. However, review of the Comprehensive Care Plan (CP) for the admitted [DATE], revealed no documented evidence a care plan was developed for Resident #2's Advance Directives and Full Code status with interventions to ensure the resident's request was honored. On [DATE], Resident #2 was found to be unresponsive and without signs of life by RN #1. After verifying the resident's Full Code status, RN #1 failed to initiate CPR, in contrast to Resident #2's wishes. (Refer to F155, F281 and F490) 2. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) which indicated the resident was cognitively intact. Continued record review revealed Resident #1 had requested to be a Full Code and signed a document noting this on [DATE]. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #1's Advance Directive and/or Full Code status with interventions to ensure the resident's request was honored. 3. Review of Resident #3's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility had assessed Resident #3 to have a BIMS score of fourteen (14) out of fifteen (15) which indicated the resident was cognitively intact. Continued record review revealed Resident #3 had Advance Directives dated [DATE], requesting to be a Full Code. However, review of the Comprehensive Care Plan, dated [DATE], revealed no documented evidence a care plan was developed for Resident #3's Advance Directive and/or Full Code status with interventions to ensure the resident's request was honored. 4. Review of Resident #4's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #4 as being moderately cognitively impaired, with a BIMS score of twelve (12) out of fifteen (15). Continued record review revealed Resident #4 had Advance Directives dated [DATE], indicating he/she did not want CPR. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #4's Advance Directive and/or Do Not Resuscitate (DNR) status with interventions to ensure the resident's request was honored. 5. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #5 as being cognitively intact, with a BIMS score of fifteen (15) out of fifteen (15). Continued record review revealed Resident #5 had Advance Directives, dated [DATE], noting the resident did not want CPR. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #5's Advance Directive and/or DNR status with interventions to ensure the resident's request was honored. 6. Review of Resident #6's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated [DATE], revealed the facility assessed the resident to be moderately cognitively impaired, with a BIMS score of twelve (12) out of fifteen (15). Continued record review revealed Resident #6 had Advance Directives, dated [DATE], noting the resident did not want CPR. However review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #6's Advance Directive and/or DNR status with interventions to ensure the resident's request was honored. 7. Review of Resident #7's medical record revealed the facility admitted the resident on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated [DATE], revealed the facility assessed the resident to be cognitively intact, with a BIMS score of fifteen (15) out of fifteen (15). Continued record review revealed Resident #7 had Advance Directives dated [DATE], requesting to be a Full Code. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #7's Advance Directive and/or Full Code status with interventions to ensure the resident's request was honored until [DATE]. 8. Review of Resident #8's medical record revealed the facility admitted the resident on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated [DATE], revealed the facility assessed the resident to be moderately cognitively impaired, with a BIMS score of eleven (11) out of fifteen (15). Continued record review revealed Resident #8 had Advance Directives dated [DATE], requesting to be a Full Code. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #8's Advance Directive and/or Full Code status with interventions to ensure the resident's request was honored until [DATE]. 9. Review of Resident #9's medical record revealed the facility admitted the resident on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated [DATE], revealed the facility assessed the resident to be cognitively intact with a BIMS score of fifteen (15) out of fifteen (15). Continued record review revealed Resident #9 had Advance Directives dated [DATE], requesting to be a Full Code. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #9's Advance Directive and/or Full Code status with interventions to ensure the resident's request was honored until [DATE]. 10. Review of Resident #10's medical record revealed the facility admitted the resident on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated [DATE], revealed the facility assessed the resident to be cognitively intact, with a BIMS score of fifteen (15) out of fifteen (15). However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #10's Advance Directive and/or Full Code status with interventions to ensure the resident's request was honored. Continued record review revealed Resident #10 changed his/her Advance Directives on [DATE] from a Full Code status to a DNR status and a care plan was developed for the DNR status at that time. 11. Review of Resident #11's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated [DATE], revealed the facility assessed the resident to be cognitively intact, with a BIMS score of fifteen (15) out of fifteen (15). Continued record review revealed Resident #11 had Advance Directives effective [DATE], requesting to be a Full Code. However, review of the Comprehensive Care Plan (CP) initiated on [DATE], revealed no documented evidence a care plan was developed for Resident #11's Advance Directive and/or Full Code status with interventions to ensure the resident's request was honored. 12. Review of Resident #12's medical record revealed the facility admitted the resident on [DATE], and readmitted him/her on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident to be cognitively intact, with a BIMS score of fifteen (15) out of fifteen (15). Continued record review revealed Resident #12 had Advance Directives effective [DATE], indicating he/she did not want CPR. However, review of the Comprehensive Care Plan (CP) dated [DATE], revealed no documented evidence a care plan was developed for Resident #12's Advance Directive and/or DNR status with interventions to ensure the resident's request was honored until [DATE]. Interview with the MDS Coordinator, on [DATE] at 9:30 AM, revealed her department was responsible for resident care plans. She stated care plans were developed based on the residents' individual needs. Per interview, the resident's code status was on the resident's face sheet. Continued review revealed residents were not care planned regarding their code status. However, she stated if a resident was a Full Code, CPR was required to be performed. The MDS Coordinator acknowledged the issue was a care need for the resident and should be care planned. Interview with the Director of Nursing (DON), on [DATE] at 4:02 PM, revealed care plans were developed based on each resident's individual needs. The DON stated the residents were not currently care planned related to their code status; however, she acknowledged it was a care need and should be care planned. She further stated the facility should develop and implement care plans for every resident which included interventions related to each individual's code status. Interview with the Administrator, on [DATE] at 4:30 PM, revealed facility residents, including Resident #2, were not care planned for code status. The Administrator stated interventions related to care needs in the event of a cessation of heart and/or lung function should be developed for every resident and included on the Comprehensive Care Plan. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) initiated an investigation into the incident involving Resident #2. The DON interviewed (Registered Nurse) RN #1, Certified Nursing Assistant (CNA) #3 and CNA #4 regarding Resident #2 not receiving Cardiopulmonary Resuscitation (CPR) even though the resident was Full Code status. RN #1 was suspended pending the facility's investigation. On [DATE], an initial report of the incident involving Resident #2 on [DATE] was sent to the State Agency by the Social Services Director. 2. On [DATE], RN #1 was terminated from her position of employment with the facility. 3. On [DATE], the facility developed a Code Status Acknowledgement policy which included the procedure for a visual identification system. Full Code status residents would be identified by application of a green bracelet to the resident's wrist, and placement of a green sticker outside the resident's door beside their name. A resident with a Do Not Resuscitate (DNR) status would have a black sticker on the door by their name. 4. On [DATE], the DON and the Assistant DON (ADON) conducted education in small group sessions to all staff (with the exception of four {4}staff on medical leave) related to their knowledge and understanding of the facility's Code Status Acknowledgement policy. Education related to the Code Status Acknowledgement policy was added to the training agenda for New Employee Orientation. 5. On [DATE], Medical Records personnel conducted a review of all current residents in the facility to verify their code status. 6. On [DATE] through [DATE], the Social Services Director (SSD) reviewed Advance Directives with all current Full Code status residents and/or their Power of Attorney (POA) to ensure their code status was accurate. 7. On [DATE], the SSD verified the Code Status Acknowledgement policy was implemented by a visual inspection of all full code status residents to ensure each had a green bracelet on their wrist and a green sticker next to their name on the door. 8. The SSD monitored daily beginning [DATE] through [DATE], to ensure all full code status residents continued to wear a green bracelet and had a green sticker next to their name on the outside of their door. 9. On [DATE] through [DATE], the Administrator and the DON made daily rounds through the facility on all shifts to question and talk with staff about the new Code Status policy. 10. On [DATE], the Administrator educated the Minimum Data Set (MDS) staff related to resident's code status documented on the resident's Comprehensive Care Plan (CCP) and it was to be reviewed at the resident Care Plan Conferences. 11. On [DATE], MDS staff conferred with Medical Records staff to verify each residents' code status was correct. The MDS staff revised all resident CCPs to reflect each resident's Advance Directives. 12. On [DATE], the Code Status Policy was revised to incorporate instructions to add code status to resident CCPs on admission. 13. Beginning [DATE], the SSD will review code status with all the residents and/or their POA during resident Care Plan Conferences. 14. On [DATE], the DON audited all licensed Charge Nurse's personnel files for the presence of current CPR certifications, and found two (2) who were not current. On [DATE], all licensed nurses were instructed to have current CPR certification by [DATE]. 15. On [DATE], the Administrator implemented a CPR policy and a Code 500 Policy. On [DATE], the Administrator provided education to the DON and the ADON related to the new CPR and Code 500 policies. 16. On [DATE] through [DATE] the DON and the ADON conducted education with all staff related to the CPR, Code Status, Code Status Acknowledgement and Code 500 policies and General Documentation Guidelines for CPR, with post-education tests implemented on [DATE], to ensure the staff's knowledge and understanding of the policies. 17. On [DATE], the Administrator audited all current resident charts to verify the code status was on each resident's CCP, with no issues identified. 18. The DON will audit new hire nursing staff for CPR certification expiration dates and will schedule CPR certification courses as necessary to ensure all charge nurses maintained CPR certifications. 19. On [DATE], the Administrator audited all nurses' personnel files to ensure all were CPR certified as instructed on [DATE]. No issues were identified and the Administrator will continue to verify the DON audits of Charge Nurse's personnel files to ensure they maintain CPR certification. 20. On [DATE], the Administrator audited the current facility schedule to verify a CPR certified staff member was present in the facility at all times. The Administrator will continue to audit the nurse schedule monthly, and when changes occur, to ensure all shifts are staffed with a CPR certified nurse. 21. On [DATE], the Administrator, the DON and the ADON conducted a Mock Code 500 drill and reviewed findings after completion with staff who responded to the drill. The facility will conduct Mock Code 500 drills on a weekly basis for the next sixty (60) days, on different days and shifts. The Administrator and the DON will monitor Code 500 documentation for completeness and accuracy. 22. On [DATE], the Administrator notified the Medical Director of the code policy revisions. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed RN #1, CNA #3 and CNA #4 were interviewed related to the Code 500 event involving Resident #2. Continued review of the investigations revealed, RN #1 was suspended on [DATE], pending the investigation results. Per review, the initial report was sent to the State Survey Agency regarding the Code event involving Resident #2 on [DATE], and it was signed by the SSD. Interview, on [DATE] at 2:26 PM, with the DON revealed she had initiated the investigation on [DATE], and interviewed the staff involved (RN #1, CNA #3 and CNA #4). Per interview, RN #1 was suspended from work pending the results of the investigation. The DON stated the SSD sent the initial report of the incident to the State Survey Agency on [DATE]. 2. Review of RN #1's personnel file verified she was terminated from her employment at the facility. Interview with RN #1 on [DATE] at 3:26 PM, confirmed her employment at the facility was terminated on [DATE]. Interview, on [DATE] at 2:26 PM, with the DON revealed RN #1's employment was terminated on [DATE]. 3. Review of the facility's Code Status Acknowledgement policy, dated [DATE], and revised [DATE], revealed it included the procedure for visual identification of a resident's code status. Per the Policy, Full Code status residents would wear a green bracelet on their wrist and have a green sticker located outside the room door by their name. Interview, on [DATE] at 2:26 PM, with the DON revealed the facility's Code Status Acknowledgement policy now included the procedure for visual identification of a resident's code status through Full Code residents wearing a green bracelet on their wrist and a green sticker placed by the resident's name outside their room door. 4. The facility's CPR policy and Code 500 policy, Code Status policy and Code Status Acknowledgement policy were reviewed. Review of the facility's in-service sign-in forms dated [DATE], revealed staff was educated on the facility's Code Status Acknowledgement policy and the other code related policies. Review of the facility's New Employee Education Pack revealed the Code Status Acknowledgement policy education had been added. Interview on [DATE] at 8:00 AM with CNA #4; at 8:20 AM with CNA#3; at 12:38 PM with LPN #6; at 1:58 PM with CNA #5; at 2:00 PM with CNA #6; at 3:55 PM with CNA #11; and, at 4:05 PM with LPN #7 revealed they had all been provided education related to the facility's Code Status Acknowledgement Policy between [DATE] and [DATE], in small group sessions. Interview, on [DATE] at 2:26 PM, with the DON revealed the education on the Code Status Acknowledgement policy had been provided as per the AOC, with all but four (4) staff receiving the education. The DON stated the four (4) staff who had not receive the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. 5. Review of the Medical Records documentation related to the verification of all residents' code status, revealed all residents' code status was verified. Interview with the DON, on [DATE] at 2:26 PM, revealed after Medical Records compiled the code status information, she verified it with comparison to the residents' written signed consents. 6. Review of the documentation of the SSD's Advance Directives review with all current Full Code status residents and/or their POAs to ensure the code was accurate revealed the code status was verified for each resident from [DATE] through [DATE]. Interview, on [DATE] at 1:20 PM, with Resident #3 revealed his/her daughter was the resident's POA and talked to staff about decisions regarding his/her care; however, a green bracelet (indicated a Full Code status) had been placed on him/her on [DATE]. Interview, on [DATE] at 11:07 AM, with Resident #9 revealed the SSD had talked to the resident about his/her Full Code status. Interview, on [DATE] at 12:24 PM, with Resident #10 revealed the SSD had discussed the resident's Full Code status with him/her and he/she had made the decision to have the code status changed to a DNR. Interview, on [DATE] at 12:45 PM, with Resident #8 revealed the resident thought someone had talked with him/her about Advance Directives; however, he/she could not recall who had talked to him/her. Resident #8 revealed he/she was not aware of what his/her Advance Directive or code status was at this time. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the Advance Directives review with Full Code status residents and/or their POA to verify the code status was accurate. The SSD revealed if a resident requested to change their status, it was changed as requested. 7. Review of documentation of the check off sheet, dated [DATE], revealed the SSD had verified all Full Code status residents had a green bracelet on their wrist and a green sticker next to their name on their door. Observation revealed eleven (11) of eleven (11) residents, who were Full Code status, were wearing a green bracelet and had a green sticker outside the room door by their name. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted a visual inspection of all Full Code residents on [DATE] to ensure the Code Status Acknowledgement policy had been implemented. Per the SSD, she verified all the Full Code status residents were wearing a green bracelet and a green sticker was by the resident's name outside their room door. 8. The computer generated Full Code status logs utilized by the SSD to monitor that all Full Code status residents had a green sticker on their door by their name and was wearing a green bracelet. The review revealed the SSD's Full Code status log had been checked and signed by the Administrator on [DATE], to verify the log had been completed by the SSD. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the monitoring beginning [DATE] through [DATE], to ensure residents had the green bracelet on if they had a Full Code status, and to ensure the green sticker was beside their names outside their room doors. Interview, on [DATE] at 3:00 PM, with Administrator revealed he had reviewed the SSD log and verified the SSD had completed the monitoring to ensure Full Code status residents had their green bracelet in place and the green sticker was beside their name outside the room door. 9. Reviewed the Administrator's and DON's daily rounds log sheet dated [DATE] through [DATE], which revealed the rounds were made each day on all shifts. Reviewed the documentation of the educational questions and answers that were reviewed with staff. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeper #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18, the Administrator and DON had been completing rounds on each shift questioning and educating staff about codes and the facility's code status policies. Interview with the DON, on [DATE] at 2:26 PM and at 3:00 PM with the Administrator, revealed they had conducted the daily rounds throughout the facility on all shifts to question and talk with staff about the facility's Code Status policy. They stated they had ensured staff understood the new policy with no problems identified. Per interview, the results of the daily rounds would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 10. Reviewed the education given to the MDS staff by the Administrator related to ensuring residents' code status was documented on the CCP and that the code status was to be reviewed at residents' care plan conferences. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed the education had been provided by the Administrator regarding residents' code status being on the care plan and ensuring the code status was discussed in the residents' care plan meetings. 11. Reviewed 100% of the facility's residents' CCPs which revealed each resident's code status was care planned with interventions. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed MDS staff had talked to the Medical Records staff to verify each resident's code status was correct. Per interview, MDS staff revised all resident's CCPs to address each resident's Advance Directives including the code status. 12. Reviewed the Code Status Policy which revealed it had been revised [DATE], and included ensuring each resident's CCP included the code status be incorporated on admission. Reviewed the facility's Admission Checklist for Nursing form which revealed it included the information for nurse's to obtain an order for [REDACTED]. Interview, on [DATE] at 3:00 PM, with Administrator revealed the facility's Code Status Policy had been revised as per the AOC. 13. Reviewed Care Plan Conference notes, dated [DATE], which included reviewing the resident's Code Status at the planned Care Plan Conferences. Interview, on [DATE] at 1:06 PM, with the SSD revealed residents' code status was being discussed at care plan conferences which began on [DATE]. 14. On [DATE], the Employee Roster Report listing of all licensed staff with CPR expiration dates and copies of their CPR certification was reviewed. Reviewed the CPR certification class roster and certification cards from classes provided by the facility on [DATE] and [DATE]. Review of the documentation revealed all licensed nursing staff now had current CPR certification. 15. Reviewed the facility's CPR and Code 500 policies. Reviewed the sign in sheet and education provided by the Administrator to the DON and ADON related to the CPR and Code 500 Policy dated [DATE]. Interview with the DON and ADON, on [DATE] at 2:26 PM, revealed they had been educated by the Administrator on [DATE], regarding the CPR and Code 500 policies. Interview, on [DATE] at 3:00 PM, with the Administrator revealed the facility's CPR and Code 500 policies had been implemented on [DATE], as per the AOC. A post-survey interview on [DATE] at 9:32 AM, with the Administrator revealed after becoming aware of the need to have someone CPR certified in the building at all times, he had read the regulatory requirements and conferenced with the Consultant Administrator for guidance. Per interview, the Consultant Administrator had discussed with him getting staff CPR certified and what needed to be done to ensure this was done. The Administrator stated he and the Consultant Administrator had communication all the way through the process and had developed the plan of action. 16. Reviewed the sign-in sheets and education provided by the DON and ADON for all staff related to the CPR and Code 500 Policy,

Based on interview, record review, review of the Job Description for Administrator, and review of the facility's policy, it was determined the facility failed to ensure it was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychological well-being of each resident. The facility's Administration failed to ensure residents' Advance Directives and code status preferences were honored; and, failed to evaluate the facility's policies and staffing requirements, to maintain an effective system to ensure Advance Directives and personal choices were implemented. On [DATE], Resident #2's Responsible Party signed Advance Directives requesting Full Code status for the resident, with life-saving measures to include cardiopulmonary resuscitation (CPR), in the event the resident's heart or lungs failed to function. On [DATE] at approximately 4:50 AM, Registered Nurse (RN) #1 found Resident #2 to be unresponsive; however, the nurse failed to honor the resident's Advanced Directives related to his/her Full Code status when she did not initiate CPR. Furthermore, the facility failed to ensure that at least one staff member trained in the provision of CPR was on duty at all times. Additionally, the facility failed to ensure residents' care plans were developed to include interventions in accordance with each resident's Advance Directives and personal preferences related to code status. Review of the facility's policies revealed they were not specific regarding the requirements related to staff providing CPR and they did not address the regulatory requirements for CPR-trained staff to be on duty at all times. (Refer to F155, F279, F281, F309 and F514.) The facility's failure to have an effective Administrator with oversight of planned interventions to ensure residents' wishes were honored at end-of-life placed Resident #2 and other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Administrator's position description titled Job Description for Administrator, signed by the Administrator on [DATE], revealed the Administrator was responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting, and the physical management of the facility, residents, and equipment, in accordance with established policies. Job Description for Administrator, signed by the Administrator on [DATE], revealed Continued review revealed the Administrator was responsible to develop policies regarding staff duties and activities, including personnel policies and individual job duties, and to delegate the authority required for staff performance of their jobs to the Department Head. Furthermore, the Administrator was to ensure the facility's policies were known by all employees. In addition, the Administrator was responsible to study and keep current with the changes of all regulations. Review of the facility's policy titled Code Status Policy, dated [DATE], revealed the facility recognized two (2) code status options for its residents, Full Code and Do Not Resuscitate (DNR) status. (DNR status indicates no life-saving resuscitative measures are to be taken if an individual is found to be without signs of life.) Further review revealed Full Code status required the resident or Responsible Party to sign a Code Status Consent form. Review of the facility's Resident Rights, undated, revealed residents had a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. Further review revealed the facility would maintain written policies and procedures regarding Advance Directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an Advance Directive. Continued review revealed the facility would provide staff education concerning its policies and procedures related to Advance Directives. Review of the facility's policy titled Resident Care Plan, dated [DATE], revealed the resident care plan would reflect the specific needs of the resident. Continued review revealed the services provided or arranged by the facility would meet professional standards. On [DATE], Resident #2 was found to be unresponsive, with no pulse and no respiratory effort, by RN #1. Review of the Advance Directives, signed by the Responsible Party on [DATE], and review of the physician's orders [REDACTED].#1 did not initiate CPR in accordance with the resident's wishes. (Refer to F155 and F281) Review of the active comprehensive Care Plan for Resident #2 revealed no interventions related to the resident's code status or personal choices according to his/her Advance Directives. (Refer to F279) Review of CPR training records and staffing schedules revealed the facility failed to have an effective system to ensure at least one (1) staff member was CPR certified and on duty in the facility at all times, as required by regulation. Review of the facility's Daily Staffing Sheet forms revealed from [DATE] through [DATE], there were three (3) night shifts which did not have a CPR certified person present in the facility. Interview with the Administrator, on [DATE] at 11:53 AM, revealed the facility did not have a policy specific to initiating CPR. He stated it was facility practice for CPR to be started immediately by a person trained to do so if a resident with Full Code status became unresponsive without cardiac and/or respiratory function. He further stated [DATE] was to be called for emergency assistance if no one present was trained in CPR. Continued interview revealed the facility did not have a policy or requirement for all licensed nursing staff to obtain and maintain a current CPR certification, and did not have a system in place to ensure a CPR certified staff member was on duty at all times. Review of the Job Description for Administrator, signed by the Administrator on [DATE], revealed the Administrator was responsible to study and keep current with the changes of all regulations. However, interview with the Administrator revealed he was not aware, prior to this survey, of the regulatory requirement regarding staffing of the facility with CPR trained individuals at all times. Interview with the Administrator, on [DATE] at 11:53 AM, revealed the facility did not have a system in place to identify which residents were a Full Code status and which were a DNR status without checking the chart or the computer. He stated it was his expectation for the licensed nurses to know the code status of their residents, and to honor each resident's personal wishes according to their Advance Directives. He further stated if a resident was Full Code, CPR should be started immediately when the resident was determined to be without signs of life. Specifically, he stated RN #1 should have initiated CPR for Resident #2 as soon as the resident was discovered to be Full Code status and unresponsive. Subsequent interview with the Administrator, on [DATE] at 4:30 PM, revealed the facility did not develop Care Plans related to Advance Directives. However, he stated honoring each resident's wishes according to their Advance Directives was a care need concern, and should be included on the Comprehensive Care Plan. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) initiated an investigation into the incident involving Resident #2. The DON interviewed (Registered Nurse) RN #1, Certified Nursing Assistant (CNA) #3 and CNA #4 regarding Resident #2 not receiving Cardiopulmonary Resuscitation (CPR) even though the resident was Full Code status. RN #1 was suspended pending the facility's investigation. On [DATE], an initial report of the incident involving Resident #2 on [DATE] was sent to the State Agency by the Social Services Director. 2. On [DATE], RN #1 was terminated from her position of employment with the facility. 3. On [DATE], the facility developed a Code Status Acknowledgement policy which included the procedure for a visual identification system. Full Code status residents would be identified by application of a green bracelet to the resident's wrist, and placement of a green sticker outside the resident's door beside their name. A resident with a Do Not Resuscitate (DNR) status would have a black sticker on the door by their name. 4. On [DATE], the DON and the Assistant DON (ADON) conducted education in small group sessions to all staff (with the exception of four {4}staff on medical leave) related to their knowledge and understanding of the facility's Code Status Acknowledgement policy. Education related to the Code Status Acknowledgement policy was added to the training agenda for New Employee Orientation. 5. On [DATE], Medical Records personnel conducted a review of all current residents in the facility to verify their code status. 6. On [DATE] through [DATE], the Social Services Director (SSD) reviewed Advance Directives with all current Full Code status residents and/or their Power of Attorney (POA) to ensure their code status was accurate. 7. On [DATE], the SSD verified the Code Status Acknowledgement policy was implemented by a visual inspection of all full code status residents to ensure each had a green bracelet on their wrist and a green sticker next to their name on the door. 8. The SSD monitored daily beginning [DATE] through [DATE], to ensure all full code status residents continued to wear a green bracelet and had a green sticker next to their name on the outside of their door. 9. On [DATE] through [DATE], the Administrator and the DON made daily rounds through the facility on all shifts to question and talk with staff about the new Code Status policy. 10. On [DATE], the Administrator educated the Minimum Data Set (MDS) staff related to resident's code status documented on the resident's Comprehensive Care Plan (CCP) and it was to be reviewed at the resident Care Plan Conferences. 11. On [DATE], MDS staff conferred with Medical Records staff to verify each residents' code status was correct. The MDS staff revised all resident CCPs to reflect each resident's Advance Directives. 12. On [DATE], the Code Status Policy was revised to incorporate instructions to add code status to resident CCPs on admission. 13. Beginning [DATE], the SSD will review code status with all the residents and/or their POA during resident Care Plan Conferences. 14. On [DATE], the DON audited all licensed Charge Nurse's personnel files for the presence of current CPR certifications, and found two (2) who were not current. On [DATE], all licensed nurses were instructed to have current CPR certification by [DATE]. 15. On [DATE], the Administrator implemented a CPR policy and a Code 500 Policy. On [DATE], the Administrator provided education to the DON and the ADON related to the new CPR and Code 500 policies. 16. On [DATE] through [DATE] the DON and the ADON conducted education with all staff related to the CPR, Code Status, Code Status Acknowledgement and Code 500 policies and General Documentation Guidelines for CPR, with post-education tests implemented on [DATE], to ensure the staff's knowledge and understanding of the policies. 17. On [DATE], the Administrator audited all current resident charts to verify the code status was on each resident's CCP, with no issues identified. 18. The DON will audit new hire nursing staff for CPR certification expiration dates and will schedule CPR certification courses as necessary to ensure all charge nurses maintained CPR certifications. 19. On [DATE], the Administrator audited all nurses' personnel files to ensure all were CPR certified as instructed on [DATE]. No issues were identified and the Administrator will continue to verify the DON audits of Charge Nurse's personnel files to ensure they maintain CPR certification. 20. On [DATE], the Administrator audited the current facility schedule to verify a CPR certified staff member was present in the facility at all times. The Administrator will continue to audit the nurse schedule monthly, and when changes occur, to ensure all shifts are staffed with a CPR certified nurse. 21. On [DATE], the Administrator, the DON and the ADON conducted a Mock Code 500 drill and reviewed findings after completion with staff who responded to the drill. The facility will conduct Mock Code 500 drills on a weekly basis for the next sixty (60) days, on different days and shifts. The Administrator and the DON will monitor Code 500 documentation for completeness and accuracy. 22. On [DATE], the Administrator notified the Medical Director of the code policy revisions. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed RN #1, CNA #3 and CNA #4 were interviewed related to the Code 500 event involving Resident #2. Continued review of the investigations revealed, RN #1 was suspended on [DATE], pending the investigation results. Per review, the initial report was sent to the State Survey Agency regarding the Code event involving Resident #2 on [DATE], and it was signed by the SSD. Interview, on [DATE] at 2:26 PM, with the DON revealed she had initiated the investigation on [DATE], and interviewed the staff involved (RN #1, CNA #3 and CNA #4). Per interview, RN #1 was suspended from work pending the results of the investigation. The DON stated the SSD sent the initial report of the incident to the State Survey Agency on [DATE]. 2. Review of RN #1's personnel file verified she was terminated from her employment at the facility. Interview with RN #1 on [DATE] at 3:26 PM, confirmed her employment at the facility was terminated on [DATE]. Interview, on [DATE] at 2:26 PM, with the DON revealed RN #1's employment was terminated on [DATE]. 3. Review of the facility's Code Status Acknowledgement policy, dated [DATE], and revised [DATE], revealed it included the procedure for visual identification of a resident's code status. Per the Policy, Full Code status residents would wear a green bracelet on their wrist and have a green sticker located outside the room door by their name. Interview, on [DATE] at 2:26 PM, with the DON revealed the facility's Code Status Acknowledgement policy now included the procedure for visual identification of a resident's code status through Full Code residents wearing a green bracelet on their wrist and a green sticker placed by the resident's name outside their room door. 4. The facility's CPR policy and Code 500 policy, Code Status policy and Code Status Acknowledgement policy were reviewed. Review of the facility's in-service sign-in forms dated [DATE], revealed staff was educated on the facility's Code Status Acknowledgement policy and the other code related policies. Review of the facility's New Employee Education Pack revealed the Code Status Acknowledgement policy education had been added. Interview on [DATE] at 8:00 AM with CNA #4; at 8:20 AM with CNA#3; at 12:38 PM with LPN #6; at 1:58 PM with CNA #5; at 2:00 PM with CNA #6; at 3:55 PM with CNA #11; and, at 4:05 PM with LPN #7 revealed they had all been provided education related to the facility's Code Status Acknowledgement Policy between [DATE] and [DATE], in small group sessions. Interview, on [DATE] at 2:26 PM, with the DON revealed the education on the Code Status Acknowledgement policy had been provided as per the AOC, with all but four (4) staff receiving the education. The DON stated the four (4) staff who had not receive the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. 5. Review of the Medical Records documentation related to the verification of all residents' code status, revealed all residents' code status was verified. Interview with the DON, on [DATE] at 2:26 PM, revealed after Medical Records compiled the code status information, she verified it with comparison to the residents' written signed consents. 6. Review of the documentation of the SSD's Advance Directives review with all current Full Code status residents and/or their POAs to ensure the code was accurate revealed the code status was verified for each resident from [DATE] through [DATE]. Interview, on [DATE] at 1:20 PM, with Resident #3 revealed his/her daughter was the resident's POA and talked to staff about decisions regarding his/her care; however, a green bracelet (indicated a Full Code status) had been placed on him/her on [DATE]. Interview, on [DATE] at 11:07 AM, with Resident #9 revealed the SSD had talked to the resident about his/her Full Code status. Interview, on [DATE] at 12:24 PM, with Resident #10 revealed the SSD had discussed the resident's Full Code status with him/her and he/she had made the decision to have the code status changed to a DNR. Interview, on [DATE] at 12:45 PM, with Resident #8 revealed the resident thought someone had talked with him/her about Advance Directives; however, he/she could not recall who had talked to him/her. Resident #8 revealed he/she was not aware of what his/her Advance Directive or code status was at this time. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the Advance Directives review with Full Code status residents and/or their POA to verify the code status was accurate. The SSD revealed if a resident requested to change their status, it was changed as requested. 7. Review of documentation of the check off sheet, dated [DATE], revealed the SSD had verified all Full Code status residents had a green bracelet on their wrist and a green sticker next to their name on their door. Observation revealed eleven (11) of eleven (11) residents, who were Full Code status, were wearing a green bracelet and had a green sticker outside the room door by their name. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted a visual inspection of all Full Code residents on [DATE] to ensure the Code Status Acknowledgement policy had been implemented. Per the SSD, she verified all the Full Code status residents were wearing a green bracelet and a green sticker was by the resident's name outside their room door. 8. The computer generated Full Code status logs utilized by the SSD to monitor that all Full Code status residents had a green sticker on their door by their name and was wearing a green bracelet. The review revealed the SSD's Full Code status log had been checked and signed by the Administrator on [DATE], to verify the log had been completed by the SSD. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the monitoring beginning [DATE] through [DATE], to ensure residents had the green bracelet on if they had a Full Code status, and to ensure the green sticker was beside their names outside their room doors. Interview, on [DATE] at 3:00 PM, with Administrator revealed he had reviewed the SSD log and verified the SSD had completed the monitoring to ensure Full Code status residents had their green bracelet in place and the green sticker was beside their name outside the room door. 9. Reviewed the Administrator's and DON's daily rounds log sheet dated [DATE] through [DATE], which revealed the rounds were made each day on all shifts. Reviewed the documentation of the educational questions and answers that were reviewed with staff. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeper #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18, the Administrator and DON had been completing rounds on each shift questioning and educating staff about codes and the facility's code status policies. Interview with the DON, on [DATE] at 2:26 PM and at 3:00 PM with the Administrator, revealed they had conducted the daily rounds throughout the facility on all shifts to question and talk with staff about the facility's Code Status policy. They stated they had ensured staff understood the new policy with no problems identified. Per interview, the results of the daily rounds would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 10. Reviewed the education given to the MDS staff by the Administrator related to ensuring residents' code status was documented on the CCP and that the code status was to be reviewed at residents' care plan conferences. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed the education had been provided by the Administrator regarding residents' code status being on the care plan and ensuring the code status was discussed in the residents' care plan meetings. 11. Reviewed 100% of the facility's residents' CCPs which revealed each resident's code status was care planned with interventions. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed MDS staff had talked to the Medical Records staff to verify each resident's code status was correct. Per interview, MDS staff revised all resident's CCPs to address each resident's Advance Directives including the code status. 12. Reviewed the Code Status Policy which revealed it had been revised [DATE], and included ensuring each resident's CCP included the code status be incorporated on admission. Reviewed the facility's Admission Checklist for Nursing form which revealed it included the information for nurse's to obtain an order for [REDACTED]. Interview, on [DATE] at 3:00 PM, with Administrator revealed the facility's Code Status Policy had been revised as per the AOC. 13. Reviewed Care Plan Conference notes, dated [DATE], which included reviewing the resident's Code Status at the planned Care Plan Conferences. Interview, on [DATE] at 1:06 PM, with the SSD revealed residents' code status was being discussed at care plan conferences which began on [DATE]. 14. On [DATE], the Employee Roster Report listing of all licensed staff with CPR expiration dates and copies of their CPR certification was reviewed. Reviewed the CPR certification class roster and certification cards from classes provided by the facility on [DATE] and [DATE]. Review of the documentation revealed all licensed nursing staff now had current CPR certification. 15. Reviewed the facility's CPR and Code 500 policies. Reviewed the sign in sheet and education provided by the Administrator to the DON and ADON related to the CPR and Code 500 Policy dated [DATE]. Interview with the DON and ADON, on [DATE] at 2:26 PM, revealed they had been educated by the Administrator on [DATE], regarding the CPR and Code 500 policies. Interview, on [DATE] at 3:00 PM, with the Administrator revealed the facility's CPR and Code 500 policies had been implemented on [DATE], as per the AOC. A post-survey interview on [DATE] at 9:32 AM, with the Administrator revealed after becoming aware of the need to have someone CPR certified in the building at all times, he had read the regulatory requirements and conferenced with the Consultant Administrator for guidance. Per interview, the Consultant Administrator had discussed with him getting staff CPR certified and what needed to be done to ensure this was done. The Administrator stated he and the Consultant Administrator had communication all the way through the process and had developed the plan of action. 16. Reviewed the sign-in sheets and education provided by the DON and ADON for all staff related to the CPR and Code 500 Policy, dated [DATE] through [DATE] and reviewed the post-tests. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeping #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18 revealed they had all been educated on the CPR and Code 500 policies, and other code policies and General Documentation Guidelines for CPR, and had taken a post-test after the education. Interview, on [DATE] at 2:26 PM, with the DON revealed all but four (4) staff had received the education on the facility's code policies and CPR policy. The DON stated the four (4) staff who had not received the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. Interview, on [DATE] at 3:00 PM, with Administrator revealed facility staff had been educated on the CPR, Code 500 and other code policies, as per the AOC. 17. Reviewed the Administrator's audits of all resident's CCP for verification that each residents' code status was care planned. The audits revealed each resident had a Code Status CCP with no issues identified and the Administrator had signed the audits as completed on [DATE]. Interview, on [DATE] at 3:00 PM, with Administrator revealed he had completed the audit of all residents' CCPs on [DATE], with no problems noted, as per the AOC. Per interview, the results of the audits would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 18. Interview, on [DATE] at 2:26 PM, with the DON revealed she would audit all newly hired nursing staff for their CPR certification expiration dates. Per interview, she would schedule CPR certification courses as necessary to make sure the Charge Nurses all maintained their CPR certification. 19. Reviewed the Administrator's audits, performed on [DATE], of all nurses' personnel files to ensure they were CPR certified. The audits revealed each licensed staff's CPR certification was present with the expiration date, and no issues were identified by the Administrator. Interview, on [DATE] at 3:00 PM, with the Administrator revealed he had performed the audits of all nurses' personnel files for CPR certification on [DATE], and had not identified a problem. The Administrator revealed he would continue to monitor the DON's verification of the Charge Nurse's CPR certification to ensure they maintained current CPR certification. Per interview, the results of the audits would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 20. Reviewed the Administrator's audit of the current facility schedule verifying a CPR certified staff member was present in the facility at all times, dated [DATE]. Interview, on [DATE] at 3:00 PM, with the Administrator revealed he had completed the audit of the facility's current schedule to verify a CPR certified staff member was present in the facility at all times on [DATE]. He revealed he would continue to monitor the nursing schedule monthly to ensure all shifts were staffed with a CPR certified nurse. Per interview, the results of the audits would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 21. Reviewed the sign in sheet and notes for the Mock Code Drill, conducted on [DATE]. Interview on [DATE]: at 11:45 AM with RN #4; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; and, at 2:10 PM with LPN #8 revealed the Mock Code Drill had been completed by the facility, and the findings had been reviewed with staff and allowed for staff input. Interview, on [DATE] at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed the Mock Code Drill had been completed on [DATE], as per the AOC. They stated the results had been discussed with staff afterwards. The Administrator and DON revealed the facility would continue to conduct Mock Code Drills weekly for sixty (60) days on different days and shifts, and they would monitor the documentation of the drills for accuracy and completeness, as per the AOC. 22. Interview, on [DATE] at 1:20 PM, with the Medical Director revealed the facility had notified him of the Immediate Jeopardy and findings. Per interview, he had also been notified of the changes made to the facility's code policies and the new system for identification of Full Code residents.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure Advance Directives for one (1) of twelve (12) sampled residents (Resident #2) were honored. On [DATE], Resident #2's Responsible Party signed Advance Directives requesting the resident have a Full Code status (Full Code indicates life-saving measures were to be implemented in the event of cardiac or [MEDICAL CONDITION]), to include Cardiopulmonary Resuscitation (CPR). However, on [DATE] at approximately 4:50 AM, when Registered Nurse (RN) #1 found Resident #2 unresponsive, with no pulse or respirations, the nurse failed to initiate CPR according to Resident #2's Advance Directives. RN #1 stated she was not aware of Resident #2's code status. She went to the nurse's station and had Certified Nursing Assistant (CNA) #3 and CNA #4 come to Resident #2's room with her, and they told her they thought the resident was a Full Code. However, RN #1 failed to initiate CPR, and again returned to the nurse's station to verify Resident #2's code status herself. RN #1 determined Resident #2 was a Full Code, but she did not initiate CPR according to the resident's Advance Directives. Per interview, RN #1 pronounced Resident #2 deceased , notified the Physician and the resident's family, and called the funeral home. The facility's failure to ensure residents' Advance Directives regarding their requested Full Code status was honored has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Advance Directives and Do Not Resuscitate Orders, undated, revealed the Patient Self-Determination Act mandated Medicare and Medicaid certified nursing facilities to give residents information about their right to make decisions concerning medical care, including the right to accept or refuse treatment and the right to formulate Advance Directives. Further review revealed Advance Directives referred to written documents completed by residents prior to a serious illness which noted the resident's choices about medical treatment, and was to include the name of an individual designated to make choices on the resident's behalf if the resident was unable to make decisions. Review of the facility's Resident Rights document, undated, revealed the facility would maintain written policies and procedures regarding Advance Directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an Advance Directive. Continued review revealed the facility would provide education for staff concerning its policies and procedures related to Advance Directives. Per the document, residents had a right to a dignified existence, self-determination, and communication, with access to persons and services inside and outside the facility. Review of the facility's policy titled, Code Status Policy, dated [DATE], revealed the facility recognized two (2) code status options for its residents, which included a Full Code status or Do Not Resuscitate (DNR) status. Continued review revealed a Full Code status required the resident or the Responsible Party to provide written consent. Review of the medical record for Resident #2 revealed the facility admitted him/her on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Admit/Readmit Screener, dated [DATE], revealed Resident #2 was the reporter (person providing the information) for this assessment. Further review revealed Resident #2 was alert to person and appropriate verbally. Review of the Code Status Consent Form, dated [DATE], revealed it was signed by the resident's Responsible Party on [DATE]. Continued review of the Form revealed it stated to observe the attending physician's orders [REDACTED].#2, USE cardiac compressions or artificial ventilation to resuscitate. Review of the physician's orders [REDACTED].#2 had an order for [REDACTED]. However, review of the Nurse's Note, dated [DATE] at 4:50 AM, signed by RN #1, revealed she had found Resident #2 lying in bed with no pulse, no blood pressure and no signs of life. Continued review revealed no documented evidence RN #1 immediately initiated CPR according to Resident #2's Advance Directive. Additional review of the Nurse's Notes revealed RN #1 notified the Physician at 5:05 AM, the family at 5:10 AM, and the funeral home at an unstated time. Review of the Provisional Report of Death form revealed Resident #2's date of death was documented as [DATE], with the time noted to be 4:50 AM. Interview, on [DATE] at 3:26 PM, with RN #1 revealed she was the Charge Nurse, and the primary nurse for Resident #2, on the night shift of [DATE]. Per interview, she was certified to perform CPR; however, when she found Resident #2 on [DATE] at 4:50 AM, she did not initiate CPR. She stated she left Resident #2's room and went to the nurse's station to request assistance from the CNAs. RN #1 stated the CNAs told her they thought Resident #2 was a Full Code, but she did not initiate CPR again and returned to the nurse's station to verify the resident's code status. RN #2 stated she noted Resident #2 was a Full Code; however, when she returned to the resident's room she once again did not initiate CPR, as per the resident's Advance Directives. According to RN #1, she instructed the CNAs to provide post-mortem care of Resident #2's body instead. Continued interview revealed the CNAs reported to her that during the provision of post-mortem care they thought they had felt a heart beat, and thought they saw Resident #2 take a breath. She stated she listened for heart sounds with a stethoscope and found none, and again did not initiate CPR. Per interview, RN #1 stated if residents were sick and had already had heart surgery, where do you draw the line?. RN #1 further stated she did not want to break Resident #2's ribs by performing CPR, did not want to desecrate the resident's body, and she felt CPR was futile. Interview with CNA #4, on [DATE] at 8:00 PM, revealed she was working on [DATE], and was assigned to care for Resident #2. She stated a little before 5:00 AM, RN #1 came to the nurse's station where she and CNA #3 were charting, and asked for help with Resident #2. CNA #4 reported upon entering Resident #2's room she observed the resident to be yellow in color, and she asked the RN if the resident was still alive. Continued interview revealed RN #1 told CNA #4 she didn't think so and to go check the resident's chart for his/her code status. CNA #4 revealed Resident #2's chart was checked and it was determined the resident was to have a Full Code status which was reported to RN #1. According to CNA #4, after RN #1 was told this information, she did not initiate CPR. Further interview revealed RN #1 told CNA #4 the resident was already gone and she didn't want to break his/her ribs, and instructed the CNAs to perform post- mortem care. Per interview, during the post-mortem care CNA #4 thought she saw Resident #2 take a breath which she reported to RN #1. The CNA stated RN #1 did not initiate CPR for Resident #1; however, she did listen for a heart beat with a stethoscope and didn't hear anything. Interview, on [DATE] at 8:20 PM, with CNA #3 revealed on [DATE] she and CNA #4 were sitting at the nurse's station charting early in the morning. RN #1 came to them at the nurse's station and requested assistance from her and CNA #4. She stated CNA #4, RN #1 and she went to Resident #2's room, and when CNA #4 saw the resident she asked RN #1 if the resident was alive, and RN #1 stated she didn't think so. Continued interview revealed RN #1 asked the CNAs to go check the resident's chart to verify Resident #2's code status. Per interview, she and CNA #4 checked Resident #2's chart and determined the resident was a Full Code, which CNA #3 reported to RN #1 and told the nurse she needed to initiate CPR immediately. According to CNA #3, RN #1 told the CNAs she wasn't going to break the resident's ribs by performing CPR, and RN #1 did not initiate CPR for Resident #2. She stated RN #1 instructed them to perform post-mortem care for Resident #2, and during the post-mortem care CNA #3 thought she felt a pulse. Per CNA #3, she reported this information to RN #1, who listened for a heartbeat with a stethoscope but didn't hear anything. CNA #3 stated CPR was never initiated for Resident #2. Further interview with CNA #3 revealed she was not CPR certified and if she found an unresponsive resident she was to report this information to the nurse. Interview, on [DATE] at 11:40 AM, with the Director of Nursing (DON) revealed RN #1 left her a voice message on her cellular telephone (cell phone) on [DATE] around 4:50 AM, telling her Resident #2 had expired. Continued interview revealed she talked to RN #1, on [DATE] around 11:30 AM, RN #1 reported she had not initiated CPR because Resident #2 had no respirations, no pulse, had already expired and she (RN #1) did not want to break the resident's ribs by doing CPR. The DON stated the facility did not have specific procedures in the event of the death of a resident who had a Full Code status, but she expected CPR would be initiated immediately and 911 notified for transporting the resident to the hospital. Per interview, RN #1 should have initiated CPR immediately for Resident #2, but this was not done. Interview, on [DATE] at 11:53 AM, with the Administrator revealed he expected the licensed nurses to know which residents had Full Code status, and to initiate CPR immediately for any Full Code resident found to be unresponsive and without signs of life. Continued interview revealed RN #1 should have initiated CPR immediately when Resident #2 was found unresponsive and it was determined he had Full Code status. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) initiated an investigation into the incident involving Resident #2. The DON interviewed (Registered Nurse) RN #1, Certified Nursing Assistant (CNA) #3 and CNA #4 regarding Resident #2 not receiving Cardiopulmonary Resuscitation (CPR) even though the resident was Full Code status. RN #1 was suspended pending the facility's investigation. On [DATE], an initial report of the incident involving Resident #2 on [DATE] was sent to the State Agency by the Social Services Director. 2. On [DATE], RN #1 was terminated from her position of employment with the facility. 3. On [DATE], the facility developed a Code Status Acknowledgement policy which included the procedure for a visual identification system. Full Code status residents would be identified by application of a green bracelet to the resident's wrist, and placement of a green sticker outside the resident's door beside their name. A resident with a Do Not Resuscitate (DNR) status would have a black sticker on the door by their name. 4. On [DATE], the DON and the Assistant DON (ADON) conducted education in small group sessions to all staff (with the exception of four {4}staff on medical leave) related to their knowledge and understanding of the facility's Code Status Acknowledgement policy. Education related to the Code Status Acknowledgement policy was added to the training agenda for New Employee Orientation. 5. On [DATE], Medical Records personnel conducted a review of all current residents in the facility to verify their code status. 6. On [DATE] through [DATE], the Social Services Director (SSD) reviewed Advance Directives with all current Full Code status residents and/or their Power of Attorney (POA) to ensure their code status was accurate. 7. On [DATE], the SSD verified the Code Status Acknowledgement policy was implemented by a visual inspection of all full code status residents to ensure each had a green bracelet on their wrist and a green sticker next to their name on the door. 8. The SSD monitored daily beginning [DATE] through [DATE], to ensure all full code status residents continued to wear a green bracelet and had a green sticker next to their name on the outside of their door. 9. On [DATE] through [DATE], the Administrator and the DON made daily rounds through the facility on all shifts to question and talk with staff about the new Code Status policy. 10. On [DATE], the Administrator educated the Minimum Data Set (MDS) staff related to resident's code status documented on the resident's Comprehensive Care Plan (CCP) and it was to be reviewed at the resident Care Plan Conferences. 11. On [DATE], MDS staff conferred with Medical Records staff to verify each residents' code status was correct. The MDS staff revised all resident CCPs to reflect each resident's Advance Directives. 12. On [DATE], the Code Status Policy was revised to incorporate instructions to add code status to resident CCPs on admission. 13. Beginning [DATE], the SSD will review code status with all the residents and/or their POA during resident Care Plan Conferences. 14. On [DATE], the DON audited all licensed Charge Nurse's personnel files for the presence of current CPR certifications, and found two (2) who were not current. On [DATE], all licensed nurses were instructed to have current CPR certification by [DATE]. 15. On [DATE], the Administrator implemented a CPR policy and a Code 500 Policy. On [DATE], the Administrator provided education to the DON and the ADON related to the new CPR and Code 500 policies. 16. On [DATE] through [DATE] the DON and the ADON conducted education with all staff related to the CPR, Code Status, Code Status Acknowledgement and Code 500 policies and General Documentation Guidelines for CPR, with post-education tests implemented on [DATE], to ensure the staff's knowledge and understanding of the policies. 17. On [DATE], the Administrator audited all current resident charts to verify the code status was on each resident's CCP, with no issues identified. 18. The DON will audit new hire nursing staff for CPR certification expiration dates and will schedule CPR certification courses as necessary to ensure all charge nurses maintained CPR certifications. 19. On [DATE], the Administrator audited all nurses' personnel files to ensure all were CPR certified as instructed on [DATE]. No issues were identified and the Administrator will continue to verify the DON audits of Charge Nurse's personnel files to ensure they maintain CPR certification. 20. On [DATE], the Administrator audited the current facility schedule to verify a CPR certified staff member was present in the facility at all times. The Administrator will continue to audit the nurse schedule monthly, and when changes occur, to ensure all shifts are staffed with a CPR certified nurse. 21. On [DATE], the Administrator, the DON and the ADON conducted a Mock Code 500 drill and reviewed findings after completion with staff who responded to the drill. The facility will conduct Mock Code 500 drills on a weekly basis for the next sixty (60) days, on different days and shifts. The Administrator and the DON will monitor Code 500 documentation for completeness and accuracy. 22. On [DATE], the Administrator notified the Medical Director of the code policy revisions. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed RN #1, CNA #3 and CNA #4 were interviewed related to the Code 500 event involving Resident #2. Continued review of the investigations revealed, RN #1 was suspended on [DATE], pending the investigation results. Per review, the initial report was sent to the State Survey Agency regarding the Code event involving Resident #2 on [DATE], and it was signed by the SSD. Interview, on [DATE] at 2:26 PM, with the DON revealed she had initiated the investigation on [DATE], and interviewed the staff involved (RN #1, CNA #3 and CNA #4). Per interview, RN #1 was suspended from work pending the results of the investigation. The DON stated the SSD sent the initial report of the incident to the State Survey Agency on [DATE]. 2. Review of RN #1's personnel file verified she was terminated from her employment at the facility. Interview with RN #1 on [DATE] at 3:26 PM, confirmed her employment at the facility was terminated on [DATE]. Interview, on [DATE] at 2:26 PM, with the DON revealed RN #1's employment was terminated on [DATE]. 3. Review of the facility's Code Status Acknowledgement policy, dated [DATE], and revised [DATE], revealed it included the procedure for visual identification of a resident's code status. Per the Policy, Full Code status residents would wear a green bracelet on their wrist and have a green sticker located outside the room door by their name. Interview, on [DATE] at 2:26 PM, with the DON revealed the facility's Code Status Acknowledgement policy now included the procedure for visual identification of a resident's code status through Full Code residents wearing a green bracelet on their wrist and a green sticker placed by the resident's name outside their room door. 4. The facility's CPR policy and Code 500 policy, Code Status policy and Code Status Acknowledgement policy were reviewed. Review of the facility's in-service sign-in forms dated [DATE], revealed staff was educated on the facility's Code Status Acknowledgement policy and the other code related policies. Review of the facility's New Employee Education Pack revealed the Code Status Acknowledgement policy education had been added. Interview on [DATE] at 8:00 AM with CNA #4; at 8:20 AM with CNA#3; at 12:38 PM with LPN #6; at 1:58 PM with CNA #5; at 2:00 PM with CNA #6; at 3:55 PM with CNA #11; and, at 4:05 PM with LPN #7 revealed they had all been provided education related to the facility's Code Status Acknowledgement Policy between [DATE] and [DATE], in small group sessions. Interview, on [DATE] at 2:26 PM, with the DON revealed the education on the Code Status Acknowledgement policy had been provided as per the AOC, with all but four (4) staff receiving the education. The DON stated the four (4) staff who had not receive the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. 5. Review of the Medical Records documentation related to the verification of all residents' code status, revealed all residents' code status was verified. Interview with the DON, on [DATE] at 2:26 PM, revealed after Medical Records compiled the code status information, she verified it with comparison to the residents' written signed consents. 6. Review of the documentation of the SSD's Advance Directives review with all current Full Code status residents and/or their POAs to ensure the code was accurate revealed the code status was verified for each resident from [DATE] through [DATE]. Interview, on [DATE] at 1:20 PM, with Resident #3 revealed his/her daughter was the resident's POA and talked to staff about decisions regarding his/her care; however, a green bracelet (indicated a Full Code status) had been placed on him/her on [DATE]. Interview, on [DATE] at 11:07 AM, with Resident #9 revealed the SSD had talked to the resident about his/her Full Code status. Interview, on [DATE] at 12:24 PM, with Resident #10 revealed the SSD had discussed the resident's Full Code status with him/her and he/she had made the decision to have the code status changed to a DNR. Interview, on [DATE] at 12:45 PM, with Resident #8 revealed the resident thought someone had talked with him/her about Advance Directives; however, he/she could not recall who had talked to him/her. Resident #8 revealed he/she was not aware of what his/her Advance Directive or code status was at this time. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the Advance Directives review with Full Code status residents and/or their POA to verify the code status was accurate. The SSD revealed if a resident requested to change their status, it was changed as requested. 7. Review of documentation of the check off sheet, dated [DATE], revealed the SSD had verified all Full Code status residents had a green bracelet on their wrist and a green sticker next to their name on their door. Observation revealed eleven (11) of eleven (11) residents, who were Full Code status, were wearing a green bracelet and had a green sticker outside the room door by their name. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted a visual inspection of all Full Code residents on [DATE] to ensure the Code Status Acknowledgement policy had been implemented. Per the SSD, she verified all the Full Code status residents were wearing a green bracelet and a green sticker was by the resident's name outside their room door. 8. The computer generated Full Code status logs utilized by the SSD to monitor that all Full Code status residents had a green sticker on their door by their name and was wearing a green bracelet. The review revealed the SSD's Full Code status log had been checked and signed by the Administrator on [DATE], to verify the log had been completed by the SSD. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the monitoring beginning [DATE] through [DATE], to ensure residents had the green bracelet on if they had a Full Code status, and to ensure the green sticker was beside their names outside their room doors. Interview, on [DATE] at 3:00 PM, with Administrator revealed he had reviewed the SSD log and verified the SSD had completed the monitoring to ensure Full Code status residents had their green bracelet in place and the green sticker was beside their name outside the room door. 9. Reviewed the Administrator's and DON's daily rounds log sheet dated [DATE] through [DATE], which revealed the rounds were made each day on all shifts. Reviewed the documentation of the educational questions and answers that were reviewed with staff. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeper #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18, the Administrator and DON had been completing rounds on each shift questioning and educating staff about codes and the facility's code status policies. Interview with the DON, on [DATE] at 2:26 PM and at 3:00 PM with the Administrator, revealed they had conducted the daily rounds throughout the facility on all shifts to question and talk with staff about the facility's Code Status policy. They stated they had ensured staff understood the new policy with no problems identified. Per interview, the results of the daily rounds would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 10. Reviewed the education given to the MDS staff by the Administrator related to ensuring residents' code status was documented on the CCP and that the code status was to be reviewed at residents' care plan conferences. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed the education had been provided by the Administrator regarding residents' code status being on the care plan and ensuring the code status was discussed in the residents' care plan meetings. 11. Reviewed 100% of the facility's residents' CCPs which revealed each resident's code status was care planned with interventions. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed MDS staff had talked to the Medical Records staff to verify each resident's code status was correct. Per interview, MDS staff revised all resident's CCPs to address each resident's Advance Directives including the code status. 12. Reviewed the Code Status Policy which revealed it had been revised [DATE], and included ensuring each resident's CCP included the code status be incorporated on admission. Reviewed the facility's Admission Checklist for Nursing form which revealed it included the information for nurse's to obtain an order for [REDACTED]. Interview, on [DATE] at 3:00 PM, with Administrator revealed the facility's Code Status Policy had been revised as per the AOC. 13. Reviewed Care Plan Conference notes, dated [DATE], which included reviewing the resident's Code Status at the planned Care Plan Conferences. Interview, on [DATE] at 1:06 PM, with the SSD revealed residents' code status was being discussed at care plan conferences which began on [DATE]. 14. On [DATE], the Employee Roster Report listing of all licensed staff with CPR expiration dates and copies of their CPR certification was reviewed. Reviewed the CPR certification class roster and certification cards from classes provided by the facility on [DATE] and [DATE]. Review of the documentation revealed all licensed nursing staff now had current CPR certification. 15. Reviewed the facility's CPR and Code 500 policies. Reviewed the sign in sheet and education provided by the Administrator to the DON and ADON related to the CPR and Code 500 Policy dated [DATE]. Interview with the DON and ADON, on [DATE] at 2:26 PM, revealed they had been educated by the Administrator on [DATE], regarding the CPR and Code 500 policies. Interview, on [DATE] at 3:00 PM, with the Administrator revealed the facility's CPR and Code 500 policies had been implemented on [DATE], as per the AOC. A post-survey interview on [DATE] at 9:32 AM, with the Administrator revealed after becoming aware of the need to have someone CPR certified in the building at all times, he had read the regulatory requirements and conferenced with the Consultant Administrator for guidance. Per interview, the Consultant Administrator had discussed with him getting staff CPR certified and what needed to be done to ensure this was done. The Administrator stated he and the Consultant Administrator had communication all the way through the process and had developed the plan of action. 16. Reviewed the sign-in sheets and education provided by the DON and ADON for all staff related to the CPR and Code 500 Policy, dated [DATE] through [DATE] and reviewed the post-tests. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeping #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18 revealed they had all been educated on the CPR and Code 500 policies, and other code policies and General Documentation Guidelines for CPR, and had taken a post-test after the education. Interview, on [DATE] at 2:26 PM, with the DON revealed all but four (4) staff had received the education on the facility's code policies and CPR policy. The DON stated the four (4) staff who had not received the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. Interview, on [DATE] at 3:00 PM, with Administrator revealed facility staff had been educated on the CPR, Code 500 and other code policies, as per the AOC. 17. Reviewed the Administrator's audits of all resident's CCP for verification that each residents' code status was care planned. The audits revealed each resident had a Code Status CCP with no issues identified and the Administrator had signed the audits as completed on [DATE]. Interview, on [DATE] at 3:00 PM, with Administrator revealed he had completed the audit of all residents' CCPs on [DATE], with no problems noted, as per the AOC. Per interview, the results of the audits would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 18. Interview, on [DATE] at 2:26 PM, with the DON revealed she would audit all newly hired nursing staff for their CPR certification expiration dates. Per interview, she would schedule CPR certification courses as necessary to make sure the Charge Nurses all maintained their CPR certification. 19. Reviewed the Administrator's audits, performed on [DATE], of all nurses' personnel files to ensure they were CPR certified. The audits revealed each licensed staff's CPR certification was present with the expiration date, and no issues were identified by the Administrator. Interview, on [DATE] at 3:00 PM, with the Administrator revealed he had performed the audits of all nurses' personnel files for CPR certification on [DATE], and had not identified a problem. The Administrator revealed he would continue to monitor the DON's verification of the Charge Nurse's CPR certification to ensure they maintained current CPR certification. Per interview, the results of the audits would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 20. Reviewed the Administrator's audit of the current facility schedule verifying a CPR certified staff member was present in the facility at all times, dated [DATE]. Interview, on [DATE] at 3:00 PM, with the Administrator revealed he had completed the audit of the facility's current schedule to verify a CPR certified staff member was present in the facility at all times on [DATE]. He revealed he would continu

Based on interview, record review and review of the facility's policy and investigation, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse for two (2) of twelve (12) sampled residents (Residents #1 and #5). On 03/15/15 at approximately 7:00 PM, Registered Nurse (RN) #2 was overheard by staff present in the area, Certified Nursing Assistant (CNA) #1, CNA #7 and Certified Medication Aide (CMA) #9, to be yelling at Resident #1 for him/her to stop coughing in her face. Interview with Resident #1 revealed a nurse did yell at him/her to stop coughing in her face; however, he/she couldn't control the cough. Interview with Resident #5, who resided in a room near Resident #1, overheard RN #2 in the hallway on 03/15/15, stating, I wish all you MF's would die. Interview with CNA #1, CNA #7 and CMA #9 revealed they thought what they had witnessed and overheard RN #2, the Charge Nurse, say and do was abuse. However, the three (3) staff failed to report the abuse incident immediately, as per the facility's abuse policy. Therefore, RN #2 was allowed to continue working the remainder of her shift on 03/15/15, approximately ten (10) hours caring for residents. The incident was not reported to the facility until the evening shift on 03/17/15 when CNA #1 called the Director of Nursing to report it, and RN #2 was suspended by the facility on 03/18/15. The facility's failure to have an effective system in place to ensure each resident remained free from abuse, was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/07/15 and determined to exist on 03/15/15. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/14/15 with the facility alleging removal of the Immediate Jeopardy on 04/12/15. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 04/12/15, prior to exit on 04/16/15, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Abuse Prevention Plan, revised June 2013, revealed verbal abuse was the use of oral, written, or gestured language which willfully included disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of age, ability to comprehend, or disability. Review of the facility's policy titled, Resident Rights, revised August 2013, revealed residents had a right to a dignified existence, self determination, and communication with persons and services inside and outside the facility. Per the Policy, the facility must protect and promote the rights of each resident including the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Review of the facility's, Resident Abuse Investigation Report Form, signed by the Social Services Director (SSD) on 03/20/15, revealed an incident had occurred on 03/15/15 around 7:30 PM, involving Resident #1, which was witnessed by three (3) staff members, CNA #1, CNA #7 and CMA #9. Continued review revealed, on 03/15/15, CNA #1 had reported RN #2 yelled at Resident #1 Do not cough in my face and I can't take you coughing in my face which the CNA did not report until 03/17/15. Per the Form, CNA #1 reported RN #2 told her she hated him, Resident #1, and all of the facility's residents. Further review revealed RN #2 was suspended during the facility's investigation on 03/18/15. In addition, the investigation revealed both verbal and emotional abuse was substantiated. 1. Record review revealed the facility admitted Resident #1 on 02/10/15, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 02/19/15, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. Continued record review revealed Resident #1 was diagnosed with [REDACTED]. Further record review revealed Resident #1 continued to have a cough after completion of the antibiotic on 03/06/15, and orders were received for a cough syrup as needed (PRN) for the cough on 03/07/15, nebulizer (neb) treatments and [MEDICATION NAME] (a non-narcotic cough medicine) on 03/16/15, and on 03/17/15 a chest x-ray was ordered due to the medications being ineffective. Review of the Nurse's Notes for Resident #1, revealed the resident continued to have a cough which was not relieved by the medication. Further review of the Notes revealed no documented evidence of entries made related to the incident which occurred on 03/15/15. Interview with Resident #1, on 04/07/15 at 2:40 PM, revealed a nurse did yell at him/her for coughing in her face; however Resident #1 reported, he/she couldn't help it, and another nurse helped me. 2. Review of Resident #5's medical record revealed the facility admitted the resident on 03/16/11, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 02/02/15, revealed the facility assessed Resident #5 as being cognitively intact, with a BIMS score of fifteen (15) out of fifteen (15). Interview, on 04/02/15 at 1:00 PM,with Resident #5, who resided near Resident #1, revealed on 03/15/15, RN #2 was in the hallway and the resident overheard the RN saying, I wish all you MF's would die. Continued interview revealed some of the CNAs were present when RN #2 made the comment and the RN's comment made Resident #5 mad. Review of the facility's investigation report documentation of RN #2's written statement, undated, revealed on Sunday (03/15/15) she had walked by Resident #1's throughout the night, and looked in on the resident. Continued review of RN #2's written statement revealed at 4:00 AM to 5:00 AM on 03/16/15, she noticed Resident #1 was trying to cough up stuff, and she entered the resident's room and handed him/her a tissue to try and bring up something for her. Further review of RN #2's written statement revealed no documented evidence she addressed the allegation of abuse. Review of (RN) #2's time sheet, for the week of 03/15/15 to 03/28/15, revealed RN #2 worked from 5:30 PM on 03/15/15 until 03/16/15 at 6:49 AM. Interview with RN #2, on 04/07/15 at 1:50 PM, revealed she stated nothing happened on 03/15/15, and she reported being hard of hearing and had a sinus infection at the time. Continued interview revealed RN #2 denied making any comments regarding hating residents and wishing they would all die. Per interview, she would never make a comment like that to a resident or where a resident could hear her. However she stated she had an off the wall sense of humor and might have said things to other staff. Interview, on 04/07/15 at 4:30 PM, with CNA #1, revealed on 03/15/15 around 7:30 PM, she witnessed an incident involving Resident #1. Per interview, CNA #1 heard RN #2 state she (RN #2) hated Resident #1 and all of the facility's other residents. CNA #1 revealed she also heard RN #2 yelling at Resident #1 to stop coughing in her face because she (RN #2) couldn't stand it. Continued interview revealed CNA #1 considered what she had witnessed RN #2 say to Resident #1 as verbal abuse; however, she did not immediately report the abuse, as RN #2 was the Charge Nurse and she had been trained to report the abuse to the Charge Nurse. Interview, on 04/07/15 at 4:20 PM, with CNA #7 revealed on 03/15/15 around 7:30 PM, she was standing in the hallway and overheard RN #2 yelling at Resident #1 to stop coughing in her face. Per interview, after RN #2 left Resident #1's room, she heard RN #2 state she hated all the residents and she was not a people person. CNA #7 revealed she considered what she had witnessed to be verbal abuse; however, she did not immediately report the abuse. Continued interview revealed she didn't know who to report the abuse to because the education she had received in orientation covered the types of abuse and that she was to report allegations to the Charge Nurse. Interview, on 04/07/15 at 2:30 PM, with CMA #9 revealed she had witnessed RN #2 yelling at Resident #1 on 03/15/15 to stop coughing in her face. Per interview, she felt what she had witnessed on 03/15/15 was verbal abuse; however, did not report the abuse because the CNA's had witnessed the whole incident and she thought they were going to report it. Interview with the DON, on 04/02/15 at 11:40 AM, revealed CNA #1 called her at her home, on her cellular phone (cell phone) on 03/17/15 at 7:00 PM to report the allegation of abuse involving Resident #1 which had occurred on 03/15/15. Continued interview, on 04/07/15 at 3:21 PM, revealed the staff who witnessed the incident on 03/15/15 were unsure of who to report the incident to since the abuse involved their Charge Nurse, RN #2. Per interview, therefore, RN #2 was allowed to continue to work and have access to all the residents. Interview, on 04/06/15 at 2:35 PM, with the Administrator revealed the incident involving Resident #1, on 03/15/15, was witnessed by three (3) staff members who had not reported alleged abuse immediately, and due to the failure of the three (3) staff to report the alleged abuse RN #2 was allowed to continue to work and have access to the facility's residents. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/14/15, which alleged removal of the IJ effective 04/12/15. Review of the AOC revealed the facility implemented the following: 1. On 03/18/15, the facility initiated an investigation into the incident involving Resident #1. The Social Worker (SW) interviewed Resident #1 regarding the alleged incident. The SW interviewed other residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater for possible abuse allegations committed by Registered Nurse (RN) #2. 2. The Director of Nursing (DON) interviewed staff who had worked from 03/15/15, the date the alleged incident occurred through 03/17/15, regarding non-interviewable residents who might have had changes in their behaviors which might indicate possible abuse. 3. The Administrator and DON reviewed the facility's abuse policy and determined the policy was in compliance with regulations. 4. The DON counseled Certified Nursing Assistant (CNA) #1, CNA #7 and CNA #9, on 03/18/15, individually and educated each one (1) that all staff are to report abuse immediately and to call the Administrator, DON or SW if they could not report allegations to their immediate supervisor. 5. After the investigation, it was determined the allegation was substantiated and Registered Nurse (RN) #2's employment was terminated on 03/18/15. 6. On 04/06/15, the Administrator met with the SW to ensure she was fully aware of the facility's Abuse Prevention Policy. 7. The SW educated all staff 04/08/15 through 04/11/15, on the facility's Abuse Prevention Policy, except for four (4) staff who were on medical leave. After the education was provided, staff had to take a post-test to determine they were knowledgeable and understood the abuse policy. The four (4) staff on medical leave will not be placed on the schedule for work until they have been educated. 8. On 04/08/15, the facility's new hire orientation was revised to include the abuse education and post-test, which new hires will receive prior to working to being oriented to their respective departments. This will go into effect for the next orientation date, 04/27/15. 9. On 04/09/15 through 04/11/15, the Administrator made rounds throughout the facility on all shifts to ensure staff were knowledgeable and had understanding of the facility's Abuse Prevention Policy, which included questioning staff on the policy. Per the AOC, all staff replied appropriately to the questions asked by the Administrator. 10. On 04/10/15, Activities staff put up an abuse prevention bulletin board in the employee break room which included information on when to report abuse allegations, to whom they should report and the types of abuse. 11. All concerns regarding the Abuse Prevention Policy will be taken to the facility's Quality Assurance/Quality Improvement (QAPI) Committee, which consists of the Medical Director, Administrator, DON, ADON, SW, Maintenance Director, Activities Director, Housekeeping/Laundry Supervisor and Dietary Manager which meets weekly. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the final Resident Abuse Investigation Report Form, dated 03/20/15, and signed by the SW and Administrator, revealed the investigation into alleged verbal abuse of Resident #1 on 03/15/15, was initiated on 03/18/15, as per the AOC. Review of the Form revealed RN #2 was suspended on 03/18/15, other residents with a BIMS score of eight (8) or greater were interviewed for possible abuse allegations committed by RN #2. Interview, on 04/16/15 at 1:06 PM, with the SW confirmed the investigation findings. The SW revealed she had interviewed residents with a BIMS score of eight (8) or greater for possible abuse allegations committed by RN #2, with no concerns voiced. Interview, on 04/16/15 at 3:00 PM, with the Administrator confirmed the investigation was performed, the SW interviewed the interviewable residents and the allegation of verbal abuse by RN #2 had been substantiated. 2. Interview, on 04/07/15 at 2:25 PM with Licensed Practical Nurse (LPN) #3, and on 04/15/15 with RN #4 at 11:45 AM, who had both worked from 03/15/15 through 03/17/15, revealed the DON had questioned them regarding residents who were non-interviewable, who might have had behavior changes which could have indicated possible abuse. Per interview, they had not observed any behavior changes in those residents. Interview, on 04/16/15 at 2:26 PM, with the DON revealed she had questioned and interviewed staff who had worked during the 03/15/15 through 03/17/15 timeframe, about whether the staff had noticed changes in non-interviewable resident's behaviors, which might have indicated possible abuse. Per interview, no reports of behavior changes indicating possible abuse were verbalized by staff. 3. Further review of the facility's final Resident Abuse Investigation Report Form revealed the facility's abuse policy was reviewed and it was determined no changes were needed. Interview, on 04/16/15 at 2:26 PM, with the DON and at 3:00 PM with the Administrator, revealed they had reviewed the facility's abuse policy and it was determined to be in compliance with the regulations. 4. Review of the facility's final Resident Abuse Investigation Report Form revealed CNA #1, CNA #7 and CNA #9 were counseled by the DON during the facility's investigation, on immediately reporting allegations of abuse. Additionally, the DON educated the three (3) CNAs on calling the Administrator, DON or SW to report alleged abuse, if unable to report to their immediate supervisor. Interview, on 04/07/15 at 3:00 PM with CNA #9, at 4:20 PM with CNA #7 and at 4:30 PM with CNA #1, revealed they had all been educated on the facility's abuse policy and to report abuse immediately to their supervisor. Per interview, they were all educated if they couldn't report allegations of abuse to their supervisor, they should call the Administrator, DON or SW to report their allegations. Interview, on 04/16/15 at 2:26 PM, with the DON revealed she had counseled and educated CNA #1, CNA #7 and CNA #9 individually regarding the abuse policy and to report allegations of abuse immediately to their supervisor, and if they couldn't report to the supervisor they should call the Administrator, SW or her to report allegations of abuse. 5. Review of the facility's final Resident Abuse Investigation Report Form revealed the allegation was substantiated and RN #2 was terminated on 03/18/15. Interview, on 04/16/15 at 1:06 PM, with the SW confirmed the investigation findings. Review of RN #2's personnel file revealed the RN was terminated on 03/18/15. Interview, on 04/07/15 at 1:50 PM, with RN #2 revealed her employment at the facility had been terminated. Interview, on 04/16/15 at 3:00 PM with the Administrator, revealed RN #2's employment was terminated, as per the AOC. 6. Interview, on 04/16/15 at 1:06 PM, with the SW confirmed the Administrator had met with her and discussed her understanding of the facility's Abuse Prevention Policy. Interview, on 04/16/15 at 3:00 PM, with the Administrator confirmed he had met with the SW and discussed her understanding of the facility's Abuse Prevention Policy to ensure she was fully aware of it. 7. The facility's abuse inservice material and post-tests were reviewed and checked against the master list of current employees. Review of the facility's in-service sign-in forms for the dates of 04/08/15 through 04/11/15, revealed all staff disciplines were educated regarding the facility's abuse policy. Interviews on 04/15/15 with RN #4 at 11:45 AM; CNA #12 at 1:20 PM; House Keeping #14 at 1:25 PM; Dietary #15 at 1:30 PM; LPN #6 at 1:40 PM; LPN #1 at 1:50 PM; LPN #8 at 2:10 PM; CNA #13 at 2:20 PM; CNA #4 at 3:40 PM; CNA #11 at 3:50 PM; LPN #9 at 7:10 PM; RN #5 at 7:20 PM; CNA #3 at 10:05 PM; CNA #4 at 10:19 PM; CNA #17 at 10:25 PM; and CNA #18 at 10:30 PM; and on 04/16/15 with CNA #4 at 8:00 AM; CNA#3 at 8:20 PM; LPN #6 at 12:38 PM; CNA #5 at 1:58 PM; CNA #6 at 2:00 PM; CNA #11 at 3:55 PM; and LPN #7 at 4:05 PM, revealed they had all been educated on the facility's abuse policy and procedure and had taken a post-test. Interview, on 04/16/15 at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed the four (4) staff on medical leave would not be allowed to work until they had received the abuse education. 8. The facility's new hire orientation information and education was reviewed and revealed it included the abuse education and post-test. Interview, on 04/16/15 at 3:00 PM, with the Administrator revealed the facility's new hire orientation included the abuse education and post-test and would go into effect 04/27/15, as per the AOC. 9. The Administrator's and DON's daily rounds log sheet dated 04/06/15 through 04/11/15 were reviewed and revealed both documented rounds made on each day, on the three (3) different shifts regarding interviewing staff about if they were knowledgeable and had understanding of the policy. Interview, on 04/15/15 at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeping #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and at 10:30 PM with CNA #18 revealed the Administrator and DON had performed rounds and asked staff about the facility's abuse policy. Interview, on 04/16/15 at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed they had performed the rounds to interview staff about their knowledge and understanding of the abuse policy, as per the AOC. 10. Observation, on 04/15/15 at 10:25 AM, of the employee break room revealed a bulletin board present which contained abuse information including when to report abuse allegations, who to report to and the types of abuse. Interview, on 04/16/15 at 3:00 PM, with the Administrator revealed Activity staff had put the bulletin board up in the employee break room. The Administrator revealed the board included abuse prevention information as per the AOC. 11. Interview, on 04/16/15 1:06 PM with the SW, at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed any concerns related to the facility's abuse policy would be taken to the facility's QAPI Committee, discussed and plans developed to implement. Interview, on 04/16/15 at 1:20 PM, with the facility's Medical Director revealed he participated in the facility's QAPI Committee and had been informed of the incident involving Resident #1. The Medical Director stated any concerns regarding the facility's abuse policy would be discussed in the QAPI Committee meeting.

Based on interview, record review, review of the facility's abuse investigation and facility's policy, it was determined the facility failed to have an effective system to ensure all alleged incidents of abuse were reported immediately to Administration, residents were protected after an allegation of abuse, and Administration immediately reported the allegations to the appropriate State Agencies for two (2) of twelve (12) sampled residents (Residents #1 and Resident #5). On 03/15/15 around 7:30 PM, Registered Nurse (RN) #2 was overheard by staff to be yelling at Resident #1, and Resident #5 overheard RN #2 in the hallway stating, I wish all you MF's would die. Although the incidents occurred on 03/15/15 around 7:30 PM, it was not reported by staff to Administration until 03/17/15 at 7:00 PM, allowing RN #2 to work the entire shift on 03/15/15. An investigation report was not initiated until 03/18/15 and the alleged abuse was not reported to the appropriate State Agencies until 03/19/15 at 4:48 PM. Based on the above findings, it was determined the facility's failure to ensure all allegations of abuse were reported immediately to the facility's Administration, failure to ensure residents were protected after an allegation of abuse was reported, and failure to ensure Administration immediately reported the allegations to the appropriate State Agencies, was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 04/07/15 and was determined to exist on 03/15/15. The facility was notified of the Immediate Jeopardy on 04/07/15. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/14/15 with the facility alleging removal of the Immediate Jeopardy on 04/12/15. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 04/12/15, prior to exit on 04/16/15, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Abuse Prevention Plan, revised June 2013, revealed all allegations of abuse would be reported immediately to one (1) of the following: Charge Nurse, Director of Nursing (DON), Administrator, Administrator in Training or the Social Services Director (SSD). According to the Policy, any employee who failed to report allegations of abuse or neglect immediately could be held responsible for the same actions. The Policy revealed employees accused of abuse or neglect would not be permitted to work during the facility's investigation. Further review revealed allegations of abuse and/or neglect would be called in to the State Survey Agency, State Adult Protective Services and Long Term Care Ombudsman immediately upon notification of allegations. Review of the facility's policy titled, Resident Rights, revised August 2013, revealed the facility should ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, were reported immediately to the Administrator and to other officials in accordance with State law through established procedures. The Policy revealed the facility must prevent further abuse of residents while the investigation was in progress. Review of the facility's, Resident Abuse Investigation Report Form, which was signed by the SSD on 03/20/15, revealed an incident had been reported on 03/18/15, involving Resident #1 being verbally abused; however, the incident had occurred on 03/15/15. Continued review of the Form revealed even though the alleged abuse had been witnessed by three (3) staff members, the staff had failed to follow the facility's policy to immediately report abuse. Further review revealed the alleged abuse involving Resident #1 was not reported to the State Agencies until 03/19/15. Interview with the SSD, on 04/07/15 at 3:08 PM and on 04/16/15 at 1:06 PM, revealed staff should have immediately reported the alleged abuse on 03/15/15, and the facility should have reported the incident to the State Agencies immediately. Continued review of the facility's, Resident Abuse Investigation Report Form, revealed Certified Nursing Assistant (CNA) #1, CNA #7 and Certified Medication Aide (CMA) #9 witnessed RN #2 yelling at Resident #1 on 03/15/15 around 7:30 PM. Interview with Resident #1, on 04/07/15 at 2:40 PM, revealed a nurse did yell at him/her for coughing in her face. Interview with CNA #1, on 04/07/15 at 4:30 PM, revealed on she heard RN #2 stating she hated Resident #1 and all the other residents on 03/15/15 around 7:30 PM. CNA #1 revealed she had considered what she witnessed as verbal abuse, but didn't immediately report it because RN #2 was the Charge Nurse, her supervisor. Further interview revealed RN #2 continued caring for residents the remainder of the shift, approximately ten (10) hours, after the incident occurred. Interview with CNA #7, on 04/07/15 at 4:20 PM, revealed she had been standing in the hallway on 03/15/15 around 7:30 PM, when she overheard RN #2 yelling at Resident #1 to stop coughing in her face. CNA #7 revealed when the RN came out of Resident #1's room, she (RN #1) stated she was not a people person and hated all the residents. Per interview, CNA #7 considered what RN #1 had done as verbal abuse, but did not immediately report the abuse, as the RN was the Charge Nurse and she did not know who to report to if the Charge Nurse had committed the abuse. According to CNA #7, RN #2 continued to remain caring for resident for the remainder of the shift which was approximately ten (10) hours, after the incident. Interview, on 04/02/15 at 1:00 PM,with Resident #5, who resided near Resident #1, revealed on 03/15/15, he/she overheard RN #2 saying, I wish all you MF's would die and this comment upset the resident. Interview with CMA #9 on 04/07/15 at 2:30 PM, revealed she had witnessed RN #2 yelling at Resident #1 on 03/15/15, to stop coughing in her face. Per interview, CMA #9 thought what she had witnessed was abuse, but the CNA's (CNA #1 and #7) had witnessed the whole incident and she thought they were going to report the abuse. CMA #9 stated the abuse should have been reported to the nurse on the other hall immediately. Interview with the Director of Nursing (DON), on 04/02/15 at 11:40 AM and on 04/07/15 at 3:21 PM, revealed CNA #1 had called her at home on her cellular telephone (cell phone) on 03/17/15 at 7:00 PM, reporting an allegation of abuse which had occurred on 03/15/15. Per the DON, after CNA #1's phone call, she had called the SSD and Administrator to notify them of the CNA's allegation of abuse. The DON revealed the staff who were present on 03/15/15 and witnessed the incident were not sure who they were to report the abuse to, since the abuse involved their Charge Nurse. She reported RN #2 continued to work caring for residents; however, the staff should have reported the allegation of abuse immediately. According to the DON, as a result of staff not reporting the alleged abuse, the facility had failed to ensure the safety and protection of the residents from further abuse. Continued interview revealed she had not identified during the facility's investigation that there might be a facility wide issue regarding staff's abuse education and the importance of immediately reporting all allegations of abuse. Per interview, she had not identified there might be other staff unsure of the facility's reporting procedures for alleged abuse. The DON revealed the facility should have reported the incident involving Resident #1, when she was notified of the alleged abuse on 03/17/15. Further interview revealed, the facility should report all allegations of abuse to the State Agencies immediately upon notification. Interview with the Administrator, on 04/06/15 at 2:35 PM and 04/07/15 at 3:30 PM, revealed the three (3) staff who had witnessed the incident involving Resident #1 and #5, on 03/15/15, did not report the incident immediately. The Administrator revealed the staff's failure to report the alleged abuse allowed RN #2 to continue to work caring for residents. Therefore, the Administrator stated the facility had unable to ensure residents' safety from further abuse. Continued interview revealed the facility's policy and procedure for abuse was for staff to report all allegations of abuse to their Charge Nurse, the SSD, the DON or him immediately to ensure residents' safety was maintained. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/14/15, which alleged removal of the IJ effective 04/12/15. Review of the AOC revealed the facility implemented the following: 1. On 03/18/15, the facility initiated an investigation into the incident involving Resident #1. The Social Worker (SW) interviewed Resident #1 regarding the alleged incident. The SW interviewed other residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater for possible abuse allegations committed by Registered Nurse (RN) #2. 2. The Director of Nursing (DON) interviewed staff who had worked from 03/15/15, the date the alleged incident occurred through 03/17/15, regarding non-interviewable residents who might have had changes in their behaviors which might indicate possible abuse. 3. The Administrator and DON reviewed the facility's abuse policy and determined the policy was in compliance with regulations. 4. The DON counseled Certified Nursing Assistant (CNA) #1, CNA #7 and CNA #9, on 03/18/15, individually and educated each one (1) that all staff are to report abuse immediately and to call the Administrator, DON or SW if they could not report allegations to their immediate supervisor. 5. After the investigation, it was determined the allegation was substantiated and Registered Nurse (RN) #2's employment was terminated on 03/18/15. 6. On 04/06/15, the Administrator met with the SW to ensure she was fully aware of the facility's Abuse Prevention Policy. 7. The SW educated all staff 04/08/15 through 04/11/15, on the facility's Abuse Prevention Policy, except for four (4) staff who were on medical leave. After the education was provided, staff had to take a post-test to determine they were knowledgeable and understood the abuse policy. The four (4) staff on medical leave will not be placed on the schedule for work until they have been educated. 8. On 04/08/15, the facility's new hire orientation was revised to include the abuse education and post-test, which new hires will receive prior to working to being oriented to their respective departments. This will go into effect for the next orientation date, 04/27/15. 9. On 04/09/15 through 04/11/15, the Administrator made rounds throughout the facility on all shifts to ensure staff were knowledgeable and had understanding of the facility's Abuse Prevention Policy, which included questioning staff on the policy. Per the AOC, all staff replied appropriately to the questions asked by the Administrator. 10. On 04/10/15, Activities staff put up an abuse prevention bulletin board in the employee break room which included information on when to report abuse allegations, to whom they should report and the types of abuse. 11. All concerns regarding the Abuse Prevention Policy will be taken to the facility's Quality Assurance/Quality Improvement (QAPI) Committee, which consists of the Medical Director, Administrator, DON, ADON, SW, Maintenance Director, Activities Director, Housekeeping/Laundry Supervisor and Dietary Manager which meets weekly. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the final Resident Abuse Investigation Report Form, dated 03/20/15, and signed by the SW and Administrator, revealed the investigation into alleged verbal abuse of Resident #1 on 03/15/15, was initiated on 03/18/15, as per the AOC. Review of the Form revealed RN #2 was suspended on 03/18/15, other residents with a BIMS score of eight (8) or greater were interviewed for possible abuse allegations committed by RN #2. Interview, on 04/16/15 at 1:06 PM, with the SW confirmed the investigation findings. The SW revealed she had interviewed residents with a BIMS score of eight (8) or greater for possible abuse allegations committed by RN #2, with no concerns voiced. Interview, on 04/16/15 at 3:00 PM, with the Administrator confirmed the investigation was performed, the SW interviewed the interviewable residents and the allegation of verbal abuse by RN #2 had been substantiated. 2. Interview, on 04/07/15 at 2:25 PM with Licensed Practical Nurse (LPN) #3, and on 04/15/15 with RN #4 at 11:45 AM, who had both worked from 03/15/15 through 03/17/15, revealed the DON had questioned them regarding residents who were non-interviewable, who might have had behavior changes which could have indicated possible abuse. Per interview, they had not observed any behavior changes in those residents. Interview, on 04/16/15 at 2:26 PM, with the DON revealed she had questioned and interviewed staff who had worked during the 03/15/15 through 03/17/15 timeframe, about whether the staff had noticed changes in non-interviewable resident's behaviors, which might have indicated possible abuse. Per interview, no reports of behavior changes indicating possible abuse were verbalized by staff. 3. Further review of the facility's final Resident Abuse Investigation Report Form revealed the facility's abuse policy was reviewed and it was determined no changes were needed. Interview, on 04/16/15 at 2:26 PM, with the DON and at 3:00 PM with the Administrator, revealed they had reviewed the facility's abuse policy and it was determined to be in compliance with the regulations. 4. Review of the facility's final Resident Abuse Investigation Report Form revealed CNA #1, CNA #7 and CNA #9 were counseled by the DON during the facility's investigation, on immediately reporting allegations of abuse. Additionally, the DON educated the three (3) CNAs on calling the Administrator, DON or SW to report alleged abuse, if unable to report to their immediate supervisor. Interview, on 04/07/15 at 3:00 PM with CNA #9, at 4:20 PM with CNA #7 and at 4:30 PM with CNA #1, revealed they had all been educated on the facility's abuse policy and to report abuse immediately to their supervisor. Per interview, they were all educated if they couldn't report allegations of abuse to their supervisor, they should call the Administrator, DON or SW to report their allegations. Interview, on 04/16/15 at 2:26 PM, with the DON revealed she had counseled and educated CNA #1, CNA #7 and CNA #9 individually regarding the abuse policy and to report allegations of abuse immediately to their supervisor, and if they couldn't report to the supervisor they should call the Administrator, SW or her to report allegations of abuse. 5. Review of the facility's final Resident Abuse Investigation Report Form revealed the allegation was substantiated and RN #2 was terminated on 03/18/15. Interview, on 04/16/15 at 1:06 PM, with the SW confirmed the investigation findings. Review of RN #2's personnel file revealed the RN was terminated on 03/18/15. Interview, on 04/07/15 at 1:50 PM, with RN #2 revealed her employment at the facility had been terminated. Interview, on 04/16/15 at 3:00 PM with the Administrator, revealed RN #2's employment was terminated, as per the AOC. 6. Interview, on 04/16/15 at 1:06 PM, with the SW confirmed the Administrator had met with her and discussed her understanding of the facility's Abuse Prevention Policy. Interview, on 04/16/15 at 3:00 PM, with the Administrator confirmed he had met with the SW and discussed her understanding of the facility's Abuse Prevention Policy to ensure she was fully aware of it. 7. The facility's abuse inservice material and post-tests were reviewed and checked against the master list of current employees. Review of the facility's in-service sign-in forms for the dates of 04/08/15 through 04/11/15, revealed all staff disciplines were educated regarding the facility's abuse policy. Interviews on 04/15/15 with RN #4 at 11:45 AM; CNA #12 at 1:20 PM; House Keeping #14 at 1:25 PM; Dietary #15 at 1:30 PM; LPN #6 at 1:40 PM; LPN #1 at 1:50 PM; LPN #8 at 2:10 PM; CNA #13 at 2:20 PM; CNA #4 at 3:40 PM; CNA #11 at 3:50 PM; LPN #9 at 7:10 PM; RN #5 at 7:20 PM; CNA #3 at 10:05 PM; CNA #4 at 10:19 PM; CNA #17 at 10:25 PM; and CNA #18 at 10:30 PM; and on 04/16/15 with CNA #4 at 8:00 AM; CNA#3 at 8:20 PM; LPN #6 at 12:38 PM; CNA #5 at 1:58 PM; CNA #6 at 2:00 PM; CNA #11 at 3:55 PM; and LPN #7 at 4:05 PM, revealed they had all been educated on the facility's abuse policy and procedure and had taken a post-test. Interview, on 04/16/15 at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed the four (4) staff on medical leave would not be allowed to work until they had received the abuse education. 8. The facility's new hire orientation information and education was reviewed and revealed it included the abuse education and post-test. Interview, on 04/16/15 at 3:00 PM, with the Administrator revealed the facility's new hire orientation included the abuse education and post-test and would go into effect 04/27/15, as per the AOC. 9. The Administrator's and DON's daily rounds log sheet dated 04/06/15 through 04/11/15 were reviewed and revealed both documented rounds made on each day, on the three (3) different shifts regarding interviewing staff about if they were knowledgeable and had understanding of the policy. Interview, on 04/15/15 at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeping #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and at 10:30 PM with CNA #18 revealed the Administrator and DON had performed rounds and asked staff about the facility's abuse policy. Interview, on 04/16/15 at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed they had performed the rounds to interview staff about their knowledge and understanding of the abuse policy, as per the AOC. 10. Observation, on 04/15/15 at 10:25 AM, of the employee break room revealed a bulletin board present which contained abuse information including when to report abuse allegations, who to report to and the types of abuse. Interview, on 04/16/15 at 3:00 PM, with the Administrator revealed Activity staff had put the bulletin board up in the employee break room. The Administrator revealed the board included abuse prevention information as per the AOC. 11. Interview, on 04/16/15 1:06 PM with the SW, at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed any concerns related to the facility's abuse policy would be taken to the facility's QAPI Committee, discussed and plans developed to implement. Interview, on 04/16/15 at 1:20 PM, with the facility's Medical Director revealed he participated in the facility's QAPI Committee and had been informed of the incident involving Resident #1. The Medical Director stated any concerns regarding the facility's abuse policy would be discussed in the QAPI Committee meeting.

Based on interview, record review, review of the facility's investigation and the facility's policies, it was determined the facility failed to have an effective system to ensure its abuse policy and procedures were implemented for two (2) of twelve (12) sampled residents (Resident #1 and #5). On 03/15/15 around 7:30 PM, three (3) staff overheard RN #2 yelling at Resident #1 to quit coughing in her face. Interviews with witnesses, revealed RN #2 was also overheard making statements in the hallway that she (RN #2) hated Resident #1 and all the facility's residents. Interview with Resident #5, who resided near Resident #1, overheard RN #2 state, I wish all you MF's would die. (Refer to F223 and F225) Based on the above findings, it was determined the facility's failure to implement its abuse policy and procedures was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 04/07/15 and was determined to exist on 03/15/15. The facility was notified of the Immediate Jeopardy on 04/07/15. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/14/14 with the facility alleging removal of the Immediate Jeopardy on 04/12/15. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 04/12/15, prior to exit on 04/16/15, with remaining non-compliance at 42 CFR 483.13, Resident Behavior and Facility Practice, F-226 Abuse, at a Scope and Severity of an D, while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure abuse policy and procedures are implemented. The findings include: Review of the facility's policy titled, Resident Rights, revised August 2013, revealed the facility should ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, were reported immediately to the Administrator and to other officials in accordance with State Law through its established procedures. Further review revealed the facility must have evidence all alleged violations were thoroughly investigated, and must prevent further abuse from occurring while its investigation was in progress. Review of the facility's policy, titled Abuse Prevention Plan, revised June 2013, revealed staff were to report all allegations of abuse immediately to either the Charge Nurse, Director of Nursing (DON), Administrator, Administrator in Training or Social Services Director (SSD). Continued review revealed allegations of abuse and/or neglect would be called in to the State Survey Agency, State Adult Protective Services, the local Long Term Care Ombudsman, the resident's Physician, and the resident's family/responsible party immediately upon notification of the allegation. Further review revealed failure by any employee to report abuse or neglect immediately meant the employee could be held responsible for the same actions. In addition, the Policy revealed employees accused of any type of abuse or neglect would not be permitted to work during the facility's investigation. Interview with the DON on 04/07/15 at 3:21 PM, revealed she was notified by CNA #1 of an allegation of verbal abuse on the evening of 03/17/15. However, review of the facility's, Resident Abuse Investigation Report Form, which was signed by the SSD on 03/20/15, revealed an incident had been reported on 03/18/15, involving Resident #1 being verbally abused; however, the incident had occurred on 03/15/15. Continued review of the Resident Abuse Investigation Report Form revealed the incident had been witnessed by CNA #1, CNA #7 and Certified Medication Aide (CMA) #9. Further review of the Form revealed the facility did not report the allegation of abuse to the State Agencies until 03/19/15. Interview, on 04/07/15 at 4:30 PM, with CNA #1, revealed on 03/15/15 around 7:30 PM, she heard RN #2 yelling at Resident #1, and heard the RN state she (RN #2) hated Resident #1 and all of the facility's residents. Per interview, CNA #1 considered what she had witnessed as verbal abuse; however, she did not immediately report the abuse,as per the facility's policy. According to CNA #1, she was a new employee and in orientation she had been educated to report alleged abuse to the Charge Nurse. She stated RN #2 was the Charge Nurse the night the incident occurred, so she didn't know who to report the abuse to. Interview, on 04/07/15 at 4:20 PM, with CNA #7, revealed on 03/15/15 around 7:30 PM, she was standing in the hallway when she overheard RN #2 yelling at Resident #1. Per interview, RN #2 later stated while standing in the hallway she hated all the facility's residents. According to CNA #7, she considered what she had witnessed as verbal abuse; however, she did not immediately report the abuse, as per the facility's policy. Continued interview revealed since RN #2 had been the Charge Nurse that night, she didn't know who to report the abuse to, since her orientation education on abuse had been for the CNAs to report alleged abuse to the Charge Nurse. Interview, on 04/07/15 at 2:30 PM, with CMA #9 revealed on 03/15/15, she had overheard RN #2 yelling at Resident #1 to stop coughing in her face. Per interview, she felt what she had heard was verbal abuse, but didn't report it herself because the CNAs had witnessed the whole incident and she thought they going to report it. According to CMA #9, the verbal abuse should have been reported to the nurse working on the other hall. Interview, on 04/07/15 at 3:08 PM and on 04/16/15 at 1:06 PM, with the SSD revealed the staff who witnessed the incident on 03/15/15, should have immediately reported the alleged abuse; however, had not followed the facility's abuse reporting process and policy on 03/15/15 when they failed to immediately report it. According to the SSD, if staff witnessed alleged abuse, they should immediately report the allegations to her, the DON, Administrator or their supervisor, as per the policy. Continued interview revealed the facility's policy was for all allegations of abuse to be reported to the State Agencies immediately upon the facility receiving notification of an alleged abuse incident. Per interview, the DON was notified on 03/17/15, at night, and she (SSD) was not aware of this information, as the DON did not report the alleged abuse to her until 03/18/15. Therefore, she revealed she did not notify the State Survey Agency until 03/19/15; however, it should have been reported to the State Survey Agency on 03/18/15. Interview, on 04/02/15 at 11:40 AM and at 2:19 PM, and on 04/07/15 at 9:35 AM and at 3:21 PM, with the DON revealed because RN #2 was the Charge Nurse on 03/15/15, the staff who witnessed the incident had been unsure of who to report the incident as the abuse involved the Charge Nurse. Per interview, the facility's policy was not followed by staff on 03/15/15, and there was a delay in staff reporting the incident to the facility's Administration. The DON revealed the facility's policy was to immediately report all allegations of abuse within twenty-four (24) hours to the State Agencies upon notification of the incident. She stated however, the facility's policy had not been followed for the incident of 03/15/15, since the incident was not reported until 03/17/15, when CNA #1 called her at home to report it. Further interview revealed she had notified the SSD and Administrator on 03/17/15, of the incident after it was reported to her by CNA #1. However, in interview the SSD stated the DON did not report the alleged abuse to her until 03/18/15. Further interview with the DON revealed the facility did not follow the policy to report incidents immediately. Interview with the Administrator, on 04/06/15 at 2:35 PM and on 04/07/15 at 4:00 PM, revealed the facility's policy and procedure for abuse was staff were to report all allegations of abuse immediately to either the Charge Nurse, the SSD, the DON or him to ensure residents' safety. Per interview, the incident involving Resident #1 which occurred on 03/15/15, was witnessed by three (3) staff members who failed to report the incident immediately, as per the facility's policy. The Administrator revealed the facility's policy was also to immediately report all allegations of abuse to the State Agencies after being notified of an alleged abuse incident. However, per interview, the facility had not followed the policy to report immediately. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/14/15, which alleged removal of the IJ effective 04/12/15. Review of the AOC revealed the facility implemented the following: 1. On 03/18/15, the facility initiated an investigation into the incident involving Resident #1. The Social Worker (SW) interviewed Resident #1 regarding the alleged incident. The SW interviewed other residents with a Brief Interview for Mental Status (BIMS) score of eight (8) or greater for possible abuse allegations committed by Registered Nurse (RN) #2. 2. The Director of Nursing (DON) interviewed staff who had worked from 03/15/15, the date the alleged incident occurred through 03/17/15, regarding non-interviewable residents who might have had changes in their behaviors which might indicate possible abuse. 3. The Administrator and DON reviewed the facility's abuse policy and determined the policy was in compliance with regulations. 4. The DON counseled Certified Nursing Assistant (CNA) #1, CNA #7 and CNA #9, on 03/18/15, individually and educated each one (1) that all staff are to report abuse immediately and to call the Administrator, DON or SW if they could not report allegations to their immediate supervisor. 5. After the investigation, it was determined the allegation was substantiated and Registered Nurse (RN) #2's employment was terminated on 03/18/15. 6. On 04/06/15, the Administrator met with the SW to ensure she was fully aware of the facility's Abuse Prevention Policy. 7. The SW educated all staff 04/08/15 through 04/11/15, on the facility's Abuse Prevention Policy, except for four (4) staff who were on medical leave. After the education was provided, staff had to take a post-test to determine they were knowledgeable and understood the abuse policy. The four (4) staff on medical leave will not be placed on the schedule for work until they have been educated. 8. On 04/08/15, the facility's new hire orientation was revised to include the abuse education and post-test, which new hires will receive prior to working to being oriented to their respective departments. This will go into effect for the next orientation date, 04/27/15. 9. On 04/09/15 through 04/11/15, the Administrator made rounds throughout the facility on all shifts to ensure staff were knowledgeable and had understanding of the facility's Abuse Prevention Policy, which included questioning staff on the policy. Per the AOC, all staff replied appropriately to the questions asked by the Administrator. 10. On 04/10/15, Activities staff put up an abuse prevention bulletin board in the employee break room which included information on when to report abuse allegations, to whom they should report and the types of abuse. 11. All concerns regarding the Abuse Prevention Policy will be taken to the facility's Quality Assurance/Quality Improvement (QAPI) Committee, which consists of the Medical Director, Administrator, DON, ADON, SW, Maintenance Director, Activities Director, Housekeeping/Laundry Supervisor and Dietary Manager which meets weekly. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the final Resident Abuse Investigation Report Form, dated 03/20/15, and signed by the SW and Administrator, revealed the investigation into alleged verbal abuse of Resident #1 on 03/15/15, was initiated on 03/18/15, as per the AOC. Review of the Form revealed RN #2 was suspended on 03/18/15, other residents with a BIMS score of eight (8) or greater were interviewed for possible abuse allegations committed by RN #2. Interview, on 04/16/15 at 1:06 PM, with the SW confirmed the investigation findings. The SW revealed she had interviewed residents with a BIMS score of eight (8) or greater for possible abuse allegations committed by RN #2, with no concerns voiced. Interview, on 04/16/15 at 3:00 PM, with the Administrator confirmed the investigation was performed, the SW interviewed the interviewable residents and the allegation of verbal abuse by RN #2 had been substantiated. 2. Interview, on 04/07/15 at 2:25 PM with Licensed Practical Nurse (LPN) #3, and on 04/15/15 with RN #4 at 11:45 AM, who had both worked from 03/15/15 through 03/17/15, revealed the DON had questioned them regarding residents who were non-interviewable, who might have had behavior changes which could have indicated possible abuse. Per interview, they had not observed any behavior changes in those residents. Interview, on 04/16/15 at 2:26 PM, with the DON revealed she had questioned and interviewed staff who had worked during the 03/15/15 through 03/17/15 timeframe, about whether the staff had noticed changes in non-interviewable resident's behaviors, which might have indicated possible abuse. Per interview, no reports of behavior changes indicating possible abuse were verbalized by staff. 3. Further review of the facility's final Resident Abuse Investigation Report Form revealed the facility's abuse policy was reviewed and it was determined no changes were needed. Interview, on 04/16/15 at 2:26 PM, with the DON and at 3:00 PM with the Administrator, revealed they had reviewed the facility's abuse policy and it was determined to be in compliance with the regulations. 4. Review of the facility's final Resident Abuse Investigation Report Form revealed CNA #1, CNA #7 and CNA #9 were counseled by the DON during the facility's investigation, on immediately reporting allegations of abuse. Additionally, the DON educated the three (3) CNAs on calling the Administrator, DON or SW to report alleged abuse, if unable to report to their immediate supervisor. Interview, on 04/07/15 at 3:00 PM with CNA #9, at 4:20 PM with CNA #7 and at 4:30 PM with CNA #1, revealed they had all been educated on the facility's abuse policy and to report abuse immediately to their supervisor. Per interview, they were all educated if they couldn't report allegations of abuse to their supervisor, they should call the Administrator, DON or SW to report their allegations. Interview, on 04/16/15 at 2:26 PM, with the DON revealed she had counseled and educated CNA #1, CNA #7 and CNA #9 individually regarding the abuse policy and to report allegations of abuse immediately to their supervisor, and if they couldn't report to the supervisor they should call the Administrator, SW or her to report allegations of abuse. 5. Review of the facility's final Resident Abuse Investigation Report Form revealed the allegation was substantiated and RN #2 was terminated on 03/18/15. Interview, on 04/16/15 at 1:06 PM, with the SW confirmed the investigation findings. Review of RN #2's personnel file revealed the RN was terminated on 03/18/15. Interview, on 04/07/15 at 1:50 PM, with RN #2 revealed her employment at the facility had been terminated. Interview, on 04/16/15 at 3:00 PM with the Administrator, revealed RN #2's employment was terminated, as per the AOC. 6. Interview, on 04/16/15 at 1:06 PM, with the SW confirmed the Administrator had met with her and discussed her understanding of the facility's Abuse Prevention Policy. Interview, on 04/16/15 at 3:00 PM, with the Administrator confirmed he had met with the SW and discussed her understanding of the facility's Abuse Prevention Policy to ensure she was fully aware of it. 7. The facility's abuse inservice material and post-tests were reviewed and checked against the master list of current employees. Review of the facility's in-service sign-in forms for the dates of 04/08/15 through 04/11/15, revealed all staff disciplines were educated regarding the facility's abuse policy. Interviews on 04/15/15 with RN #4 at 11:45 AM; CNA #12 at 1:20 PM; House Keeping #14 at 1:25 PM; Dietary #15 at 1:30 PM; LPN #6 at 1:40 PM; LPN #1 at 1:50 PM; LPN #8 at 2:10 PM; CNA #13 at 2:20 PM; CNA #4 at 3:40 PM; CNA #11 at 3:50 PM; LPN #9 at 7:10 PM; RN #5 at 7:20 PM; CNA #3 at 10:05 PM; CNA #4 at 10:19 PM; CNA #17 at 10:25 PM; and CNA #18 at 10:30 PM; and on 04/16/15 with CNA #4 at 8:00 AM; CNA#3 at 8:20 PM; LPN #6 at 12:38 PM; CNA #5 at 1:58 PM; CNA #6 at 2:00 PM; CNA #11 at 3:55 PM; and LPN #7 at 4:05 PM, revealed they had all been educated on the facility's abuse policy and procedure and had taken a post-test. Interview, on 04/16/15 at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed the four (4) staff on medical leave would not be allowed to work until they had received the abuse education. 8. The facility's new hire orientation information and education was reviewed and revealed it included the abuse education and post-test. Interview, on 04/16/15 at 3:00 PM, with the Administrator revealed the facility's new hire orientation included the abuse education and post-test and would go into effect 04/27/15, as per the AOC. 9. The Administrator's and DON's daily rounds log sheet dated 04/06/15 through 04/11/15 were reviewed and revealed both documented rounds made on each day, on the three (3) different shifts regarding interviewing staff about if they were knowledgeable and had understanding of the policy. Interview, on 04/15/15 at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeping #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and at 10:30 PM with CNA #18 revealed the Administrator and DON had performed rounds and asked staff about the facility's abuse policy. Interview, on 04/16/15 at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed they had performed the rounds to interview staff about their knowledge and understanding of the abuse policy, as per the AOC. 10. Observation, on 04/15/15 at 10:25 AM, of the employee break room revealed a bulletin board present which contained abuse information including when to report abuse allegations, who to report to and the types of abuse. Interview, on 04/16/15 at 3:00 PM, with the Administrator revealed Activity staff had put the bulletin board up in the employee break room. The Administrator revealed the board included abuse prevention information as per the AOC. 11. Interview, on 04/16/15 1:06 PM with the SW, at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed any concerns related to the facility's abuse policy would be taken to the facility's QAPI Committee, discussed and plans developed to implement. Interview, on 04/16/15 at 1:20 PM, with the facility's Medical Director revealed he participated in the facility's QAPI Committee and had been informed of the incident involving Resident #1. The Medical Director stated any concerns regarding the facility's abuse policy would be discussed in the QAPI Committee meeting.

Based on interview, record review, review of the facility's policy and review of the Kentucky Board of Nursing's (KBN's), Accountability & Responsibility of Nurses document and Advisory Opinion Statements (AOS), it was determined the facility failed to have an effective system to ensure services provided met professional standards of quality for one (1) of twelve (12) sampled residents (Resident #2) regarding ensuring nursing staff honored the resident's Advance Directives. On [DATE], Resident #2's Responsible Party, signed Advance Directives requesting the resident have a Full Code status (Full Code indicates life-saving measures would be implemented in the event of cardiac or [MEDICAL CONDITION]) with life-saving measures to include Cardiopulmonary Resuscitation (CPR). Resident #2 also had a physician's orders [REDACTED]. However, on [DATE] at approximately 4:50 AM, when Registered Nurse (RN) #1 entered Resident #2's room and found the resident unresponsive she failed to honor the resident's Advance Directive regarding his/her Full Code status. RN #1 checked for Resident #2's pulse and respirations and could not obtain any; however, she failed to immediately initiate CPR. RN #1 reported she went to the nurse's station to get assistance from the Certified Nursing Assistants (CNAs) and upon re-entering the room with the CNAs, they advised her they thought Resident #2 was a Full Code. RN #1 again failed to initiate CPR for Resident #2 after being told this by the CNAs, instead she went back to the nurse's station to check the resident's code status where she determined the resident to be a Full Code. RN #1 returned to Resident #2's room and again failed to initiate CPR for the resident. Per interview, RN #1 pronounced Resident #2 deceased , notified the Physician, family and called the funeral home. The facility's failure to ensure nursing staff honored residents' Advance Directives regarding their requested code status has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the KBN's, Accountability & Responsibility of Nurses document revealed KRS 314.021 (2) held nurses individually responsible and accountable for rendering safe, effective nursing care to clients and for judgements exercised and actions taken in the course of providing care. Review of the KBN's Advisory Opinion Statement (AOS) #36, Resuscitation, approved February 2008, revealed nurses were required to honor the Advance Directives of patients who had the Advance Directives documented in their medical record, unless a Physician or healthcare facility refused to comply, and the patient and surrogate were informed of the refusal. Review of the facility's policy, titled Code Status Policy, dated [DATE], revealed two (2) code status options were recognized by the facility for its residents, a Full code status or a Do Not Resuscitate (DNR) status. The Policy stated the resident or their responsible party had to sign a Code Status Consent form under the Full Code options in order to have a Full Code status. Interview with the Director of Nursing (DON), on [DATE] at 11:40 AM and at 2:19 PM, revealed the facility did not have a policy specific to CPR requirements; however, her expectation was if a resident was found non-responsive, the resident should be assessed by the nurse and if no pulse or breathing was found, the resident's code status should be checked. Per interview, the facility also did not have specific procedures in place in the event death occurred for a resident with a Full Code status; however, her expectation was for CPR to be initiated immediately and 911 called to transport the resident to a hospital. Review of Resident #2's medical record revealed the facility admitted him/her on [DATE], with [DIAGNOSES REDACTED]. Review of the [DATE] Code Status Consent Form signed by Resident #2's Responsible Party, revealed the Responsible Party had requested and consented in the event of death for staff to use cardiac compressions or artificial ventilation to resuscitate the resident. Review of the [DATE], Admit/Readmit Screener document for Resident #2 revealed the resident provided the information for the assessment. Continued review of the document revealed Resident #2 was assessed to be appropriate verbally and alert to person. Review of the physician's orders [REDACTED]. Review of the Nurse's Notes revealed a Note dated [DATE], timed 4:50 AM, documented by RN #1 which stated the RN had found the resident lying in bed with no pulse, no blood pressure and no signs of life. Continued review revealed no documented evidence RN #1 immediately initiated CPR as per Resident #2's physician's orders [REDACTED].#1 notified the Physician at 5:05 AM of the resident being deceased , the family at 5:10 AM and the funeral home at an undocumented time. Review of the Provisional Report of Death form revealed Resident #2's date and time of death was noted as being on [DATE] at 4:50 AM. Review of the facility's Resident Abuse Investigation Report Form, dated [DATE], which was the Final Report regarding an incident involving Resident #2 on [DATE]. Review of the Form revealed the facility had investigated an allegation of neglect involving Resident #2, and had determined RN #1 had not honored the resident's Advance Directives by not initiating a Full Code with CPR when she found the resident non-responsive. Continued review of the Form and attachments revealed Resident #2 had wanted to be a Full Code which was indicated by his/her Responsible Party's signature on the Code Status Consent Form, dated [DATE] and as noted in the medical record. Review of the investigation revealed RN #1 was suspended pending the investigation results. Interview with RN #1, on [DATE] at 3:26 PM, revealed on [DATE], she was the facility's Charge Nurse and the primary care nurse for Resident #2. Per interview, she was CPR certified; however, when she found Resident #2 unresponsive at 4:50 AM on [DATE], she did not perform CPR for the resident, because she was not sure of the resident's code status. She stated she went to the nurse's station to get the CNAs to come help her and returned to the resident's room. She stated the CNAs told her they thought Resident #2 was a Full Code. However, according to RN #1, she did not initiate CPR; she went back to the nurse's station to check Resident #2's code status where she noted the resident was a Full Code. Continued interview with RN #1 revealed she returned to Resident #2's room, but she did not initiate CPR. RN #1 stated she told the CNAs to perform post-mortem care on Resident #2's body. She stated during the post-mortem care the CNAs thought they felt a heart beat and thought they saw Resident #2 take a breath which they reported to her. RN #1 stated she listened for heart sounds with a stethoscope and determined there were none; she did not initiate CPR. RN #1 stated when residents were sick and had had heart surgery, At what point do you draw the line?. Further interview revealed RN #1 stated she did not want to break Resident #2's ribs by performing CPR; she felt it was futile; and, she did not want to desecrate Resident #2's body. In addition, RN #1 stated she guessed Resident #2 had been deceased at minimum one (1) hour and probably two (2) to four (4) hours when she found him/her non-responsive. Review of RN #1's written statement, dated [DATE], revealed when she found Resident #2 unresponsive on [DATE], the resident appeared to have been deceased for thirty (30) to forty (40) minutes. Per the written statement, RN #1 observed no signs of life and asked the CNAs to come to the room with her where they all agreed the resident was deceased . Continued review revealed when she discovered Resident #2 was a Full Code, there was nothing that could be done, and she notified the Physician and family. Further review revealed RN #1 documented there was nothing that could be done by the nurse for Resident #2. Interview with CNA #3 on [DATE] at 8:20 PM, revealed she was working when RN #1 found Resident #2 unresponsive. CNA #3 stated she and CNA #4 were charting at the nurse's station when RN #1 came and requested help with Resident #2. According to CNA #3, the three (3) of them went to Resident #2's room, and when CNA #4 saw the resident she asked RN #1 if the resident was still alive. Per interview, RN #1 stated she didn't think so, and then asked her and CNA #4 to go to the nurse's station and check the resident's code status, which they did. She stated they noted Resident #2 was a Full Code and returned to the resident's room and informed RN #1 of this information and that she (RN #1) needed to initiate CPR for Resident #2. Per CNA #3, RN #1 told her and CNA #4 she did not want to break Resident #2's ribs, and RN #1 didn't initiate CPR for the resident. Review of CNA #3's written statement, undated, which was included in the facility's investigation documentation, revealed after she and CNA #4 told RN #1 the resident was a Full Code, the RN requested the CNAs perform post-mortem care for Resident #2's body. Per the written statement, CNA #3 stated that while performing the post-mortem care, she felt a pulse on Resident #2 and CNA #4 saw the resident breathing and they reported this to RN #1. RN #1 then listened for a heartbeat with a stethoscope and determined there was none and pronounced him/her as deceased . Interview with CNA #4, on [DATE] at 8:00 PM, revealed she was assigned to Resident #2's care when the incident occurred. Per interview, she had completed rounds on her assigned residents approximately every two (2) hours during her shift, and Resident #2 had been in no distress during the rounds. According to CNA #4, she had last rounded on Resident #2 at approximately 4:00 AM. She stated before 5:00 AM, RN #1 came to the nurse's station where she and CNA #3 were charting, and requested the CNAs help her with Resident #2. Continued interview revealed when the three (3) of them entered Resident #2's room, CNA #4 observed the resident's color to be yellow. She stated she asked RN #1 if Resident #2 was still alive, and RN #1 stated she didn't think so. Per CNA #4, RN #1 asked her and CNA #3 to return to the nurse's station and check Resident #2's code status. She stated she and CNA #3 checked Resident #2's code status as requested and found the resident was a Full Code and advised RN #1 of this. However, CNA #4 stated RN #1 told the CNAs she wasn't going to do CPR because she didn't want to break the resident's ribs, and asked them to do post-mortem care on Resident #2's body. Further interview revealed Resident #2's body was warm and while providing the post-mortem care she thought she saw the resident take a breath which she reported to the RN. CNA #4 stated RN #1 listened with a stethoscope for a heartbeat, and she didn't hear one and requested the CNAs continue with the post-mortem care. Continued interview with the DON, on [DATE] at 11:40 AM and at 2:19 PM, revealed on [DATE] at approximately 4:50 AM, RN #1 had left her a voice mail message on her cellular telephone (cell phone) reporting Resident #2 had expired. The DON stated on [DATE] around 11:30 AM, she had spoken to RN #1 who reported she had not initiated CPR for Resident #2 because the resident had already expired, had no respirations and no pulse. She stated RN #1 stated the resident had been sick and she (RN #1) did not want to break his/her ribs. Continued interview revealed RN #1 told her Resident #2 had a lot of heart and medical issues. The DON stated CPR was not initiated for Resident #2, who was a Full Code status, but should have been. Interview with the Administrator, on [DATE] at 11:53 AM, revealed the facility's procedure had been if staff was certified to perform CPR they were to initiate CPR, otherwise they were to call 911 for emergency services for residents. The Administrator stated his expectation for the licensed nurses was they should know which residents had a Full Code status. Per interview, if a resident had a Full Code status, CPR should immediately be initiated if the resident was found non-responsive with no signs of life. The Administrator revealed RN #1 should have initiated CPR for Resident #2, who was a Full Code, when she found the resident non-responsive with no signs of life. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) initiated an investigation into the incident involving Resident #2. The DON interviewed (Registered Nurse) RN #1, Certified Nursing Assistant (CNA) #3 and CNA #4 regarding Resident #2 not receiving Cardiopulmonary Resuscitation (CPR) even though the resident was Full Code status. RN #1 was suspended pending the facility's investigation. On [DATE], an initial report of the incident involving Resident #2 on [DATE] was sent to the State Agency by the Social Services Director. 2. On [DATE], RN #1 was terminated from her position of employment with the facility. 3. On [DATE], the facility developed a Code Status Acknowledgement policy which included the procedure for a visual identification system. Full Code status residents would be identified by application of a green bracelet to the resident's wrist, and placement of a green sticker outside the resident's door beside their name. A resident with a Do Not Resuscitate (DNR) status would have a black sticker on the door by their name. 4. On [DATE], the DON and the Assistant DON (ADON) conducted education in small group sessions to all staff (with the exception of four {4}staff on medical leave) related to their knowledge and understanding of the facility's Code Status Acknowledgement policy. Education related to the Code Status Acknowledgement policy was added to the training agenda for New Employee Orientation. 5. On [DATE], Medical Records personnel conducted a review of all current residents in the facility to verify their code status. 6. On [DATE] through [DATE], the Social Services Director (SSD) reviewed Advance Directives with all current Full Code status residents and/or their Power of Attorney (POA) to ensure their code status was accurate. 7. On [DATE], the SSD verified the Code Status Acknowledgement policy was implemented by a visual inspection of all full code status residents to ensure each had a green bracelet on their wrist and a green sticker next to their name on the door. 8. The SSD monitored daily beginning [DATE] through [DATE], to ensure all full code status residents continued to wear a green bracelet and had a green sticker next to their name on the outside of their door. 9. On [DATE] through [DATE], the Administrator and the DON made daily rounds through the facility on all shifts to question and talk with staff about the new Code Status policy. 10. On [DATE], the Administrator educated the Minimum Data Set (MDS) staff related to resident's code status documented on the resident's Comprehensive Care Plan (CCP) and it was to be reviewed at the resident Care Plan Conferences. 11. On [DATE], MDS staff conferred with Medical Records staff to verify each residents' code status was correct. The MDS staff revised all resident CCPs to reflect each resident's Advance Directives. 12. On [DATE], the Code Status Policy was revised to incorporate instructions to add code status to resident CCPs on admission. 13. Beginning [DATE], the SSD will review code status with all the residents and/or their POA during resident Care Plan Conferences. 14. On [DATE], the DON audited all licensed Charge Nurse's personnel files for the presence of current CPR certifications, and found two (2) who were not current. On [DATE], all licensed nurses were instructed to have current CPR certification by [DATE]. 15. On [DATE], the Administrator implemented a CPR policy and a Code 500 Policy. On [DATE], the Administrator provided education to the DON and the ADON related to the new CPR and Code 500 policies. 16. On [DATE] through [DATE] the DON and the ADON conducted education with all staff related to the CPR, Code Status, Code Status Acknowledgement and Code 500 policies and General Documentation Guidelines for CPR, with post-education tests implemented on [DATE], to ensure the staff's knowledge and understanding of the policies. 17. On [DATE], the Administrator audited all current resident charts to verify the code status was on each resident's CCP, with no issues identified. 18. The DON will audit new hire nursing staff for CPR certification expiration dates and will schedule CPR certification courses as necessary to ensure all charge nurses maintained CPR certifications. 19. On [DATE], the Administrator audited all nurses' personnel files to ensure all were CPR certified as instructed on [DATE]. No issues were identified and the Administrator will continue to verify the DON audits of Charge Nurse's personnel files to ensure they maintain CPR certification. 20. On [DATE], the Administrator audited the current facility schedule to verify a CPR certified staff member was present in the facility at all times. The Administrator will continue to audit the nurse schedule monthly, and when changes occur, to ensure all shifts are staffed with a CPR certified nurse. 21. On [DATE], the Administrator, the DON and the ADON conducted a Mock Code 500 drill and reviewed findings after completion with staff who responded to the drill. The facility will conduct Mock Code 500 drills on a weekly basis for the next sixty (60) days, on different days and shifts. The Administrator and the DON will monitor Code 500 documentation for completeness and accuracy. 22. On [DATE], the Administrator notified the Medical Director of the code policy revisions. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed RN #1, CNA #3 and CNA #4 were interviewed related to the Code 500 event involving Resident #2. Continued review of the investigations revealed, RN #1 was suspended on [DATE], pending the investigation results. Per review, the initial report was sent to the State Survey Agency regarding the Code event involving Resident #2 on [DATE], and it was signed by the SSD. Interview, on [DATE] at 2:26 PM, with the DON revealed she had initiated the investigation on [DATE], and interviewed the staff involved (RN #1, CNA #3 and CNA #4). Per interview, RN #1 was suspended from work pending the results of the investigation. The DON stated the SSD sent the initial report of the incident to the State Survey Agency on [DATE]. 2. Review of RN #1's personnel file verified she was terminated from her employment at the facility. Interview with RN #1 on [DATE] at 3:26 PM, confirmed her employment at the facility was terminated on [DATE]. Interview, on [DATE] at 2:26 PM, with the DON revealed RN #1's employment was terminated on [DATE]. 3. Review of the facility's Code Status Acknowledgement policy, dated [DATE], and revised [DATE], revealed it included the procedure for visual identification of a resident's code status. Per the Policy, Full Code status residents would wear a green bracelet on their wrist and have a green sticker located outside the room door by their name. Interview, on [DATE] at 2:26 PM, with the DON revealed the facility's Code Status Acknowledgement policy now included the procedure for visual identification of a resident's code status through Full Code residents wearing a green bracelet on their wrist and a green sticker placed by the resident's name outside their room door. 4. The facility's CPR policy and Code 500 policy, Code Status policy and Code Status Acknowledgement policy were reviewed. Review of the facility's in-service sign-in forms dated [DATE], revealed staff was educated on the facility's Code Status Acknowledgement policy and the other code related policies. Review of the facility's New Employee Education Pack revealed the Code Status Acknowledgement policy education had been added. Interview on [DATE] at 8:00 AM with CNA #4; at 8:20 AM with CNA#3; at 12:38 PM with LPN #6; at 1:58 PM with CNA #5; at 2:00 PM with CNA #6; at 3:55 PM with CNA #11; and, at 4:05 PM with LPN #7 revealed they had all been provided education related to the facility's Code Status Acknowledgement Policy between [DATE] and [DATE], in small group sessions. Interview, on [DATE] at 2:26 PM, with the DON revealed the education on the Code Status Acknowledgement policy had been provided as per the AOC, with all but four (4) staff receiving the education. The DON stated the four (4) staff who had not receive the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. 5. Review of the Medical Records documentation related to the verification of all residents' code status, revealed all residents' code status was verified. Interview with the DON, on [DATE] at 2:26 PM, revealed after Medical Records compiled the code status information, she verified it with comparison to the residents' written signed consents. 6. Review of the documentation of the SSD's Advance Directives review with all current Full Code status residents and/or their POAs to ensure the code was accurate revealed the code status was verified for each resident from [DATE] through [DATE]. Interview, on [DATE] at 1:20 PM, with Resident #3 revealed his/her daughter was the resident's POA and talked to staff about decisions regarding his/her care; however, a green bracelet (indicated a Full Code status) had been placed on him/her on [DATE]. Interview, on [DATE] at 11:07 AM, with Resident #9 revealed the SSD had talked to the resident about his/her Full Code status. Interview, on [DATE] at 12:24 PM, with Resident #10 revealed the SSD had discussed the resident's Full Code status with him/her and he/she had made the decision to have the code status changed to a DNR. Interview, on [DATE] at 12:45 PM, with Resident #8 revealed the resident thought someone had talked with him/her about Advance Directives; however, he/she could not recall who had talked to him/her. Resident #8 revealed he/she was not aware of what his/her Advance Directive or code status was at this time. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the Advance Directives review with Full Code status residents and/or their POA to verify the code status was accurate. The SSD revealed if a resident requested to change their status, it was changed as requested. 7. Review of documentation of the check off sheet, dated [DATE], revealed the SSD had verified all Full Code status residents had a green bracelet on their wrist and a green sticker next to their name on their door. Observation revealed eleven (11) of eleven (11) residents, who were Full Code status, were wearing a green bracelet and had a green sticker outside the room door by their name. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted a visual inspection of all Full Code residents on [DATE] to ensure the Code Status Acknowledgement policy had been implemented. Per the SSD, she verified all the Full Code status residents were wearing a green bracelet and a green sticker was by the resident's name outside their room door. 8. The computer generated Full Code status logs utilized by the SSD to monitor that all Full Code status residents had a green sticker on their door by their name and was wearing a green bracelet. The review revealed the SSD's Full Code status log had been checked and signed by the Administrator on [DATE], to verify the log had been completed by the SSD. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the monitoring beginning [DATE] through [DATE], to ensure residents had the green bracelet on if they had a Full Code status, and to ensure the green sticker was beside their names outside their room doors. Interview, on [DATE] at 3:00 PM, with Administrator revealed he had reviewed the SSD log and verified the SSD had completed the monitoring to ensure Full Code status residents had their green bracelet in place and the green sticker was beside their name outside the room door. 9. Reviewed the Administrator's and DON's daily rounds log sheet dated [DATE] through [DATE], which revealed the rounds were made each day on all shifts. Reviewed the documentation of the educational questions and answers that were reviewed with staff. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeper #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18, the Administrator and DON had been completing rounds on each shift questioning and educating staff about codes and the facility's code status policies. Interview with the DON, on [DATE] at 2:26 PM and at 3:00 PM with the Administrator, revealed they had conducted the daily rounds throughout the facility on all shifts to question and talk with staff about the facility's Code Status policy. They stated they had ensured staff understood the new policy with no problems identified. Per interview, the results of the daily rounds would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 10. Reviewed the education given to the MDS staff by the Administrator related to ensuring residents' code status was documented on the CCP and that the code status was to be reviewed at residents' care plan conferences. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed the education had been provided by the Administrator regarding residents' code status being on the care plan and ensuring the code status was discussed in the residents' care plan meetings. 11. Reviewed 100% of the facility's residents' CCPs which revealed each resident's code status was care planned with interventions. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed MDS staff had talked to the Medical Records staff to verify each resident's code status was correct. Per interview, MDS staff revised all resident's CCPs to address each resident's Advance Directives including the code status. 12. Reviewed the Code Status Policy which revealed it had been revised [DATE], and included ensuring each resident's CCP included the code status be incorporated on admission. Reviewed the facility's Admission Checklist for Nursing form which revealed it included the information for nurse's to obtain an order for [REDACTED]. Interview, on [DATE] at 3:00 PM, with Administrator revealed the facility's Code Status Policy had been revised as per the AOC. 13. Reviewed Care Plan Conference notes, dated [DATE], which included reviewing the resident's Code Status at the planned Care Plan Conferences. Interview, on [DATE] at 1:06 PM, with the SSD revealed residents' code status was being discussed at care plan conferences which began on [DATE]. 14. On [DATE], the Employee Roster Report listing of all licensed staff with CPR expiration dates and copies of their CPR certification was reviewed. Reviewed the CPR certification class roster and certification cards from classes provided by the facility on [DATE] and [DATE]. Review of the documentation revealed all licensed nursing staff now had current CPR certification. 15. Reviewed the facility's CPR and Code 500 policies. Reviewed the sign in sheet and education provided by the Administrator to the DON and ADON related to the CPR and Code 500 Policy dated [DATE]. Interview with the DON and ADON, on [DATE] at 2:26 PM, revealed they had been educated by the Administrator on [DATE], regarding the CPR and Code 500 policies. Interview, on [DATE] at 3:00 PM, with the Administrator revealed the facility's CPR and Code 500 policies had been implemented on [DATE], as per the AOC. A post-survey interview on [DATE] at 9:32 AM, with the Administrator revealed after becoming aware of the need to have someone CPR certified in the building at all times, he had read the regulatory requirements and conferenced with the Consultant Administrator for guidance. Per interview, the Consultant Administrator had discussed with him getting staff CPR certified and what needed to be done to ensure this was done. The Administrator stated he and the Consultant Administrator had communication all the way through the process and had developed the plan of action. 16. Reviewed the sign-in sheets and education provided by the DON and ADON for all staff related to the CPR and Code 500 Policy, dated [DATE] through [DATE] and reviewed the post-tests. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeping #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18 revealed they had all been educated on the CPR and Code 500 policies, and other code policies and General Documentation Guidelines for CPR, and had taken a post-test after the education. Interview, on [DATE] at 2:26 PM, with the DON revealed all but four (4) staff had received the education on the facility's code policies and CPR policy. The DON stated the four (4) staff who had not received the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. Interview, on [DATE] at 3:00 PM, with Administrator revealed facility staff had been educated on the CPR, Code 500 and other code policies, as per the AOC. 17. Reviewed the

Based on interview, record review, review of the facility's policy and investigation reports, it was determined the facility failed to have an effective system in place to ensure residents received Cardiopulmonary Resuscitation (CPR) according to established professional standards to promote the highest practicable physical well-being of residents regarding their Advance Directives and code status for one (1) of twelve (12) sampled residents (Resident #2). Resident #2 had Advance Directives, dated [DATE], requesting life-saving measures be instituted in the event of cardiac or [MEDICAL CONDITION], to include CPR. On [DATE] at approximately 4:50 AM, Resident #2 was found unresponsive by RN #1. RN #1 checked for Resident #2's pulse and respirations, which were not obtained; however, RN #1 failed to initiate CPR as per the resident's Advance Directives regarding his/her Full Code status. RN #1 reported she was not sure of the resident's code status, and went to the nurse's station to get assistance from the Certified Nursing Assistants (CNAs). RN #1 was informed by the CNAs that they thought Resident #2 was a Full Code. However, RN #1 again failed to initiate CPR as per Resident #2's Advance Directives. Per interview, RN #1 pronounced Resident #2 as deceased , notified the Physician, family and called the funeral home. Even though RN #1 was aware of Resident #2's Full Code status, she failed to honor Resident #2's request for the provision of CPR. The facility's failure to provide the necessary care and services related to the resident's requested Full Code status and the provision of CPR, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Advance Directives and Do Not Resuscitate Orders, undated, revealed the Patient Self-Determination Act mandated residents be given information about their right to make decisions concerning medical care, including the right to accept or refuse treatment and the right to formulate Advance Directives. The Policy revealed Advance Directive referred to documents written before serious illness occurred which stated the resident's preferences regarding medical treatment and/or named someone to make choices for medical treatment if the resident became unable to make decisions. Further review revealed an Advance Directive was a personal decision and would not be a condition of whether or not the resident received services from a health care provider. Review of the facility's policy titled, Code Status Policy, dated [DATE], revealed the facility would recognize two (2) code status options for the facility's residents, a Full Code status or a Do Not Resuscitate (DNR) status. Further review revealed, for a resident to have a Full Code status, the resident or responsible party had to sign a Code Status Consent Form under the Full Code options. Review of the facility's policy titled, Notification of Change in Resident's Condition/Accidents, dated [DATE], revealed in the event of a resident status change: the nurse would assess the situation; provide necessary care; notify the attending Physician, responsible party or interested family member; document in the resident's medical record; and follow up as indicated. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Admit/Readmit Screener document, dated [DATE], revealed the resident was the person providing the information for the assessment. Continued review of the document revealed Resident #2 was alert to person and was verbally appropriate. Review of Resident #2's physician's orders [REDACTED]. Continued record review revealed a Code Status Consent Form, dated [DATE], which gave the resident the option to check whether he/she wanted CPR or not. Continued review of the Form, signed by Resident #2's Responsible Party on [DATE], revealed the Responsible Party had requested and consented for the use of cardiac compressions or artificial ventilation to resuscitate him/her in the event of cardiopulmonary failure. Review of the Electronic Medication Administration Record [REDACTED]. Review of the Electronic Treatment Administration Record (e-TAR), dated [DATE], revealed Resident #2 had a Full Code status. However, review of Resident #2's Nurse's Note, dated [DATE] at 4:50 AM, revealed RN #1 found the resident lying on the bed with no pulse, no blood pressure and no signs of life. Even though RN #1 documented the Note, continued review revealed no documented evidence she immediately initiated CPR, as per Resident #2's Advance Directives and physician's orders [REDACTED].#1 notified the Physician at 5:05 AM of the resident's condition, the family at 5:10 AM and the funeral home with no time documented. Review of the Provisional Report of Death form for Resident #2 revealed the date of death was documented as [DATE], and the time of death as 4:50 AM. Review of the facility's, Resident Abuse Investigation Report Form, signed by the Social Service Director (SSD) on [DATE] and attachments, revealed it was the facility's Final Report of an incident which occurred on [DATE]. Review of the Form revealed the facility had investigated an allegation of neglect involving Resident #2, who was found non-responsive at approximately 4:50 AM on [DATE]. Per the investigation information, the facility determined RN #1 had not respected Resident #2's Advance Directives and Physician order [REDACTED]. Continued review of the Form and attachments revealed Resident #2 had wanted to be a Full Code status, which was indicated by his/her Responsible Party's signature on the Code Status Consent Form, dated [DATE]. Review of the investigation information revealed RN #1 was suspended pending the investigation outcome. Further review of the investigation documentation revealed witness statements were obtained from RN #1, CNA #3, CNA #4, CNA #19, CNA #2, Licensed Practical Nurse (LPN) #2, LPN #3 and RN #2. Review of RN #1's written statement, dated [DATE], revealed she noted she had observed Resident #2 to be unresponsive lying on his/her bed. Per the written statement, RN #1 documented Resident #2 had no signs of life, no pulse, no breathing or movement of any kind. Continued review revealed RN #1 noted she did a sternum rub (a painful stimulus applied to the sternum to check for responsiveness) with no signs of life and the resident appeared to have been deceased for thirty (30) or forty-five (45) minutes. RN #1's written statement revealed she left the resident's room and asked the CNAs to come to the room with her, where they all agreed the resident was deceased . RN #1 documented she listened with a stethoscope for a heartbeat with none found, and she asked the CNAs if Resident #2 was a Full Code, then they left the resident's room to find out. Per RN #1's statement, when she discovered Resident #2 was a Full Code, she notified the Physician and family because she knew there was nothing that could be done. RN #1 documented CPR would have been futile, as there was no heartbeat. RN #1 further documented there was nothing that could be done by the nurse. Interview with RN #1, on [DATE] at 3:26 PM, revealed she was the primary nurse for Resident #2, and the facility's Charge Nurse on [DATE]. RN #1 stated she was certified to perform CPR; however, she was not aware of Resident #2's code status when she found the resident unresponsive at 4:50 AM, and therefore, she did not initiate CPR for the resident. Continued interview revealed she went to the nurse's station to get the CNAs to help her. According to RN #1, the CNAs told her they thought Resident #2 was a Full Code; however she still did not initiate CPR, as per the resident's requested wishes and the physician's orders [REDACTED].#1 stated she went back to the nurse's station to check Resident #2's chart for his/her code status and determined the resident was a Full Code. However she did not initiate CPR, as per the resident's request and the physician's orders [REDACTED].#2's body, and the CNAs reported they thought they felt a heart beat, and had seen the resident take a breath during the post-mortem care. RN #1 stated she listened for heart sounds with a stethoscope and determined there were none and again she did not initiate CPR, as per the resident's request and the physician's orders [REDACTED].#2, At what point do you draw the line? RN #1 stated she guessed Resident #2 had been deceased at a minimum of one (1) hour and probably two (2) to four (4) hours when she found him/her non-responsive. She further stated she did not want to break Resident #2's ribs by performing CPR, and felt it was futile to do it. Further interview revealed RN #1 stated she also did not want to desecrate Resident #2's body. Interview with CNA #3 on [DATE] at 8:20 PM, revealed she was working at the time of the incident involving Resident #2. Per interview, she and CNA #4 were at the nurse's station charting when RN #1 requested help with Resident #2. She stated she, RN #1 and CNA #4 went to Resident #2's room, and CNA #4 asked if the resident was still alive with RN #1 responding she didn't think so. CNA #3 stated RN #1 requested the CNAs go back to the nurse's station to check the resident's chart to determine if Resident #2 was a Full Code. Per CNA #3, they went back to the nurse's station, checked the chart and noted the resident was a Full Code. Continued interview revealed when they returned to Resident #2's room, they informed RN #1 the resident was a Full Code and she needed to initiate CPR. CNA #3 stated RN #1 told them (the CNAs) she did want to break Resident #2's ribs. She stated RN #1 did not initiate CPR. Review of the facility's investigation's documents of CNA #3's written statement, undated, revealed after being told Resident #2 was a Full Code, RN #1 stated she didn't want to break Resident #2's ribs and requested CNA #3 and CNA #4 perform post-mortem care on the resident's body. Continued review of the investigation revealed CNA #3 thought she felt a pulse, and CNA #4 thought she saw the resident breathing during the provision of post-mortem care which they reported to RN #1. Further review of CNA #3's written statement revealed RN #1 listened for a heartbeat with a stethoscope and determined there was none, then she pronounced the resident deceased . Interview with CNA #4 on [DATE] at 8:00 PM, revealed she was working at the time of the incident involving Resident #2, and had completed her resident rounds approximately every two (2) hours. Per CNA #4, she had last rounded on Resident #2 at approximately 4:00 AM, and the resident was in no distress. CNA #4 stated before 5:00 AM, RN #1 came to the nurse's station and asked her and CNA #3 to help her with Resident #2. According to CNA #4, when the three (3) of them entered Resident #2's room, she observed the resident to be yellow in color and she asked the RN if the resident was still alive. She stated RN #1 replied she didn't think so, and then asked them (the two (2) CNAs) to go to the nurse's station to check the chart for Resident #2's code status. She stated she and CNA #3 checked Resident #3's chart, noted the resident was a Full Code and returned to tell RN #1 this information. CNA #4 stated RN #1 told her and CNA #3 she wasn't going to do CPR because she didn't want to break Resident #2's ribs. The CNA stated RN #1 didn't initiate CPR even though Resident #2 was a Full Code, and then RN #1 asked her and CNA #3 to do post-mortem care on the resident's body. Further interview revealed during the post-mortem care, Resident #2's body was warm and she thought she saw the resident take a breath which she reported to RN #1. CNA #4 stated RN #1 listened with a stethoscope for a heartbeat, and she didn't hear one and requested the CNAs to continue with the post-mortem care. Interview, on [DATE] at 12:38 PM, with RN #4 revealed she had reported to work on [DATE] at 6:00 AM, and it was reported to her Resident #2 had just passed away. She stated when she got to work, the night shift CNAs, (CNA #3 and CNA #4) were teary eyed because the nurse had not done CPR for Resident #2. RN #4 stated CNA #3 reported to her that she had felt a pulse two (2) or three (3) times, and had told RN #1. According to RN #4, CNA #4 told her Resident #2 had taken at least one (1) breath, maybe two (2) and she had reported this information to RN #1. RN #4 stated RN #1 reported to her she didn't do CPR for Resident #2 because she didn't want to break the resident's ribs. Interview with the Director of Nursing (DON), on [DATE] at 11:40 AM and at 2:19 PM, revealed RN #1 had left her a voice message on her cellular (cell) telephone (phone) on [DATE] around 4:50 AM, reporting Resident #2 had expired. Continued interview revealed she talked to RN #1 on [DATE] around 11:30 AM, and RN #1 reported to her she did not initiate CPR for Resident #2 because the resident had already expired and she (RN #1) did not want to break the resident's ribs. She stated RN #1 reported Resident #2 had a lot of heart and medical issues. The DON revealed the facility did not have specific procedures in the event death should occur to a resident with a Full Code status; however, her expectation was CPR would be initiated immediately and 911 called to transport the resident to a hospital. She stated the facility also did not have a CPR specific policy but her expectation was if a resident was found unresponsive, the nurse should assess the resident and if no pulse or breathing was found, check for the resident's code status. The DON stated for Resident #2, CPR was not initiated and it should have been, as per the resident's wishes. Interview with the Administrator, on [DATE] at 11:53 AM, revealed the facility's procedure had been for staff to initiate CPR if they were certified to do so, otherwise they were to call 911 for emergency services. The Administrator stated his expectation was the facility's licensed nurses should know which residents had a Full Code Status and if that was their status, CPR should immediately be initiated if the resident was found unresponsive with no signs of life. Further interview revealed RN #1 should have initiated CPR when she identified Resident #2 was unresponsive with no signs of life. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) initiated an investigation into the incident involving Resident #2. The DON interviewed (Registered Nurse) RN #1, Certified Nursing Assistant (CNA) #3 and CNA #4 regarding Resident #2 not receiving Cardiopulmonary Resuscitation (CPR) even though the resident was Full Code status. RN #1 was suspended pending the facility's investigation. On [DATE], an initial report of the incident involving Resident #2 on [DATE] was sent to the State Agency by the Social Services Director. 2. On [DATE], RN #1 was terminated from her position of employment with the facility. 3. On [DATE], the facility developed a Code Status Acknowledgement policy which included the procedure for a visual identification system. Full Code status residents would be identified by application of a green bracelet to the resident's wrist, and placement of a green sticker outside the resident's door beside their name. A resident with a Do Not Resuscitate (DNR) status would have a black sticker on the door by their name. 4. On [DATE], the DON and the Assistant DON (ADON) conducted education in small group sessions to all staff (with the exception of four {4}staff on medical leave) related to their knowledge and understanding of the facility's Code Status Acknowledgement policy. Education related to the Code Status Acknowledgement policy was added to the training agenda for New Employee Orientation. 5. On [DATE], Medical Records personnel conducted a review of all current residents in the facility to verify their code status. 6. On [DATE] through [DATE], the Social Services Director (SSD) reviewed Advance Directives with all current Full Code status residents and/or their Power of Attorney (POA) to ensure their code status was accurate. 7. On [DATE], the SSD verified the Code Status Acknowledgement policy was implemented by a visual inspection of all full code status residents to ensure each had a green bracelet on their wrist and a green sticker next to their name on the door. 8. The SSD monitored daily beginning [DATE] through [DATE], to ensure all full code status residents continued to wear a green bracelet and had a green sticker next to their name on the outside of their door. 9. On [DATE] through [DATE], the Administrator and the DON made daily rounds through the facility on all shifts to question and talk with staff about the new Code Status policy. 10. On [DATE], the Administrator educated the Minimum Data Set (MDS) staff related to resident's code status documented on the resident's Comprehensive Care Plan (CCP) and it was to be reviewed at the resident Care Plan Conferences. 11. On [DATE], MDS staff conferred with Medical Records staff to verify each residents' code status was correct. The MDS staff revised all resident CCPs to reflect each resident's Advance Directives. 12. On [DATE], the Code Status Policy was revised to incorporate instructions to add code status to resident CCPs on admission. 13. Beginning [DATE], the SSD will review code status with all the residents and/or their POA during resident Care Plan Conferences. 14. On [DATE], the DON audited all licensed Charge Nurse's personnel files for the presence of current CPR certifications, and found two (2) who were not current. On [DATE], all licensed nurses were instructed to have current CPR certification by [DATE]. 15. On [DATE], the Administrator implemented a CPR policy and a Code 500 Policy. On [DATE], the Administrator provided education to the DON and the ADON related to the new CPR and Code 500 policies. 16. On [DATE] through [DATE] the DON and the ADON conducted education with all staff related to the CPR, Code Status, Code Status Acknowledgement and Code 500 policies and General Documentation Guidelines for CPR, with post-education tests implemented on [DATE], to ensure the staff's knowledge and understanding of the policies. 17. On [DATE], the Administrator audited all current resident charts to verify the code status was on each resident's CCP, with no issues identified. 18. The DON will audit new hire nursing staff for CPR certification expiration dates and will schedule CPR certification courses as necessary to ensure all charge nurses maintained CPR certifications. 19. On [DATE], the Administrator audited all nurses' personnel files to ensure all were CPR certified as instructed on [DATE]. No issues were identified and the Administrator will continue to verify the DON audits of Charge Nurse's personnel files to ensure they maintain CPR certification. 20. On [DATE], the Administrator audited the current facility schedule to verify a CPR certified staff member was present in the facility at all times. The Administrator will continue to audit the nurse schedule monthly, and when changes occur, to ensure all shifts are staffed with a CPR certified nurse. 21. On [DATE], the Administrator, the DON and the ADON conducted a Mock Code 500 drill and reviewed findings after completion with staff who responded to the drill. The facility will conduct Mock Code 500 drills on a weekly basis for the next sixty (60) days, on different days and shifts. The Administrator and the DON will monitor Code 500 documentation for completeness and accuracy. 22. On [DATE], the Administrator notified the Medical Director of the code policy revisions. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed RN #1, CNA #3 and CNA #4 were interviewed related to the Code 500 event involving Resident #2. Continued review of the investigations revealed, RN #1 was suspended on [DATE], pending the investigation results. Per review, the initial report was sent to the State Survey Agency regarding the Code event involving Resident #2 on [DATE], and it was signed by the SSD. Interview, on [DATE] at 2:26 PM, with the DON revealed she had initiated the investigation on [DATE], and interviewed the staff involved (RN #1, CNA #3 and CNA #4). Per interview, RN #1 was suspended from work pending the results of the investigation. The DON stated the SSD sent the initial report of the incident to the State Survey Agency on [DATE]. 2. Review of RN #1's personnel file verified she was terminated from her employment at the facility. Interview with RN #1 on [DATE] at 3:26 PM, confirmed her employment at the facility was terminated on [DATE]. Interview, on [DATE] at 2:26 PM, with the DON revealed RN #1's employment was terminated on [DATE]. 3. Review of the facility's Code Status Acknowledgement policy, dated [DATE], and revised [DATE], revealed it included the procedure for visual identification of a resident's code status. Per the Policy, Full Code status residents would wear a green bracelet on their wrist and have a green sticker located outside the room door by their name. Interview, on [DATE] at 2:26 PM, with the DON revealed the facility's Code Status Acknowledgement policy now included the procedure for visual identification of a resident's code status through Full Code residents wearing a green bracelet on their wrist and a green sticker placed by the resident's name outside their room door. 4. The facility's CPR policy and Code 500 policy, Code Status policy and Code Status Acknowledgement policy were reviewed. Review of the facility's in-service sign-in forms dated [DATE], revealed staff was educated on the facility's Code Status Acknowledgement policy and the other code related policies. Review of the facility's New Employee Education Pack revealed the Code Status Acknowledgement policy education had been added. Interview on [DATE] at 8:00 AM with CNA #4; at 8:20 AM with CNA#3; at 12:38 PM with LPN #6; at 1:58 PM with CNA #5; at 2:00 PM with CNA #6; at 3:55 PM with CNA #11; and, at 4:05 PM with LPN #7 revealed they had all been provided education related to the facility's Code Status Acknowledgement Policy between [DATE] and [DATE], in small group sessions. Interview, on [DATE] at 2:26 PM, with the DON revealed the education on the Code Status Acknowledgement policy had been provided as per the AOC, with all but four (4) staff receiving the education. The DON stated the four (4) staff who had not receive the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. 5. Review of the Medical Records documentation related to the verification of all residents' code status, revealed all residents' code status was verified. Interview with the DON, on [DATE] at 2:26 PM, revealed after Medical Records compiled the code status information, she verified it with comparison to the residents' written signed consents. 6. Review of the documentation of the SSD's Advance Directives review with all current Full Code status residents and/or their POAs to ensure the code was accurate revealed the code status was verified for each resident from [DATE] through [DATE]. Interview, on [DATE] at 1:20 PM, with Resident #3 revealed his/her daughter was the resident's POA and talked to staff about decisions regarding his/her care; however, a green bracelet (indicated a Full Code status) had been placed on him/her on [DATE]. Interview, on [DATE] at 11:07 AM, with Resident #9 revealed the SSD had talked to the resident about his/her Full Code status. Interview, on [DATE] at 12:24 PM, with Resident #10 revealed the SSD had discussed the resident's Full Code status with him/her and he/she had made the decision to have the code status changed to a DNR. Interview, on [DATE] at 12:45 PM, with Resident #8 revealed the resident thought someone had talked with him/her about Advance Directives; however, he/she could not recall who had talked to him/her. Resident #8 revealed he/she was not aware of what his/her Advance Directive or code status was at this time. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the Advance Directives review with Full Code status residents and/or their POA to verify the code status was accurate. The SSD revealed if a resident requested to change their status, it was changed as requested. 7. Review of documentation of the check off sheet, dated [DATE], revealed the SSD had verified all Full Code status residents had a green bracelet on their wrist and a green sticker next to their name on their door. Observation revealed eleven (11) of eleven (11) residents, who were Full Code status, were wearing a green bracelet and had a green sticker outside the room door by their name. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted a visual inspection of all Full Code residents on [DATE] to ensure the Code Status Acknowledgement policy had been implemented. Per the SSD, she verified all the Full Code status residents were wearing a green bracelet and a green sticker was by the resident's name outside their room door. 8. The computer generated Full Code status logs utilized by the SSD to monitor that all Full Code status residents had a green sticker on their door by their name and was wearing a green bracelet. The review revealed the SSD's Full Code status log had been checked and signed by the Administrator on [DATE], to verify the log had been completed by the SSD. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the monitoring beginning [DATE] through [DATE], to ensure residents had the green bracelet on if they had a Full Code status, and to ensure the green sticker was beside their names outside their room doors. Interview, on [DATE] at 3:00 PM, with Administrator revealed he had reviewed the SSD log and verified the SSD had completed the monitoring to ensure Full Code status residents had their green bracelet in place and the green sticker was beside their name outside the room door. 9. Reviewed the Administrator's and DON's daily rounds log sheet dated [DATE] through [DATE], which revealed the rounds were made each day on all shifts. Reviewed the documentation of the educational questions and answers that were reviewed with staff. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeper #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18, the Administrator and DON had been completing rounds on each shift questioning and educating staff about codes and the facility's code status policies. Interview with the DON, on [DATE] at 2:26 PM and at 3:00 PM with the Administrator, revealed they had conducted the daily rounds throughout the facility on all shifts to question and talk with staff about the facility's Code Status policy. They stated they had ensured staff understood the new policy with no problems identified. Per interview, the results of the daily rounds would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 10. Reviewed the education given to the MDS staff by the Administrator related to ensuring residents' code status was documented on the CCP and that the code status was to be reviewed at residents' care plan conferences. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed the education had been provided by the Administrator regarding residents' code status being on the care plan and ensuring the code status was discussed in the residents' care plan meetings. 11. Reviewed 100% of the facility's residents' CCPs which revealed each resident's code status was care planned with interventions. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed MDS staff had talked to the Medical Records staff to verify each resident's code status was correct. Per interview, MDS staff revised all resident's CCPs to address each resident's Advance Directives including the code status. 12. Reviewed the Code Status Policy which revealed it had been revised [DATE], and included ensuring each resident's CCP included the code status be incorporated on admission. Reviewed the facility's Admission Checklist for Nursing form which revealed it included the information for nurse's to obtain an order for [REDACTED]. Interview, on [DATE] at 3:00 PM, with Administrator revealed the facility's Code Status Policy had been revised as per the AOC. 13. Reviewed Care Plan Conference notes, dated [DATE], which included reviewing the resident's Code Status at the planned Care Plan Conferences. Interview, on [DATE] at 1:06 PM, with the SSD revealed residents' code status was being discussed at care plan conferences which began on [DATE]. 14. On [DATE], the Employee Roster Report listing of all licensed staff with CPR expiration dates and copies of their CPR certification was reviewed. Reviewed the CPR certification class roster and certification cards from classes provided by the facility on [DATE] and [DATE]. Review of the documentation revealed all licensed nursing staff now had current CPR certification. 15. Reviewed the facility's CPR and Code 500 policies. Reviewed the sign in sheet and education provided by the Administrator to the DON and ADON related to the CPR and Code 500 Po

Based on interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to have an effective system to ensure accurate clinical records were maintained for one (1) of twelve (12) sampled residents (Resident #2). Resident #2 had Advance Directives which noted he/she requested to be a Full Code (indicates life-saving measures would be instituted in the event of cardiac or [MEDICAL CONDITION]) to include performance of Cardiopulmonary Resuscitation (CPR). On [DATE], Resident #2 was found unresponsive by Registered Nurse (RN) #1, who checked for a pulse and respirations and was unable to obtain either. RN #1 left the room and returned with two (2) Certified Nursing Assistants (CNAs) who informed the nurse they thought the resident was a Full Code status. RN #1 left the room a second time to verify Resident #2's code status for herself and returned to the room a third time. Per interview, RN #1 did not initiate CPR or any other life-saving interventions during any of her three (3) encounters with Resident #2. However, review of the medical record revealed no documented evidence of why RN #1 did not initiate CPR for Resident #2 who had a Full Code status. In addition, there was no documented evidence of RN #1's encounters in Resident #2's medical record until 4:50 AM, when RN #1 documented the resident had no signs of life and the funeral home was notified. The facility's failure to ensure the provision of CPR for a Full Code resident, with all information accurately documented in the resident's record, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] with the facility alleging removal of the Immediate Jeopardy on [DATE]. Immediate Jeopardy was verified to be removed on [DATE] as alleged by the State Survey Agency prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Notification of Change in Resident's Condition/Accidents, dated [DATE], revealed in the event of a resident status change requiring emergency care, nursing documentation would include assessment findings and an account of care provided. Review of the Job Description for Charge Nurse, undated, revealed the Charge Nurse would ensure the medical record included detailed evaluations of all residents and reflected progress and condition of residents at all times. Review of the medical record revealed the facility admitted Resident #2 on [DATE], and readmitted the resident on [DATE]. Review of the Advance Directives, dated [DATE] and signed by Resident #1, revealed the resident requested to have a Full Code status which included CPR in the event of becoming unresponsive with no respirations or heart beat. Review of Resident #2's physician's orders [REDACTED]. Review of RN #1's written statement, dated [DATE] and obtained by the facility during the course of their investigation of the events involving Resident #2 on that date, revealed RN #1 observed Resident #2 to be unresponsive lying on his/her bed. Continued review of the written statement revealed Resident #2 had no signs of life, no pulse, and no breathing or movement of any kind. RN #1 noted she did a sternum rub (a painful stimulus applied to the sternum to check for responsiveness) with no signs of life noted, and the resident appeared to have been deceased for thirty (30) or forty-five (45) minutes. Further review of the statement revealed RN #1 left Resident #2's room and returned two (2) times. Review of the Nurse's Note, dated [DATE] timed 4:50 AM, documented by RN #1 revealed Resident #2 was found lying on the bed with no blood pressure or pulse, and no signs of life. Continued review of the Note revealed RN #1 documented notifying the resident's Physician at 5:05 AM; his/her family at 5:10 AM; and the funeral home with no documented evidence of the time of notification. Further review revealed no documented evidence of a reason for why RN #1 had not immediately initiated CPR, as per Resident #2's Advance Directives and Full Code status. In addition, record review revealed no documented evidence of the account given by RN #1 in her written statement, to include the performance of the sternum rub and the nurse's findings, and no documented evidence of the time at which she found Resident #2 nonresponsive. Review of the Provisional Report of Death form with a date of death noted as [DATE] for Resident #2 revealed time of death documented as 4:50 AM. Interview with RN #1 on [DATE] at 3:26 PM, revealed she was the nurse providing care Resident #2 on [DATE], and was also the facility's Charge Nurse. RN #1 stated she was not aware of Resident #2's code status on [DATE] when she found the resident unresponsive with no signs of life, so she did not immediately initiate CPR. Per interview, she left the resident's room and went to the nurse's station where CNA #3 and CNA #4 were and had them come to Resident #2's room with her. She revealed the CNAs told her they thought Resident #2 was a Full Code, but she left the resident's room again to check his/her code status herself. According to RN #1, she returned to Resident #2's room once more after finding out for herself the resident was a Full Code; however, she did not initiate CPR and instructed the CNAs to start post-mortem care. Per RN #1, the CNAs told her during post-mortem care they thought they had felt a pulse and saw the resident take a breath, which she assessed for, but did not feel or observe. However, record review revealed no documented evidence of RN #1 being informed by the CNAs they thought they had felt a pulse and saw Resident #2 take a breath, or documented evidence of her assessment performed after being told by the CNAs. Further interview with RN #1 revealed however, she did not document the events. Interview with the Director of Nursing (DON) on [DATE] at 11:40 AM and at 2:19 PM, revealed the primary nurse was responsible for initiating and documenting the code events. Continued interview revealed the facility did not have a written policy which addressed the code process to include documentation. Interview with the Administrator on [DATE] at 11:53 AM, he confirmed there was no written policy for conducting a code to include documentation requirements. However, he revealed nurses should document all details of a resident incident in the medical record. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE], which alleged removal of the IJ effective [DATE]. Review of the AOC revealed the facility implemented the following: 1. On [DATE], the Director of Nursing (DON) initiated an investigation into the incident involving Resident #2. The DON interviewed (Registered Nurse) RN #1, Certified Nursing Assistant (CNA) #3 and CNA #4 regarding Resident #2 not receiving Cardiopulmonary Resuscitation (CPR) even though the resident was Full Code status. RN #1 was suspended pending the facility's investigation. On [DATE], an initial report of the incident involving Resident #2 on [DATE] was sent to the State Agency by the Social Services Director. 2. On [DATE], RN #1 was terminated from her position of employment with the facility. 3. On [DATE], the facility developed a Code Status Acknowledgement policy which included the procedure for a visual identification system. Full Code status residents would be identified by application of a green bracelet to the resident's wrist, and placement of a green sticker outside the resident's door beside their name. A resident with a Do Not Resuscitate (DNR) status would have a black sticker on the door by their name. 4. On [DATE], the DON and the Assistant DON (ADON) conducted education in small group sessions to all staff (with the exception of four {4}staff on medical leave) related to their knowledge and understanding of the facility's Code Status Acknowledgement policy. Education related to the Code Status Acknowledgement policy was added to the training agenda for New Employee Orientation. 5. On [DATE], Medical Records personnel conducted a review of all current residents in the facility to verify their code status. 6. On [DATE] through [DATE], the Social Services Director (SSD) reviewed Advance Directives with all current Full Code status residents and/or their Power of Attorney (POA) to ensure their code status was accurate. 7. On [DATE], the SSD verified the Code Status Acknowledgement policy was implemented by a visual inspection of all full code status residents to ensure each had a green bracelet on their wrist and a green sticker next to their name on the door. 8. The SSD monitored daily beginning [DATE] through [DATE], to ensure all full code status residents continued to wear a green bracelet and had a green sticker next to their name on the outside of their door. 9. On [DATE] through [DATE], the Administrator and the DON made daily rounds through the facility on all shifts to question and talk with staff about the new Code Status policy. 10. On [DATE], the Administrator educated the Minimum Data Set (MDS) staff related to resident's code status documented on the resident's Comprehensive Care Plan (CCP) and it was to be reviewed at the resident Care Plan Conferences. 11. On [DATE], MDS staff conferred with Medical Records staff to verify each residents' code status was correct. The MDS staff revised all resident CCPs to reflect each resident's Advance Directives. 12. On [DATE], the Code Status Policy was revised to incorporate instructions to add code status to resident CCPs on admission. 13. Beginning [DATE], the SSD will review code status with all the residents and/or their POA during resident Care Plan Conferences. 14. On [DATE], the DON audited all licensed Charge Nurse's personnel files for the presence of current CPR certifications, and found two (2) who were not current. On [DATE], all licensed nurses were instructed to have current CPR certification by [DATE]. 15. On [DATE], the Administrator implemented a CPR policy and a Code 500 Policy. On [DATE], the Administrator provided education to the DON and the ADON related to the new CPR and Code 500 policies. 16. On [DATE] through [DATE] the DON and the ADON conducted education with all staff related to the CPR, Code Status, Code Status Acknowledgement and Code 500 policies and General Documentation Guidelines for CPR, with post-education tests implemented on [DATE], to ensure the staff's knowledge and understanding of the policies. 17. On [DATE], the Administrator audited all current resident charts to verify the code status was on each resident's CCP, with no issues identified. 18. The DON will audit new hire nursing staff for CPR certification expiration dates and will schedule CPR certification courses as necessary to ensure all charge nurses maintained CPR certifications. 19. On [DATE], the Administrator audited all nurses' personnel files to ensure all were CPR certified as instructed on [DATE]. No issues were identified and the Administrator will continue to verify the DON audits of Charge Nurse's personnel files to ensure they maintain CPR certification. 20. On [DATE], the Administrator audited the current facility schedule to verify a CPR certified staff member was present in the facility at all times. The Administrator will continue to audit the nurse schedule monthly, and when changes occur, to ensure all shifts are staffed with a CPR certified nurse. 21. On [DATE], the Administrator, the DON and the ADON conducted a Mock Code 500 drill and reviewed findings after completion with staff who responded to the drill. The facility will conduct Mock Code 500 drills on a weekly basis for the next sixty (60) days, on different days and shifts. The Administrator and the DON will monitor Code 500 documentation for completeness and accuracy. 22. On [DATE], the Administrator notified the Medical Director of the code policy revisions. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facility's investigation of the incident revealed RN #1, CNA #3 and CNA #4 were interviewed related to the Code 500 event involving Resident #2. Continued review of the investigations revealed, RN #1 was suspended on [DATE], pending the investigation results. Per review, the initial report was sent to the State Survey Agency regarding the Code event involving Resident #2 on [DATE], and it was signed by the SSD. Interview, on [DATE] at 2:26 PM, with the DON revealed she had initiated the investigation on [DATE], and interviewed the staff involved (RN #1, CNA #3 and CNA #4). Per interview, RN #1 was suspended from work pending the results of the investigation. The DON stated the SSD sent the initial report of the incident to the State Survey Agency on [DATE]. 2. Review of RN #1's personnel file verified she was terminated from her employment at the facility. Interview with RN #1 on [DATE] at 3:26 PM, confirmed her employment at the facility was terminated on [DATE]. Interview, on [DATE] at 2:26 PM, with the DON revealed RN #1's employment was terminated on [DATE]. 3. Review of the facility's Code Status Acknowledgement policy, dated [DATE], and revised [DATE], revealed it included the procedure for visual identification of a resident's code status. Per the Policy, Full Code status residents would wear a green bracelet on their wrist and have a green sticker located outside the room door by their name. Interview, on [DATE] at 2:26 PM, with the DON revealed the facility's Code Status Acknowledgement policy now included the procedure for visual identification of a resident's code status through Full Code residents wearing a green bracelet on their wrist and a green sticker placed by the resident's name outside their room door. 4. The facility's CPR policy and Code 500 policy, Code Status policy and Code Status Acknowledgement policy were reviewed. Review of the facility's in-service sign-in forms dated [DATE], revealed staff was educated on the facility's Code Status Acknowledgement policy and the other code related policies. Review of the facility's New Employee Education Pack revealed the Code Status Acknowledgement policy education had been added. Interview on [DATE] at 8:00 AM with CNA #4; at 8:20 AM with CNA#3; at 12:38 PM with LPN #6; at 1:58 PM with CNA #5; at 2:00 PM with CNA #6; at 3:55 PM with CNA #11; and, at 4:05 PM with LPN #7 revealed they had all been provided education related to the facility's Code Status Acknowledgement Policy between [DATE] and [DATE], in small group sessions. Interview, on [DATE] at 2:26 PM, with the DON revealed the education on the Code Status Acknowledgement policy had been provided as per the AOC, with all but four (4) staff receiving the education. The DON stated the four (4) staff who had not receive the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. 5. Review of the Medical Records documentation related to the verification of all residents' code status, revealed all residents' code status was verified. Interview with the DON, on [DATE] at 2:26 PM, revealed after Medical Records compiled the code status information, she verified it with comparison to the residents' written signed consents. 6. Review of the documentation of the SSD's Advance Directives review with all current Full Code status residents and/or their POAs to ensure the code was accurate revealed the code status was verified for each resident from [DATE] through [DATE]. Interview, on [DATE] at 1:20 PM, with Resident #3 revealed his/her daughter was the resident's POA and talked to staff about decisions regarding his/her care; however, a green bracelet (indicated a Full Code status) had been placed on him/her on [DATE]. Interview, on [DATE] at 11:07 AM, with Resident #9 revealed the SSD had talked to the resident about his/her Full Code status. Interview, on [DATE] at 12:24 PM, with Resident #10 revealed the SSD had discussed the resident's Full Code status with him/her and he/she had made the decision to have the code status changed to a DNR. Interview, on [DATE] at 12:45 PM, with Resident #8 revealed the resident thought someone had talked with him/her about Advance Directives; however, he/she could not recall who had talked to him/her. Resident #8 revealed he/she was not aware of what his/her Advance Directive or code status was at this time. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the Advance Directives review with Full Code status residents and/or their POA to verify the code status was accurate. The SSD revealed if a resident requested to change their status, it was changed as requested. 7. Review of documentation of the check off sheet, dated [DATE], revealed the SSD had verified all Full Code status residents had a green bracelet on their wrist and a green sticker next to their name on their door. Observation revealed eleven (11) of eleven (11) residents, who were Full Code status, were wearing a green bracelet and had a green sticker outside the room door by their name. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted a visual inspection of all Full Code residents on [DATE] to ensure the Code Status Acknowledgement policy had been implemented. Per the SSD, she verified all the Full Code status residents were wearing a green bracelet and a green sticker was by the resident's name outside their room door. 8. The computer generated Full Code status logs utilized by the SSD to monitor that all Full Code status residents had a green sticker on their door by their name and was wearing a green bracelet. The review revealed the SSD's Full Code status log had been checked and signed by the Administrator on [DATE], to verify the log had been completed by the SSD. Interview, on [DATE] at 1:06 PM, with the SSD revealed she had conducted the monitoring beginning [DATE] through [DATE], to ensure residents had the green bracelet on if they had a Full Code status, and to ensure the green sticker was beside their names outside their room doors. Interview, on [DATE] at 3:00 PM, with Administrator revealed he had reviewed the SSD log and verified the SSD had completed the monitoring to ensure Full Code status residents had their green bracelet in place and the green sticker was beside their name outside the room door. 9. Reviewed the Administrator's and DON's daily rounds log sheet dated [DATE] through [DATE], which revealed the rounds were made each day on all shifts. Reviewed the documentation of the educational questions and answers that were reviewed with staff. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeper #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18, the Administrator and DON had been completing rounds on each shift questioning and educating staff about codes and the facility's code status policies. Interview with the DON, on [DATE] at 2:26 PM and at 3:00 PM with the Administrator, revealed they had conducted the daily rounds throughout the facility on all shifts to question and talk with staff about the facility's Code Status policy. They stated they had ensured staff understood the new policy with no problems identified. Per interview, the results of the daily rounds would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 10. Reviewed the education given to the MDS staff by the Administrator related to ensuring residents' code status was documented on the CCP and that the code status was to be reviewed at residents' care plan conferences. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed the education had been provided by the Administrator regarding residents' code status being on the care plan and ensuring the code status was discussed in the residents' care plan meetings. 11. Reviewed 100% of the facility's residents' CCPs which revealed each resident's code status was care planned with interventions. Interview with the MDS Coordinator on [DATE] at 3:05 PM, revealed MDS staff had talked to the Medical Records staff to verify each resident's code status was correct. Per interview, MDS staff revised all resident's CCPs to address each resident's Advance Directives including the code status. 12. Reviewed the Code Status Policy which revealed it had been revised [DATE], and included ensuring each resident's CCP included the code status be incorporated on admission. Reviewed the facility's Admission Checklist for Nursing form which revealed it included the information for nurse's to obtain an order for [REDACTED]. Interview, on [DATE] at 3:00 PM, with Administrator revealed the facility's Code Status Policy had been revised as per the AOC. 13. Reviewed Care Plan Conference notes, dated [DATE], which included reviewing the resident's Code Status at the planned Care Plan Conferences. Interview, on [DATE] at 1:06 PM, with the SSD revealed residents' code status was being discussed at care plan conferences which began on [DATE]. 14. On [DATE], the Employee Roster Report listing of all licensed staff with CPR expiration dates and copies of their CPR certification was reviewed. Reviewed the CPR certification class roster and certification cards from classes provided by the facility on [DATE] and [DATE]. Review of the documentation revealed all licensed nursing staff now had current CPR certification. 15. Reviewed the facility's CPR and Code 500 policies. Reviewed the sign in sheet and education provided by the Administrator to the DON and ADON related to the CPR and Code 500 Policy dated [DATE]. Interview with the DON and ADON, on [DATE] at 2:26 PM, revealed they had been educated by the Administrator on [DATE], regarding the CPR and Code 500 policies. Interview, on [DATE] at 3:00 PM, with the Administrator revealed the facility's CPR and Code 500 policies had been implemented on [DATE], as per the AOC. A post-survey interview on [DATE] at 9:32 AM, with the Administrator revealed after becoming aware of the need to have someone CPR certified in the building at all times, he had read the regulatory requirements and conferenced with the Consultant Administrator for guidance. Per interview, the Consultant Administrator had discussed with him getting staff CPR certified and what needed to be done to ensure this was done. The Administrator stated he and the Consultant Administrator had communication all the way through the process and had developed the plan of action. 16. Reviewed the sign-in sheets and education provided by the DON and ADON for all staff related to the CPR and Code 500 Policy, dated [DATE] through [DATE] and reviewed the post-tests. Interview, on [DATE]: at 11:45 AM with RN #4; at 1:20 PM with CNA #12; at 1:25 PM with House Keeping #14; at 1:30 PM with Dietary #15; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; at 2:10 PM with LPN #8; at 2:20 PM with CNA #13; at 3:40 PM with CNA #4; at 3:50 PM with CNA #11; at 7:10 PM with LPN #9; at 7:20 PM with RN #5; at 10:05 PM with CNA #3; at 10:19 PM with CNA #4; at 10:25 PM with CNA #17; and, at 10:30 PM with CNA #18 revealed they had all been educated on the CPR and Code 500 policies, and other code policies and General Documentation Guidelines for CPR, and had taken a post-test after the education. Interview, on [DATE] at 2:26 PM, with the DON revealed all but four (4) staff had received the education on the facility's code policies and CPR policy. The DON stated the four (4) staff who had not received the education were on medical leave, but would not be put on the schedule to work until they had received the education. Per interview, the education was added to the new hire orientation training agenda. Interview, on [DATE] at 3:00 PM, with Administrator revealed facility staff had been educated on the CPR, Code 500 and other code policies, as per the AOC. 17. Reviewed the Administrator's audits of all resident's CCP for verification that each residents' code status was care planned. The audits revealed each resident had a Code Status CCP with no issues identified and the Administrator had signed the audits as completed on [DATE]. Interview, on [DATE] at 3:00 PM, with Administrator revealed he had completed the audit of all residents' CCPs on [DATE], with no problems noted, as per the AOC. Per interview, the results of the audits would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 18. Interview, on [DATE] at 2:26 PM, with the DON revealed she would audit all newly hired nursing staff for their CPR certification expiration dates. Per interview, she would schedule CPR certification courses as necessary to make sure the Charge Nurses all maintained their CPR certification. 19. Reviewed the Administrator's audits, performed on [DATE], of all nurses' personnel files to ensure they were CPR certified. The audits revealed each licensed staff's CPR certification was present with the expiration date, and no issues were identified by the Administrator. Interview, on [DATE] at 3:00 PM, with the Administrator revealed he had performed the audits of all nurses' personnel files for CPR certification on [DATE], and had not identified a problem. The Administrator revealed he would continue to monitor the DON's verification of the Charge Nurse's CPR certification to ensure they maintained current CPR certification. Per interview, the results of the audits would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 20. Reviewed the Administrator's audit of the current facility schedule verifying a CPR certified staff member was present in the facility at all times, dated [DATE]. Interview, on [DATE] at 3:00 PM, with the Administrator revealed he had completed the audit of the facility's current schedule to verify a CPR certified staff member was present in the facility at all times on [DATE]. He revealed he would continue to monitor the nursing schedule monthly to ensure all shifts were staffed with a CPR certified nurse. Per interview, the results of the audits would be taken to the facility's Quality Assurance/Performance Improvement (QA/PI) Committee, and any issues discussed with development of a plan to correct the problem. 21. Reviewed the sign in sheet and notes for the Mock Code Drill, conducted on [DATE]. Interview on [DATE]: at 11:45 AM with RN #4; at 1:40 PM with LPN #6; at 1:50 PM with LPN #1; and, at 2:10 PM with LPN #8 revealed the Mock Code Drill had been completed by the facility, and the findings had been reviewed with staff and allowed for staff input. Interview, on [DATE] at 2:26 PM with the DON and at 3:00 PM, with the Administrator revealed the Mock Code Drill had been completed on [DATE], as per the AOC. They stated the results had been discussed with staff afterwards. The Administrator and DON revealed the facility would continue to conduct Mock Code Drills weekly for sixty (60) days on different days and shifts, and they would monitor the documentation of the drills for accuracy and completeness, as per the AOC. 22. Interview, on [DATE] at 1:20 PM, with the Medical Director revealed the facility had notified him of the Immediate Jeopardy and findings. Per interview, he had also been notified of the changes made to the facility's code policies and the new system for identification of Full Code residents.