Every finding on record at Pleasant View Nursing Center

Based on record review, interviews, and review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation, Abuse Prevention: Fast Alerts, the facility failed to ensure a complete and thorough abuse investigation was conducted for six of nine Residents (R) (R2, R3, R4, R6, R5, and R9) reviewed for abuse investigations out of a total sample of 22 residents. This failure had the potential to result in additional residents to be abused by the same perpetrator.Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation, Abuse Prevention: Fast Alerts, dated 10/2023, revealed All alleged violations involving mistreatment, sexually inappropriate behaviors, and abuse or neglect will be thoroughly investigated…An immediate investigation into the alleged incident, during the shift it occurred on …2. Interview the resident or other resident witness.' 1.Review of R2's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, indicated R2 was admitted to the facility with diagnoses that included but not limited to, Parkinson's disease with dyskinesia, delusional disorders, end stage renal disease, paranoid schizophrenia, and vascular dementia. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/2025, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating R2 was moderately cognitively impaired. R2 exhibited hallucinations and delusions. Review of Facility Reportable Incident (FRI) dated 1/20/2025 with date of incident: 1/20/2025 at 6:30 pm provided by the facility, recorded Resident [R2] called the police. Police arrived at the facility. Resident stated that staff has taken her items and other residents touched her…Alleged perpetrators: Two men in building-Other residents. 2. Review of R3's undated admission Record located in the EMR under the Profile tab, indicated R3 was admitted to the facility with diagnoses that included but not limited to, chronic obstructive pulmonary disease, peripheral vascular disease, and major depressive disorder. Review of R3's quarterly MDS with an ARD of 6/11/2025, located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. R3 was assessed as experiencing delusions. Review of R4's undated admission Record located in the EMR under the Profile tab, indicated R4 was admitted to the facility with diagnoses that included but not limited to, schizoaffective disorder, bipolar type, drug induced subacute dyskinesia, and thrombocytosis. Review of R4's quarterly MDS with an ARD of 3/22/2025, located in the EMR under the MDS tab, revealed a BIMS core of 14 out of 15 which indicated R4 was cognitively intact, and exhibited the behavior of wandering for one to three days during the assessment period. Review of the Facility Reportable Incident provided by the facility, dated 4/14/2025, recorded that on 4/11/2025 around 11:30 pm, R4 reported that her male friend (R3) hit her in the chest when she was in bed with him asleep. 3. Review of R6's undated admission Record located in the EMR under the Profile tab, indicated R6 was admitted to the facility with diagnoses that included but not limited to, bipolar disorder, psychosis not due to a substance or physiological condition, major depressive disorder, schizoaffective disorder, bipolar type, schizophrenia, adjustment disorder with mixed disturbance of emotions and conduct, and borderline intellectual functioning. Review of R6's quarterly MDS with an ARD of 3/20/2025 located in the EMR under the MDS tab, revealed a BIMS of 99 out of 15. The staff assessment for cognitive skills revealed R6 was severely cognitively impaired. R6 was assessed for exhibiting hallucinations and delusions. Review of R5's undated admission Record located in the EMR under the Profile tab indicated R5 was admitted to the facility with diagnoses that included but not limited to, schizophrenia, major depressive disorder, and mild cognitive impairment. Review of R5's quarterly MDS with an ARD of 7/5/2025 located in the EMR under the MDS tab revealed a BIMS score of 11 out of 15, indicating the resident was moderately cognitively impaired and was assessed as not exhibiting behaviors. Review of the Facility Reported Incident provided by the facility and dated 4/8/2025 revealed On Tuesday, April 8, 202025, R5 alleged that R6 put his hand around her neck while removing her smoking apron. Staff immediately intervened and separated the residents. R6 was placed on one-on-one supervision. No bruising or visible injury was observed by nursing. During an interview on 9/10/2025 at 9:45 am, the Administrator confirmed that additional resident interviews were not conducted during the investigation for the above FRIs and should have been conducted. 4. Review of R9's EMR revealed the Profile tab indicated R9 was admitted on [DATE] and discharged on 8/22/2025. Review of R9's EMR Progress notes tab revealed a note, dated 6/10/2025 at 7:23 pm, EMS [Emergency Medical Services] arrived to transport resident [R9] to hospital due to elevated lab values Review of a note, dated 6/11/2025 at 9:46 am, indicated Received a phone call from [name of Social Worker at (Name) Hospital] stating that she was concerned about some bruises noted on pts [patients] body. Explained to her that the pt had fallen frontwards out of his wheelchair because he tends to lean forward. The note indicated the previous Director of Nursing (DON) was the person notified. During an interview on 9/8/2025 at 2:56 pm, the Administrator stated that she knew of the call from the hospital's Social Worker. The Administrator confirmed that there was no documentation that this allegation was investigated and that it should have been investigated.

Based on record review, interview, and review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to notify the State Survey Agency (SSA) of an allegation of physical abuse for one of seven Residents (R) (R9) reviewed for abuse out of 22 sampled residents. Specifically, there was no documentation that the SSA was notified of an allegation of physical abuse when the Director of Nursing (DON) was notified of bruising to R9's body by the hospital's Social Worker. This failure had the potential to contribute to further abuse or injury, which could result in mental anguish, physical harm, or fear.Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated October 2023, indicated . Reporting-All employees are required to immediately notify the administrative.staff of any complaint, allegation.of resident abuse.as soon as the facility is aware of a situation.they must immediately notify the administrator and other officials.including the State Survey Agency. Review of R9's electronic medical record (EMR) revealed on the Profile tab that R9 was admitted on [DATE] and discharged on 8/22/2025. Review of R9's EMR Progress notes tab revealed a note dated 6/10/2025 at 7:23 pm EMS [Emergency Medical Services] arrived to transport resident [R9] to hospital due to elevated lab values. Review of a note, dated 6/11/2025 at 9:46 am revealed, Received a phone call from [name of Social Worker at [Name] Hospital] stating that she was concerned about some bruises noted on pts [patients] body. Explained to her that the pt had fallen frontwards out of his wheelchair because he tends to lean forward. The note indicated the previous Director of Nursing (DON) was the person notified. During an interview on 9/8/2025 at 2:56 pm, the Administrator stated that she knew of the call from the hospital's Social Worker. The Administrator confirmed that this allegation was not reported to the SSA and should have been.

Based on observations and staff interviews, the facility failed to ensure three of three garbage dumpsters were maintained in sanitary conditions, free from trash and debris on the ground, and with secure fitting lids. The deficient practice had the potential to promote the harboring of pests, rodents, insects, and other organisms. The facility census was 101 residents. Findings include: Observation of the dumpster on 8/18/2024 at 3:15 pm with the Dietary Manager (DM) and Maintenance Director revealed trash piled up high and spilling over to the ground in three of three dumpsters. Further observation revealed opened bags of trash, exposing dirty briefs with fecal matter, wipes covered in feces were observed scattered on the ground surrounding the dumpsters. Continued observation revealed swarms of flies and at least 50 large clear white trash bags on the ground around the dumpsters. The large clear bags contained food, trash, and soiled personal care items. An interview at the time of observation on 8/18/2024 at 3:16 pm was conducted with the DM and Maintenance Director. Both staff members confirmed that the dumpsters were not being maintained in sanitary conditions. They confirmed the exposure of feces from the briefs, food items, and trash. The DM reported the problem with the dumpsters had existed since the previous Monday. She stated that trash bags on the ground increased due to not having enough room in the dumpsters to place the trash. The Maintenance Director reported the problem existed because the bill for the trash service had not been paid by the facility. In an interview on 8/18/2024 at 3:41 pm, the Maintenance Director revealed that trash was not picked up due to nonpayment to the trash pick-up company. He reported the trash started to pile up the previous Sunday. He stated the scheduled days for trash pick-up were Monday and Thursday, and the trash was last picked up on 8/8/2024. The Maintenance Director further stated he informed the Administrator of the failure of the trash being picked up on 8/13/2024. He stated he was not given specific instructions on what to do about the trash. In an interview on 8/21/2024 at 9:18 am, the Administrator confirmed the dumpsters were not maintained in sanitary conditions, and he had failed to provide staff with instructions on handling the trash pile up. He stated the corporate office was notified on 8/14/2024 about a problem with payment to the trash pick-up company, and he understood the bill was already paid. He stated having trash dumpsters in an unsanitary manner increased the risk of animals, pests, and insects. He stated he was unaware the bags were spilling trash on the ground and stated that if he had been notified of trash on the ground, he would have removed it.

Based on observations, staff interviews, and review of the facility's policies titled, Laundry Linen: Handling of, and Biohazardous/Infectious Waste, the facility failed to follow acceptable infection control practices to prevent cross-contamination during a glucometer check for one resident, during the storage of linen in one linen storage room, during the storage of soiled linen in two shower rooms, and during the storage of washbasins and urinals in three resident restrooms. These deficient practices had the potential to increase the risk of cross-contamination and spread infections. Findings include: 1. During observation of the glucometer procedure on 8/19/2024 at 10:30 am, Licensed Practical Nurse (LPN) GG performed a fingerstick blood sugar on one resident. Observation revealed LPN GG placed the supplies on the surface of the cart before entering the resident's room without sanitizing or placing a barrier on the cart. She performed the procedure and placed the used supplies (including the glucometer, used alcohol pad, and used fingerstick device) on the surface of the cart without sanitizing or using a barrier on the surface of the cart. In an interview at the time of the observation, LPN GG confirmed she did not use a barrier to put her supplies on. She stated she should have used a barrier under the meter and supplies. During an interview on 8/21/2024 at 4:30 pm, the Unit Manager stated the nurse should use a barrier to put the glucometer and supplies on and not just lay them on the surface of the cart. During an interview on 8/21/2024 at 4:45 pm, the Director of Nursing (DON) stated the nurse should use a barrier on the surface of the cart after using the glucometer. 49138 2. An observation on 8/18/2024 at 2:45 pm of room [ROOM NUMBER]A 400 Hall revealed one washbasin in the bathroom unbagged and not labeled with a resident's name. An observation on 8/18/2024 at 2:37 pm of room [ROOM NUMBER]B 400 Hall revealed one washbasin in the bathroom unbagged and not labeled with a resident's name. An observation on 8/18/2024 at 2:32 pm of room [ROOM NUMBER]B 200 Hall revealed three washbasins in the tub and one urinal hanging on the toilet paper holder unbagged and not labeled with a resident's name. In an interview on 8/20/24 at 3:25 pm, the DON confirmed all washbasins and urinals should be bagged and labeled with a resident's name. 49675 3. A review of the facility policy titled, Laundry Linen: Handling of, revised September 2023, revealed the section titled, Transportation of Clean Linen included . 3. Cover stored linen to protect from contamination until the linen is distributed for resident use. 5. Transport collected and bagged linen by cart or soiled linen chute to the laundry area at regular intervals as needed. a. Do not allow hampers to overfill, lids must be closed. A review of facility policy titled, Biohazardous/Infectious Waste, revised September 2023, revealed the section titled Overview included The facility will dispose of Infectious Waste according to the Federal Government Environmental Protection Agency (EPA) requirements or according to state and local regulations, whichever is the strictest. The section titled Procedure included . 5. Dispose of sharps, used and unused, in an impervious, rigid, puncture-resistant, leak-proof on the sides and bottom, closable sharps container. Do not overfill. Observation on 8/19/2024 at 1:23 pm revealed a small storage room with an exit door from the main building that led to the outdoor laundry facility. The storage room contained two wire racks. The bottom shelf of the racks contained pillows that were touching the concrete floor. The other shelves contained linen which was uncovered and exposed to the environment. During an observation and interview on 8/19/2024 at 1:35 pm, the Account Manager stated he was over the laundry and housekeeping departments and confirmed the pillows in the storage room were touching the floor, and the linen was uncovered. He stated this was a mistake and would be corrected. Observations on 8/18/2024 at 5:19 pm and 8/19/2024 at 11:58 am of the D Hall Shower Room revealed a basket of soiled clothes, a plastic hamper of soiled towels, soiled towels lying on the floor, soiled toilet paper lying next to the toilet, a box fan turned on and running covered in dirt and dust sitting on the back of the toilet, numerous clothing items such as shoes and clothes hanging on grab bars and lying on the floor, two rolls of toilet paper lying on the floor, and a sharps container overfilled with a razor exposed. Observations on 8/18/2024 at 5:27 pm and 8/19/2024 at 11:55 am of the C Hall Shower Room revealed soiled wet towels in the shower stall, numerous soiled wet towels in a pile on the shower room floor, an overflowing trash can, and an uncovered plastic tub full of clothing on a shower bed. During observation and interview on 8/19/2024 at 3:35 pm, the Administrator and Maintenance Director confirmed the findings in both shower rooms. The Administrator stated the findings in the shower rooms were unacceptable. He acknowledged the identified concerns were infection control issues and would be corrected. During an observation and interview on 8/19/2024 at 4:50 pm, LPN BB confirmed a sharps container located in the D Hall Shower Room was full and had an exposed disposable razor. LPN BB stated the sharps container was full and needed to be changed out. In an interview on 8/21/2024 at 4:30 pm, the Infection Control Preventionist (ICP) stated her expectations were for staff to ensure linens were always covered during storage and for linen and clothing to be off of the floors to avoid exposure to contamination. She further stated sharps containers should be changed out when they were full and acknowledged these concerns could spread infection. In an interview on 8/21/2024 at 4:53 pm, the Regional Director of Nursing confirmed that sharps containers should be emptied when they are full. She revealed there was no one designated to change out sharp containers.

Based on observations, interviews, and a review of the facility's policy titled, Medication Administration Guidelines, the facility failed to ensure that one of two medication carts was locked and secured when unattended by the nurse. The deficient practice had the potential to allow unauthorized persons, including residents and visitors, to access medications. The census was 101 residents. Findings include: A review of the facility policy titled, Medication Administration Guidelines, dated August 2021, revealed the section titled Safe Medication Administration included, Medication carts are to be kept locked at all times and under the vision supervision of the licensed nurse. During observation on 8/18/2024 from 12:15 pm to 12:21 pm, Medication Cart 2 was parked in the hallway, unattended, and unlocked. The medication drawer was pulled, and it opened without a problem. Registered Nurse (RN) JJ approached the cart and locked it. During an observation on 8/18/2024 at 6:41 pm, Medication Cart 2 was parked in the hallway, unattended, out of sight of a nurse, and unlocked. Licensed Practical Nurse (LPN) II noticed the surveyor looking at the cart and locked it. During an interview on 8/18/2024 at 7:00 pm, RN JJ revealed the medication cart should be locked unless a nurse was at the cart. She confirmed that the cart was unlocked this shift and there was not a nurse at the cart. During an interview on 8/18/2024 at 7:05 pm, LPN II revealed the medication cart needs to be locked unless the nurse was at the cart. LPN II confirmed she left the cart opened earlier this shift and stated she had a resident who was transported to the emergency room and she forgot and left the cart open. During an interview on 8/21/2024 at 5:00 pm, the Unit Manager stated the medication cart should always be locked unless the nurse is present and giving medications. During an interview on 8/21/2024 at 5:30 pm, the Director of Nursing (DON) revealed the medication cart should be locked when the nurse is not present at the cart.

Based on observations, staff interviews, record review, and review of the facility policy titled, F-689 Accidents -Water Temperatures, the facility failed to maintain safe water temperatures at the hand washing sink in 12 of 28 resident bathrooms and two of three resident shower rooms. In addition, the facility failed to ensure an environment free from chemical and environmental hazards in one of three shower rooms. This deficient practice placed the residents residing in the affected rooms and using the affected shower rooms at risk of avoidable injuries and a diminished quality of life. The census was 101 residents. Findings include: 1. A review of the facility's undated policy titled, F-689 Accidents - Water Temperatures, revealed the section titled F - 689 Description stated, The facility must ensure that the resident environment remains free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. The section titled Purpose included, The purpose of recording your water temperatures is to assure the Surveyor that your facility is remaining as free from accidental burns and scalds as possible and that any issues are addressed in a prompt and consistent manner. During observation on 8/18/2024 at 2:00 pm, the hot water in the shared bathroom of Rooms A1 and A3 felt hot to touch. The surveyor was able to keep a hand under the water for only about five seconds. During an interview on 8/18/2024 at 2:45 pm, the Maintenance Director revealed he checked water temperatures every day and randomly picked rooms and sinks to test. On 8/18/2024, the following water temperatures in resident bathroom sinks were obtained by the Maintenance Director using the facility's calibrated thermometer: 4:23 pm Rooms A1 and A3 shared bathroom = 117 degrees Fahrenheit (F). 4:24 pm Rooms A9 and A11 shared bathroom = 116 degrees F. 4:50 pm Rooms B3 and B5 shared bathroom = 114 degrees F. 4:53 pm Rooms B7 and B9 shared bathroom = 114 degrees F. 4:56 pm Room B11 bathroom = 114 degrees F. 5:00 pm Room B1 bathroom = 112 degrees F. 5:05 pm Rooms A5 and A7 shared bathroom = 111 degrees F. 5:07 pm Rooms A10 and A12 shared bathroom = 110.3 degrees F. 5:10 pm Rooms D2 and D4 shared bathroom = 119 degrees F. 5:12 pm Rooms D1 and D3 shared bathroom = 123 degrees F. 5:15 pm Room D19 bathroom = 115 degrees F. 5:17 pm Room D16 bathroom = 111 degrees F. 5:19 pm D Hall Shower = 112 degrees F. 5:27pm C Hall Shower = 116 degrees F. A review of a temperature logbook dated 5/20/2024 through 8/16/2024 revealed documented temperatures for the shower rooms ranging from 112 to 118 degrees F. During an interview on 8/18/24 at 5:00 pm, the Director of Maintenance stated the hot water temperature should be 107 or 108 degrees F. He verified the temperatures documented in the logbook and stated someone had told him to keep the temperatures at 114 degrees F for the shower rooms. During an interview on 8/18/2024 at 6:00 pm, the Maintenance Director stated the mixing valve unit was set at 110 degrees F and further stated he turned the device down, but it went up to 116 degrees F. He stated the hot water heater in the Behavioral Unit was at 115 F, and he had turned it down. On 8/18/2024 at 6:15 pm, the Administrator was informed of the elevated water temperatures. He stated the temperatures of the entire building would be checked every shift until the temperatures were down, and the residents in the Behavior Unit would be monitored until the water temperatures were down. During an interview on 8/18/2024 at 6:45 pm, the Director of Maintenance stated the mixing valve was set at 112 degrees F. He stated he may have turned it up instead of down, and he turned it down. During an interview on 8/19/2024 at 10:00 am, the Director of Maintenance stated water temperatures in resident rooms were checked every four hours during the evening and night shifts, and the temperatures were below 110 degrees F. He stated he would continue to check the temperatures every four hours. During an interview and observation of hot water temperatures on 8/19/2024 at 1:00 pm with the Director of Maintenance, the following temperatures were observed: Rooms D1 and D3 shared bathroom = 116 degrees F. Rooms D6 and D8 shared bathroom = 115 degrees F. During an interview on 8/19/2024 at 1:45 pm, the Administrator stated he would notify the [NAME] President of the company to discuss the rising water temperatures in the Behavioral Unit. During an interview on 8/19/2024 at 2:30 pm, the [NAME] President stated there was a faulty thermostat on the re-circulation pump and the Director of Maintenance would re-adjust it, which should maintain the temperatures. During an interview on 8/19/2024 at 4:00 pm, the Director of Maintenance stated he checked the water temperatures in the building, and none were elevated. Observations of temperature checks with the Maintenance Director on 8/19/2024 at 6:25 pm revealed the water temperature in Rooms D1 and D3 shared bathroom = 100 degrees F and in Rooms D6 and D8 shared bathroom = 94 degrees F. 49675 2. Observations on 8/18/2024 at 5:27 pm, 8/19/2024 at 2:46 pm, and 8/19/2024 at 5:50 pm in the D Hall Shower Room located in the secured Behavioral Health Unit revealed a cart containing a bottle of 70 percent isopropyl alcohol and a hand-held hair dryer. The hair dryer was plugged into a wall electrical outlet on one side of the sink, with the cord running under the sink. Further observation revealed four wet floor signs, shoes, clothing, toilet paper, and towels scattered on the floor. During observation and interview on 8/19/2024 at 3:35 pm, the Administrator and the Maintenance Director confirmed the findings in the D Hall Shower Room. The Administrator unplugged the hair dryer from the wall and placed it on the cart next to the sink stating someone could get seriously hurt. He stated that the condition of the shower room was unacceptable and posed numerous accident hazards. During observation and interview on 8/19/2024 at 4:50 pm, Licensed Practical Nurse (LPN) BB confirmed the bottle of 70 percent isopropyl alcohol was on a cart and stated it should be in a locked cabinet. In an interview on 8/21/2024 at 4:53 pm, the Regional Director of Nursing revealed hazardous chemicals, such as isopropyl alcohol, should not be in resident shower rooms. A policy pertaining to environmental hazards was requested and not provided.

Based on observations, staff interviews, and record review, the facility failed to place a privacy bag over the indwelling urinary catheter drainage bag of one of two residents (R) (R251) reviewed with a urinary catheter. This failure had the potential to diminish R251's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A policy was requested and not provided. A review of the clinical record revealed that R251 was admitted to the facility on [DATE], and the Minimum Data Set (MDS) was in progress. A review of the Physician's Orders revealed an order dated 8/9/2024 for a urinary catheter. A review of R251's care plan dated 8/19/2024 revealed a focus area of an indwelling urinary catheter due to urinary retention. There were no interventions for placing the drainage bag in a privacy bag. An observation on 8/18/2024 at 2:23 pm revealed R251's urinary catheter drainage bag was not in a privacy bag and was uncovered. An observation on 8/18/2024 at 5:30 pm revealed R251 walking down Hall 300 with his urinary catheter drainage bag strapped to his leg, not in a privacy bag, and uncovered. An interview on 8/20/2024 at 1:03 pm with the Director of Nursing (DON) confirmed that R251's urinary catheter drainage bag should be covered with a dignity bag. An interview on 8/21/2024 at 4:08 pm with Certified Nursing Assistant (CNA) DD revealed that R251's urinary catheter drainage bag should be covered for dignity purposes. An interview on 8/21/2024 at 4:12 pm with the Administrator revealed that R251's urinary catheter drainage bag should not be exposed and should be covered for dignity purposes.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure two of 54 residents (R) (R49 and R1) reviewed did not have unsecured, unauthorized medications and over-the-counter medication products stored at the bedside. This failure placed R49 and R1 at risk for inappropriate and unsafe medication use and had the potential to allow unauthorized access to medications to other residents and visitors in the facility. Finding include: 1. Record review revealed R49 had diagnoses including, but not limited to, vascular dementia, moderate without other behavioral disturbances, chronic obstructive pulmonary disease with acute exacerbation, and hypokalemia. A review of R49's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). A review of the Physician's Orders revealed an order dated 4/4/2024 for Ventolin HFA (high-flow aerosol) solution 108 mcg/act (micrograms/actuation) (a medication used to treat wheezing and shortness of breath [SOB]), one puff orally every six hours as needed for SOB. A review of R49's Self-Administration assessment dated [DATE] revealed the resident was not capable or approved to self-administer medications, including inhalants. Observation of R49's room on 8/18/2024 at 3:00 pm revealed a prescription albuterol inhaler (generic medication for Ventolin) in a small pan near the resident's bed within open view. In an interview at the time of observation on 8/18/2024 at 3:01 pm, R49 reported receiving the inhaler from a previous medical appointment. He stated that his nurse was aware of the medication and advised him to keep it in his room. He reported using the inhaler every now and then. During an interview and observation on 8/18/2024 at 4:07 pm in R49's room, the Unit Manager (UM)/Licensed Practical Nurse (LPN) confirmed the albuterol inhaler in R49's room. She reported that R49 was not assessed to self-administer medication or approved to have medication in his room. She reported being unaware of the medication in the room and removed the medications from the resident's room. She reported that her expectation was for nurses to monitor resident rooms for medications at the bedside. In an interview on 8/21/2024 at 12:22 pm, the Director of Nursing (DON) reported being unaware of R49 having prescription medication (albuterol inhaler) in his room. She described the risk of a resident receiving duplicate inhalant medication as a possibility of increased heart rate. She reported that once the resident returned from his appointment, the nurse should have placed the albuterol medication from the doctor's office on the medication cart and notified the physician. 2. A review of R1's medical record revealed diagnoses including, but not limited to, dementia, schizophrenia, and bipolar disorder. A review of R1's quarterly MDS dated [DATE] revealed a BIMS of seven (indicating severe cognitive impairment). A review of R1's clinical record revealed there was no assessment for self-administration of medication for R1. Observation of R1's room on 8/18/2024 at 5:03 pm revealed a bottle of mouthwash (containing six percent alcohol) on the bedside stand within open view. At the time of observation, an interview was conducted with R1 regarding the mouthwash. R1 reported using the mouthwash daily and that a friend purchased the mouthwash for her. During an observation of R1's room and an interview with the UM/LPN on 8/18/2024, the UM/LPM confirmed the unauthorized mouthwash product at the bedside. She reported that only alcohol-free base mouthwash products were allowed for resident use. The UM/LPN removed the mouthwash from the room. In an interview on 8/21/2024 at 4:49 pm, the DON reported that her expectation was for staff to remove any harmful products from resident rooms and to monitor for unauthorized medication products. She further stated the risk of a resident using unauthorized medication products could have an adverse effect on the resident's blood pressure and cause other medical complications.

Based on staff interviews, record review, and review of the facility policy titled, New Hire Checklist, the facility failed to ensure pre-employment screenings, specifically reference checks and fingerprinting, were conducted prior to employment for four of 10 employees reviewed. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The census was 101 residents. Findings include: A review of the facility policy titled New Hire Checklist, revised December 21, 2023, revealed information obtained upon hire included employee references (at least two), background checks to include sex offender state and nationwide, and fingerprint if applicable. The section titled Background and Criminal Checks stated, A background check will be conducted including, but not limited to, consumer credit history, criminal history, fingerprints, driving record, employment, military, education, and general public records, which will provide information concerning these areas, and your character and general reputation. Your former employers, educational institutions, managers, co-workers, and references, may be contacted as part of this process. During a review of employee files on 8/19/2024 at 2:30 pm with the Director of Human Resources, it was revealed the following information was not available: Dietary Supervisor LL was hired on 5/27/1998, and a reference check was not completed. Certified Nursing Assistant (CNA) MM was hired on 7/23/2024, and a reference check was not completed. Dietary [NAME] NN was hired on 7/23/2024, and a reference check was not completed. Activities Assistant OO was hired on 7/18/2024 and a fingerprint procedure was not completed. Activities Assistant OO worked 7/23/2024, 7/24/2024, 7/25/2024, 7/26/2024, 7/27/2024, 7/29/2024, 7/30/2024, 7/31,2024, 8/1/2024, 8/2/2024, 8/5/2024, 8/6/2024, 8/8/2024, 8/10/2024, 8/11/2024, 8/13/2024, 8/14/2024, 8/15/2024, 8/16/2024, 8/19/2024 without having a fingerprint procedure completed. During an interview on 8/19/2024 at 2:40 pm, the Director of Human Resources verified the missing pre-employment requirements and revealed she did not obtain the information because she had been very busy and did not get around to calling the references. She further stated she missed the date to get fingerprinting done for Activities Assistant OO. She stated she had 30 days after hire to get the fingerprinting done. During an interview on 8/21/2024 at 7:30 pm, the Administrator stated he was unaware of the missing pre-employment requirements. He stated he did not have an explanation of why the information was not in the files.

Based on observations, staff interviews, record review, and review of the facility policy titled RAI (Resident Assessment Instrument)/Care Planning Management, the facility failed to implement the person-centered comprehensive care plan for one of 12 residents (R) (R78) with a care plan for fall mats and two of two R (R49 and R68) with a care plan for oxygen (O2). This failure had the potential for R78, R49, and R68 to not receive treatment and/or care according to their needs. Findings include: A review of the facility's undated policy titled RAI/Care Planning Management revealed the section titled Process for Completing the MDS (Minimum Data Set), CAAs (Care Area Assessments), and Care Plans stated, Standard: It is the practice of this facility to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. Objective: 1. To identify resident's individual needs and care requirements. 2. To assure [sic] that an interdisciplinary team assesses the emotional, psychosocial, mental, and physical needs of each resident. 1. A review of R78's clinical record revealed diagnoses including, but not limited to, paranoid schizophrenia, Alzheimer's disease with late onset, and vascular dementia, severe, with other behavioral disturbances. A review of R78's care plan, last revised on 7/23/2024, revealed that R78 was at risk for falls related to poor safety awareness, medication side effects, a history of behaviors, and had a history of falls. The goal was for R78 to be free of fall-related injuries through the review date. Interventions included a fall mat to be placed on the floor beside the bed. Observations on 8/18/2024 at 3:20 pm, 8/19/2024 at 9:37 am, and 8/20/2024 at 10:09 am revealed the resident was lying in bed asleep, and there was no fall mat on the floor. In an observation and interview on 8/20/2024 at 4:15 pm, Licensed Practical Nurse (LPN) AA verified the resident did not have a fall mat by his bedside and that his care plan included interventions of a fall mat. LPN AA stated it was her expectation that she and other nurses follow the resident's care plans and use the interventions the care team implemented for the safety of the resident. In an interview on 8/21/2024 at 4:14 pm, the Regional Director of Nursing revealed it was her expectation that staff follow care plans and ensure fall mats were placed by the bedside if included in the care plan. In an interview on 8/21/2024 at 6:36 pm, the MDS Coordinator revealed she expected staff to follow the care plans. She stated she reviewed changes every morning in clinical meetings, and then care plans were updated as needed. She further stated care plan changes were communicated to staff when they occur. 36377 2. A review of R49's medical record revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) with acute exacerbation and hypokalemia. A review of R49's Physician Orders revealed an order dated 7/10/2024 for O2 per nasal cannula (NC) at 2 liters per minute (LPM) at night and as needed (PRN). A review of R49's care plan revealed a focus area, last revised on 6/12/2024, for being at risk for respiratory complications related to the disease process of COPD, and the resident will take O2 on and off and adjust settings. The interventions included administering O2 as ordered and observing O2 settings every shift and PRN while in use. Observations on 8/18/2024 at 1:01 pm, 4:00 pm, and 5:55 pm and on 8/19/2024 at 11:00 am revealed R49 receiving O2 via a NC at 2.5 LPM instead of 2.0 LPM. An observation and interview on 8/19/2024 at 11:21 am with LPN CC confirmed that R49 was receiving O2 at 2.5 LPM instead of 2.0 LPM. LPN CC reported being unaware of the care plan to monitor and check periodically to ensure R49's oxygen was set on the ordered flow rate. During an observation and interview on 8/20/2024 at 10:48 am, the Unit Manager confirmed that R49 's O2 was set at 2.5 LPM instead of 2.0 LPM and adjusted the O2 to 2.0 LPM. She reported being unaware of the resident's care plan to monitor the O2 settings. 3. A review of R68's medical record revealed diagnoses including, but not limited to, acute chronic respiratory failure with hypoxia or hypercapnia and chronic atrial fibrillation. A review of R68's Physician Orders revealed an order dated 6/11/2024 for O2 per NC at 2 liters LPM PRN shortness of breath (SOB). A review of R68's care plan revealed a focus area, last revised on 8/12/2024, for altered respiratory status/difficulty breathing related to sleep apnea, respiratory failure, obesity with hypoventilation, and COPD. The interventions included administering oxygen as ordered. Observations on 8/18/2024 at 2:00 pm and 4:03 pm and 8/19/2024 at 9:00 am and 11:24 am revealed R68 receiving O2 via a NC at 2.5 LPM instead of 2.0 LPM. In an interview on 8/21/2024 at 6:36 pm, the MDS Coordinator reported her expectation was for staff to follow the resident's care plans. The MDS Coordinator stated updates or changes to a resident's care plan were addressed in the morning clinical meetings. Cross-Reference F695

Based on observations, staff interviews, and record review, the facility failed to follow the physician's orders for two residents (R) (R43 and R78). Specifically for an evaluation for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) for R43 and for gastrostomy tube (G-tube) water flushes for R78. This failure had the potential for R43 and R78 to not receive medical treatment according to their needs and placed them at risk for adverse consequences. Findings include: 1. A review of R43's Face Sheet revealed R43 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, contracture of left hand. A review of the admission Minimum Data Set (MDS), dated [DATE], and the quarterly MDS, dated [DATE], revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status Score (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented the resident did not receive PT, OT, or ST. A review of R43's Physician Orders revealed an order dated 5/2/2024 for evaluations for PT, OT, and ST. Observation during the survey from 8/18/2024 through 8/20/2024 revealed R43 lying in bed with no splint device, and his left hand third and fourth fingers were folded into the palm of his hands. During an interview on 8/18/2024 at 3:25 pm, R43 reported a concern about not receiving therapy services for a splint device and range of motion (ROM) for his left-hand contracture. In an interview on 8/21/2024 at 12:58 pm, the Unit Manager acknowledged that R43 had a physician order for therapy evaluation. She reported being unaware that the order was not followed up on. In an interview on 8/21/2024 at 1:10 pm, the Director of Rehabilitation confirmed the therapy department had not performed therapy evaluations for R43. She confirmed that she met the resident at the time of admission and was aware of his contracture. She stated she felt the resident would benefit from ROM therapy services and a splint device. In an interview on 8/21/2024 at 4:55 pm, the Director of Nursing (DON) reported that her expectation was for physician orders to be followed. 49675 2. A review of R78's Face Sheet revealed diagnoses including, but not limited to, dysphagia and unspecified severe protein-calorie malnutrition. A review of R78's Significant Change MDS, dated [DATE], revealed section K (Swallowing/Nutritional Status) documented R78 had a feeding tube and received 51 percent or more of total calories and 501 cubic centimeters (cc) or more per day of fluid intake through the feeding tube. A review of R78's care plan, revised on 8/12/2024, revealed R78 will receive feeding and hydration via G-tube as ordered. A review of the Physician's Orders revealed an order dated 8/10/2024 to flush the G-tube with 5 cc of water after each medication and flush the G-tube with 30 cc of water before and after feedings. Further review revealed an order dated 8/11/2204 for Jevity 1.5, give 237 milliliters (ml) every four hours. A review of the medication administration record (MAR) dated 8/2024 revealed no documentation of G-tube water flushes with medications or feeding. A review of the Progress Notes revealed no documentation of water flushes of the G-tube. In an interview on 8/20/2024 at 4:15 pm, Licensed Practical Nurse (LPN) AA verified water flushes of the G-tube were not documented on the MAR or in the clinical record. She revealed her expectations were for staff to follow physician orders by flushing the G-tube and document if it was performed. In an interview on 8/21/2024 at 4:14 pm, the Regional Director of Nursing revealed the nurse who receives the physician's order was responsible for transcribing it onto the MAR. She stated her expectation was for physician orders to be listed on the MAR and followed.

Based on observations, staff interviews, and record review, the facility failed to provide services to increase or prevent a decrease in range of motion (ROM) for one of 52 sampled residents (R) (R43). The deficient practice had the potential to place R43 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of R43's Face Sheet revealed that R43 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, contracture of the left hand. A review of the admission Minimum Data Set (MDS), dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status Score (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented the resident did not receive Physical Therapy (PT) or Occupational Therapy (OT). A review of R43's Physician Orders revealed an order dated 5/2/2024 for evaluations for PT, OT, and Speech Therapy. A review of 43's care plan, last revised on 7/26/2024, revealed a focus area of being at risk for complications related to contractures, being dependent on staff for ADLs (Activities of Daily Living), and having impaired mobility. Interventions included providing ROM as tolerated during ADL care. A review of the Plan of Care (POC) used by the Certified Nursing Assistants (CNAs) revealed no instruction to provide ROM to the resident's left hand. Continued review revealed the contracture of the left hand was not identified on the form. Observation during the survey from 8/18/2024 through 8/20/2024 revealed R43 lying in bed with no splint device, and his left hand third and fourth fingers were folded into the palm of his hands. In an interview on 8/18/2024 at 3:25 pm, R43 reported that staff was not providing ROM of his left hand. R43 reported that he did not have full flexion of the fingers on his left hand. He further stated he had not been evaluated by therapy since admission to the facility. In an interview on 8/21/2024 at 12:54 pm, CNA DD confirmed not providing ROM to R43's left hand. She reported being aware that the resident had a contracture of the left hand. In an interview on 8/21/2024 at 12:58 pm, the Unit Manager reported she was aware that R43 had a contracture of the left hand. She stated she thought the resident was referred for PT and OT to evaluate him to address the contracture. In an interview on 8/21/2024 at 1:10 pm, the Director of Rehabilitation stated the therapy department had not performed a therapy evaluation for R43. She confirmed that she was aware of the resident's contracture of his left hand. In an interview on 8/21/2024 at 4:55 pm, the Director of Nursing (DON) stated once the therapy department evaluated a resident, therapy recommendations were added to the CNA POC.

Based on observations, staff interviews, record review, and review of the facility policy titled, Respiratory System Management Standard, the facility failed to ensure two residents (R) (R49 and R68) receiving oxygen (O2) therapy were administered O2 in accordance with the physician order. The deficient practice had the potential to increase the risk of respiratory complications for R49 and R68. The sample size was 52 residents. Findings include: A review of the facility's undated policy titled, Respiratory System Management Standard, revealed the section titled Oxygen Therapy Protocol stated, Standard oxygen therapy is the administration of oxygen at concentrations greater than ambient air to: Treat or prevent hypoxemia, decrease work of breathing, decrease myocardial work. Procedure to follow in order (1). Check the physician's orders in the resident's clinical record. 1. A review of R49's medical record revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) with acute exacerbation and hypokalemia. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed section O (Special Treatments and Programs) documented that R49 received O2 while a resident. A review of the Physician Orders revealed an order dated 7/10/2024 for O2 per nasal cannula (NC) at 2 liters per minute (LPM) at night and as needed (PRN). Observations on 8/18/2024 at 1:01 pm, 4:00 pm, and 5:55 pm, 8/19/2024 at 11:11 am, and 8/20/2024 at 10:48 am, revealed R49 receiving O2 by a concentrator and via a NC at 2.5 LPM. 2. A review of R68's medical record revealed diagnoses including, but not limited to, acute chronic respiratory failure with hypoxia and hypercapnia. A review of the quarterly MDS dated [DATE] revealed section O (Special Treatments and Programs) documented that R49 received O2 while a resident. A review of R68's Physician Orders revealed an order dated 6/11/2024 for O2 per NC at 2 liters LPM PRN shortness of breath (SOB). Observations on 8/18/2024 at 2:00 pm and 4:03 pm, 8/19/2024 at 9:00 am, and 8/20/2024 at 10:48 am revealed R68 receiving O2 by a concentrator and via a NC at 2.5 LPM. In an interview at the time of observations on 8/19/2024, Licensed Practical Nurse (LPN) CC confirmed that R49 and R68 were receiving O2 by a concentration and via a NC at 2.5 LPM instead of 2.0 LPM. LPN CC reported being unaware to monitor and ensure R49's O2 was set on the correct liter. She further stated she was unaware if the resident adjusted the O2 flow meter on the concentrator. During an interview and observation on 8/20/2024 at 10:48 am, the Unit Manager confirmed that R49 and R68's O2 were set to 2.5 liters instead of 2.0 liters. She adjusted the O2 to 2.0 LPM for both residents. She reported that her expectation was to ensure residents were receiving O2 as ordered. She said that R49 was capable of putting on his NC appropriately but not competent in adjusting the flow meter for the correct liter per his physician's order. She reported that her expectation was for the nurse to monitor the O2 during the medication pass. She reported that the resident independently adjusting his O2 and staff not monitoring the O2 setting placed R49 at risk for complications. In an interview on 8/21/24 at 6:36 pm, the MDS Coordinator stated R49 had a history of adjusting the flow meter on his O2 concentrator. She reported that her expectation was for staff to monitor R49 and R68 's O2 settings. In an interview on 8/21/2024 at 12:17 pm, the Director of Nursing (DON) reported that her expectation was for staff to ensure O2 was administered according to the physician's order. She further stated that R49 was at risk of COPD exacerbation by receiving more than the ordered amount of O2.

Based on observations, staff interviews, and a review of the facility's policy titled, Food storage, the facility failed to cover stored food, keep scoops and cups out of stored dried foods, store meat, vegetables, nutritional supplements, and bread products in a kitchen reach-in freezer at zero degrees Fahrenheit (F) or lower, and date nutritional supplements when removed from freezer storage. This failure had the potential to affect all 99 residents who consumed food from the kitchen. Findings include: Review of the facility's undated policy titled, Food storage, revealed Temperatures for freezer should be 0 degrees or below and must be recorded daily., Scoops are not to be stored in the food containers but are kept covered in a protected are near the containers. and Leftover food is stored in covered containers or wrapped carefully and securely. Review of the facility's undated policy titled, Shelf Life of House Supplements and Thickened Liquids, specified the shelf life of frozen shakes was 14 days (with an internal temperature of) 41 degrees or below & unopened. 1. Observations made during the initial kitchen inspection on 02/20/2023 at 11:20 a.m. of food stored in the kitchen's reach in refrigerator revealed a pan of tuna fish was only partially covered with a piece of aluminum foil. Approximately six inches of the tuna stored in this pan was completely uncovered and unprotected from contamination. Interview on 02/21/2023 at 2:15 p.m. with the Dietary Manager (DM) revealed the tuna fish was no longer in this refrigerator and all stored food should be completely covered. 2. Observations made during the initial kitchen inspection on 02/20/2023 at 11:20 a.m. of food stored in the kitchen's dry storage area revealed a large, open box of croissants that was only partially covered with aluminum foil. Croissants stored at the end of the box were completely uncovered and unprotected from contamination. Interview on 02/21/2023 at 2:15 p.m. with the DM revealed that the box of croissants was no longer in the kitchen's dry storage area and all stored food should be completely covered when stored. 3. Observations made during the initial kitchen inspection on 02/20/2023 at 11:20 a.m. of food stored in the kitchen's dry storage area revealed a large rolling bin that had corn meal and a large scoop stored inside. The scoop's handle was observed to be in direct contact with the corn meal stored inside this bin. Observations on 02/21/2023 at 2:20 p.m. revealed that a large scoop was again stored inside the corn meal bin, and the scoop's handle was in direct contact with the corn meal stored inside the bin. Interview on 02/21/2023 at 2:20 p.m. with the DM revealed that staff should not store scoops in the food storage bins. 4. Observations made during the initial kitchen inspection on 02/20/2023 at 11:20 a.m. of food stored in the kitchen's dry storage area revealed a large storage container with dry beans and a large Styrofoam cup stored inside. The Styrofoam cup was in direct contact with the dried beans. Observations on 02/21/2023 at 2:20 p.m. revealed that a large Styrofoam cup was again stored in the large container of dried beans. The Styrofoam cup was in direct contact with the beans stored inside the container. Interview on 02/21/2023 at 2:20 p.m. with the DM revealed that Styrofoam cups should not be stored in food storage bins. 5. Observations made during the initial kitchen inspection on 02/20/2023 at 11:20 a.m. of food stored in the kitchen's chest freezer revealed that a large plastic bag of cookie dough was stored opened and unprotected from contamination. Interview on 02/21/2023 at 2:15 p.m. with the DM revealed that all stored food should be completely covered by staff. 6. Observations on 02/20/2023 at 11:35 a.m. revealed the interior temperature of the kitchen's three door reach-in freezer was measured at 36 degrees Fahrenheit (F). Observations also revealed one of the freezer's doors would not completely shut because a box of food stored inside the freezer was pressing directly against the door preventing it from closing. Additionally, observations of the freezer's three interior door gaskets revealed two of these gaskets were loose and did not provide a tight seal around their doors to prevent cold air from escaping from the freezer's interior storage compartment. Further observations revealed ice had formed on the top of the freezer's inner compartment and the ice was melting onto the boxes of food stored in the freezer and the water was pooling and refreezing at the bottom of the freezer. Boxes of food observed stored in this freezer included meats, bacon, vegetables, nutritional supplements, and French toast. Review of this freezer's February 2023 monthly temperature log, which was posted on the exterior of the freezer, revealed that on 02/20/2023 staff recorded this freezer was operating at seven degrees F. Further review of this temperature log revealed during the month of February 2023 staff recorded this freezer was operating at temperatures that ranged from zero degrees F. to twenty-four degrees F. However, the only date that staff documented this freezer was operating at a temperature of zero degrees F. or below was on 02/11/2023. Observations on 02/21/2023 at 2:40 p.m., revealed that the interior temperature of the kitchen's three door reach-in freezer was measured at 28 degrees F. Observations of the freezer's three door gaskets revealed that two of them were still loose and not completely affixed around their door. The internal temperature of a nutritional supplement, stored inside this freezer, was measured at 20.6 degrees F. Review of the monthly December 2022 and January 2023 temperature logs for the kitchen's three door reach-in freezer revealed daily temperatures that ranged from minus five degrees F. to 32 degrees F. Interview on 02/21/2023 at 2:40 p.m. with the DM revealed he had not notified the facility's Maintenance Director (MD) about the kitchen's three door reach-in freezer not operating at a temperature of zero degrees F. or below. Observation on 02/22/2023 at 8:05 a.m. revealed that the interior temperature of kitchen's three door reach-in freezer was measured at 10 degrees F. The freezer's three door gaskets were observed to be tightly affixed to their doors. Interview on 02/22/2023 at 8:05 a.m. with the DM revealed he notified the maintenance staff on 02/21/2023 about the kitchen's three door reach-in freezer not operating at zero degrees F. or below. The DM stated that the maintenance staff responded and affixed each of the freezer's three door gaskets tightly around each door. Observation on 02/22/2023 at 1:05 p.m. revealed that the interior temperature of the kitchen's three door reach-in freezer was measured at 18 degrees F. Observations of a box of bacon stored inside this freezer revealed that the top layer of bacon was only partially frozen. Interview on 02/22/2023 at 1:05 p.m. with the DM revealed that the maintenance staff had affixed the freezer's door gaskets per his request and hoped this would fix the problem. But, he would again inform the maintenance staff that the reach-in freezer was still not operating at a temperature of zero degrees F. or below. Observation on 02/23/2023 at 11:50 a.m. revealed that the interior temperature of the kitchen's three door reach-in freezer was measured at 18 degrees F. Interview on 02/23/2023 at 11:50 a.m. with the DM revealed that the MD turned the freezer's thermostat down to minus one degree F. to lower the freezer's internal temperature. Interview on 02/23/2023 at 3:45 p.m. with the facility's Administrator revealed she was made aware the kitchen's three door reach-in freezer was not operating at zero degrees F. or below, and the facility's maintenance staff was making attempts to fix this freezer. Interview on 02/23/2023 at 3:55 p.m. with the facility's MD revealed he was first informed about the kitchen's three door reach-in freezer not operating at zero degrees F. or below on Tuesday (02/21/2023) of this week. The MD stated he affixed the freezer's door gaskets and turned the freezer's thermometer down to its lowest setting of minus one degree F. and the freezer was able to reach an internal temperature of zero degrees F. 7. Observations on 02/20/2023 at 11:40 a.m. of food stored in the facility's D Hall refrigerator revealed nine undated four-ounce cartons of nutritional shakes that were thawed. Interview on 02/20/2023 at 11:40 a.m. with the DM revealed that the nine thawed nutritional shakes should have been dated by staff when they were removed from freezer storage because they were only good for fourteen days after being thawed per the manufacturer's specifications.

Based on observations, staff and resident interviews, and record review the facility failed to serve food that was hot and/or well-seasoned to four of five sampled residents (R) (#48, #82, #57, and #75) reviewed for food palatability. This failure had the potential to affect all 99 residents who consumed food from the kitchen. Findings include: 1. Review of the electronic medical record (EMR) for R#75 revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/2022 located under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated the resident was cognitively intact. Interview on 02/20/2023 at 12:45 p.m., R#75 stated that the hot foods did not taste hot and that the vegetables were not seasoned. 2. Review of R#72's EMR revealed a quarterly MDS with an ARD of 01/20/2023 located under the MDS tab revealed a BIMS score of 13 of 15 which indicated the resident was cognitively intact. Interview on 02/20/2023 at 1:05 p.m. R#72 stated that the hot foods did not taste hot and that cold foods did not always taste cold. 3. Review of R#48's quarterly MDS with an ARD (ARD) of 02/05/2023 located in the EMR under the MDS tab revealed the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. During interviews with R#48 on 02/21/2023 at 9:42 a.m. and on 02/23/2023 at 10:15 a.m., the resident stated that the food the facility served at meals did not always taste good to him because it was not seasoned. 4. Review of R#82's quarterly MDS with an ARD of 02/02/2023 located in the EMR under the MDS tab revealed the resident had a BIMS score of 12 out of 15 which indicated the resident was moderately cognitively impaired. During interviews with R#82 on 02/20/2023 at 3:14 p.m., and on 02/23/2023 at 10:35 a.m., the resident stated that the food that he received at meals did not always taste good because it was not seasoned. 5. Observations and test tray sampled from the A Hall on 02/22/2023 at 12:53 p.m. with the Dietary Manager (DM) present, revealed the following: Observations of the baked pork, herbed green beans, and roasted potatoes on the test tray revealed they were served on a Styrofoam plate, and the plate was placed directly on the tray. An insulated dome lid covered the plate, but there was no insulated bottom present. The baked pork served on the test tray tasted slightly warm and tasted bland. The DM tasted the baked pork and confirmed the pork was not hot and tasted bland. The green beans served on the test tray were warm to taste. The DM tasted the green beans and confirmed they were not hot. During an interview with the (Dietary Manager) DM on 02/22/2023 at 12:55 p.m., he revealed the foods on the test tray being served on a Styrofoam plate and staff not placing the plate on an insulated plate bottom were factors in the baked pork and green beans not being hot when tasted and staff needed to ensure that food was properly seasoned prior to serving it to residents from the kitchen's tray line. 09262

Based on observation, staff and resident interviews, record review, and a review of the facility's policy titled, Pest Control, the facility failed to maintain an effective pest control program so that the facility was free of rodents. This failure had the potential for all the residents of the facility to be at risk for diseases caused by rodent infestations. Findings include: Review of facility policy titled, Pest Control dated 03/2016 revealed The facility strives to protect the residents, staff, and visitors from insects and other pests by controlling infestation through contracts with outside pest control agencies. It is the responsibility of all staff members to detect and report immediately the presence of pests to their supervisor. Actual Presence .In the event that insects and or pests are noted in a resident's room or on the resident, immediate steps will be taken to prevent or decrease the risk for actual or potential harm. Remove resident(s), immediately, from the vicinity. If there is no potential for harm . Place resident(s) in an area free of insects/pests until insects/pests are removed. Return resident to their room when it is free of insects/pests. Review of the most recent quarterly Minimum Data Set (MDS) for Resident (R) (#99) dated 12/20/2022, located in the MDS tab of the electronic medical record (EMR), revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R#99 was moderately impaired. Interview on 02/21/2023 at 9:48 a.m. with R#99 said, We have mice running between the rooms, but I am not afraid of them. Interview on 02/21/2023 at 2:48 p.m. with Certified Nursing Assistant (CNA)4 said, We have plenty of mice here. Observation in the day room on 02/22/2023 at 5:30 a.m. a small mouse was observed scurrying across the floor and then running behind the bookshelf. Rodent droppings were observed in the cabinet under the sink in the day room. Interview on 02/22/2023 at 8:19 a.m. with Maintenance Director (MD1) said, I have heard there are some mice. I put the glue traps out and contacted the pest control company. Interview on 02/23/2023 at 2:10 p.m. with the Administrator stated they are working to get rid of the mice.

Based on observations, staff interviews, and a review of the facility's policy titled, Homelike Environment, the facility failed to ensure the secure unit was in good repair, and free from odors. Additionally, the facility failed to ensure that dressers were kept in good repair in the secure unit for four residents (R) (#2, #15, #48, and #82). This failure had the potential to affect all 51 residents who resided in the secure unit. Findings include: Review of the facility's policy titled, Homelike Environment dated August 2021Residents are provided a safe, clean, comfortable, and homelike environment and encourage using their personal belongings to the extent possible .The facility staff and management will maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. During the initial tour and the daily observations from 02/20/2023 through 02/23/2023 revealed there was a pervasive odor of urine and/or body odor throughout the secure unit. Interview on 02/21/2023 at 10:00 a.m. Housekeeping Staff 1 said she used an air freshener and did her best to get rid of the odor by keeping the unit clean and mopped and emptying trash frequently however confirmed the odor is always there. During an interview on 2/22/2023 at 7:28 a.m. with Licensed Practical Nurse (LPN)1, revealed that there are the three residents in the first room in the hallway all have behaviors that include urinating outside of a restroom. Interview on 02/21/2023 at 11:40 a.m. with the Administrator, she confirmed that the building is very old and in need of repairs. The Administrator further revealed she was aware of the odor on the secure unit, and they are trying different things such as air fresheners, and frequent deep cleans. However, you name it, and it needs fixing, and some things need to be replaced. These odors are seeped into the tiles and the wood furnishings on the unit, and from years of wear and tear on the building. Observation on 02/21/2023 at 11:21 a.m. revealed that R#15, R#2, R#48, and R#82's dressers were found to be in disrepair. The drawers on both dressers were broken and did not function properly. The dresser drawers were off on the track and lopsided, they were difficult to open or close. Interview on 02/22/2023 at 8:23 a.m. with the Maintenance Director (MD) said a schedule to repair these items was being made. Interview on 02/22/2023 at 2:34 p.m. the Administrator stated, All those items should be looked at and fixed. 30067

Based on observations and staff interviews, the facility failed to ensure adequate staffing to provide routine care and adequate supervision for the 51 residents on the secure unit out of a total of 99 residents in the facility. Findings include: All the residents in the secure unit were observed to be ambulatory, either by wheelchair or with/without assistive devices such as walkers. All of the residents in the secure unit were required to get up, get dressed, and out of their bed/room for at least part of the day. Several of the residents wandered and walked constantly. A few of the residents in the secure unit could answer general satisfaction questions about their care, but they could not provide specifics or reliable in-depth interviews. Interview on 02/21/2023 at 3:50 p.m. with Activity Staff 1 (ACT)1 revealed that activity staff did not assist in Activities of Daily Living (ADLs) or resident hygiene, however, were assigned to the secure unit, specifically, to increase resident supervision and help redirect resident behaviors when needed. Observation and interview on 02/22/2023 at 5:00 a.m. revealed that only one Licensed Practical Nurse (LPN) 1 and one Certified Nurse Aid (CNA) 3 were assigned to provide care for all 51 of the residents in the secure unit. CNA3 revealed staffing is supposed to be at least two CNAs at night and three during the day. She stated that one CNA for night shift (7:00 p.m. to 7:00 a.m.) had become routine, and it is impossible for one person/CNA to do. She said all of the residents require assistance, especially upon rising, to make sure their continence needs are met before breakfast. CNA3 revealed some of them can get themselves down there (to breakfast in the day/dining room) but they all need clean briefs or clothes on when they first get up, and I can't do 50 of them by myself , and if just one of them has behaviors, and they do, then we are tied up, with nobody to watch the other residents. Interview on 02/22/23 at 7:00 AM with LPN 1 revealed that we are always short staffed back on the secure unit. I don't know what the answer is but two people can't supervise all these folks with known aggressive behaviors and it happens every day. We are tied up with a behavior, and by the time you get that fire put out there's another one. Interview on 02/22/2023 at 7:28 a.m. with CNA3 stated that somedays there aren't two staff available to provide showers (and never two available at night) and she won't allow herself to get locked in the shower room, with one of these men and him decide to go off with no-one else to hear or help me. Interview on 02/22/23 at 9:40 a.m. with the Director of Nursing (DON) and the Administrator both confirmed the staffing on the secure unit the night before had been one LPN and one CNA for 51 residents. The DON and Administrator both confirmed there just aren't enough staff willing to work on the secure unit. The Administrator said she used agency nursing staff to supplement her staffing needs, however, they are routinely no shows. There have been several occasions when I have had to come in to staff back there because there wasn't anyone else to do it. The Administrator confirmed there are dates on the working schedule that had low staffing numbers within the last two weeks (one LPN and one CNA) and intermittently beyond the two-week look back. A policy was requested related to staffing on the secure unit, and the Administrator stated there was no specific facility policy that spoke to staffing numbers/ratios for the secure unit.

Based on observations, staff interviews, and a review of the facility's policy titled, Mobility Aids: Conduct wheelchair Inspection, the facility failed to provide wheelchairs and geri-chairs that were functional, clean, and in good repair for 10 of 49 sampled Residents (R) (#3, #22, #42, #61, #63, #9, #27, #87, #5, and #11) who used wheelchairs or geri-chairs. This failure had the potential to affect residents' mobility and have a negative impact on their quality of life. Findings include: Review of the undated facility policy titled, Mobility Aids: Conduct wheelchair Inspection revealed Inspect wheelchairs for damaged or missing components .Check wheelchairs for the following: Hand grips, Brakes, Casters, Wheels, Seats, Leg rests, Backs, Arm pads, check for cracks . Repair or replace as necessary. Items identified as poor condition should be removed from service. During the initial facility observation on 02/21/2023 at 12:10 p.m. the following was observed: 1. R#22's wheelchair had dried food, crumbs, and liquid stains on the arm rests and chair pad. 2. R#3 and R#61's geri-chairs had large tears in the leg rest areas. 3. R#9's wheelchair had a torn left arm rest. 4. R#27's right arm rest was missing. 5. R#87's wheelchair had padding missing from right side arm rest. 6. R#5's wheelchair was missing the left arm rest. 7. R#63's wheelchair was missing both arm rest pads. 8. R#42's wheelchair had a cracked arm rest. 9. R#9's wheelchair had a torn left arm rest. Interview on 02/22/2023 at 8:23 a.m. the Maintenance Director (MD1) said a schedule to repair the transport devices is being made. Interview on 02/22/2023 at 2:34 p.m. with Administrator confirmed the wheelchairs and geri-chairs should be looked at and fixed.

Based on observations, staff and resident interviews, the facility failed to promote a dignified dining experience at meals by serving residents food and beverages on disposable Styrofoam plates, disposable Styrofoam cups, small disposable plastic cups, and disposable plastic eating utensils for three of four sampled residents (R) (#48, #76, and #82) reviewed for dignity while dining. This failure had the potential to affect all 51 residents who resided in the facility on hallways A, B, and C. Findings include: The facility did not have a policy regarding dignity while dining for residents. Observations on 02/20/2023 from 12:18 p.m. to 12:52 p.m. of the resident's lunch meal service in the facility's main dining room revealed that resident beverages were served in disposable Styrofoam cups and resident desserts were served in small disposable plastic cups. Observations on 02/22/2023 from 12:05 p.m. to 12:36 p.m. revealed that dietary staff was preparing and serving resident lunch meals from the kitchen tray line to residents who resided in the facility's A, B, and C hallways. The dietary staff was observed serving resident meals, which include baked pork, potatoes, and green beans, on disposable Styrofoam plates. The dietary staff was observed serving resident beverages in disposable Styrofoam cups, serving resident desserts in small disposable plastic cups, and providing a package of disposable plastic eating utensils and a napkin with each resident meal. Interview on 02/22/2023 at 12:40 p.m. with the Dietary manager (DM), stated the kitchen staff served resident lunch meals in Styrofoam plates today to the residents who resided in the facility's A, B, and C hallways because a dietary employee did not come into work. The DM explained that when the kitchen is short staffed, they serve residents meals on Styrofoam plates and provide plastic eating utensils, so there will not be as many dishes for the staff to wash after the meal. The DM stated that the kitchen normally serves resident beverages in disposable Styrofoam cups and resident desserts in small disposable plastic cups at each meal. 1. Review of the most recent quarterly Minimum Data Set (MDS) for R#48 dated 02/05/2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Interview on 02/23/2023 at 10:15 a.m. with R#48, the resident stated that his lunch meal on 02/22/2023 was served on a Styrofoam plate, the beverage in a Styrofoam cup, and the dessert in a small plastic cup. R#48 further revealed that he received plastic eating utensils, and he preferred to have his meals on regular plates, bowls, cups, and eating utensils. 2. Review of the most recent annual MDS for R#76 dated 02/05/2023 revealed the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Interview on 02/23/2023 at 10:20 a.m. with R#76, the resident stated that sometimes his meals are served on Styrofoam plates with plastic eating utensils and his dessert in a small plastic cup. R#76 stated that he preferred to have his meals served on regular plates and receive regular eating utensils. 3. Review of the most recent quarterly MDS for R#82 with dated 02/02/2023 revealed the resident had a BIMS score of 12 out of 15 which indicated the resident was moderately cognitively impaired. Interview on 02/23/2023 at 10:35 a.m. with R#82, the resident stated that his lunch meal on 02/22/2023 was served on a Styrofoam plate, beverage in a Styrofoam cup, dessert in a small plastic cup and received plastic eating utensils. R#82 stated that he preferred to have his meals served on regular plates, bowls, and receive regular eating utensils. R#82 stated that resident meals are served on Styrofoam plates about twice a week. Interview on 02/23/2023 at 11:55 a.m. with Cook (C)1, she revealed that typically twice a week the kitchen will serve residents lunch and evening meals on Styrofoam plates and provide residents with plastic eating utensils because a dietary employee called in and not having enough staff in the kitchen. C1 explained that serving the resident beverages in Styrofoam cups and resident desserts in small plastic cups at the lunch and evening meals was the kitchen's normal practice. Interview on 02/23/2023 at 3:45 p.m. with the Administrator, she stated that meals prepared by kitchen staff should serve foods and beverages to residents on Styrofoam plates or Styrofoam cups and plastic eating utensils should not be provided to residents to eat their meals because a kitchen employee did not come into work as scheduled.

Based on record reviews, staff and resident interviews, and review of the facility policies Freedom of Abuse, Neglect and Exploitation; Abuse Prevent, Fast Alerts, and Behavior Unit Admission/Discharge Policy, revised August 2021, the facility failed to protect the rights of two of nine residents (R) (R#1 and R#8) reviewed for abuse/neglect. Findings include: 1. A review of the clinical record revealed that R#1 was admitted to the facility on [DATE] and readmitted on [DATE]. R#1 was discharged from the facility on 9/7/22. A review of R#1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. Further, she was assessed to require the assistance of two staff members to help her complete her Activities of Daily Living (ADL). A review of the Electronic Medical Record (EMR) revealed that R#1 had multiple co-morbidities with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan last updated 8/25/22 revealed the following areas of care interventions: Verbal/physical/socially inappropriate behaviors, attention seeking, repetitive health complaints, resisting care, easily angered, impatient, fabricates the truth, multiple consensual sexual encounters with male residents, thrives on seeking male attention, history of crying episodes, and manipulative behaviors. A review of the clinical record revealed that R#2 was admitted to the facility on [DATE] and discharged on [DATE] to a behavioral hospital for stabilization. A review of the EMR revealed that R#2 had multiple co-morbidities/diagnoses, and this is not an all-inclusive list: [CONDITION(S)] Disorder [CONDITION(S)] type, anxiety disorder, dementia with behaviors, diabetes, hypertension, [CONDITION(S)], [CONDITION(S)], and Alzheimer's Disease. A review of R#2's Quarterly MDS assessment dated [DATE] revealed that the resident had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Further, she was assessed to require over-sight and supervision from staff members to complete Activities of Daily Living (ADL). She was also coded as having behaviors directed towards others, hitting scratching and rummaging are coded as daily occurring. A review of the care plan last updated 8/25/22 (this is not an all-inclusive list): risk of elopement, behaviors taking items that don't belong to her, claims they were a gift, hoarding. Voodoo items in room, physically aggressive (for 9/6/22 resident to resident altercation was care planned), falls, nutrition, sexual behaviors, housed on the secure unit related to her behaviors, mental health services provided, cognition, pain, cardiac concerns, diabetes, risk for adverse effects from medications, self-care deficit, verbally aggressive, and verbal outbursts. A review of the electronic progress notes for R#1 dated 9/6/22, noted the following: Staff entered R#1's room to find bruising and a laceration to her head and neck area with blood on her face and sheets. R#1 stated that she had been awakened by R#2 coming into her room and punching her in the face. Resident #1 was sent to the hospital for evaluation and treatment and R#2 was placed on 1:1 with a staff member until she was transferred out of the facility for behavioral management. When R#1 returned on 9/7/22 she was given a room that was not on the locked unit. During an interview with the Administrator on 9/9/22 at 11:44 a.m., she stated she was looking into increasing the staffing on that secured unit but that the investigation was not complete related to the resident-to-resident altercation of R#1 and R#2 and that the Interdisciplinary Team (IDT) was meeting to discuss the appropriateness of the placement of each individual resident in the locked secured unit. The Administrator stated that at each care plan the IDT discusses the appropriateness of the resident being placed on the secured unit, based on the facility policy, Behavior Unit Admission/Discharge Policy. 2. A review of the clinical record revealed that R#8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly MDS assessment dated [DATE] revealed that he was coded for delusions and daily behaviors no directed toward others. The assessment revealed that R#8 had a BIMS of out nine of 15, indicating moderate impairment. He was also assessed and coded for requiring assistance of one staff member to assist him to complete his Activities of Daily Living (ADL). A review of the facility document dated 7/29/22, revealed that on 7/29/22 Licensed Practical Nurse (LPN) GG, approached R#8 to help him up off the floor and that the resident began swinging and kicking at her. Nurse GG was witnessed by another staff member to kick R#8 in the torso, head, and neck. Nurse GG was escorted out of the facility, pictures taken of R#8, a police report made as well as the physician, Responsible Party and the Behavioral Services provider were notified. The nurse was suspended until the investigation was over then terminated. The resident stated he had no pain/injury after the assessment was completed. In review of the policy, Freedom of Abuse, Neglect and Exploitation; Abuse Prevent, Fast Alerts, under Staff to Resident Abuse it states the facility is responsible for the actions of its employees, including intentional acts of employees who are aware they are doing wrong and are in conflict with the facility's policies and procedures. This policy also states, Staff members are expected to be in control of their own behavior and understand how to work with the nursing home population. During an interview with the Administrator on 9/16/22 at 1:50 p.m., she stated that the LPN GG, was hired prior to her employment at the facility. She further stated that the current Director of Nursing (DON) and Human Resources (HR) FF was also not employed at the facility at the time that LPN GG was hired. She indicated that the previous Administrator HH, had reported this nurse to the nurse licensing board on 7/30/22.

Based on record review and staff interviews, it was determined that the facility failed to provide care in a manner which prohibited neglect by not providing care and services to residents, including: adequate supervision including on 7/20/16 when resident (R17) fell resulting in a laceration to his head while there was no nurse on duty; failed to ensure the LN who was assigned to the secured unit was not impaired; failed to have a licensed nurse (LN) on the secured unit to administer medications and blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents (7, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32 and 33) on 8/21/16 at 6:00 a.m.; on 10/10/16, R7 sustained a fall and suffered a subarachnoid hemorrhage, and nasal fracture, with a blood sugar of 567 and a [DIAGNOSES REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, remains on-going. 1. On November 2, 2016 at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. 2. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: 1.R17 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Incident/Accident Report dated 7/20/16 at 12:10 a.m. (date and time of incident), revealed documentation that the resident turned off the door alarm, went out on smoke porch to get a cola, lost his balance and fell causing a laceration to the top of the head. The resident was ambulating back into the building and notified staff. The physician was notified but the resident refused to go to the emergency room . (Cross to F 323) 2. R35 had a 24.3% weight loss in three (3) months, in on 10/21/16 without a physician order [REDACTED]. R35 remained NPO On 10/23/2016 R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. 3. R7 had a [DIAGNOSES REDACTED]. However, a review of the clinical record, including the MARs was withheld by licensed nursing staff for various blood sugar parameters. The insulin was not administered as ordered for R7 three (3) in June 2016, four (40 times in July 2016, one (1) time in September 2016; and one time in October 2016. Review of the hospital transfer form dated 10/10/2016 at 12:00 a.m. the blood sugar was 484 with increased behaviors for R7 and on 10/9/16 at 11:55 p.m. revealed that R7 sustained an injury due to hitting the doorframe of her room and was transferred to the hospital. Review of the hospital record revealed that R7resident had multiple admitting [DIAGNOSES REDACTED]. The serum blood sugar on 10/10/16 at 5:21 a.m. was 567 (normal is 65-110) for R7. (cross refer to F309) 4. R11 was admitted on [DATE] with [DIAGNOSES REDACTED]. Continued review of the MARs revealed that there was no evidence that the FSBS was obtained ten (10) times in August 2016 and six (6) times in October 2016. (cross refer to F309) 5. R12 was admitted on [DATE] with multiple diagnosis. Review of the August 2016 MAR indicated [REDACTED]. Review of the August 2016, September 2016 and October 2016 MARs for R12 revealed no evidence that the insulin was administered eleven (11) times in August 2016 and two (2) times in October 2016. Continued review of the MARs for R12 revealed no evidence that FSBS were obtained twenty-two (22) times in August 2016, twelve (12) times in September 2016 and seven (7) times in October 2016. (cross refer to F309) 6 . R27 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the August 2016 MAR indicated [REDACTED]. In addition there was no evidence that the FSBS were obtained 5 times in August 2016 and three (3) times in October 2016. (cross refer to F309) 7. R28 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the August 2016 MAR indicated [REDACTED]. Continued review of the MARs revealed there was no evidence of the FSBS being obtained five (5) times in August 2016 and one time in October 2016. (cross refer to F309) 8. R29 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the August 2016 MAR indicated [REDACTED]. Continued review of the MARs revealed there was no evidence that the insulin and FSBS was administered/obtained five (5) times in August 2016, and five times in October 2016. (cross refer to F309) 9. R32 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the August 2016 MAR indicated [REDACTED]. Review of the MARs for R32 revealed there was no evidence that the 40 units of [MEDICATION NAME] 70/30 Insulin was administered at 6:30 a.m. two (2) times in August 2016 and three times in October 2016. There was no evidence that the 10 units of [MEDICATION NAME] 70/30 Insulin was administered as follows: August 2016 a total of four (4) times; in September 2016 a total of two (2) times; and in October 2016 a total of nine (9) times. (cross refer to F309) 10. R33 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the August 2016 MAR for R33 revealed that licensed nursing staff failed to administer the [MEDICATION NAME] and [MEDICATION NAME] Insulin, [MEDICATION NAME] Insulin 60 units SQ and failed to obtain the FSBS at 6:30 a.m. as ordered on [DATE]. Review of the MARs revealed there was no evidence that the 12 units of [MEDICATION NAME] Insulin was administered seven (7) times in August 2016 , two (2) times in September 2016 (9/26/16 at 12 noon and 4:00 p.m.) and two (2) times in October 2016. There was no evidence that the 60 units of [MEDICATION NAME] Insulin was administered five (5) times in August 2016 and six (6) times in September 2016. October 2016 MAR indicated [REDACTED]. (cross refer to F309) 11. R20 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. (cross refer to F309) 12. R16 had current [DIAGNOSES REDACTED]. Review of the August 2016 MAR indicated [REDACTED]. (cross refer to F309) 13. R17 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED].:00 p.m.). Review of the August 2016 MAR indicated [REDACTED] 14. R18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MARs for August 2016 revealed no evidence of insulin administered two (2) times, nine (9) times in September 2016 and three (3) times in October 2016 MARs. Review of the MARs for August 2016 revealed no evidence of FSBS being obtained seven (7) times and in one (1) time in October 2016. (cross refer to F309) 15. R19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. Review of the MARs revealed that the FSBS was not obtained as ordered sixteen (16) times in August 2016, ten (10) times in September 2016 and nine (9) times in October 2016. (cross refer to F309) 16. R21 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the August 2016 MAR indicated [REDACTED] 17. R22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the August 2016 MAR indicated [REDACTED] 18. R23 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the August 2016 MAR indicated [REDACTED] 19. R24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the August 2016 MAR indicated [REDACTED] 20. R25 was admitted on [DATE] with [DIAGNOSES REDACTED]. (cross refer to F309) 21. R26 had a [DIAGNOSES REDACTED]. (cross refer to F309) 22. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Continued review of the MARs revealed there was no evidence of FSBS follows: in August 2016: twenty four (24) times, and in September 2016: eight (8) times. (cross refer to F309) 23. R13 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. (cross refer to F309) 24. R14 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MARs revealed there was no evidence that the FSBS were obtained on 8/22/16 and 8/26/16. (cross refer to F309) Review of the August 2016 schedules and actual time sheets (Punch Detail Report) for Pleasant View and the second facility, revealed that LPN MM worked at both facilities at the same time on 8/10/16, 8/11/16, 8/13/16 and 8/20/16 from 7:00 p.m. to 7:00 a.m. which left the secured unit without a nurse to assess the residents for changes in condition, provide medications as needed (PRN) and scheduled, supervise the residents for safety and/or emergency situations including medical i.e. respiratory/[MEDICAL CONDITION], or environmental disaster i.e. fire needing evacuation. Review of a text correspondence between LPN MM and the previous DON, dated 8/20/16 at 11:44 p.m., revealed a text from the DON asking LPN MM if she was working that night. LPN MM responded yes, what's wrong. The DON responded that LPN WW told her there was no nurse on the back D Hall (secured unit) hall. LPN MM replied That's not true, I told her what was going on, I had to help with both jobs, there was no one to pass meds tonight. LPN MM further stated in the text that the Human Resources Manager at Pleasant View did not have anyone at all to come in tonight and she agreed to help out. LPN MM stated in the text that she just left her other job and told the other nurse, she was coming right back, everyone was medicated and she had her number. The text further stated that LPN MM was going right back over there as soon as she finished in a few minutes, that she was so dramatic and there was absolutely nothing going on and everyone was in the bed. She further stated the keys were with LPN WW. Interview on 10/14/2016 at 12:00 p.m. via telephone with the Administrator of the second facility confirmed that LPN MM was working full time at their facility. Review of the time sheet dated 8/20/16 revealed that LPN MM was clocked in at both locations (second facility and Pleasant View) for the same dates and timeframe. Interview with LPN WW on 10/18/16 at 12:30 p.m., she stated that on the evening of 8/20/16, LPN MM walked in around 2:00 a.m. and said that she had been at her other job and they knew she had to work over there tonight. LPN WW stated she did not report this because she thought management knew about it. Interview with LPN MM on 10/18/16 at 2:20 p.m., revealed that on 8/20/16 she was working at another facility in a neighboring city when she received a telephone call from supervisory staff at Pleasant View asking her to come and pass the 9:00 p.m. medications because there was not a nurse on the secured unit that evening. LPN MM stated she left the second facility and arrived at Pleasant View around 10:45 p.m. LPN MM stated that she passed out all of the 9:00 p.m. medications and left Pleasant View around 12:00 a.m. to return to her other job at the second facility. Further interview revealed that LPN MM did not return to Pleasant View to administer morning medications to the residents on 8/21/16. LPN MM stated when she left Pleasant View there was not a nurse to relieve her and she left the secured unit unsupervised. Interview with LPN FF on 10/19/16 at 10:00 a.m., revealed that on the morning of 8/21/16 there was not a night shift nurse present on the secured unit when she came on duty. Review of her time sheet revealed she clocked in at 6:30 a.m. LPN FF stated that it was hearsay that the night shift nurse came and passed the evening medications, left and didn't come back. LPN FF stated that a few times in the past in August 2016 and September 2016 she has come on duty and there was not a night shift nurse on secured unit. LPN FF stated this has happened approximately four (4) times. LPN FF stated the night shift nurse is responsible for the 6:00 a.m. and the 6:30 a.m. medications and finger stick blood sugars. LPN FF stated prior to the 8/20/16 incident, she talked to the DON and the Administrator about LPN MM leaving during her shift and did not know if they looked into it or not. Interview with LPN CC on 10/19/16 at 11:00 a.m., she stated that LPN MM on several occasions about a month to a month and a half ago would come in around 8:30 p.m. - 9:00 p.m., stay a couple of hours to pass the medications, leave around 11:00 p.m., return around 3:00 a.m. and then leave again around 5:00 a.m. (cross refer to F309). Interview with LPN JJ on 10/19/16 at 11:45 a.m., revealed that on the morning of 8/21/16 when she and another nurse came on duty on secured unit, there was not a night shift nurse there. LPN JJ stated the night shift nurse on Unit One told them that on 8/20/16 LPN MM came in and stayed for about two hours and left. Interview with LPN MM on 10/19/16 at 12:10 p.m. resulted in LPN MM supplying a written statement, to the surveyor at the second facility, confirming that she was clocked in at both locations on the same night. The second facility Administrator and DON were cooperative in supplying time sheets and schedules, which confirmed that LPN MM was working at the two locations on 8/10/16, 8/11/16, 8/13/16, and 8/20/16 from 7:00 p.m. to 7:00 a.m. Interview with LPN JJ on 10/27/16 at 1:00 p.m., she stated that Registered Nurse (RN) UU was impaired while working nightshift on the secured unit. LPN JJ stated that staff would find beer cans in the bathroom and in the medication room. LPN JJ stated that she and everybody else complained to the Administrator and the Administrator's response would be I will get rid of her as soon as I find a replacement. Interview with LPN CC on 11/1/16 at 9:35 a.m., she stated that on 7/20/16 R17 fell on the D Hall when there was no nurse on duty that night. She stated that she was the only nurse in the entire building from 8:00 p.m. until around 2:30 a.m. when another LPN JJ came in to help. (cross refer to F323) Review of the nursing schedule for 6/26/16 through 7/30/16 revealed LPN CC and another LPN were scheduled to work 7:00 p.m. - 7:00 a.m. on 7/19/16. (Cross to F353) LPN CC stated LPN MM was never in the building when she came on duty and when she was going off duty. LPN CC stated on one occasion LPN MM came in and stated I know this looks weird, I am also working at another job, but management has approved this. LPN CC stated that on the nights LPN MM would leave, she would be the only nurse in the building. She further stated that on the nights LPN MM would leave, she, LPN CC, would call the secured unit and instruct the CNAs to call her if anything happened. Continued interview with LPN CC stated that several months ago RN UU worked nightshift on the secured unit while she was impaired. LPN CC stated that she observed RN UU walking up to Unit 1 and attempted to get in the bed with a resident while she was impaired. Later that same evening RN UU walked back to Unit 1 with a plastic bag full of empty beer cans. LPN CC stated RN UU was wet from her shoulders down to her feet. When she asked RN UU why she was wet she replied, I fell in a piss pot back there. LPN CC stated that RN UU was so impaired that she could hardly walk and she made RN UU sit down behind the nurse's station where RN UU later passed out (therefore leaving the secured unit without a nurse). She stated on other occasions she thought she smelled alcohol on UU's breath. She stated that CNA VV notified the DON that night of RN UU being impaired/intoxicated. Interview with CNA VV on 11/1/16 at 9:45 a.m., she stated that she and another CNA on the secured unit saw RN UU lying down on the floor in the hall after hearing a loud noise. She stated they had to help her up and walk her to the nurse's station because RN UU was so impaired. CNA VV stated that RN UU and the nurse's station smelled like beer. CNA VV stated that after she helped RN UU to the nurse's station she walked up to Unit 1 to report it to the charge nurse on that unit. CNA VV stated that she called the DON to report the impaired RN. Further interview revealed that the DON instructed her to wake up RN UU and send her back to the D Hall and that they already knew about it. She stated the DON never came up to the facility after she reported the nurse. CNA VV stated that they did not wake up RN UU because she was in no shape to care for the residents. Interview with the previous Human Resource Manager on 11/1/16 at 4:30 p.m. she stated that the nurse scheduled to work with LPN CC did not work. She stated LPN CC was the only nurse in the building on Unit One from 8:00 p.m. on 7/19/16 to 2:30 a.m. on 7/20/16. Interview with the previous DON on 11/2/16 at 10:00 a.m., she stated that staff had brought to her attention that RN UU smelled like alcohol before this last incident. She stated that she reported the concerns to the previous Administrator and thought that she had talked to RN UU. The previous DON stated that she was not sure if anything was done because RN UU continued to work after she reported the concerns. The previous DON confirmed the telephone number on the text was her number but denied having the text conversation with LPN MM. She stated that LPN WW sent her a text telling her there was no staff on the secured unit. The previous DON then called LPN MM and asked her where she was. LPN MM told her she stepped out for a minute and would be right back. The previous DON stated she had the understanding LPN MM had stepped out for a break and would return. She stated she had no idea LPN MM was at another job. Interview with the previous Administrator on 11/2/16 at 11:15 a.m., she stated that one time LPN FF told her she thought that LPN MM was leaving at night to work at another facility at the same time. She stated that she did not look any further into this because she didn't feel LPN MM was doing this and LPN FF did not have any proof (cross refer to F490). Continued interview with the previous Administrator stated that she would expect staff to call her that night if the nurse was impaired. She stated that prior to this incident staff would tell her that they thought RN UU was drinking but staff was not willing to write a statement. She stated even though staff reported the suspicion of RN UU drinking, she did not do a random drug screen. She stated she just asked RN UU if she had been drinking and RN UU said no. She stated the facility did not have a policy and procedure for a drug free workplace until after surveyor inquiry on 11/2/16 at 3:35 p.m. She stated that RN UU last worked at the facility on 7/27/16. Although staff had reported to previous Administrator their suspicion of RN UU drinking alcohol while on duty, administrative staff failed to investigate the concerns to ensure that RN UU did not place the residents at risk including but not limited to errors in clinical judgement, medication errors, and a lack of emergency response on the secured unit.

Based on observation, staff interviews, physician interview, record review and facility policy review, the facility failed to provide an environment that was free of accident hazards, including: one resident (R15) with a lap tray device who continuously slid down in the wheelchair under the lap tray and failed to ensure a bed alarm was functional for one resident with a history of falls; failed to ensure measures were in place to prevent injuries for one resident (R7) who had a history of [REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. 1. On November 2, 2016 at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. 2. On October 25, 2016 at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8/21/16 when R15 was observed, by the surveyor, sitting in a wheel chair with a lap tray applied to the wheel chair, R15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. R15 consistently slid underneath the lap trap, the staff was not educated on the proper application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, failed to have R15 assessed, re-assessed and continued the use of the use of the lap tray for R15 with known sliding behavior placing R15 at risk of entrapment. The facility failed to ensure the bed alarm was functional for R15 who has a history of falls, and; failed to provide adequate supervision on the secured unit to prevent R17 from accessing the smoking porch, who fell and sustained a laceration to the head. Immediate Jeopardy related to the facility's noncompliance with the program requirements at 42 C.F.R. was identified to have existed on 7/20/16 the first date verified that the secured unit had no licensed nursing staff, at which time one resident (R17) exited the unit, sustained a fall with an injury. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: 1. R17 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had a Fall Risk Evaluation completed on 5/16/16 and on 7/20/16 which assessed the resident as being at high risk for falls. There was a Quarterly MDS completed on 8/13/16. The facility had assessed and coded the resident as requiring supervision with bed mobility and transfers, independently ambulatory in the room, and being provided supervision with ambulation in the corridor. The resident ' s Brief Interview for Mental Status (BIMS) was assessed as 9 indicating moderate cognitive impairment. During an interview with Licensed Practical Nurse (LPN) CC on 11/1/16 at 9:35 a.m., she stated that on 7/20/16 she was the only nurse in the building on the night shift when R17 fell on the secure unit and hit his head while no nurse was on the unit. (Cross refer to 224 and 353) She stated that after the resident fell , the D Hall Certified Nursing Assistant (CNA) called her, and she had to leave her unit (unit 1) unsupervised, to go and assess the resident. She stated the nurse scheduled to work the D Hall that evening did not show up. She stated she was the only nurse in the building from 8:00 p.m. to 2:30 a.m., when another nurse came on duty. Review of the nursing schedule for 6/26/16 through 7/30/16 revealed LPN CC and another licensed nurse were scheduled to work 7:00 p.m. to 7:00 a.m. on 7/19/16. During an interview with the previous Human Resource Manager on 11/1/16 at 4:30 p.m., she stated that the nurse scheduled to work with LPN CC did not show up for work. She confirmed LPN CC was the only nurse in the building, on Unit One, from 8:00 p.m. on 7/19/16 until 2:30 a.m. on 7/20/16. Review of the Time Sheet Data Report with the previous Human Resources Manager for 7/19/16 through 7/20/16 revealed that LPN JJ worked on 7/19/16 from 7:15 a.m. to 8:00 p.m., then returned on 7/20/16 at 3:00 a.m. to 7:15 a.m. During an interview with the previous Administrator on 11/2/16 at 11:15 a.m., revealed that an LPN told her one time that she thought that LPN MM was leaving at night to work at another facility at the same time. Continued interview revealed that she did not look any further into LPN FF's statement because she didn't feel LPN MM was doing this and LPN FF did not have any proof (cross refer to F224). During an interview with LPN JJ on 10/27/16 at 1:00 p.m., she stated on 7/19/16 she worked from 6:30 a.m. to 8:00 p.m. When she left at 8:00 p.m., there was not a nurse on the D Hall. She went home to get a few hours of sleep and called back up to the facility to see if another nurse showed up to help nurse LPN CC. Since another nurse did not come in, she went back up to the facility at 2:30 a.m. to work the D Hall (secure unit) until 7:15 a.m. Review of the Incident/Accident Report dated 7/20/16 at 12:10 a.m. (date and time of incident), revealed documentation that the resident turned off the door alarm, went out on smoke porch to get a cola, lost his balance and fell causing a laceration to the top of the head. The resident was ambulating back into the building and notified staff. The physician was notified but the resident refused to go to the emergency room . Further review of the report revealed a Charge Nurse/Supervisors Investigation Report which gave a summary of what happened. Staff noted to prevent this from re-occuring was to have the resident ask for assistance with the vending machine and educated the resident regarding not turning off the alarm. There was no documentation in the investigation regarding no nurse being on duty on the secure unit at the time of the incident to ensure the supervision and safety of the residents. 2. R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record revealed repeated nurses' notes entries, since 6/24/16, that noted the resident would hit herself in the face and head, slap herself, and hit and kick the walls and doors. The resident was hospitalized from [DATE] through 7/27/16. The hospital history and physical documented the resident was hospitalized for [REDACTED]. The history and physical also documented for the majority of her life, the resident had been self-injurious in nature. On 10/9/16 a nurses note entry at 11:55 p.m. documented the resident was standing at the doorway (of her room) yelling. The resident had a laceration to the right eyebrow and across her nose, with a small amount of bleeding. Blood was also noted on the doorframe. A further review of the nurse's notes revealed the resident was transported to the emergency room and subsequently admitted to the hospital with [REDACTED]. Review of the hospital records of 10/10/16 reveal the resident was first transferred to a hospital near the facility then transferred to a larger hospital. The hospital records for the second hospital reveal a CT scan of the head without contrast completed on 10/10/16. Impression: Small intraparenchymal hemorrhage versus chronic calcification of the right cerebellum. Acute nasal bone fracture. During an interview on 11/1/16 at 10:55 a.m., the resident's physician stated that he would presume facility staff would try a helmet and would presume the nurses would initiate that (to protect her head). He stated that a helmet would be warranted or at least tried and nursing staff should document the helmet was tried. The facility had a policy of Fall Prevention and Management. The policy documented in the section Intervention that if a resident falls, the service plan should be updated. R7 had a 60-day Minimum Data Set (MDS), dated [DATE], that documented the resident had impaired communication and cognition (Brief Interview for Mental Status (BIMS) of 99) and was ambulatory with supervision to limited assistance of staff. There was a care plan in place, dated 6/1/16, that she was at risk for falls related to impaired vision, hearing impairment, medication side effects, and poor safety awareness with behaviors. The resident was identified as being a high risk for falls on the Fall Risk Evaluation form completed by nursing staff on 5/12/16, 7/27/16, 9/11/16, 9/17/16, 9/25/16 and 9/28/16. A review of the clinical record revealed the resident sustained [REDACTED]. A nurse's note entry at 5:30 p.m. on 8/2/16 documented that the resident leaned over and fell out of a chair in the dining room and sustained a small abrasion to the forehead. A nurse's note entry at 6 a.m. on 9/11/16 documented the resident reported she fell between the toilet and the wall (in her bathroom) and sustained a bump on her head. On 9/17/16 at 11:50 a.m. a nurse's note entry documented the resident fell in the hall after tripping over another resident's foot, hitting her head and sustained a reddened area to the forehead. A nurse's note entry on 9/25/16 at 10:30 a.m. documented the resident attempted to get out of a recliner (in her room), lost her balance, hit her head on the wall and slid to the floor, causing a small abrasion to the left side of the forehead. On 9/28/16 at 1 p.m. a nurse's note documented the resident walked into a wall, hitting her right eyebrow and forehead, then fell to the floor on her buttocks, sustaining a hematoma to the right eyebrow and forehead. However, a review of the care plan reviewed that only the falls that occurred on 8/2/16 and 9/25/16 were included on the care plan with new interventions to prevent further falls. In addition, the new intervention added on 9/25/16, that stated for the resident to sit and wait until fully aware prior to standing, would be inappropriate for a resident who had poor safety awareness with impaired cognition and communication. Review of a nurses note entry of 10/9/16 at 11:55 p.m. revealed that R7 sustained an injury due to hitting the doorframe of her room and was transferred to the hospital. Review of the hospital admission records on 10/10/16 revealed the resident was transferred from a smaller local hospital to a higher acuity of care hospital. The resident had multiple admitting [DIAGNOSES REDACTED]. The serum blood sugar on 10/10/16 at 5:21 a.m. was 567 (normal is 65-110) for R7. The trauma chief resident notes on 10/10/16 at 5:24 a.m. revealed the resident had profound acidosis, patient on DKA (Diabetic Ketoacidosis) protocol including intravenous bolus Insulin. 3. R15 was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [REDACTED]. Review of the facility's Clinical Programs Manual for Restraint Management and Evaluation noted the interdisciplinary team determines how a device will affect resident functional status and freedom of movement. Evaluating a resident for a restraint and/or enabler includes, but is not limited to: Evaluation of alternative measures to physical restraint use, evaluation of medical symptoms that affect resident functional status and how a restraint and/or enabler may assist the resident to function at a higher level. Further review of the procedure revealed staff were to complete the Restraint/Enabler Data Collection and Evaluation form, re-evaluate the use of a restraint and/or enabler at least quarterly or with change in resident condition during Care Management Meeting and to review and revise the care plan as indicated. The facility developed a care plan dated 4/12/16 that the resident was at risk for falls related to unsteady gait, psychotropic medications, generalized muscle weakness and difficulty in walking with an intervention to ensure an activity tray was in place. Although the care plan mentioned the resident had an activity tray, there was no care plan developed to address the use of a lap tray and the potential negative outcomes from the use of the device. The resident had a quarterly Minimum Data Set (MDS) with an assessment reference date of 10/13/16. Facility staff assessed and coded the resident as having severely impaired cognition (BIMS of 99), having physical and verbal behaviors directed at others, requiring extensive assistance with bed mobility and transfers, unable to ambulate. The resident had a physician's orders [REDACTED]. However, there was no documentation to indicate the facility had evaluated the lap tray device as an enabler/positioning device. Review of the Monthly Nursing Summary, dated 8/21/16, revealed documentation that the resident had an activity tray on the wheelchair and the resident would slide himself under the tray and onto the floor. Review of the manufacturer's instructions for Skil-Care wheelchair lap trays revealed the purpose of the wheelchair lap trays were designed to serve as therapeutic interventions that assist patients in achieving proper body position, balance and alignment. The instructions noted to place the lap tray on top of the wheelchair arms, then wrap the Velcro bands around the chair arms and tray. On 10/18/16 at 12:55 p.m., the resident was observed, by the surveyor, sliding down in the wheelchair with his chin hanging on the lap tray. The resident then completely slid off of the wheelchair, under the lap tray and onto the floor. Two certified nursing assistants (CNAs) placed the resident back into the wheelchair with the lap tray. One of the CNAs then incorrectly placed the lap tray straps around the back of the wheelchair and secured the straps with knots. During an interview with CNA II on 10/24/16 at 1:50 p.m. and on 10/25/16 at 11:05 a.m., she stated that the lap tray had been broken for about one month. She stated that she just ties the straps around the back of the wheelchair where the resident can't reach the straps. She also stated that the resident slides down under the lap tray to the point the lap tray is resting on the resident's chest. On 10/25/16 at 1:50 p.m., the resident was observed, by the surveyor, in his room lying on the floor next to his bed. Although a bed alarm was attached to the bed, it was not working. The nurse was immediately informed by the surveyor of the resident lying on the floor. Once LPN FF arrived in the room she confirmed the bed alarm was not working. It was determined that the sensor pad, which was positioned on the mattress, was not working. She stated that the resident would crawl out of bed onto the floor several times a day. She further stated that there was not a routine schedule to check bed alarms to ensure they were functioning. She stated that the resident's alarm was usually constantly alarming, so that was how they knew the alarm worked. She also stated that no other interventions have been attempted to address the resident's behavior of crawling out of bed. During interviews with CNAs GG and HH on 10/25/16 at 1:50 p.m., who were also present in the room, they stated the resident crawls out of the bed onto the floor. During an interview with Licensed Practical Nurse (LPN) FF on 10/25/16 at 1:50 p.m., she stated that the resident usually slides under the lap tray several times a day. During an interview with the Certified Occupational Therapy Assistants RR and TT and the Physical Therapy Assistant SS on 10/26/16 at 2:30 p.m., they stated that the therapy department had not assessed the resident for the use of the lap tray. They stated that therapy should be involved in assessing for the use of a device. They were unable to provide any documentation where therapy was asked to screen the resident for the device when it was ordered on [DATE]. They further stated that a lap tray would not be an appropriate device for someone who slides under the device. During an interview with Occupational Therapist KK on 10/27/16 at 9:50 a.m., she stated that she was unaware the resident was using a lap tray. She further stated the lap tray was not an appropriate device for the resident due to the resident sliding down in the chair which put the resident at risk for suffocation. During an interview with the previous Administrator on 10/26/16 at 1:55 p.m., she stated that the facility did not evaluate the resident for the use of the lap tray and was unable to provide documentation where therapy evaluated the use of the lap tray when the device was ordered on [DATE]. She stated that she discovered the staff were using the straps wrong by fastening the straps around the back of the wheelchair instead of on the wheelchair armrests. She was unable to provide documentation where the staff had been educated on how to properly apply the device. During an interview with LPN JJ on 10/27/16 at 9:15 a.m., she stated that she has seen the resident slide down under the lap tray at least two to three times a day. During an interview with CNA LL on 10/31/16 at 3:55 p.m., she stated the resident would slide under the lap tray on a daily basis. Despite the facility staff's identification of the resident's behavior of sliding down in the wheelchair while the lap tray was in use, the facility continued to use the lap tray even though the device became a hazard risk for him. There was no documentation that the facility had assessed or re-evaluated the resident's sliding behavior and the continued use of the lap tray device as a hazard risk for the resident after he had slid down to where his chin or chest was against the device. (Cross refer to F221, F224)

Based on observation, record review and staff interview, it was determined that the facility failed to provide sufficient staff on the secured unit to prevent falls for one (1) resident (R17); failed to provide sufficient staff and supervision for the residents residing on the secured unit who had cognitive impairment and/or aggressive behaviors; failed to ensure one Registered Nurse (RN) was impaired while on the job on the secured unit; and failed to provide sufficient staff to ensure for twenty-two (22) residents (7, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32 and 33) received medications as ordered Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. On November 2, 2016 at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: 1. Interview with LPN MM on 10/18/16 at 2:20 p.m., revealed that on 8/20/16 she was working at another second facility, in a neighboring city, when she received a telephone call from supervisory staff at Pleasant View asking her to come and pass the 9:00 p.m. medications because there was not a nurse on the D Hall that evening. She stated she left the second facility, in the neighboring town, and arrived at Pleasant View around 10:45 p.m. to administer all of the 9:00 p.m. medications. Further interview revealed that she left the facility at 12 a.m. to work at the other facility and did not return to administer the morning medications on 8/21/16. Continued interview revealed that she left the secured unit unsupervised by a Licensed/Registered nurse. (cross refer to F224 and F309) Review of the August 2016 schedules and actual time sheets (Punch Detail Report) for Pleasant View and the second facility, in a neighboring city, revealed that licensed nurse MM worked at these two facilities at the same time on 8/10/16, 8/11/16, 8/13/16 and 8/20/16 from 7:00 p.m. to 7:00 a.m. leaving the secured unit without a nurse and unsupervised. (Cross to F224 and F309) Review of the August 2016 Medication Administration Records revealed that there was no evidence that licensed nurse MM administered the medications and/or FSBS as ordered by the physician for R7, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32 and 33. (cross to F224 and F309) Interview with LPN FF on 10/19/16 at 10:00 a.m., revealed that on the morning of 8/21/16 there was not a night shift nurse present when she came on duty. She stated the secured unit nurse's station was locked and the narcotic keys were locked inside the nurse's station. She stated she and the other oncoming nurse had to wait for another staff person to unlock the nurse's station. Stated a few times in the past in August 2016 and September 2016 she has come on duty and there was not a night shift nurse on the secured unit. She stated prior to the 8/20/16 and 8/21/16 incident, she talked to the previous Director of Nursing and the Administrator about the secured unit night shift nurse leaving during their shift and did not know if they looked into it or not. Interview with the previous Administrator on 11/2/16 at 11:15 a.m., revealed that one time LPN FF told her she thought that LPN MM was leaving at night to work at another facility at the same time. Stated she did not look any further into this because she didn't feel LPN MM was doing this and LPN FF did not have any proof of this. Interview with LPN CC on 10/19/16 at 11:00 a.m., revealed that LPN MM on several occasions about a month to a month and a half ago would come in around 8:30 p.m. - 9:00 p.m., stay a couple of hours to pass the medications, leave around 11:00 p.m., return around 3:00 a.m. and then leave again around 5:00 a.m. She stated LPN MM was never in the building when she came on duty and when she was going off duty. LPN CC stated that on the nights LPN MM would leave, she would be the only nurse in the building. She further stated that on the nights LPN MM would leave, she, would call the D Hall (secured unit) and instruct the CNAs to call her if anything happened. Interview with LPN JJ on 10/19/16 at 11:45 a.m., revealed that on the morning of 8/21/16 when she and another nurse came on duty, there was not a night shift nurse on D hall (secured unit). She stated the night shift nurse on Unit One told them that on 8/20/16 LPN MM came in and stayed for about two hours and left. A text message and statement from LPN MM supplied by a state surveyor during a standard survey at the second facility (10/17/16 through 10/20/2016) based on an interview with LPN MM at 10/19/16 at 12:10 p.m., was sent to the Pleasant View survey team via email on 10/25/16 at 11:26 a.m. Review of the text message between the DON and LPN MM on the night of 8/20/2016 reveals that LPN MM was working at both locations and the DON ' s telephone number was confirmed by an interview on 11/2/2016 at 10:00 a.m. (Cross to F224 and F309). During an interview with the previous DON on 11/2/16 at 10:00 a.m., she confirmed the phone number on the text was her number but denied having a text conversation with LPN MM on the night of 8/20/2016. The previous DON revealed they had a telephone conversation and the she had understood that LPN MM had left the building for a break but would be right back. The previous DON denies being aware that LPN MM was working at the second facility. (Cross-refer F224 and F309). 2. Interview with LPN JJ on 10/27/16 at 1:00 p.m., revealed that Registered Nurse (RN) UU was impaired while working nightshift on the D Hall. She stated that staff would find beer cans in the bathroom and in the medication room. She stated that she and everybody else complained to the previous Administrator and the previous Administrator's response would be I will get rid of her as soon as I find a replacement. Interview with LPN CC on 11/1/16 at 9:35 a.m., revealed that several months ago RN UU worked nightshift on the D Hall (secured unit) while she was impaired. She stated that she observed RN UU walking up to Unit 1 and attempted to get in the bed with a resident while she was impaired. She stated that RN UU was so impaired she could hardly walk and she made RN UU sit down behind the nurse's station where she later passed out. She stated on other occasions she thought she smelled alcohol on RN UU breath. She stated that CNA VV notified the previous Director of Nursing that night of RN UU being impaired. Interview with CNA VV on 11/1/16 at 9:45 a.m., revealed that she and another CNA on the D Hall (secured unit) saw RN UU lying down on the floor in the hall after hearing a loud noise. She stated they had to help her up and walk her to the nurse's station because RN UU was so impaired. She stated that RN UU and the nurse's station smelled like beer. She stated that after she helped RN UU to the nurse's station she walked up to Unit 1 to report it to the charge nurse on that unit. CNA VV stated that she called the previous Director of Nursing (DON) to report the impaired nurse. The previous Director of Nursing (DON) instructed her to wake up RN UU and send her back to the D Hall (secured unit), although this occurred on the D Hall, and that they already knew about it. She stated the previous Director of Nursing never came up to the facility after she reported the nurse. Interview with the previous DON on 11/2/16 at 10:00 a.m., revealed that staff had brought to her attention that RN UU smelled like alcohol before this last incident. Continued interview revealed that she reported the concerns to the previous Administrator and thought the previous Administrator had talked to RN UU although she was not sure if anything was done because RN UU continued to work after she had reported her concerns. Interview with the previous Administrator on 11/2/16 at 11:15 a.m., revealed that she would expect staff to call her that night if a nurse was working impaired. She stated that prior to this incident staff would tell her that they thought RN UU was drinking but, staff was not willing to write a statement. Continued interview revealed that even though staff reported the suspicion of RN UU drinking, she did not do a random drug screen. She stated she just asked RN UU if she had been drinking and RN UU said no. She stated that RN UU last worked at the facility on 7/27/16. (Cross refer to F490) Although staff had reported to previous Administration their suspicion of Registered Nurse UU drinking alcohol while working at the facility, administrative staff failed to investigate staff's concerns to ensure Nurse RN UU was not a potential danger to the residents on the secured unit. (Cross-refer to F224 and F490) 3. Interview with LPN CC on 11/1/16 at 9:35 a.m., revealed that on 7/20/16 R17 fell on the secured unit and that she was the only nurse in the entire building from 8:00 p.m. until around 2:30 a.m. when another LPN JJ came in to help. An interview with the previous Human Resource Manager on 11/1/16 at 4:30 p.m. she stated that the nurse scheduled to work with CC did not work. She stated LPN CC was the only nurse in the building on Unit One from 8:00 p.m. on 7/19/16 to 2:30 a.m. on 7/20/16. Documentation in the 7/20/16 Incident/Accident Report noted that at 12:10 a.m., R17 turned off the door alarm, went out on smoke porch to get a cola, lost his balance and fell causing a laceration to the top of the scalp with a one inch reopened old area with a small amount of bleeding. It further noted the resident was ambulating back into the building and notified the staff. The physician was notified and the resident refused to go to the emergency room . (Cross- refer to F323)

Based on record review, review of the Administrator job description and interviews, the facility failed to be administered in a manner to ensure that residents received the necessary care and services, specifically: 1. The previous Administrator failed to provide oversight related to staffing of the secured unit therefore, R#17 on 7/20/16 at 12:10 a.m. turned off the door alarm, on the D unit, went out onto the smoking porch in order to get a soft drink and fell resulting in a laceration to the resident's head. At this time, there was no Licensed Nurse assigned to the D unit, and only one nurse onsite in the facility (cross refer to F224, F280, F281, F309, F353, F354). On 7/27/16, a licensed practical nurse supervisor on the secured unit worked while impaired. In addition, review of the August 2016 schedules and actual time sheets (Punch Detail Report) for Pleasant View and the second facility, revealed that the LPN worked at these two facilities at the same time on 8/10/16, 8/11/16, 8/13/16 and 8/20/16 from 7:00 p.m. to 7:00 a.m. leaving the secured unit without a nurse and with residents unsupervised, without a nurse to assess any changes in condition, or to act in the event of a life threatening emergency including cardiac or respiratory event and/or a disaster such as a fire. 2. The previous Administrator failed to ensure that the facility was free of restraints related to R#15, who had a lap tray applied to the wheel chair when out of bed, R#15 consistently slid underneath the lap trap, the staff was not educated on the application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, the facility failed to have the resident assessed for the use of the lap tray (cross refer to F221 and F279). It determined to exist on 8/21/16 when R#15 was observed, by the surveyor, sitting in a wheel chair with a lap tray applied to the wheel chair, R#15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. The facility failed to assess or re-evaluate the resident with known sliding behavior and the continued use of the lap tray, in addition staff were instructed on the proper application of the lap tray, in addition, and R#15 was not assessed for the use of the lap tray as a restraint. 3. The previous Administrator failed to ensure that administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents on 8/21/16 at 6:00 a.m. when there was no licensed staff scheduled on the secured unit (cross refer to F224, F309, F353). Review of the August 2016 schedules and actual time sheets (Punch Detail Report) for Pleasant View and the second facility, revealed that an LPN worked at these two facilities at the same time on 8/10/16, 8/11/16, 8/13/16 and 8/20/16 from 7:00 p.m. to 7:00 a.m., interview with the LPN confirmed that on 8/20/16, she administered the 9:00 p.m. medications (on 8/20/16) after arrival to Pleasant View at approximately 10:45 p.m. by and administered all of the medications scheduled for 9:00 p.m. to the residents on the secured unit by 12 midnight, however she did not return to administer the 6:00 a.m. to 7:00 a.m. medications on 8/21/16. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, remains on-going. 1. On November 2, 2016 at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. 2. On October 25, 2016 at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8/21/16 when R15 was observed, by the surveyor, sitting in a wheel chair with a lap tray applied to the wheel chair, R15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. R15 consistently slid underneath the lap trap, the staff was not educated on the proper application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, failed to have R15 assessed, re-assessed and continued the use of the use of the lap tray for R15 with known sliding behavior placing R15 at risk of entrapment. The facility failed to ensure the bed alarm was functional for R15 who has a history of falls, and; failed to provide adequate supervision on the secured unit to prevent R17 from accessing the smoking porch, who fell and sustained a laceration to the head. 3. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. Immediate Jeopardy related to the facility's noncompliance with the program requirements at 42 C.F.R. was identified to have existed on 7/20/16 the first date verified that the secured unit had no licensed nursing staff, at which time one resident (R17) exited the unit, sustained a fall with an injury. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: An interview with the interim Administrator via telephone on 11/14/2016 at 11:13 a.m. revealed that she was transferred to Pleasant View on 11/14/2016. Review of the facility job description titled Administrator indicated that the Administrator must implement procedures and controls necessary to provide quality resident care; supervise and provide guidance and support to department heads; meet with personnel as scheduled to assist in identifying and correcting problems and/or the improvement of services, and; review and check competence of work force. Interview with the Administrator on 11/2/16 at 11:15 a.m., revealed that LPN FF told her one time that she thought that LPN MM was leaving at night to work at another facility at the same time. Continued interview revealed that she did not look any further into LPN FF's statement because she didn't feel LPN MM was doing this and LPN FF did not have any proof (cross refer to F224). Interview on 10/18/16 at 2:20 p.m. with Licensed Practical Nurse (LPN) MM revealed that she worked as a nurse at Pleasant View and a second facility in a neighboring town. Continued interview revealed that she was working at the second facility on 8/20/16 on the 7:00 p.m. to 7:00 a.m. shift and received a phone call from supervisory staff at Pleasant View requesting her to come in to administer 9:00 p.m. medications because the scheduled nurse had called out. Further interview with LPN MM revealed that she arrived at Pleasant View at approximately 10:45 p.m. and administered all of the medications scheduled for 9:00 p.m. to the residents on the secured unit by 12 midnight. Continued interview revealed that LPN MM left the residents on the secured unit at 12 midnight with only two Certified Nursing Assistants (CNAs) and no nurse to go back to work at the second facility. Further interview revealed that she did not return to Pleasant View to administer the 6:00 a.m. to 7:00 a.m. medications on 8/21/16. During the nurse ' s absence the narcotic keys were left with the CNA on the secured unit (cross refer to F281 and F431). After reviewing the time sheets for both facilities it was determined that the nurse was clocked in at both facilities at the same time on 8/10/2016, 8/11/2016 and 8/13/2016. Review of the medical records revealed no evidence that medications and blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents (#7, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32 and 33) were administered (cross refer to F309). On October 25, 2016 at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8/21/16 when R15 was observed, by the surveyor, sitting in a wheel chair with a lap tray applied to the wheel chair, R15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. R15 consistently slid underneath the lap trap, the staff was not educated on the proper application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, failed to have R15 assessed, re-assessed and continued the use of the use of the lap tray for R15 with known sliding behavior placing R15 at risk of entrapment. Interview with the previous Administrator on 10/26/16 at 1:55 p.m., she stated that she discovered the staff were using the straps wrong by fastening the straps around the back of the wheelchair instead of on the wheelchair armrests during the survey. She was unable to provide documentation where the staff had been educated on how to properly apply the device. Review of the Incident/Accident Report dated 7/20/16 at 12:10 a.m. revealed documentation that the R#17 (who resided on the secured unit) turned off the door alarm, went out on the smoke porch to get a cola, lost his balance and fell causing a laceration to the top of the head. The resident was ambulating back into the building and notified staff. The physician was notified but the resident refused to go to the emergency room (cross refer to F224 and F323). Interview with LPN CC on 11/1/16 at 9:35 a.m., she stated that on 7/20/16 she was the only nurse in the building on the night shift when R17 fell on the secured unit and hit his head while there was no nurse on the unit. LPN CC stated that after the resident fell , the secured unit CNA called her and she left her unit (unit 1) unsupervised to go to the secured unit and assess the resident. LPN CC stated the nurse scheduled to work the D Hall that evening did not show up. Further interview with LPN CC revealed that she was the only nurse in the building from 8:00 p.m. to 2:30 a.m. when another nurse came on duty (Cross refer to F224 and F323). Interview with the previous Administrator on 11/3/16 at 3:20 p.m. revealed that she was unaware that there was no licensed/registered nursing staff supervising the secured unit (D unit) on 7/20/16 when R17 fell and sustained a laceration. Although, she revealed that being in the Daily Stand Up meetings were falls were discussed, including R17, without specific interventions to address his falls. Continued interview with the previous Administrator revealed that she was unaware that LPN MM had left the residents on D unit unsupervised on the 7:00 p.m. to 7:00 a.m. shift on 8/20/16-8/21/16 to work at another facility and that MM had not administered the 6:00 a.m. to 7:00 a.m. medications to the residents on the D unit on 8/21/16. Further interview revealed that she had been responsible for scheduling licensed/registered nursing staff until July 2016 when that responsibility was given to the DON. Further interview with the Administrator revealed that she was not aware that LPN UU was intoxicated while providing care for the residents on D unit until 7/26/16 when staff called her and notified her that the nurse had passed out on the D unit. The previous Administrator revealed that she called LPN UU the next day and notified her that the facility would not allow her to work at the facility again. The previous Administrator revealed that the facility had problems hiring and keeping nursing staff since at least July 2016 but, was unaware that there was a lack of adequate licensed/registered nursing staff to supervise the secured D unit. The previous Administrator revealed that she did not know if staff had attempted any type of head protection for R7 to prevent further head injuries. The previous Administrator revealed that R7 would probably not keep any protective device on her head because she enjoyed listening to music through headphones. Further interview revealed that she had not been notified by staff that R15 was sliding under the lap tray on his wheelchair posing a choking hazard or that the device was incorrectly applied by staff. Further interview revealed that she, the previous Director of Nursing (DON) and all Department Heads meet every morning in the morning meeting to discuss incident/fall reports, admission/discharges, grievances and any other concerns from the previous twenty-four (24) hours. The previous Administrator stated that she was dumbfounded that staff had not informed her of the above concerns and that staff should have notified her immediately. The previous Administrator revealed that staff are used to the abnormal being the normal on the D unit. Further interview revealed that the nurses needed to be proactive with resident issues/concerns and reeducated on better communication. Interview with LPN JJ on 10/27/16 at 1:00 p.m., revealed that Registered Nurse (RN) UU was drunk while working nightshift on the D Hall. JJ stated that staff would find beer cans in the bathroom and in the medication room. She stated that she and everybody else complained to the previous Administrator and the previous Administrator's response would be I will get rid of her as soon as I find a replacement. Interview with the previous DON on 11/2/16 at 10:00 a.m., revealed that staff had brought to her attention that RN UU smelled like alcohol before this last incident. Continued interview revealed that she reported the concerns to the previous Administrator and thought that the previous Administrator had spoken to UU (cross to F224). Interview with the previous Administrator on 11/2/16 at 11:15 a.m., revealed that she would expect staff to call her that night if the nurse was drunk. She stated that prior to this incident staff would tell her that they thought RN UU was drinking alcohol but, staff were not willing to write a statement. She stated even though staff reported the suspicion of UU drinking alcohol, she did not do a random drug screen. She stated she just asked UU if she had been drinking and UU said no. Continued interview revealed that the facility did not have a policy and procedure for a drug free workplace until after surveyor inquiry on 11/2/16 at 3:35 p.m. Further interview with the previous Administrator revealed that RN UU last worked at the facility on 7/26/16. A telephone interview on on 11/4/2016 at 11:57 a.m. with the Vice President of Operations who started on August 1, 2016, revealed that he had asked the previous Administrator why the impaired nurse was not reported to Corporate or reported to the Nursing Board and why Corporate had not been made aware of the severe nursing shortage. He stated that Corporate feels, after doing their own investigation, interviewing the same staff that the surveyors had spoken to during the survey, that both the previous Administrator and the previous DON were aware of the situation with both nurses and took no action. He further revealed that the previous DON has been suspended and that a new Administrator will be in place within the week.

Based on observation, record review and staff interview, it was determined that the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed and implemented corrective action plans to correct a problem of inadequate staffing, and the falls management program for three (3) residents (R7, R17, R15). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, remains on-going. 1. On November 2, 2016 at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. (Cross refer to F224, F323 and F353) The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. 2. On October 25, 2016 at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8/21/16 when R15 was observed, by the surveyor, sitting in a wheel chair with a lap tray applied to the wheel chair, R15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. R15 consistently slid underneath the lap trap, the staff was not educated on the proper application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, failed to have R15 assessed, re-assessed and continued the use of the use of the lap tray for R15 with known sliding behavior placing R15 at risk of entrapment. (Cross refer to F221 and F323) The facility failed to ensure the bed alarm was functional for R15 who has a history of falls, and; failed to provide adequate supervision on the secured unit to prevent R17 from accessing the smoking porch, who fell and sustained a laceration to the head. 3. On 11/22/16 the current interim Administrator, and current DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. Immediate Jeopardy related to the facility's noncompliance with the program requirements at 42 C.F.R. was identified to have existed on 7/20/16 the first date verified that the secured unit had no licensed nursing staff, at which time one resident (R17) exited the unit, sustained a fall with an injury. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: Review of the facility's QAA Committee's Quarterly Meeting sign-in sheets revealed that the Medical Director, Administrator, DON and several Department heads met on 4/15/16, 7/28/16 and 9/20/16. Interview with the previous Administrator on 11/3/16 at 3:20 p.m. revealed that the QAA committee met quarterly and consisted of the Medical Director, Administrator, DON and five to six department heads. Continued interview revealed that open staffing positions had been an on-going concern since at least July 2016 when the Assistant Director of Nursing (ADON) and about five (5) LPNs resigned. She stated that the facility had placed advertisements in the newspaper and have recruited potential employees through the college and by word of mouth. The previous Administrator stated that the QAA committee had identified a shortage of available licensed/registered nursing staff but, had not identified inadequate staffing related to impaired nursing staff and/or lack of supervision by licensed/registered nursing staff on the D unit. Continued interview with the previous Administrator revealed that the QAA committee had discussed residents with falls, including R17, to ensure that interventions were in place; however, she stated that she had not been notified that the resident had fallen while left unsupervised by licensed/registered nursing staff on the secured unit. Further interview revealed that specific interventions to protect from injury for R7 had not been discussed in the meetings. The Administrator stated at that time that these concerns had been identified by the QAA committee although corrective actions were not developed and implemented to correct problems related to lack of adequate staffing and supervision and accident/hazards. Interview with the Medical Director on 11/1/16 at 10:55 a.m. revealed that he visited the facility to see his residents every month. He stated that he did not see any residents on the secured unit and that those residents were the responsibility of Dr. NN. Continued interview revealed that he attended the quarterly QAA committee meetings and that he was aware that staffing had been a problem. Interview with Dr. NN on 10:40 a.m. revealed that he believed that there were some dedicated nurses who worked the secured unit and provided needed care and services but, that there were also some nurses who were just there for the paycheck. Continued interview revealed that he believed the residents on D unit received the care they needed. Further interview revealed that it was imperative that the residents on D unit received their medications.

Based on record review and staff interviews, it was determined that the facility failed to ensure that services being provided by a licensed practical nurse (LPN) and a registered nurse (RN) met professional standards of quality as referenced in Rules and Regulations of the State of Georgia, Chapter 410-10 Standards of Practice, including: leaving the secured unit without an nurse, therefore not administering medications as ordered by the physician to twenty-two (22) residents (7, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32 and 33), in addition on 7/20/16, R17 fell resulting in a laceration to his head while there was no nurse on duty on 7/27/16 the RN was impaired while on duty on the secured unit, failed to ensure that Narcotic keys were not left with Certified Nursing Assistant or left unsecured on the Secured unit and; failed to obtain a physician order [REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. 1. On November 2, 2016 at 5:00 p.m., the Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, only one nurse onsite in the facility and the LN was leaving the Narcotic keys with a Certified Nurse Assistant or leaving the keys unsecured area on the secured unit. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. 2. On 11/22/16 the Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. Immediate Jeopardy related to the facility's noncompliance with the program requirements at 42 C.F.R. was identified to have existed on 7/20/16 the first date verified that the secured unit had no licensed nursing staff, at which time one resident (R17) exited the unit, sustained a fall with an injury. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: Review of the Rules and Regulations of the State of Georgia, Chapter 410-10 Standards of Practice, Rule 410-10-.01 Standards of Practice for Registered Professional Nurses addressed standards related to the registered nurse's responsibilities as a member of the nursing profession , but were not limited to, the following: Function within the legal boundaries of nursing practice based upon knowledge of statutes and regulations governing nursing and notify the appropriate party of any unprofessional conduct which may jeopardize patient/client safety. Review of the Rules and Regulations of the State of Georgia, Rule 410-10-.02 Standards of Practice for Licensed Practical Nurse addressed Rule 410-10-.03 Definition of Unprofessional Conduct to include, but not limited to: Nursing conduct failing to meet the minimal standards of acceptable and prevailing nursing practice, which could jeopardize the health, safety, and welfare of the public, shall constitute unprofessional conduct. This conduct shall include, but not be limited to the following: Using inappropriate or unsafe judgement, technical skill or interpersonal behaviors in providing nursing care and Abandoning or knowingly neglecting patients/clients requiring nursing care. 1. Interview with LPN CC on 11/1/16 at 9:35 a.m., revealed that on 7/20/16 R17 fell on the secured unit when there was no nurse on duty that night. She stated that she was the only nurse in the entire building from 8:00 p.m. until around 2:30 a.m. when another LPN JJ came in to help. (Cross refer to F224, F323, F353) Interview with LPN JJ on 10/27/16 at 1:00 p.m., and on 11/1/16 at 9:35 a.m. with LPN CC, and on 11/1/16 at 9:45 a.m. with CNA VV, they all stated that they witnessed RN UU on the secured unit impaired including gait disturbances, unconsciousness and/or sleeping like behavior, lying on the floor, and they stated she smelled of alcohol. (Cross refer to F224) Review of the personnel record for RN UU revealed a Position Description for a Registered Nurse Charge Nurse. It noted the position goal was to provide a safe and effective nursing care to all patients utilizing the nursing process. Essential duties included the Registered Nurse is responsible for the direct and indirect total nursing care of his/her assigned patients. He/she is also responsible for the supervision of assigned personnel. Due to RN UU being impaired while on duty would prevent her from carrying out the duties of an RN. (Cross refer to F224 and F353) Interview with the previous DON on 11/2/16 at 10:00 a.m., and with the previous Administrator on 11/2/16 at 11:15 a.m., both confirmed knowledge of the behavior of RN UU and staff concerns, however neither took any actions to investigate, report to the Board of Nursing, offer treatment alternatives, and/or to quality care and services were administered to the residents. (Cross refer to F224) 3. LPN MM also signed an Employee Responsibility Statement verifying she had carried out her duties to assure residents received the best possible care, not participated or acted in any way that caused or encouraged inadequate resident care, neglect or abuse to occur, documented in writing any concerns of inadequate care, neglect or abuse of any resident including specific dates, times and personnel involved and reported, in person, any incidents of suspected inadequate resident care, neglect or abuse to my supervisors. LPN MM also left the Narcotic keys with a CNA and/or left the Narcotic keys unsecured in the Medication Administration book on the Secured Unit. (Cross refer to F224) Interviews on 10/18/16 at 2:20 p.m. with LPN FF; on 10/19/16 at 10:00 a.m. with LPN FF; on 11/2/16 at 11:15 a.m. with the previous Administrator , on 10/19/16 at 11:00 a.m. with LPN CC, on 10/19/16 at 11:45 a.m. with LPN JJ, on 10/18/16 at 12:30 p.m. with LPN WW confirmed that LPN MM was leaving Pleasant View to work at another facility, leaving the secured unit without a nurse and leaving the Narcotic keys unsured. (Cross refer to F224, F353) Review of the August 2016 Medication Administration Records (MARs) for R10, R11, R12, R16, R17, R18, R19, R20, R21, R22, R23, R24, R27, R28, R29, R32, R33, revealed that there was no evidence licensed nurse MM administered the 8/20/16 9:00 p.m. medications and the medications due on 8/2/16 between 6:30 a.m. and 7:00 a.m. (Cross refer to F224, F309 and F353) 4. Record review revealed that on 10/20/2016 Speech Therapy made a recommendation for NPO with alternative means of nutrition for R35. The recommendation was initiated by LPN AA without obtaining a physician order [REDACTED]. The staff attempted at least six times without success to start the IV fluids but did not notify the doctor that they were unable to follow the orders. R35 was NPO from 10/21/16 through 10/23/16 when the family insisted the resident be sent to the hospital. (Cross refer to F224, F325 and F327)

Based on record review and staff interview, it was determined that the facility failed to follow the care plans indicating to document the administration of routine and sliding scale insulin per physician orders [REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. On November 2, 2016 at 5:00 p.m., the Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: 1. Resident (R10) had a [DIAGNOSES REDACTED]. Continued review of the MARs revealed that licensed nursing staff failed to obtain and document the Accucheck as care planned twenty four (24) times in August 2016 and eight (8) times in September 2016. 2. R11 had a [DIAGNOSES REDACTED]. Continued review of the MARs revealed that licensed nursing staff failed to obtain and document the FSBS as care planned eight (8) times in August 2016 and six (6) times in October 2016. 3. R12 had a [DIAGNOSES REDACTED]. Licensed nursing staff failed to document that the 30 units of [MEDICATION NAME] was administered at bedtime (9:00 p.m.) seven (7) times in August 2016 and one (1) time in October 2016. Continued review of the MARs revealed that licensed nursing staff failed to document that FSBS were obtained twenty-two (22) times in August 2016 and twelve (12) times in September 2016. 4. R26 had a [DIAGNOSES REDACTED]. In 5. R32 had a [DIAGNOSES REDACTED]. Licensed nursing staff failed to document that 10 units of [MEDICATION NAME] 70/30 Insulin was administered at 12 noon one (1) time in August 2016 and three (3) times in October 2016. Licensed nursing staff failed to document that 30 units of [MEDICATION NAME] 70/30 Insulin was administered at 5:00 p.m. one (1) time in August 2016, two (2) times in September 2016 and three (3) times in October 2016. Continued review revealed that licensed nursing staff failed to document that the FSBS was obtained on 10/4/16. 6. R33 had a [DIAGNOSES REDACTED]. Licensed nursing staff failed to document that the 60 units of [MEDICATION NAME] Insulin was administered five (5) times in August 2016, and six (6) times in September 2016. Review of the October 2016 physician's orders [REDACTED]. 7. R25 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on four (4) times in August 2016 and on 9/25/16. 8. R7 had a care plan, dated 6/1/16, for having a [DIAGNOSES REDACTED]. The care plan included an intervention for licensed nursing staff to administer insulin per physician's orders [REDACTED]. Interview on 10/27/16 at 10:07 a.m., the Director of Nursing (DON) stated that she would expect licensed nursing staff to administer insulin as ordered. 9. R16 had a care plan, dated 7/18/16, for having a [DIAGNOSES REDACTED]. The care plan included an intervention for licensed nursing staff to administer insulin per physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, review of the August 2016, September 2016, and the October 2016 MARs revealed no documentation the insulin was administered 26 times in August 2016, 8 times in September 2016, and 12 times in October 2016. 10. R17 had a care plan, dated 5/28/15, for having a [DIAGNOSES REDACTED]. The care plan included an intervention for licensed nursing staff to administer insulin per physician's orders [REDACTED]. Review of the clinical record, including the MARs, revealed that licensed nursing staff withheld, and did not document the administration of the insulin as care planned on 8/20/16 and 8/21/16. 11. R18 had a care plan, dated 1/20/16, for having a [DIAGNOSES REDACTED]. The care plan included an intervention for licensed nursing staff to administer insulin per physician's orders [REDACTED]. Review of the August 2016 MAR indicated [REDACTED]. There was a physician's orders [REDACTED]. However, review of the August 2016, September 2016 and October 2016 revealed no evidence of insulin administered twice in August 2016, nine (9) times in September 2016, and three (3) times in October 2016. There was a physician's orders [REDACTED]. 12. R19 had a care plan, dated 12/26/14, for having a [DIAGNOSES REDACTED]. The care plan included an intervention for licensed nursing staff to administer insulin per physician's orders [REDACTED]. Review of the August 2016 MAR indicated [REDACTED]. Review of the August 2016 MARs revealed no evidence of FSBS was obtained 18 times as ordered including 8/21/16 at 6:30 a.m.; in September 2016 was not obtained 38 times, and: in October 2016 was not obtained 9 times. 13. R20 had a care plan, dated 6/17/16, for having a [DIAGNOSES REDACTED]. The care plan included an intervention to check blood sugars as ordered, document and notify if warrants. Review of the August 2016 revealed no evidence of FSBS assessments six (6) times. 14. R21 had a care plan, dated 4/6/16, for having a [DIAGNOSES REDACTED]. The care plan included an intervention for licensed nursing staff to administer insulin per physician's orders [REDACTED]. Review of the August 2016 MAR indicated [REDACTED]. Interview on 10/18/16 at 2:20 p.m. with LPN MM revealed that she worked as a nurse at Pleasant View and another facility in a neighboring town, during the same twelve hour shift, and did not administer the 6:00 a.m., 6:30 a.m. or 7:00 a.m. medications or obtain the FSBS on 8/21/16. (Cross refer to F224 and F514) An interview with Licensed Practical Nurse FF on 10/19/2016 at 10:00 a.m. revealed that the night shift nurse was responsible for administering the 6:00 a.m. and 6:30 a.m. medications and FSBS. An interview on 11/1/2016 at 2:20 p.m. with the previous Director of Nursing (DON), revealed that after the Assistant DON resigned in July 2016 that she has not had the time to review the MARs on a regular basis to ensure that medications were administered and recorded. She further revealed that the Pharmacy Consult had discussed the holes in the MARs with her but she has not been able to address this issue since July 2016. Cross Refer to F309

Based on staff interview and record review, it was determined the facility failed to administer medications and finger blood sugar levels (FSBS) as ordered by the physician for fifteen (15) residents (R10, 11, 12, 16, 18, 19, 20, 21, 22, 23, 27, 28, 29, 32 and 33), on 8/21/16 at 6:00 a.m. when there was no licensed nurse scheduled to the secured unit to administer medications or FSBS. Insulin as ordered and for one resident (R7) and for medications to administered timely and not past the one hour window, allowed by Federal Regulation, on 8/20/16 at 9:00 p.m. for three residents (R17, 24 and 25). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. On November 2, 2016 at 5:00 p.m., the previous Administrator and previous Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for nineteen (19) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. Findings include: Review of the facility Schedule Sheet for July 31, 2016 to September 3, 2016 revealed that LPN MM was scheduled to work on the secured unit, on 8/20/16 through 8/21/16 on the 7:00 p.m. to 7:00 a.m. shift. Interview on 10/18/16 at 2:20 p.m. with LPN MM revealed that she worked as a nurse at Pleasant View and another facility in a neighboring town, during the same twelve hour shift, and did not administer the 6:00 a.m. on medications or obtain the FSBS on 8/21/16. Continued interview revealed that on 8/20/16 she was working at another facility in a neighboring city, she stated that she arrived at Pleasant View at approximately 10:45 p.m. and then passed out all of the 9:00 p.m. She stated that she left Pleasant View around 12:00 a.m. to return to her other job at the second facility. Further interview revealed that LPN MM did not return to Pleasant View to administer morning medications to the residents on 8/21/16. LPN MM stated when she left Pleasant View there was not a nurse to relieve her and she left the secured unit unsupervised. Which was confirmed through review of actual time sheets (punch sheets) at both facilities. (Cross refer to F224 and F514) 1. R7 had a [DIAGNOSES REDACTED]. However, a review of the clinical record, including the MARs was withheld by licensed nursing staff for various blood sugar parameters. The insulin was not administered as ordered for R7 on the following dates: in June 2016: On 6/17/16 at 6:30 a.m., on 6/23/16 at 6:30 a.m., and on 6/24/16 at 6:30 a.m., the insulin was not administered but without an explanation. July 2016: On 7/8/16 at 9 p.m., the insulin was withheld for a blood sugar level of 114 for R7. On 7/9/16 the insulin was withheld at 6:30 a.m. for a blood sugar level of 129 and at 9 p.m. for a blood sugar level of 79. On 7/10/16 at 6:30 a.m., the insulin was withheld for a blood sugar level of 101. On 7/28/16 at 6:30 a.m., the insulin was withheld for a blood sugar level of 88. September 2016: On 9/16/16 at 6:30 a.m. the insulin was withheld for an initial blood sugar of 31 and a follow up blood sugar of 120 for R7. October 2016: On 10/7/16 at 9 p.m., the insulin was not administered but without an explanation for R7. Record review of the October 2016 MAR reveals no evidence that on 10/9/2016 at 6:30 a.m. and 4:30 p.m. of a blood sugar check or sliding scale insulin give. On the same day at 9:00 p.m. the blood sugar was 399 with [MEDICATION NAME] R 10U given. Review of the Transfer Form (hospital transfer) dated 10/10/2016 at 12:00 a.m. the blood sugar was 484 with increased behaviors for R7. Review of a nurses note entry of 10/9/16 at 11:55 p.m. revealed that R7 sustained an injury due to hitting the doorframe of her room and was transferred to the hospital. Review of the hospital admission records on 10/10/16 revealed the resident was transferred from a smaller local hospital to a higher acuity of care hospital. The resident had multiple admitting [DIAGNOSES REDACTED]. The serum blood sugar on 10/10/16 at 5:21 a.m. was 567 (normal is 65-110) for R7. The trauma chief resident notes on 10/10/16 at 5:24 a.m. revealed the resident had profound acidosis, patient on DKA (Diabetic Ketoacidosis) protocol including intravenous bolus Insulin. An interview with the previous Director of Nursing (DON) on 10/25/2016 at 5:30 p.m. revealed that she could not explain why the resident's Insulin was held or why the Physician was not notified. She revealed that she was not aware of the policy for contacting the Physician for abnormal FSBS. 2. R11 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. However, review of the August 2016, September 2016 and October 2016 Medication Administration Records (MARs) for R11 revealed that no evidence that the 35 units of [MEDICATION NAME] Insulin was administered daily at 7:00 a.m. three (3) times in August 2016 (8/1/16, 8/21/16, 8/23/16) and three (3) times in October 2016 (10/4/16, 10/13/16 and 10/20/16). Continued review of the MARs revealed that there was no evidence that the FSBS as care planned ten (10) times in August 2016 (8/20/16 at 9:00 p.m., on 8/21/16 at 6:00 a.m. when there was no LN available on the secured unit and 9:00 p.m., on 8/26/16 at 6:00 a.m. and 9:00 p.m., 8/26/16 at 6:00 a.m. and 9:00 p.m., 8/27/16 at 9:00 p.m., 8/28/16 at 6:00 a.m., on 8/29/16 at 9:00 p.m.) and six (6) times in October 2016 (10/3/16 at 9:00 p.m., on 10/4/16 at 6:00 a.m., on 10/12/16 at 9:00 p.m., on 10/13/16 at 6:00 a.m., on 10/19/16 at 9:00 p.m. and on 10/20/16 at 6:00 a.m. Review of the medical record for R11 revealed that the resident was stable with no evidence of adverse reactions related to medications. Review of pertinent labs done 6/20/16 revealed that the HGBA1C was elevated at 7.6 (normal is <6.5) and the [MEDICATION NAME] acid level ([MEDICATION NAME]) was within normal limits. 3. R12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED].) every day (scheduled at 6:30 a.m.); a physician's orders [REDACTED]. every day (scheduled at 6:30 a.m.); a physician's orders [REDACTED].=5 units; 301-400=10 units; 401-500=15 units; 501-550=18 units. However, review of the August 2016 MAR revealed that licensed nursing staff failed to administer the [MEDICATION NAME] and [MEDICATION NAME] at 6:30 a.m. and failed obtain the FSBS at 6:30 a.m. as ordered on [DATE] for R12. However, review of the August 2016, September 2016 and October 2016 MARs for R12 revealed no evidence that the 45 units of [MEDICATION NAME] was administered daily at 6:30 a.m. eleven (11) times in August 2016 (8/9/16, 8/18/16, 8/21/16, 8/22/16, 8/23/16, 8/26/16, 8/27/16) and two (2) times in October 2016 (10/15/16, and 10/20/16), on 8/21/16 there was no nurse at 6:30 a.m. to administer the medication. There was no evidence that the 30 units of [MEDICATION NAME] was administered at bedtime (9:00 p.m.) seven (7) times in August 2016 (8/15/16, 8/17/16, 8/18/16, 8/20/16, 8/21/16, 8/22/16, 8/25/16) and one (1) time in October 2016 (10/19/16). On 8/20/16 at 9:00 p.m. there was no nurse available to administer the medication. Continued review of the MARs for R12 revealed no evidence that FSBS were obtained twenty-two (22) times in August 2016 (8/17/16 at 9:00 p.m., on 8/18/16 at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m., on 8/19/16 at 6:30 a.m., on 8/20/16 at 9:00 p.m., on 8/21/16 at 6:30 a.m. (on 8/20/16 at 7:00 p.m. through 8/21/16 at 7:00 a.m. there was no nurse assigned to the secured unit) and 9:00 p.m., on 8/22/16 at 6:30 a.m. and 9:00 p.m., on 8/23/16 at 6:30 a.m., on 8/25/16 at 9:00 p.m., on 8/26/16 at 6:30 a.m. and 9:00 p.m., on 8/27/16 at 11:30 a.m. and 9:00 p.m., on 8/28/16 at 6:30 a.m., on 8/29/16 at 11:30 a.m. and 4:30 p.m., on 8/31/16 at 11:30 a.m. and 4:30 p.m.); twelve (12) times in September 2016 (9/1/16 at 9:00 p.m., on 9/2/16 at 11:30 a.m. and 9:00 p.m., on 9/3/16 at 9:00 p.m., on 9/11/16 at 11:30 a.m. and 4:30 p.m., on 9/19/16 at 11:30 a.m. and 4:30 p.m., on 9/28/16 at 11:30 a.m., 4:30 p.m. and 9:00 p.m., on 9/29/16 at 6:30 a.m.); and seven (7) times in October 2016 (10/15/16 at 11:30 a.m. and 4:30 p.m., on 10/20/16 at 6:30 a.m., on 10/21/16 at 11:30 a.m. and 4:30 p.m. and on 10/22/16 at 11:30 a.m. and 4:30 p.m.). Furthermore, review of the MARs for R12 revealed no evidence that Insulin was administered per sliding scale three (3) times in August 2016 and eight (8) times in September 2016 for the following FSBS: In August 2016: a. On 8/1/16 at 11:30 a.m. was 298. However, there was no evidence that the 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. b. On 8/1/16 at 4:30 p.m., the resident's FSBS was 312. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. c. On 8/31/16 at 9:00 p.m., the resident's FSBS was 402. However, there was no evidence that the 15 units of [MEDICATION NAME] R Insulin was administered per sliding scale. In September 2016: d. On 9/2/16 at 6:30 a.m., the resident's FSBS was 227. However, there was no evidence that that 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. e. On 9/4/16 at 11:30 a.m. the resident's FSBS was 269. However, there was no evidence that the 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. f. On 9/6/16 at 9:00 p.m. was 303. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. h. On 9/7/16 at 6:30 a.m., the resident's FSBS was 291. However, there was no evidence that the 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. i. On 9/7/16 at 9:00 p.m., the resident's FSBS was 379. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. J. On 9/11/16 at 9:00 p.m. the resident's FSBS was 332. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. k. On 9/23/16 at 6:30 a.m., the resident's FSBS was 259. However, there was no evidence that the 5 units of [MEDICATION NAME] R Insulin was administered per sliding scale. l. On 9/23/16 at 9:00 p.m., the resident's FSBS was 381. However, there was no evidence that the 10 units of [MEDICATION NAME] R Insulin was administered per sliding scale. Review of the medical record for R12 revealed that the resident was stable with no evidence of adverse reactions related to medications. Review of pertinent labs done 4/6/16 revealed that the HGBA1C was abnormally high at 13.1 (normal is <6.5) and the [MEDICATION NAME] acid level was within normal limits. 4. R27 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. However, review of the August 2016 MAR revealed that licensed nursing staff failed to obtain the FSBS at 6:30 a.m. as ordered on [DATE] (as there was no nurse assigned to the secured unit). Interview on 10/18/16 at 2:20 p.m. with LPN MM revealed she did not administer morning medications to the residents on 8/21/16. Review of the August 2016 MAR revealed that there was no evidence that [MEDICATION NAME] 10 mgs, [MEDICATION NAME] 100 mgs., [MEDICATION NAME] ER 250 mgs., [MEDICATION NAME] 200 mgs and [MEDICATION NAME] 30 units SQ was administered to R27 as scheduled at 9:00 p.m. on 8/20/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs for R27 revealed there was no evidence that the [MEDICATION NAME] was administered on 8/11/16, 8/20/16, 8/21/16, 8/22/16, 8/25/16, 8/26/16, 9/6/16, 9/7/16, 9/10/16, 9/11/16, 9/18/16, 10/3/16 and 10/12/16. There was no evidence that the FSBS were obtained on 8/21/16, 8/22/16, 8/26/16, 8/27/16, 8/28/16, 10/4/16, 10/13/16 and 10/20/16. Review of the medical record for R27 revealed no adverse reactions related to medications. The HGBA1C done 5/27/16 was within normal limits. 5. R28 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed physician's orders [REDACTED]. Three times a day (scheduled at 6:00 a.m., 2:00 p.m. and 10:00 p.m.) and to obtain FSBS every morning (scheduled at 6:30 a.m.). However, review of the August 2016 MAR revealed that licensed nursing staff failed to administer the [MEDICATION NAME] at 6:30 a.m. and the [MEDICATION NAME] at 6:00 a.m. as ordered on [DATE]. Licensed nursing staff failed to obtain the FSBS at 6:30 a.m. as ordered on [DATE]. Interview on 10/18/16 at 2:20 p.m. with LPN MM revealed that she worked as a nurse at Pleasant View and another facility in a neighboring town and did not obtain the FSBS on 8/21/16. Review of the August 2016 MAR revealed that there was no evidence of [MEDICATION NAME] 1000 mgs., [MEDICATION NAME] 1 mg., [MEDICATION NAME] 25 mgs., [MEDICATION NAME] 17 gms , [MEDICATION NAME] 20 mgs., [MEDICATION NAME] SR 150 mgs., and [MEDICATION NAME] 2 mgs to R28 being administered as scheduled at 9:00 p.m. on 8/20/16. Interview on 10/18/16 at 2:20 p.m. with LPN MM revealed that on 8/20/16 she was working at another facility in a neighboring city, she stated that she arrived at Pleasant View at approximately 10:45 p.m. and then passed out all of the 9:00 p.m. She stated that she left Pleasant View around 12:00 a.m. to return to her other job at the second facility. Review of the medical record for R28 revealed a physician's orders [REDACTED]. However, review of the MARs revealed there was no evidence that the FSBS on 8/8/16, 8/21/16, 8/22/16, 8/23/16, 8/28/16, 8/31/16 and 10/4/16. Although there was no evidence that the on the MARs that the resident refused FSBS on other days, there was no evidence that the FSBS were attempted on these dates. There was no adverse reactions related to medications for R28. 6. R29 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed physician's orders [REDACTED]. The resident also had a physician's orders [REDACTED]. However, review of the August 2016 MAR revealed that licensed nursing staff failed to administer the [MEDICATION NAME] and [MEDICATION NAME] and failed to obtain the FSBS at 6:30 a.m. as ordered on [DATE]. Review of the August 2016 MAR revealed that there was no evidence that [MEDICATION NAME] 80 mgs, Klonopin 1 mg, [MEDICATION NAME] 600 mgs, [MEDICATION NAME] 10 mgs and [MEDICATION NAME] 50 units SQ to R29 was administered as scheduled at 9:00 p.m. on 8/20/16. Review of the record for R29 revealed a physician's orders [REDACTED]. However, review of the MARs revealed there was no evidence that the [MEDICATION NAME] was administered on 8/1/16, 8/6/16, 8/24/16, 8/25/16, 8/26/16, 10/1/16, 10/2/16, 10/4/16, 10/12/16 and 10/13/16. Review of the record for R29 revealed a physician's orders [REDACTED]. However, review of the MARs revealed there was no evidence that the FSBS were obtained on 8/2/16, 8/7/16, 8/25/16, 8/26/16, 8/27/16, 10/3/16, 10/4/16, 10/13/16, 10/14/16 and 10/20/16. Review of the medical record for R29 revealed no evidence of an adverse reactions related to medications. The HGBA1C done 6/6/16 was high at 7 (normal is <6.5). 7. R32 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. Review of the August 2016 MAR revealed that licensed nursing staff failed to administer the [MEDICATION NAME] 70/30 at 6:30 a.m. as ordered on [DATE]. Continued review of the August 2016 MAR revealed that there was no evidence that [MEDICATION NAME] 200 mgs was administered to R32 as scheduled at 9:00 p.m. on 8/20/16. Review of the medical record revealed a physician's orders [REDACTED]. [REDACTED]. However, review of the MARs for R32 revealed there was no evidence that the 40 units of [MEDICATION NAME] 70/30 Insulin was administered at 6:30 a.m. two (2) times in August 2016 (8/21/16, 8/22/16) and three times in October (10/4/16, 10/13/16 and 10/20/16). There was no evidence that the 10 units of [MEDICATION NAME] 70/30 Insulin was administered as follows: August 2016 on 8/21/16 at 6:30 a.m., on 8/22/16 at 6:30 a.m., 8/27/16 at 12 noon and 5:00 p.m. a total of four (4) times; in September 2016 on 9/6/16 at 5:00 p.m., 9/28/16 at 5:00 p.m., a total of two (2) times; and in October 2016 on 10/4/16 at 6:30 a.m., 12 noon and 5:00 p.m., 10/13/16 at 6:30 a.m., 10/14/16 at 12 noon and 5:00 p.m., 10/20/16 at 6:30 a.m. and on 10/21/16 at 12 noon and 5:00 p.m. a total of nine (9) times. Continued review revealed there was no evidence that the FSBS was obtained on 10/4/16. Review of the medical record for R32 revealed no adverse reactions related to medications. The HGBA1C done 6/23/16 was high at 8.1 (normal is <6.5). 8. R33 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. The resident also had a physician's orders [REDACTED]. However, review of the August 2016 MAR for R33 revealed that licensed nursing staff failed to administer the [MEDICATION NAME] at 6:30 a.m. and [MEDICATION NAME] Insulin at 7:00 a.m. and failed to obtain the FSBS at 6:30 a.m. as ordered on [DATE]. Review of the August 2016 MAR revealed no evidence that [MEDICATION NAME] Insulin 60 units SQ was administered to R33 as scheduled at 9:00 p.m. on 8/20/16. Review of the medical record revealed for R33 a physician's orders [REDACTED]. However, review of the MARs revealed there was no evidence that the 12 units of [MEDICATION NAME] Insulin was administered seven (7) times in August 2016 (8/21/16 at 7:00 a.m., 8/22/16 at 7:00 a.m., (see above notations related to 8/21/16 regarding no nurse available) 8/23/16 at 4:00 p.m., 8/25/16 at 4:00 p.m., 8/28/16 at 7:00 a.m., 8/29/16 at 12 noon and 8/30/16 at 12 noon), two (2) times in September 2016 (9/26/16 at 12 noon and 4:00 p.m.) and two (2) times in October 2016 (10/20/16 at 7:00 a.m. and 10/24/16 at 7:00 a.m.). There was no evidence that the 60 units of [MEDICATION NAME] Insulin was administered five (5) times in August 2016 (8/20/16 at 9:00 p.m., 8/21/16 at 9:00 p.m., (see above notations related to 8/20/16 and 8/21/16, when no nurse was available to administer medications) 8/25/16 at 9:00 p.m., 8/26/16 at 9:00 p.m. and 8/28/16 at 9:00 p.m.) and six (6) times in September 2016 (9/2/16 at 9:00 a.m., 9/7/16 at 9:00 p.m., 9/21/16 at 9:00 a.m., 9/27/16 at 9:00 p.m. and 9/30/16 at 9:00 a.m.). Review of the October 2016 physician's orders [REDACTED]. Further review revealed there was no evidence that the FSBS was obtained four (4) times in August 2016 (8/21/16, 8/22/16, (see above notations related to 8/21/16, when no nurse was available to administer medications) 8/23/16 and 8/28/16). Review of the medical record for R33 revealed no evidence adverse reactions related to medications. The HGBA1C done 9/27/16 was high at 7.2 (normal is <6.5). 9. R20 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R20 had a physician's orders [REDACTED]. However, review of the August 2016 MAR revealed there was no evidence that the FSBS was obtained as ordered on [DATE] and 8/22/16 at 6:30 a.m., 8/26/16 at 6:30 a.m., 8/27/16 at 6:30 a.m. and 4:30 p.m., 8/28/16 at 6:30 a.m. There was a physician's orders [REDACTED]. However, review of the August 2016 MAR revealed there was no evidence that the FSBS were obtained as ordered on [DATE] and 8/22/16 at 6:30 a.m., 8/26/16 at 6:30 a.m., 8/27/16 at 6:30 a.m. and 4:30 p.m., 8/28/16 at 6:30 a.m. 10. R16 had current [DIAGNOSES REDACTED]. R16 had a physician's orders [REDACTED]. However, a review of the August 2016 MAR revealed there was no evidence that the FSBS was obtained on 8/22/16 and 8/26/16 as ordered by the physician. There was also a physician's orders [REDACTED]. However, review of the August 2016, September 2016 and the October 2016 MARs revealed there was no evidence that the insulin was administered on 8/2/16, 8/3/16 and 8/4/16 at 4:00 p.m., on 8/9/16 at 7:00 a.m., on 8/13/16 at 4:00 p.m., 8/14/16 at 7:00 a.m. and 4:00 p.m., 8/16/16 at 4:00 p.m., 8/18/16 at 7:00 a.m. and 4:00 p.m., 8/20/16 at 4:00 p.m., 8/21/16, 8/22/16, 8/23/16 at 7:00 a.m. and 4:00 p.m., 8/24/16 at 4:00 p.m., 8/25/16 at 7:00 a.m. and 4:00 p.m., 8/27/16 and 8/28/16 at 7:00 a.m. and 4:00 p.m. and on 9/2/16 at 7:00 a.m., 9/6/16 at 4:00 p.m., 9/11/16 at 4:00 p.m., 9/14/16 at 7:00 a.m., 9/19/16 at 7:00 a.m. and 4:00 p.m., 9/26/16 at 7:00 a.m. and on 9/28/16 at 4:00 p.m. and on 10/4/16 at 7:00 a.m. and 4:00 p.m., 10/8/16, 10/9/16, 10/10/16, and 10/13/16 at 7:00 a.m., 10/14/16 at 4:00 p.m., 10/20/16 at 7:00 a.m. and 4:00 p.m. and on 10/21/16 and 10/22/16 at 4:00 p.m. 11. R17 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED].:00 p.m.). However, review of the August 2016 MAR revealed there was no evidence that the medications were administered on 8/20/16 at 9:00 p.m. including the [MEDICATION NAME], Zocar and the [MEDICATION NAME] 25 units SQ at bedtime on 8/20/16. 12. R18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R18 had a physician's orders [REDACTED]. However, review of the August 2016 MAR revealed there was no evidence that the insulin was given as ordered on [DATE], 8/18/16, 8/20/16 and 8/21/16. There was a physician's orders [REDACTED]. However, review of the August 2016, September 2016 and the October 2016 MARs revealed there was no evidence that the insulin was administered as ordered on [DATE] and 8/22/16 at 6:30 a.m. and on 9/2/16 at 11:30 a.m., 9/8/16 at 11:30 a.m., 9/21/16 at 11:30 a.m. and 4:30 a.m., 9/26/16 at 11:30 a.m. and 4:30 p.m., 9/27/16 at 11:30 a.m. and 9/30/16 at 6:30 a.m. and 11:30 a.m. and on 10/20/16 at 6:30 a.m., 10/23/16 at 11:30 a.m. and on 10/24/16 at 6:30 a.m. There was a physician's orders [REDACTED]. on 8/7/16 and 8/16/16 at 11:30 a.m. and 4:30 p.m., 8/19/16 at 4:30 p.m., 8/21/16 and 8/22/16, and 8/29/16 at 6:30 a.m., and on 10/20/16 at 6:30 a.m. 13. R19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of the physician's order [REDACTED]./6/16 for FSBS before meals and at bedtime (scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m. and at 9:00 p.m.) and an order since 11/11/15 for [MEDICATION NAME] 20 units SQ twice a day (scheduled at 6:30 a.m. and 9:00 p.m.). However, review of the August MAR revealed and the [MEDICATION NAME] and [MEDICATION NAME] was not administered and the FSBS was not obtained at 6:30 a.m. on 8/21/16 as ordered by the Physician due to the lack of nursing coverage on the Secured Unit at that time. Further review of the August MAR revealed there was no evidence that the [MEDICATION NAME], Solace, [MEDICATION NAME] were not administered and the FSBS was not obtained on 8/20/16 at 9:00 p.m. Interview with the previous Director of Nursing on 10/25/16 at 3:35 p.m., she confirmed that the 9:00 p.m. FSBS were not done as ordered for the entire month of September 2016. She stated the staff failed to transcribe the order over to the MAR and that the nurses should have caught the error. 14. R21 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. [REDACTED].:00 p.m.) an order since 7/30/13 for [MEDICATION NAME] 40 mg at bedtime (scheduled for 9:00 p.m.) and an order for [REDACTED]. However, review of the August 2016 MAR revealed that the [MEDICATION NAME] and [MEDICATION NAME] was not administered on 8/21/16 at 6:30 a.m., and there is no evidence that [MEDICATION NAME], [MEDICATION NAME] and the [MEDICATION NAME] were administered on 8/20/16 at 9:00 p.m. 15. R22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. There was an order since 8/12/14 for [MEDICATION NAME] 50 mg twice a day (scheduled at 9:00 a.m. and 9:00 p.m.), an order since 4/17/15 for [MEDICATION NAME] 20 mg three times a day (scheduled for 9:00 a.m., 5:00 p.m. and 9:00 p.m.) and an order since 5/22/14 for [MEDICATION NAME] 160 mg everyday (scheduled at 9:00 p.m.). However, review of the August 2016 MAR revealed that the [MEDICATION NAME] and [MEDICATION NAME] were not administered on 8/21/16 at 6:30 a.m. and the [MEDICATION NAME] and [MEDICATION NAME] were not administered on 8/20/16 at 9:00 p.m. 16. R23 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. However, review of the August 2016 Mar revealed no evidence that the [MEDICATION NAME] and [MEDICATION NAME] were administered on 8/20/16 at

Based upon record review, staff and family interviews the facility failed to ensure nutritional needs were met for one (1) resident (R35) who had a 24.3% weight loss in three (3) months, in addition on 10/21/16 without a physician order [REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. At the time of exit on 11/23/16, an acceptable Allegation of Credible Compliance had not been received, therefore the IJ remains on-going. Findings include: 1. Review of the monthly weight record revealed that R35 on 8/1/2016 weighed 152 pounds. On 9/7/16 R35 weighed 131 pounds which indicated a 13.8% weight loss in one (1) month, and he was placed on weekly weights. On 10/17/2016 and upon discharge on 11/9/2016, R35 weighed 115 pounds, a 24.3 % indicating a significant weight loss in three (3) months. Record review revealed a comprehensive metabolic panel (CMP) laboratory test result dated 9/8/2016 revealed an [MEDICATION NAME] level of 1.9 (normal 3.5-5.0). Review of the physician progress notes [REDACTED]. Review of the physician orders [REDACTED]. Record review of dietary intake form beginning August 22, 2016 through October 20, 2016 revealed for R35 indicated the intake was 50% or less with every meal. Review of the registered dietitian (RD) nutritional assessment notes dated 3/29/2016 revealed the resident has chewing and swallowing difficulties with no recommendations. Review of a nutritional assessment dated [DATE] revealed that R35 was not seen by the RD due to the resident being in the hospital on [DATE]. Interview on 11/22/16 at 8:45 a.m. the Dietary Manager (DM) revealed that she runs a report monthly to determine significant weight loss and puts a list together for the RD of residents to see on the monthly visits. She supplied the monthly RD monitoring sheet for September 2016 revealed that R35 was on the list. The DM continued to reveal that she did not know the process for alerting the RD for changes in conditions which could impact their nutrition prior to the RD visit. The DM revealed that she is part of the daily stand up meetings and in the past would give her list to the former DON. She has not made a list since the former DON was released in early November 2016. Interview on 11/22/16 at 9:13 a.m. with the RD revealed that she last saw the resident on March 29, 2016. She stated the R35 was in the hospital on her 9/27/16 visit and the DM did not inform her when the resident returned. She could not assess a resident who was not in the building. She was not aware of the resident ' s significant weight loss, wounds or very low [MEDICATION NAME] level. Interview on 11/22/2016 at 8:24 a.m. with the wound physician revealed that she started seeing R35 in September 2016. She revealed that R35 has had a decline especially in October 2016 when R35 was non-responsive during wound care. She felt R35 would benefit from palliative care and wrote an order for [REDACTED]. R35 was hosptalized on [DATE] with severe dehydration, and multiple wounds. The hospital discharge summary, dated 11/3/2016, revealed R35 had a percutaneous endoscopic (PEG) gastrostomy tube (feeding tube) placement and surgical debridement of decubitus wound. R35 was discharged back to the facility on [DATE] with continuous feedings via the PEG tube of Glucerna 1.2 at 40 milliliter (ml) per hour and water flushes, 200 ml, every four (4) hours. The low [MEDICATION NAME] level of 1.9 on 9/8/2016 and lack of oral intake was not addressed until 10/23/2016 when the family insisted that R35 be sent to the hospital and the PEG tube was inserted for nutrition. R35 was discharged , at the family ' s request, on 11/9/2016 to a facility closer to the family.

Based upon record review, staff and family interviews the facility failed to ensure that one (1) resident (R35) had enough fluids to keep the resident hydrated which resulted in hospitalization with a [DIAGNOSES REDACTED]. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. At the time of exit on 11/23/16, an acceptable Allegation of Credible Compliance had not been received, therefore the IJ remains on-going. Findings include: Record review revealed that R35 was re-admitted to the facility on [DATE] after a hospital admission for Altered Mental Status (AMS), wound infection and decreased oral intake. The resident was hospitalized again 9/26/16 and discharged back to the facility on [DATE] for Anorexia, AMS and failure to thrive, pneumonia and clinical severe dehydration with [MEDICAL CONDITION] (166), hyperchloridemia (139) and acute [MEDICAL CONDITION]. R35 was placed on the ST service for dysphagia management, diet modification and linguistic retraining. Continued review revealed a ST recommendation dated 10/14/16 for the discontinued nectar thick liquids to be discontinued and changed to puree with honey thick liquids and no straws which contained Dr. XX signature stamp but did not include a date for the signature. Review of a ST recommendation dated 10/20/16 revealed a recommendation for NPO with alternative means of nutrition which was signed off by Licensed Practical Nurse (LPN) AA . Review of a physician telephone order sheet dated 10/22/16 at 6:55 p.m. revealed an order for [REDACTED]. Record review of the diet intake form revealed that from 10/16/2016 through 10/20/2016 for R35 revealed the intake was 20-30 percent then starting on 10/21/16 revealed the resident was NPO. Interview with ST Supervisor CCC on 11/21/16 at 2:56 p.m. reveals that her department only makes recommendations for treatment and it is the nurse ' s responsibility to contact the physician. She supplied a copy of the ST treatment and evaluation. Record review of the ST daily treatment note dated 10/20/2016 revealed that during nursing report that R35 was holding solids in oral cavity. A Certified Nursing Assistant (CNA) reported having similar feeding difficulties from previous evening. R35 demonstrated holding of pureed solids in oral cavity, unable to initiate/complete swallow despite maximum cues. R35 was judged to be unsafe for PO (by mouth) intake at this time. Nursing staff, DON and dietary/kitchen staff notified of recommendation and diet change. A note dated 10/21/2016 by ST CCC revealed R35 continues to be unsafe for PO intake with recommended alternative means of nutrition. ST consulted with nursing regarding current intake status of R35. Interview on 11/21/16 at 3:22 p.m., via telephone, with the Durable Power of Attorney (DPA) for Healthcare for R35 revealed the facility had contacted her regarding the resident declining and to discuss Hospice on 10/21/2016. The family visited on 10/22/16 at which time the roommate of R35 revealed the facility hadn ' t been feeding R35. Interview on 11/21/16 at 4:22 p.m. via telephone with another family member revealed when the family arrived on 10/22/16 around 6:00 p.m. they discovered that R35 was NPO and the roommate stated the facility had not feed the R35 since 10/19/2016. The family insisted on speaking to Dr. XX which revealed he knew nothing of the condition of R35 but would do everything possible. She stated that Dr. XX ordered intravenous (IV) fluids to be started and continue until the resident could have a Gastric Tube inserted for nutrition and hydration. She further revealed that when the family returned on 10/23/2016 around 6:00 p.m. R35 had not received any IV fluids and demanded R35 be sent to the hospital. Interview on 11/22/16 at 8:20 a.m. with R36 the roommate of R35 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that R36 was cognitively intact. R36 revealed that R35 was holding food and liquid in his mouth, would not swallow and had very little intake for the week prior to discharge to the hospital. Interview on 11/22/16 at 2:00 p.m. with LPN AA and the current interim Administrator revealed that LPN AA had not contacted the Dr. XX regarding the ST recommendation for NPO. She could not provide a reason for not contacting the physician or for putting the recommendation in place without a physician's order [REDACTED]. Review of the nursing notes dated 10/22/16 at 7:35 p.m. revealed an entry by LPN DDD , attempted times 3 to start IV without success. On-coming nurse made aware. Review of a nursing note dated 10/23/2016 at 2:00 p.m. by registered nurse (RN) ZZ revealed R35 declining, has been NPO since 10/20/2016, several attempts to start IV failed. Continued review revealed a nursing note dated 10/23/16 at 6:20 p.m. by RN ZZ revealed family present wants resident sent to emergency room (ER). EMS notified and R35 was sent to the ER. Interview on 11/23/2016 at 10:19 a.m. via telephone with RN ZZ revealed that she had worked 7:00 a.m. to 7:00 p.m. on 10/23/2016. She revealed that the previous shift had reported attempting to start the IV without success but she had not attempted herself. She did not contact the doctor because she thought the family was meeting with Hospice later in the day and thought the NPO status was per the family and physician request. (Cross refer to F157) Interview on 11/23/16 at 10:37 a.m. via telephone with Dr. XX revealed that he was unaware of the status of NPO. (Cross refer to F157 for details) Interview on 11/23/16 at 11:00 a.m. via telephone with Dr. NN revealed that staff did not contact him regarding the ST recommendation of NPO with alternative means of nutrition. (Cross refer to F157 for details) Interview, via telephone, on 11/23/16 at 11:04 a.m. with LPN DDD revealed that she worked 7:00 a.m. to 7:00 p.m. on 10/22/16 and had made three attempts to start the IV without success. She passed this along to the on-coming nurse and had stayed late to make the attempts at starting the IV. Review of the hospital history and physical dated 10/23/2016 revealed that a work up in the ER revealed the resident to be hypotensive (78/50), respiratory rate of 40, temperature of 102.0 degrees Fahrenheit, and urine positive for bacteria. Initially, the resident was so clinically dehydrated that access (IV) was difficult. Laboratory results revealed a serum sodium level of 166 (indicating dehydration), potassium of 3.4 and a white blood count of 14.8 (indicating infection). Additionally, the physical examination revealed at least nine decubitus ulcers. The hospital discharge summary, dated 11/3/2016, revealed R35 had an ultrasound guided right internal jugular vein catheter placement, percutaneous endoscopic gastrostomy (PEG) tube (feeding tube) placement and surgical debridement of decubitus wound. R35 was discharged back to the facility on [DATE], then transferred to a facility closer to them on 11/9/2016.

Based on staff interviews and record review, (Standards of Practice) the facility failed to revise the care plan to include self-injurious behaviors with interventions to prevent injury and failed to revise the care plan after falls with injuries to prevent further falls and/or injuries for one resident (R7). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified and determined to exist on 7/20/16. On November 2, 2016 at 5:00 p.m., the Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. On 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan was developed on 6/1/16 that documented R7 was at risk for verbally, physically, and socially inappropriate behavior related to a [DIAGNOSES REDACTED]. The care plan problem also documented that R7 would get upset and agitated at times for no certain reason and would start yelling and calling for her brother. A review of the clinical record revealed repeated nurses' notes entries, since 6/24/16, that noted R7 would hit herself, slap herself, and hit and kick the walls and doors. The resident was hospitalized from [DATE] through 7/27/16. The hospital history and physical documented the resident was hospitalized for [REDACTED]. Interview on 10/26/16 at 4:20 p.m., Licensed Practical Nurse (LPN) AA stated R7 would slap herself and hit the wall with her hands and head at times. During the times R7 exhibited these behaviors, LPN AA stated that staff would distract the resident and change her attention to something else by doing various things like singing to her or giving her a snack. They would attempt to remove her from the situation that upset her. Interviews on 10/26/16 at 11 a.m. and 4:55 p.m., the DON stated the resident would hit her head against the wall. Interview on 10/27/16 at 11:58 a.m., LPN BB stated that R7 would hit her face hard, hit walls with her hands and head at times and kick and slam doors. She stated that staff would always comfort, try to calm and administer medications as needed for the behaviors for R7. Interview on 10/31/16 at 2:30 p.m., Minimum Data Set (MDS) coordinator EE stated she was unsure why all of the falls were not included on the care plan that they should have been. Interview on 11/3/16 at 4 p.m., Certified Nursing Assistant (CNA) QQ stated R7 would hit and kick and would bump into things and the wall a lot. When she would bump into the wall (when she walked), she would at times bump her head. Although staff documented and stated R7 exhibited physical self-injurious behaviors, they failed to revise the care plan to reflect those actual behaviors with interventions to ensure the safety of R7 and failed to determine what caused the behaviors that put her at risk for injury. R7 had a care plan, dated 6/1/16, for being at risk for falls related to impaired vision, hearing impairment, medication side effects, and poor safety awareness with behaviors. A review of the clinical record revealed that R7 sustained five falls, on 8/2/16, 9/11/16, 9/17/16, 9/25/16 and 9/28/16 each time, hitting her head. Cross-refer to F309 and F323

Based on observation, record review and staff interview, it was determined that the facility failed to develop a comprehensive plan of care to include the use of a lap tray and the risk of negative outcomes including entrapment of the device for one (1) resident (R15). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On October 25, 2016 at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8/21/16 when R15 was observed, by the surveyor, sitting in a wheel chair with a lap tray applied to the wheel chair, R15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. R15 consistently slid underneath the lap trap, the staff was not educated on the proper application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, failed to have R15 assessed, re-assessed and continued the use of the use of the lap tray for R15 with known sliding behavior placing R15 at risk of entrapment. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: Resident (R15) was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [REDACTED]. Review of the Clinical Programs Manual for Restraint Management and Evaluation revealed the interdisciplinary team, re-evaluate the use of a restraint and/or enabler at least quarterly or with change in resident condition during Care Management Meeting and to review and revise the care plan as indicated. The facility developed a care plan dated 4/12/16 that R15 was at risk for falls related to unsteady gait, [MEDICAL CONDITION] medications, generalized muscle weakness and difficulty in walking with an intervention to ensure the activity tray (which the facility is using a lap tray as the activity tray) is in place. Although the care plan mentioned the resident had an activity tray, there was not a care plan developed to address the resident's use a lap tray, the actual device the resident used, and at risk for negative outcomes from the use of the device. R15 had a quarterly Minimum Data Set (MDS) with an assessment reference date of 10/13/16. Facility staff assessed and coded the resident as having severely impaired cognition Brief Interview for Mental Status (BIMS) was 99, having physical and verbal behaviors directed at others, requiring extensive assistance with bed mobility and transfers, and unable to ambulate. R15 had a physician order [REDACTED]. Review of the manufacturer's instructions for wheelchair lap trays revealed the purpose of the wheelchair lap trays are designed to serve as therapeutic interventions that assist patients in achieving proper body position, balance and alignment. Review of the instructions revealed to place tray on arms of wheelchair arms, then wrap the velcro bands around chair arms and tray. Review of the monthly nursing summary dated 8/21/16 and multiple interviews with staff (CNA II, GG, HH, LL, licensed nursing staff FF and JJ), revealed that the resident had an lap tray on the wheelchair and will slide self under the tray onto the floor. (cross to F221 and F323) Observation, by the surveyor, on 10/18/16 at 12:55 p.m., by the surveyor, R15 was observed sliding down in the wheelchair with his chin hanging on the lap tray. The resident then completely slid off of the wheelchair, under the lap tray and onto the floor. Two certified nursing assistants (CNA) placed the resident back into the wheelchair with the lap tray. The CNA then incorrectly placed the lap tray straps around the back of the wheelchair and secured the straps with knots. Interview with the previous Administrator on 10/26/16 at 1:55 p.m., she stated that she discovered the staff were using the straps wrong by fastening the straps around the back of the wheelchair instead of on the wheelchair armrests during the survey. She was unable to provide documentation where the staff had been educated on how to properly apply the device. Despite the facility staff's identification of the resident's behavior of sliding down in the wheelchair while the lap tray was in use, the facility continued to use the lap tray even though the device became a hazard for him. There was no evidence that the facility had assessed or re-evaluated the resident's sliding behavior and the continued use of the lap tray device as a potential hazard for the resident after he had slid down to where his chin or chest was against the device.

Based on record review and interviews the facility failed to notify the physican when insulin was withheld or were not within acceptable ranges (70-100) for resident (R7) and; failed to notify the physician of a Speech Therapy (ST) recommendation which indicated nothing by mouth (NPO) for R35. On November 2, 2016 at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents on 8/21/16 at 6:00 a.m. and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: 1. Record review for R35 revealed that on 10/20/2016, ST, wrote a recommendation for Nothing by Mouth (NPO) with alternative means of nutrition. The physician was not notified of the recommendation by ST, however on 10/21/2016 the facility implemented the recommendation. Interview on 11/21/16 at 2:19 p.m. with Licensed Practical Nurse (LPN) AA revealed that she had signed off on the ST recommendation of NPO and did not think about contacting the physician. She could not give a reason for not contacting the doctor or following up with the DON. Interview on 11/23/16 at 10:19 a.m. with Registered Nurse (RN) ZZ who was working on 10/23/16 revealed that she did not contact the physician because she thought the family was going to put R35 on Hospice. Interview with Physician XX on 11/23/2016 at 10:37 a.m. via telephone revealed he was not made aware of the condition of R35. He further revealed that he would not have left the resident in such a condition. He stated the staff must have contacted the on-call Physician. Interview on 11/23/16 at 11:00 a.m. via telephone with the on-call Physician NN revealed that he was not aware of the resident and no one had contacted him. Cross refer to F281, F325, and F327 2. Record review revealed R7 had a [DIAGNOSES REDACTED]. The insulin was not administered as ordered in June 2016 three (3) times; in July 2016 insulin was withheld a total of five (5) times; in September 2016, on 9/16/16 at 6:30 a.m. the insulin was withheld for an initial blood sugar of 31 and a follow up blood sugar of 120, and; in October 2016 on 10/7/16. There was no evidence in the clinical record that Licensed Nurses (LNs) notified the physician that they were withholding the insulin and not administering it as ordered. Interview on 10/27/16 at 10:07 a.m., the previous DON stated that she would expect LNs staff to administer insulin as ordered. Interview on 11/1/16 at 10:55 a.m., the Physician for R7 stated that the LN should be administering the routine insulin as ordered, not withholding it. In addition the Physician stated that on 9/25/16 when the insulin was withheld for the FSBS of 31 the LN should have called him. Cross refer to F309

Based on observations, record review and staff interviews, it was determined that the facility failed to provide a restraint free environment for one (1) resident (R15); failed to assess the use of a lap tray, failed to re-assess the use of the lap tray when the resident was at risk for serious harm related to entrapment when the lap tray was in use, failed to follow the facility policy related to Restraint Management and Evaluation and failed to educate the staff related to the manufactures recommendations for applying the use of the lap tray. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, remains on-going. On October 25, 2016 at 6:10 p.m. the previous Administrator, previous DON and Corporate Registered Nurse were notified of IJ that was determined to existed on 8/21/16 when R15 was observed sitting in a wheel chair with a lap tray applied to the wheel chair, R15 slid down in the wheelchair with his chin resting on the lap tray which had been applied inappropriately to the wheelchair. R15 consistently slid underneath the lap trap, the staff was not educated on the proper application of the lap tray, the staff incorrectly tied the straps to the lap tray behind the chair, failed to have R15 assessed, re-assessed and continued the use of the use of the lap tray for R15 with known sliding behavior placing R15 at risk of entrapment. At the time of exit on November 23, 2016, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: Resident (R15) was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [REDACTED]. Review of the Clinical Programs Manual for Restraint Management and Evaluation revealed the interdisciplinary team determines how a device will affect resident functional status and freedom of movement. Evaluating a resident for a restraint and/or enabler includes, but is not limited to: Evaluation of alternative measures to physical restraint use, evaluation of medical symptoms that affect resident functional status and how a restraint and/or enabler may assist the resident to function at a higher level. Further review of the procedure revealed staff were to complete the Restraint/Enabler Data Collection and Evaluation form, re-evaluate the use of a restraint and/or enabler at least quarterly or with change in resident condition during Care Management Meeting and to review and revise the care plan as indicated. Review of a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/13/16 for R15 revealed that staff assessed and coded the resident as severely cognitively impaired cognition (Brief Interview for Mental Status, BIMS of 99), exhibiting physical/verbal behaviors directed at others, requiring extensive assistance with bed mobility and transfers, and unable to ambulate. Review of a physician orders [REDACTED]. There was no evidence to indicate the facility had evaluated the lap tray device as an enabler/positioning/restraint device. Review of the Monthly Nursing Summary dated 8/21/16 revealed that R15 had an activity tray, (however the tray was identified to be a lap tray) on the wheelchair and R15 will slide himself under the tray onto the floor. Review of the manufacturer's instructions for wheelchair lap trays revealed the purpose of the wheelchair lap trays are designed to serve as therapeutic interventions that assist patients in achieving proper body position, balance and alignment. Review of the instructions revealed to place tray on arms of wheelchair arms then wrap the velcro bands around chair arms and tray. Observation on 10/18/16 at 12:55 p.m., by the surveyor, R15 was observed sliding down in the wheelchair with his chin hanging on the lap tray. R15 completely slid off of the wheelchair, under the lap tray and onto the floor. Two certified nursing assistants (CNA) placed R15 back into the wheelchair, reapplied the lap tray and then incorrectly placed the lap tray straps around the back of the wheelchair and secured the straps with knots. Interview with CNA II on 10/24/16 at 1:50 p.m. and on 10/25/16 at 11:05 a.m., revealed that the lap tray has been broken (buckle on straps were broken) for about one month. She stated that she just ties the straps around the back of the wheelchair so R15 cannot reach the straps. She also stated that R15 slides down under the lap tray to the point the lap tray is resting on the chest of R15. Interview with Licensed Practical Nurse (LPN) FF on 10/25/16 at 1:50 p.m., revealed that R15 usually slides under the lap tray several times a day. Interviews with CNAs GG and HH on 10/25/16 at 1:50 p.m., revealed that R15 would slide out of the wheelchair under the lap tray. Interview with LPN JJ on 10/27/16 at 9:15 a.m., she stated that she has seen R15 slide down under the lap tray at least two to three times a day. Interview with CNA LL on 10/31/16 at 3:55 p.m., revealed that R15 would slide under the lap tray on a daily basis. Interview with the Certified Occupational Therapy Assistants RR and TT and the Physical Therapy Assistant SS on 10/26/16 at 2:30 p.m., they stated that the therapy department has not assessed R15 for the use of the lap tray. They stated that therapy should be involved in assessing for the use of a device. They were unable to provide any evidence that therapy was asked to screen R15 for the device when it was ordered on [DATE]. They further stated that a lap tray would not be an appropriate device for someone who slides under the device. Interview with Occupational Therapist KK on 10/27/16 at 9:50 a.m., she stated that she was unaware that R15 was using a lap tray. She further stated the lap tray was not an appropriate device for R15 due to the resident sliding down in the chair and put the resident at risk for suffocation. Interview with the previous Administrator on 10/26/16 at 1:55 p.m., she stated that the facility did not evaluate R15 for the use of the lap tray and was unable to provide documentation that therapy evaluated the use of the lap tray when the device was ordered on [DATE]. She stated that she discovered the staff were using the straps wrong by fastening the straps around the back of the wheelchair instead of on the wheelchair armrests during the survey. She was unable to provide documentation indicating that staff had been educated on how to properly apply the lap tray. Despite the facility staff's identification of the resident's behavior of sliding down in the wheelchair while the lap tray was in use, the facility continued to use the lap tray even though the device became a hazard. There was no evidence that the facility had assessed or re-assessed the sliding behavior of R15 and continued use of the lap tray device even though they knew the lap tray was a hazard for R15 after he had slid down to where his chin or chest was against the device. Cross to F279 and F323

Based on record review and staff interviews the facility failed to ensure that the Minimum Data Set (MDS) was coded accurately including pressure sores (PSores), indwelling urinary catheter and weight loss for one (1) resident (R35). The failure of inaccurate coding of the MDS resulted in a lack of care planning. Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 11/22/16 the current interim Administrator, and DON were notified of IJ that was determined to exist on 10/21/16 when the facility failed to ensure the nutritional and hydration needs were maintained for R35 a Speech Therapist (ST) recommended that R35 receive nothing by mouth (NPO) due to the inability of the R35 to swallow. The ST recommended an alternate means of hydration and nutrition, however the physician was not notified and the staff placed R35 NPO. R35 remained NPO until 10/23/2016 when the family intervened and R35 was transferred to the hospital and was admitted on [DATE] with a [DIAGNOSES REDACTED]. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, an acceptable Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: Record review of the Quarterly MDS dated [DATE] revealed that R35 was coded to have one (1) Stage II PSores. R35 was discharged to the hospital on [DATE] with 1 Stage II PSores. R35 was re-admitted to the facility on [DATE]. Review of the wound physician notes dated 9/7/2016 revealed R35 had five (5) PSores at this time including: two (2) stage II and one (1) unstageable on the coccyx; 2 fluid filled blisters to the heels one each heel. However, review of the re-entry MDS dated [DATE] revealed that only 1 Stage III PSores coded on the MDS, and there was no evidence on the MDS of coding for the weight loss, review of the monthly weight monitoring form revealed that R35 weighed 152 pounds (lbs) on 8/1/16. (Cross refer to F325) Review of the wound physician progress notes [REDACTED]. However, R35 continued to have the following PSore: a stage III w to the central coccyx measuring 3.9 x 3.4 x 0.2 centimeters (cm); a unstageable wound to the right, lateral heel with eschar, measuring 2.9 x 3.5 x not measureable depth and a shear wound to the left, posterior, lateral hip with eschar, measuring 4.5 x 4.5 x 0.1 cm. However review of the 14 day MDS dated [DATE] revealed that the PSore coding was unchanged without additional PSore and no there was no evidence of the weight loss being coded. Review of the monthly weights revealed that on 9/7/16 R35 weighed 115lbs. (Cross refer to F325) Review of the wound physician progress notes [REDACTED]. However, review of the discharge MDS dated [DATE] revealed that the coding was unchanged indicating that R35 had one Stage III PSore and no evidence of weight loss. Review of a MDS dated [DATE] revealed that PSores were not coded although the admission skin assessment revealed R35 had seven (7) PSores and an indwelling urinary catheter coded, nor was the weight loss. Review of the five day MDS dated [DATE] remained unchanged with 1 Stage III PSore, no coding of the indwelling urinary catheter and no coding to indicate the weight loss. Review of the wound physician progress notes [REDACTED]. Review of the discharge MDS dated [DATE] revealed that R35 had 2 Stage II and 3 Stage III PSores, nor was the weight loss coded on the MDS. Review of the re-entry MDS dated [DATE] revealed that PSores were not coded, however review of the re-admission skin assessment dated [DATE] revealed that R35 had 7 PSores. The Wound Physician did not see the resident after re-admission on 11/3/2016 and before discharge on 11/9/2016. R35 was hosptalized on [DATE] with severe dehydration and multiple wounds. The hospital discharge summary, dated 11/3/2016, revealed R35 had a percutaneous endoscopic (PEG) gastrostomy tube (feeding tube) placement and surgical debridement of decubitus wound. R35 was discharged back to the facility on [DATE] with continuous feedings via the PEG tube of Glucerna 1.2 at 40 milliliter (ml) per hour and water flushes, 200 ml, every four (4) hours. Review of the wound physician progress notes [REDACTED]. Review of the wound physician progress notes [REDACTED]. R35 was not seen on 10/26/16 due to hospitalization and on 11/9/2016 R35 was discharged to another facility. Interview on 11/22/2016 at 2:00 p.m. with Licensed Practical Nurse (LPN) EE and the current interim Administrator revealed that the former DON would give her the information to enter into the MDS. LPN EE stated she had no idea that the information was incorrect or that she should be looking at the residents for accuracy of PS, indwelling urinary catheter or weight loss herself to ensure the information was correct prior to finalizing the MDS.

Based on record review and staff interview, the facility failed to maintain accurate clinical records regarding the administration of medications, scheduled Insulin, Sliding Scale Insulin and FSBS for eighteen (18) residents (10, 11, 12, 13, 14, 16, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 32). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was one hundred and seventeen (117) residents and the sample size was thirty-nine (39). A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on 7/20/16 and at the time of exit on 11/23/16, remains on-going. On November 2, 2016 at 5:00 p.m., the previous Administrator and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ) when the facility failed to ensure a licensed nurse (LN) was assigned to the secured unit, on 7/20/16 at 12:10 a.m. R17 turned off the door alarm, on the secured unit went out onto the smoking porch to get a soft drink and fell suffering a laceration to the head, there was no licensed nurse (LN) assigned to the secured unit, and only one nurse onsite in the facility. On 7/27/16, a registered nurse (RN) on the secured unit worked while impaired. The facility failed to administer medications and assess blood sugar levels (FSBS) as ordered by the physician for twenty-two (22) residents and on 10/9/16, R7 sustained bilateral nasal bone fractures and a right cerebellar subacute hematoma, after running into a door frame, and was hospitalized with a blood sugar of 567 and [DIAGNOSES REDACTED]. Findings include: Review of the facility's policy titled General Dose Preparation and Medication Administration, revealed that nurses should document necessary medication administration (e.g., when medications are given) on appropriate forms. 1. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED].) every day (scheduled at 9:00 a.m.). However, review of the Medication Administration Records (MARs) revealed that licensed nursing staff failed to document that the Aspirin was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/4/16. Review of the medical record for R10 revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the HCTZ was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/4/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARS revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/4/16. Review of the medical record for R10 revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/4/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the Calcium was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/4/16. Review of the medical record for R10 revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered at 9:00 a.m. on 8/27/16, 8/31/16, 9/11/16, 9/19/16, 9/28/16, 10/4/16 and 10/12/16. Licensed nursing staff failed to document that the [MEDICATION NAME] was administered at 9:00 p.m. on 8/21/16, 8/22/16, 8/25/16, 8/26/16, 9/30/16 and 10/12/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered twice a day on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/12/16. Licensed Nursing staff failed to document that the [MEDICATION NAME] was administered on 10/4/16 at 9:00 a.m. Review of the medical record for R10 revealed a physician's orders [REDACTED]. However, review of the MARS revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered as ordered on [DATE] at 9:00 p.m., 8/31/16 at 9:00 a.m., 9/11/16 at 9:00 a.m., 9/19/16 at 9:00 a.m., 9/28/16 at 9:00 a.m., 10/4/16 at 9:00 a.m., 10/12/16 at 9:00 a.m. and 5:00 p.m. and 10/21/19 at 9:00 a.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/26/16 at 5:00 p.m., 8/31/16 at 9:00 a.m. and 5:00 p.m., 9/10/16 at 5:00 p.m., 9/11/16 at 9:00 a.m. and 5:00 p.m., 9/19/16 at 9:00 a.m. and 5:00 p.m. , 9/28/16 at 9:00 a.m. and 5:00 p.m., 10/4/16 at 9:00 a.m. and 5:00 p.m., 10/12/16 at 9:00 a.m. and 5:00 p.m. and on 10/21/16 at 5:00 p.m. 2. R11 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] DR was administered on 8/20/16 at 9:00 p.m., 8/21/16 at 9:00 p.m., 9/11/16 at 9:00 a.m., 9/19/16 at 9:00 a.m. and on 9/28/16 at 9:00 a.m. On 10/5/16 the physician decreased the [MEDICATION NAME] DR to 250 mgs twice a day per the consultant pharmacist ' s recommendation. However, review of the MAR indicated [REDACTED] review of the resident's medical record revealed [REDACTED]. However, review of the MARs for R11 revealed that licensed nursing staff failed to document that the Glucaphage was administered 9/3/16 at 5:00 p.m., 9/4/16 at 5:00 p.m., 9/10/16 at 5:00 p.m., 9/11/16 at 9:00 a.m. and 5:00 p.m., 9/19/16 at 9:00 a.m. and 5:00 p.m., 9/28/16 at 9:00 a.m. and 5:00 p.m.; and on 10/4/16 at 9:00 a.m. and 5:00 p.m. review of the resident's medical record revealed [REDACTED]. twice a day for [MEDICAL CONDITION] (scheduled at 9:00 a.m. and 9:00 p.m.). However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/20/16 at 9:00 p.m. and on 8/21/16 at 9:00 p.m.; on 9/11/16 at 9:00 a.m., 9/19/16 at 9:00 a.m. and 9/28/16 at 9:00 a.m.; and on 10/4/16 at 9:00 a.m. and 5:00 p.m. Review of the medical record for R11 revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered 8/20/16 at 9:00 p.m. and 8/21/16 at 9:00 p.m.; on 9/11/16 at 9:00 a.m., 9/19/16 at 9:00 a.m., 9/28/16 at 9:00 a.m.; and on 10/4/16 at 9:00 a.m. and 5:00 p.m. Review of the R11 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered 8/20/16 at 9:00 p.m., 8/21/16 at 9:00 p.m. and 8/25/16 at 9:00 p.m.; on 9/11/16 at 9:00 a.m. and 1:00 p.m., on 9/19/16 at 9:00 a.m. and 1:00 p.m., on 9/28/16 at 9:00 a.m. and 1:00 p.m., and on 9/29/16 at 9:00 p.m.; and on 10/4/16 at 9:00 a.m. and 1:00 p.m., 10/12/16 at 9:00 p.m., 10/17/16 at 9:00 p.m. and on 10/20/16 at 9:00 p.m. Review of the medical record for R11 revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/20/16 at 9:00 p.m., on 8/21/16 at 9:00 p.m.; and on 9/11/16 at 9:00 a.m. and 1:00 p.m., on 9/12/16 at 9:00 a.m. and 1:00 p.m. and on 9/28/16 at 9:00 a.m. and 1:00 p.m. On 10/5/16, the physician decreased the [MEDICATION NAME] to 350 mgs twice a day (scheduled for 9:00 a.m. and 9:00 p.m.). However, review of the October 2016 MAR indicated [REDACTED] Review of the R11 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/20/16 at 9:00 p.m. and on 8/21/16 at 9:00 p.m. Review of the medical record for R11 revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the Trazadone was administered on 8/20/16 at 9:00 p.m., on 8/21/16 at 9:00 p.m. and on 8/22/16 at 9:00 p.m. Review of the medical record for R11 revealed a physician's orders [REDACTED]. However, review of the MARS revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/22/16 at 9:00 a.m.; on 9/11/16 at 9:00 a.m., on 9/19/16 at 9:00 a.m. and on 9/28/16 at 9:00 a.m.; and on 10/4/16 at 9:00 a.m. Review of the R11 medical record revealed a physician's orders [REDACTED]. Review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 9/11/16 at 9:00 a.m., on 9/19/16 at 9:00 a.m. and on 9/28/16 at 9:00 a.m. and on 10/4/16 at 9:00 a.m. Review of the medical record for R11 revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the Actos was administered on 9/11/16 at 9:00 a.m., 9/19/16 at 9:00 a.m. and on 9/28/16 at 9:00 a.m. and on 10/4/16 at 9:00 a.m. Review of the R11 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the K-Dur was administered 9/11/16 at 9:00 a.m., 9/19/16 at 9:00 a.m. and on 9/28/16 at 9:00 a.m. and on 10/4/16 at 9:00 a.m. Review of the medical record for R11 revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the multivitamin was administered 9/11/16 at 9:00 a.m., 9/19/16 at 9:00 a.m., 9/28/16 at 9:00 a.m. and 10/4/16 at 9:00 a.m. Review of the R11 medical record revealed a physician's orders [REDACTED]. However, review of the MARS revealed that licensed nursing staff failed to document that the Invokana was administered on 9/11/16 at 9:00 a.m., on 9/19/16 at 9:00 a.m., on 9/28/16 at 9:00 a.m. and on 10/4/16 at 9:00 a.m. 3. R12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the R12 medical record revealed a physician's orders [REDACTED].) every day for [MEDICAL CONDITION] (scheduled at 6:30 a.m.) However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered 8/21/16, 8/22/16 and 10/20/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. At bedtime (scheduled at 9:00 p.m.). However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] ER was administered at 9:00 a.m. on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/19/16. Licensed nursing staff failed to document that the [MEDICATION NAME] ER was administered at 9:00 p.m. on 8/20/16, 8/21/16, 9/28/16 and 10/19/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. every day for supplement (schedules at 9:00 a.m.). However, review of the MARs revealed that licensed nursing staff failed to document that the Folic Acid was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/22/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the HCTZ on 8/31/16, 9/11/16, 9/19/16, 9/28/16, and 10/22/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARS revealed that licensed nursing staff failed to document that the Invokana was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/22/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/22/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARS revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/31/16, 9/11/16, 9/19/16 and 9/28/16 and 10/22/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/21/16, 8/22/16 and 8/23/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARS revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/22/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the K-Dur was administered on 8/27/16, 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/22/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARS revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered twice a day on 8/31/16, 9/11/16, 9/19/16 and 9/28/16. The resident was readmitted from the psychiatric hospital on [DATE] with a physician's orders [REDACTED]. However, review of the October 2016 MAR indicated [REDACTED] Review of the R12 medical record revealed a physician's orders [REDACTED]. Licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 10/22/16 at 9:00 a.m. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered twice a day on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/22/16. Licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 10/18/16 at 5:00 p.m., on 10/20/16 at 9:00 a.m., and on 10/21/16 at 5:00 p.m. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/20/18, 8/21/16 and 9/28/16. Review of the R12 medical record revealed a physician's orders [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/20/16, 8/21/16, 9/28/16 and 10/16/16. 4. R13 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 9/11/16, 9/19/16, 9/28/16 and 10/4/16. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. twice a day (9:00 a.m. and 5:00 p.m.). However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/27/16 at 5:00 p.m., on 9/11/16 at 9:00 a.m. And 5:00 p.m., on 9/19/16 at 9:00 a.m. and 5:00 p.m., on 9/28/16 at 9:00 a.m. and 5:00 p.m. and on 10/4/16 at 9:00 a.m. and 5:00 p.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 9/11/16 at 9:00 a.m., 9/19/16 at 9:00 a.m., 9/28/16 at 9:00 a.m., 10/4/16 at 9:00 a.m. and on 10/12/16 at 9:00 p.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the Metroprolol was administered on 8/27/16 at 5:00 p.m., 9/10/16 at 5:00 p.m., 9/11/16 at 9:00 a.m. and 5:00 p.m., 9/19/16 at 9:00 a.m. and 5:00 p.m., 9/28/16 at 9:00 a.m. and 5:00 p.m. and on 10/4/16 at 9:00 a.m. and 5:00 p.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 9/11/16 at 9:00 a.m. and 5:00 p.m., 9/19/16 at 9:00 a.m. and 5:00 p.m., 9/28/16 at 9:00 a.m. and 5:00 p.m. and on 10/4/16 at 9:00 a.m. and 5:00 p.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/25/16 at 9:00 p.m., 9/10/16 at 5:00 p.m., 9/11/16 at 9:00 a.m. and 5:00 p.m., 9/18/16 at 5Z:00 p.m., 9/19/16 at 9:00 a.m. and 5:00 p.m., on 9/28/16 at 9:00 a.m. and 5:00 p.m., 10/4/16 at 9:00 a.m. and 5:00 p.m. and on 10/12/16 at 9:00 p.m. review of the resident's medical record revealed [REDACTED]. Review of pertinent labs done 6/6/16 revealed a [MEDICATION NAME] acid level that was within normal limits. 5. R14 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the residents' medical record revealed a physician's orders [REDACTED]. However review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 10/14/16 and 10/20/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered to the resident on 8/30/16, 8/31/16, 10/14/16 and 10/20/16. review of the resident's medical record revealed [REDACTED]. At 9:00 p.m. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] 500 mgs. Was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16, 10/4/16 and 10/22/16 and failed to document that the 1500 mgs was administered on 9/28/18 and 10/4/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/31/16, 9/11/16, 9/19/16, 9/28/16 and 10/4/16. review of the resident's medical record revealed [REDACTED]. a.m. and 5:00 p.m. and 10/4/16 at 9:00 a.m. and 5:00 p.m. review of the resident's medical record revealed [REDACTED]. a.m. and 5:00 p.m. and 10/4/16 at 9:00 a.m. and 5:00 p.m. review of the resident's medical record revealed [REDACTED].:00 a.m. and 5:00 p.m. and 10/4/16 at 9:00 a.m. and 5:00 p.m. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. and [MEDICATION NAME] 15 mgs at bedtime (9:00 p.m.). However, review of the MARs revealed that licensed nursing staff failed to administer the [MEDICATION NAME] and [MEDICATION NAME] on 10/12/16. review of the resident's medical record revealed [REDACTED]. Review of [MEDICATION NAME] acid level done 6/28/16 revealed that it was within normal limits. 6. R25 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/16/16 at 5:00 p.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/20/16, 8/21/16, 8/25/16, and 8/26/16 and on 9/25/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/20/16, 8/21/16 and 10/19/16. 7. R27 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the Glucaphage was administered on 8/19/16 at 5:00 p.m., 8/27/16 at 5:00 p.m., 9/28/16 at 9:00 a.m. and 5:00 p.m., and on 10/4/16 at 9:00 a.m. and 5:00 p.m. Review of the resident's record revealed a physician's orders [REDACTED]. Twice a day (9:00 a.m. and 9:00 p.m.). However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/18/16 at 9:00 p.m., 8/20/16 at 9:00 p.m., 8/21/16 at 9:00 p.m., 9/10/16 at 9:00 a.m., 9/28/16 at 9:00 a.m. and on 10/4/16 at 9:00 a.m. and 9:00 p.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/18/16 at 9:00 p.m., 8/19/16 at 5:00 p.m., 8/20/16 at 9:00 p.m., 8/21/16 at 9:00 p.m., 9/10/16 at 5:00 p.m., 9/28/16 at 9:00 a.m. and 5:00 p.m., 10/4/16 at 9:00 a.m. and 5:00 p.m., 10/12/16 at 9:00 p.m., 10/19/16 at 9:00 p.m. and on 10/22/16 at 5:00 p.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 9/28/16 at 9:00 a.m., 1:00 p.m. and 5:00 p.m., on 10/4/16 at 9:00 a.m., 1:00 p.m. and 5:00 p.m., on 10/18/16 at 5:00 p.m. and on 10/22/16 at 5:00 p.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/18/16 at 9:00 p.m., 8/19/16 at 5:00 p.m., 8/20/16 at 9:00 p.m., 8/21/16 at 9:00 p.m., 9/28/16 at 9:00 a.m. and 5:00 p.m., on 10/4/16 at 9:00 a.m. and on 10/12/16 at 9:00 p.m. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/18/16, 8/20/16, 8/21/16, and 10/12/16. review of the resident's medical record revealed [REDACTED]. The [MEDICATION NAME] acid level was low at 44.6 (normal is between 50 and 100) on 5/27/16. 8. R28 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Licensed nursing staff failed to document that the 150 mgs of [MEDICATION NAME] was administered on 8/20/16, 8/21/16 and 10/12/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered 9/10/16, 9/11/16, 9/19/16, 9/28/16 and 10/4/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 9/5/16 and 10/20/16. review of the resident's medical record revealed [REDACTED]. However, review of the MARs revealed that licensed nursing staff failed to document that the [MEDICATION NAME] was administered on 8/20/16 at 9:00 p.m., 8/21/16 at 9:00 p.m., 8/22/16 at 9:00 p.m., 8/31/16 at 9:00 a.m., 9/11/16 at 9:00 a.m., 9/19/16 at 9:00 a.m., 9/28/16 at 9:00 a.m. and 10/4/16 at 9:00 a.m. review of the resident's medical record revealed [REDACTED].

Based on observation, clinical record review, Bedside Swallow Assessment review, County EMS Medical Necessity Form For Transportation By Ambulance form review, hospital Radiology Department X-ray report review, hospital History and Physical form review, hospital Physician Documentation Sheet review, hospital Emergency Department Record Physician order [REDACTED].#1 and #6) who were assessed by the Speech Language Pathologist to require skilled speech therapy services and/or a Modified [MEDICATION NAME] Swallow Study due to Oropharyngeal Dysphagia and a risk for aspiration pneumonia, and for one (1) resident (#2), related to the provision of pressure sore treatment as ordered and care planned, on the total survey sample of eight (8) residents. For Resident #1, the resident was later noted to have altered mental status and respiratory distress, was transferred to the hospital and noted to have left lower lobe volume loss and partial left lower lobe collapse, was diagnosed with [REDACTED]. The facility's failure to provide the necessary skilled speech therapy services resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on June 4, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on April 3, 2014 (the date the facility failed to notify the physician of Resident #1 having demonstrated signs and symptoms of aspiration characterized by a gurgly/wet voice, watery eyes and nose, and an unproductive cough/clear, and of the resident being at risk for aspiration and aspiration pneumonia without skilled speech therapy intervention), continued through June 5, 2014, and was removed on June 6, 2014. On June 5, 2014, the facility implemented a credible allegation of jeopardy removal. During an interview conducted on June 3, 2014 at 1:50 p.m., the Administrator acknowledged a delay in Resident #1 obtaining skilled speech therapy services as assessed by the Speech Language Pathologist, and a 06/06/2014, 9:50 a.m. interview with the DON acknowledged that the Care Plan of Resident #1 specified that the resident receive speech therapy as warranted. An allegation of jeopardy removal was received on June 5, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on June 6, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of evaluating, on an ongoing basis, the effectiveness the modified Policy for physician Change of Condition Notification, the newly implemented Procedure for Follow-Up of Therapy Recommendations, and the newly implemented Policy and Procedure for Obtaining Pay Source Verification and Funding For Therapy Services. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's procedures regarding physician notification and obtaining rehabilitation therapy services to meet the needs of residents. Resident records were reviewed to ensure that physicians were notified of significant changes in resident status, and that rehabilitation therapy services were provided in accordance with the assessed needs of residents. Findings include: 1. Resident #1's Admission Minimum Data Set (MDS) of 04/09/14 documented an admission date of [DATE], and Section I-Active [DIAGNOSES REDACTED]. Section K - Swallowing/Nutritional Status documented that Resident #1 received a mechanically altered diet, and the 04/01/2014 Admission physician's orders [REDACTED]. The comprehensive Care Plan for Resident #1 identified as a Focus area dated 04/09/2014 that the resident was at risk for an alteration in nutrition related to receiving a mechanically altered diet, as identified on the MDS referenced above. Resident #1's Care Plan identified as Interventions, related to the resident's nutritional status and receipt of a mechanically altered diet, to monitor the resident for choking, regurgitation, and aspiration, and also for speech therapy to treat the resident if warranted/ordered. Resident #1's 04/01/2014 Admission physician's orders [REDACTED]. A 04/02/2014 therapy screening form signed by Certified Occupational Therapy Assistant (COTA) "AA" documented that Resident #1 was referred to speech therapy, and a memo of 04/03/14 documented that a Bedside Swallow Assessment had been completed by the Speech Language Pathologist. This Bedside Swallow Assessment revealed Resident #1 to have Oropharyngeal Dysphagia and also revealed findings which included poor bolus manipulation/control, a swallow trigger delay, and a weak cough/clear. The Speech Language Pathologist documented that Resident #1 demonstrated signs/symptoms of aspiration, and documented the required interventions of a Modified [MEDICATION NAME] Swallow Study and skilled speech therapy for swallow function and safety 3 times per week for 8 weeks, noting that without skilled intervention Resident #1 was at risk for aspiration pneumonia. However, even though the Speech Language Pathologist assessed Resident #1, via the 04/03/2014 Bedside Swallow Assessment referenced above, to be at risk for aspiration pneumonia and specified the interventions of a Modified [MEDICATION NAME] Swallow Study and skilled speech therapy 3 times weekly for 8 weeks, and even though Resident #1's Care Plan specified as an Intervention for speech therapy to treat Resident #1 if warranted/ordered and also noted, under Interventions, that Resident #1 was at risk for choking and aspiration, there was no evidence to indicate that the Modified [MEDICATION NAME] Swallow and skilled speech therapy had been provided, or that the physician had been consulted regarding these interventions. A 05/03/2014, 1:20 p.m. Nurse's Notes entry documented that the attending physician, upon examination, had noted Resident #1 to have coughing with crackles and course sounds in the left/right lower lobes and had given an order to send the resident to the hospital. A 05/03/2014, 1:30 p.m. Nurse's Notes entry documented EMS's facility arrival to transport Resident #1 to the hospital (Hospital A). Resident #1's Hospital A Radiology Department X-ray report of 05/04/2014 at 12:03 a.m. documented left lower lobe volume loss with associated atelectasis, with left lower lobe lung airspace disease and partial left lower lobe collapse concerning for aspiration pneumonia. An Emergency Department Record Physician order [REDACTED].#1 to Hospital B, and the County EMS Medical Necessity Form For Transportation By Ambulance form of 05/04/2014 documented medical conditions, upon transfer to Hospital B, which included Aspiration Pneumonia. The History and Physical (H&P) of Hospital B documented Resident #1's 05/04/2014, 3:00 a.m. admission to Hospital B, having coarse rhonchi on the left and [DIAGNOSES REDACTED]. The Hospital B Physician Documentation Sheet documented Emergency Department Final [DIAGNOSES REDACTED].#1 was being admitted to Critical Care in serious condition. During an interview conducted on 06/06/2014 at 9:50 a.m., the DON acknowledged the Speech Language Pathologist's screened interventions for Resident #1 involving the Modified [MEDICATION NAME] Swallow Study and skilled speech therapy services, and acknowledged the Care Plan Interventions requiring that Resident #1 receive speech therapy as warranted; however, the DON also acknowledged that Resident #1 had not received the skilled speech therapy services specified by the Speech Language Pathologist. Cross refer to F325, and also to F406, example 1, for more information regarding Resident #1. 2. Resident #6's Admission MDS of 04/28/2014 documented [DIAGNOSES REDACTED]. Section K - Swallowing/Nutritional Status documented that Resident #6 received a mechanically altered diet, and the May 2014 physician's orders [REDACTED]. The Care Plan for Resident #6 identified as a Focus area that the resident was at risk for an alteration in nutrition related to the mechanically altered diet and a history of [MEDICAL CONDITION], and Interventions indicated to monitor the resident for choking and aspiration, and also for speech therapy to treat the resident if ordered/warranted. The Speech Language Pathologist's Initial Assessment of 05/07/14 indicated Resident #6 had Oropharyngeal Dysphagia and documented findings including, but not limited to, decreased oral stage function, oral holding, and a mild swallow trigger delay. The Speech Language Pathologist documented that Resident #6 was at risk for possible aspiration, requested a Modified [MEDICATION NAME] Swallow, and documented that Resident #6 required skilled speech therapy 3 times a week for 4 weeks. A 05/07/14 Physician's Telephone Order specified skilled speech therapy 3 times weekly for 4 weeks, and a Modified [MEDICATION NAME] Swallow as indicated. The Speech Therapist (ST) - Therapist Progress notes of 05/13/2014, 05/20/2014, and 05/27/2014 documented that Resident #6 received skilled speech therapy as ordered; however, further record review revealed no evidence to indicate that the Modified [MEDICATION NAME] Swallow Study, originally ordered on [DATE], was obtained until 06/05/2014, after the initiation of this complaint survey. During interview on 06/06/2014 at 12:00 p.m., the Speech Language Pathologist acknowledged she had requested a Modified [MEDICATION NAME] Swallow for Resident #6 on 05/07/14, in part to identify deficits and treatment, and that the Study was not done until 06/05/2014. Based on the above, despite Resident #6 having Oropharyngeal Dysphagia; despite the Speech Language Pathologist assessing Resident #6 on 05/07/14, indicating that oral deficits placed the resident at risk for possible aspiration and requesting a Modified [MEDICATION NAME] Swallow, in part to identify deficits and treatment; despite a 05/07/14 physician's orders [REDACTED]. Cross refer to F406, example 2, for more information regarding Resident #6. 3. Resident #2's MDS of 06/05/14 documented [DIAGNOSES REDACTED]. The May 2014 physician's orders [REDACTED].#2's left heel with wound cleanser, apply Hydrogel, cover with a dry dressing, wrap with gauze, and secure with tape once daily and as needed. Resident #2's Care Plan identified, as a Focus area, that the resident had impaired skin integrity related to the presence of the heel pressure sore. The Care Plan for Resident #2 referenced Interventions related to this pressure sore which included to administer and evaluate the effectiveness of prescribed medications and treatments. However, during a 05/21/14, 1:30 p.m. observation, Resident #2's left heel pressure sore dressing was noted to be dated 05/19/14 (2 days prior), even though the order specified daily treatment changes. During interview on 05/21/14 at 1:30 p.m., the Treatment Nurse acknowledged that the treatment dressing was dated 2 days prior and had not been applied as ordered. Cross refer to F314 for more information regarding Resident #2. The immediate jeopardy was removed on June 6, 2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: A. On June 4, 2014, the facility developed and implemented a procedure entitled Procedure: Follow Up of Therapy Recommendations. This new Procedure specified that upon receipt of a therapy recommendation, the Therapy Program Manager (TPM) would provide a copy of the therapy recommendation to facility nursing staff to obtain a physician's orders [REDACTED]. B. On June 4, 2014, the facility developed and implemented a new policy entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services. This new Policy and Procedure allowed for obtaining payor source approval and funding approval, if necessary, for all residents when skilled therapy services are provided. This Policy and Procedure specified that when therapy services are required for a resident, the TPM would verify the payor source with the Business Office Manager (BOM). The BOM will then approve the payor source for resident's having Medicare, Health Maintenance Organization coverage, or other insurance coverage. For residents who were responsible for privately paying for the cost of care, or who had a conservator or power of attorney, the Policy and Procedure outlined multiple steps, including coordination between the BOM and therapy staff, immediate contact with the responsible party with treatment cost information, immediate notification by the BOM of therapy company management staff, and involvement of the facility Administrator in cases where funding is in question. This process is to ensure the timely receipt of funding for treatment to ensure the timely provision of treatment. C. On June 4, 2014, the facility reviewed and revised the existing procedure for physician notification of a change in resident status and consulting with the physician regarding treatment recommendations. This procedure specified who was responsible for identifying and confirming significant changes of resident status, as well as other circumstances requiring physician consultation, such as a need to alter treatment significantly, and included the use of a Change of Condition Notification form upon which nursing staff were to document an explanation of the resident's condition and the contact information of the physician who was consulted. The procedure also specified the maintenance of a Change of Condition Flow Sheet at the nurse's station for review and for presentation at Patient At Risk Committee meetings for monitoring and discussion. D. On June 4, 2014, the facility's DON conducted a complete resident chart review of 100 percent of resident charts to ensure that all recommendations regarding resident care were had been identified and addressed. E. On June 5, 2014, the TPM conducted a resident chart audit on residents currently on the therapy caseload to ensure that follow-up was completed for therapy care recommendations. F. On June 5, 2014, the facility continued the process of conducting nursing staff in-service training regarding the newly implemented procedure related to therapy recommendations, entitled Procedure: Follow Up of Therapy Recommendations; provided staff training on the newly implemented policy and procedure for the procurement of therapy payor source, entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services; additionally, staff training was provided on the revised procedure related to physician notification of resident status change, and on the accompanying Change of Condition Notification form to be utilized by nursing staff to clearly explain resident condition and to document physician contact. As of June 5, 2014, of the facility's current 113 nursing staff employees, 112 had received this training. The remaining nursing staff employee was currently unavailable for training at that time, and will receive training upon returning to work. In addition, all newly hired employees will receive in-service training regarding these policies and procedures as part of the orientation program conducted upon hire. G. On June 5, 2014, the facility implemented a procedure by which the DON, ADON, or designated Nursing Supervisor would conduct a weekly audit of sampled resident clinical records to ensure timely follow-through for all therapy recommendations. This weekly resident record audit will also monitor staff compliance with the identification of, and follow-up for, resident changes in condition. The QA Audit Tool will be utilized to document this weekly resident record audit. H. On June 5, 2014, the facility implemented a procedure by which the results of facility management staffs' monitoring of staff compliance with the newly implemented policies and procedures regarding physician notification of changes in resident status and follow-up on therapy recommendations, via the QA Audit Tool, would be presented at the monthly Quality Assessment (QA) Committee meetings. Additionally, the QA Committee reviewed and approved all of the newly implemented interventions the facility had put into place, including the Procedure: Follow Up of Therapy Recommendations policy, the new Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy, and the newly revised procedure related to physician notification of resident status change involving the Change of Condition Notification form. The QA Committee will continue the review process, during monthly QA Committee meetings, related to management staffs' findings of facility nursing staff compliance with these newly implemented policies and procedures, to ensure that the QA Committee provides for the ongoing monitoring and oversight of facility nursing staff compliance with these new procedures, and to allow the Committee to identify any future need for policy modification and/or additional staff training. During this complaint survey, on the following referenced dates, each newly developed and implemented policy, procedure, and system included in the facility's credible allegation of jeopardy removal, as referenced above, was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On June 5, 2014, the facility's newly implemented procedure entitled Procedure: Follow Up of Therapy Recommendations was reviewed, and it was found that the facility had implemented this procedure related to actions to be taken upon receipt of a therapy recommendation, including the involvement of the DON, ADON, or Nursing Supervisor to ensure follow-up. - On June 5, 2014, the facility's newly developed and implemented Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy was reviewed and found to address the process of obtaining payor source approval and funding for resident therapy, including both residents with Medicare, Health Maintenance Organization coverage, or other insurance, and private pay residents. - On June 5, 2014, the facility's reviewed and revised procedure for physician notification regarding resident changes in status or physician notification of treatment recommendations was reviewed, and was found to address these issues, including the staff responsible for the notification. - On June 6, 2014, a review was conducted to ensure completion of the facility's 100 percent resident clinical record audit which had been completed on June 5, 2014 by the DON to ensure that resident care recommendations had been identified and addressed. - On June 6, 2014, a review was conducted to ensure completion of the resident chart audit, as indicated on the facility's credible allegation of jeopardy removal, which was conducted on June 5, 2014, by the TPM for residents currently on the therapy caseload to ensure follow-up on therapy recommendations. - On June 6, 2014, the nursing staff in-service training regarding the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the revised procedure for physician notification of resident status change was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On June 6, 2014, it was confirmed via procedural review that the DON/ADON/Nursing Supervisor would conduct weekly audits of sampled resident clinical records to monitor for timely follow-through for all therapy recommendations and significant changes in resident condition. - On June 6, 2014, it was confirmed via procedural review that the results of management staffs' monitoring of staff compliance with the new policies and procedures involving physician notification and follow-up on therapy recommendations using the QA Audit Tool would be presented at the monthly Quality Assessment (QA) Committee meetings to ensure the QA Committee's ongoing monitoring and oversight of staff compliance with these procedures. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to timely follow-up on recommendations for therapy services and significant changes in resident status, was removed on June 6, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had developed, implemented, and/or revised policies and procedures, such as the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the procedure for physician notification of a change in resident status, and had conducted nursing staff in-service training on these policies and procedures. As of June 5, 2014, the facility had provided this in-service training to 112 of the facility's 113 current nursing staff employees, with the remaining nursing staff employee to receive this in-service training upon the return to work. Additionally, the facility had indicated that all newly hired employees were to receive in-service training upon hire. A future review will be necessary to determine the completion of the indicated staff in-service training on these policies and procedures for the remaining current employee, and any new employees hired after the June 6, 2014 exit date of this complaint survey. In addition, the facility had implemented a procedure involving a DON/ADON/Nursing Supervisor weekly audit of sampled resident clinical records to ensure follow-through for therapy recommendations and accurate identification of resident changes in status. However, this new weekly audit procedure had been implemented on June 5, 2014, with the first weekly resident chart audit to be completed the week following the June 6, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with the completion of these weekly resident chart audits will need to be evaluated by way of a future review. To allow for the further evaluation of scheduled nursing staff in-service training regarding the newly implemented policies and procedures and of facility supervisory staffs' ongoing weekly resident chart audits, the noncompliance continues, with the scope and severity decreased to the "D" level.

Based on clinical record review, staff interview, County EMS report review, County EMS Medical Necessity Form For Transportation By Ambulance form review, Bedside Swallow Assessment form review, Diet Intake Percentage form review, Monthly Weight Record form review, hospital History and Physical form review, hospital Radiology Department Computed Tomography review, hospital Emergency Department Record Physician order [REDACTED].#1), who was assessed to have Oropharyngeal Dysphagia and to be at risk for aspiration pneumonia, on the total survey sample of eight (8) residents. Resident #1 was found in respiratory distress, was transferred to the hospital and noted with atelectasis and partial left lower lobe collapse, was diagnosed with [REDACTED]. The facility's failure to provide the necessary speech therapy services and timely physician consultation for Resident #1, despite the resident's assessed risk for aspiration pneumonia, represented neglect by resulting in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on June 4, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on April 3, 2014 (the date the facility failed to notify the physician of Resident #1 having demonstrated signs and symptoms of aspiration characterized by a gurgly/wet voice, watery eyes and nose, and an unproductive cough/clear, and of the resident being at risk for aspiration and aspiration pneumonia without skilled speech therapy intervention), continued through June 5, 2014, and was removed on June 6, 2014. On June 5, 2014, the facility implemented a credible allegation of jeopardy removal. During an interview conducted on June 3, 2014 at 1:50 p.m., the Administrator acknowledged being aware of a delay in obtaining speech therapy services as specified by Resident #1's speech therapy evaluation. An allegation of jeopardy removal was received on June 5, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on June 6, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of evaluating, on an ongoing basis, the effectiveness the modified Policy for physician Change of Condition Notification, the newly implemented Procedure for Follow-Up of Therapy Recommendations, and the newly implemented Policy and Procedure for Obtaining Pay Source Verification and Funding For Therapy Services. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's procedures regarding physician notification and obtaining rehabilitation therapy services to meet the needs of residents. Resident records were reviewed to ensure that physicians were notified of significant changes in resident status and that rehabilitation therapy services were provided in accordance with the assessed needs of residents. Findings include: Resident #1's Admission Minimum Data Set of 04/09/2014 documented diagnoses, in Section I - Active Diagnoses, including [MEDICAL CONDITION] Reflux Disease, Arthritis, and [MEDICAL CONDITION]. A 04/01/2014, 11:55 a.m. Nurse's Notes entry documented Resident #1's facility admission and documented the resident to have no shortness of breath or respiratory distress. A subsequent 04/03/2014 memo by the Speech Language Pathologist documented that a Bedside Swallow Assessment of Resident #1 revealed Oropharyngeal Dysphagia, with Oral Phase deficits which included residue throughout the oral cavity post-swallow, and Pharyngeal Phase deficits which included a delayed swallow trigger. The Speech Language Pathologist documented that Resident #1 demonstrated signs/symptoms of aspiration, including a gurgly/wet voice, watery eyes/nose, and an unproductive cough/clear. The Speech Language Pathologist specified required interventions of a Modified [MEDICATION NAME] Swallow Study for the determination of penetration and/or aspiration, and skilled therapy three (3) times per week for eight (8) weeks, and cautioned that without skilled intervention, Resident #1 was at risk for aspiration pneumonia. However, further record review for Resident #1 revealed no evidence of immediate physician consultation, despite the Speech Language Pathologist noting Resident #1 to exhibit signs/symptoms of aspiration, including a gurgly/wet voice, watery eyes/nose, and an unproductive cough/clear during the 04/03/2014 Bedside Swallow Assessment as above. There was also no evidence to indicate that the Modified [MEDICATION NAME] Swallow Study had been done or that skilled speech therapy had been provided, even though the Speech Language Pathologist had indicated that both interventions were required based on the 04/03/2014 Bedside Swallow Assessment, and had cautioned that Resident #1 was at risk for aspiration without skilled intervention. During a 06/06/2014, 9:50 a.m. interview, the DON acknowledged that the required interventions for speech therapy services specified on the 04/03/2014 Bedside Swallow Assessment for Resident #1 had not been done. After the facility's failure to obtain the required Modified [MEDICATION NAME] Swallow Study and skilled speech therapy services for Resident #1's assessed Dysphagia and swallowing difficulties, the resident's April 2014 Diet Intake Percentage form documented low meal consumption ranging from 20 percent to 50 percent on 17 days during breakfast, and on 12 days during lunch, for the period from 04/01/2014 through 04/28/2014. Resident #1's April 2014 Monthly Weight Record then documented weight loss from 149 pounds on 04/01/2014 to 128 pounds on 04/28/2014, representing a 14 percent weight loss during this period. The Registered Dietician (RD) completed a Nutrition Assessment for Resident #1 on 04/29/2014 and noted that this unintentional weight loss was related to decreased oral intake. In addition, a 05/03/2014, 1:20 p.m. Nurse's Notes entry documented that Resident #1 had coughing with crackles and course sounds in the left and right lower lobes, with the physician ordering hospital transfer. A 05/03/2014, 1:30 p.m. Nurse's Notes entry documented EMS had arrived for Resident #1's transport to the hospital (Hospital A), and the County EMS report of 05/03/2014 documented Resident #1 to be in sinus [MEDICAL CONDITION] to have an oxygen saturation of 68 % on room air, to have pale/cool skin, and to have constricted pupils. A 05/03/2014 Radiology Department Computed Tomography report of Hospital A for Resident #1 documented volume loss throughout the left lower lobe, debris within the left lower lobe bronchi which could reflect aspiration pneumonia or mucus plugging, and partial left lower lobe [MEDICAL CONDITION] collapse. A subsequent 05/04/2014, 12:03 a.m. Radiology Department X-ray report documented atelectasis, partial left lower lobe collapse, and a concern for aspiration pneumonia. An Emergency Department Record Physician order [REDACTED].#1 to Hospital B, and a County EMS Medical Necessity Form For Transportation By Ambulance form documented Resident #1's 05/04/2014 transfer to Hospital B with medical conditions which included Aspiration Pneumonia. Resident #1's Hospital B 05/04/2014 History and Physical (H&P) documented respiratory distress, systolic/diastolic blood pressure readings of 60 and 35, respectively, and coarse rhonchi on the left side. Resident #1 was mechanically ventilated with [DIAGNOSES REDACTED]. This H&P documented that Resident #1 received antibiotic coverage with [MEDICATION NAME] and [MEDICATION NAME] for aspiration pneumonia, and the Physician Documentation Sheet of Hospital B documented that Resident #1 was being admitted to Critical Care in serious condition. Based on the above, despite the Speech Language Pathologist assessing Resident #1 to have Oropharyngeal Dysphagia and observing the resident to demonstrate signs/symptoms of aspiration which included a gurgly/wet voice, watery eyes/nose, and an unproductive cough/clear, the facility neglected Resident #1 by failing to immediately consult with the physician regarding this resident's observed signs/symptoms of aspiration. Additionally, despite the Speech Language Pathologist specifying a Modified [MEDICATION NAME] Swallow Study and skilled speech therapy 3 times per week for 8 weeks (with a caution that without skilled intervention, Resident #1 was at risk for aspiration pneumonia), the facility neglected Resident #1 by failing to consult with the physician regarding the need to obtain the Modified [MEDICATION NAME] Swallow Study and skilled speech therapy, and thus failing to provide the necessary skilled speech therapy services. Resident #1 subsequently experienced a low percentage of meal intake and a weight loss from 149 pounds on 04/01/2014 to 128 pounds on 04/28/2014. Additionally, Resident #1 was later transferred to the hospital and noted with atelectasis and partial left lower lobe collapse, was diagnosed with [REDACTED]. Cross refer to F157, F325, and F406, example #1, for more information regarding Resident #1. The immediate jeopardy was removed on June 6, 2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: A. On June 4, 2014, the facility developed and implemented a procedure entitled Procedure: Follow Up of Therapy Recommendations. This new Procedure specified that upon receipt of a therapy recommendation, the Therapy Program Manager (TPM) would provide a copy of the therapy recommendation to facility nursing staff to obtain a physician's orders [REDACTED]. B. On June 4, 2014, the facility developed and implemented a new policy entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services. This new Policy and Procedure allowed for obtaining payor source approval and funding approval, if necessary, for all residents when skilled therapy services are provided. This Policy and Procedure specified that when therapy services are required for a resident, the TPM would verify the payor source with the Business Office Manager (BOM). The BOM will then approve the payor source for resident's having Medicare, Health Maintenance Organization coverage, or other insurance coverage. For residents who were responsible for privately paying for the cost of care, or who had a conservator or power of attorney, the Policy and Procedure outlined multiple steps, including coordination between the BOM and therapy staff, immediate contact with the responsible party with treatment cost information, immediate notification by the BOM of therapy company management staff, and involvement of the facility Administrator in cases where funding is in question. This process is to ensure the timely receipt of funding for treatment to ensure the timely provision of treatment. C. On June 4, 2014, the facility reviewed and revised the existing procedure for physician notification of a change in resident status and consulting with the physician regarding treatment recommendations. This procedure specified who was responsible for identifying and confirming significant changes of resident status, as well as other circumstances requiring physician consultation, such as a need to alter treatment significantly, and included the use of a Change of Condition Notification form upon which nursing staff were to document an explanation of the resident's condition and the contact information of the physician who was consulted. The procedure also specified the maintenance of a Change of Condition Flow Sheet at the nurse's station for review and for presentation at Patient At Risk Committee meetings for monitoring and discussion. D. On June 4, 2014, the facility's DON conducted a complete resident chart review of 100 percent of resident charts to ensure that all recommendations regarding resident care were had been identified and addressed. E. On June 5, 2014, the TPM conducted a resident chart audit on residents currently on the therapy caseload to ensure that follow-up was completed for therapy care recommendations. F. On June 5, 2014, the facility continued the process of conducting nursing staff in-service training regarding the newly implemented procedure related to therapy recommendations, entitled Procedure: Follow Up of Therapy Recommendations; provided staff training on the newly implemented policy and procedure for the procurement of therapy payor source, entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services; additionally, staff training was provided on the revised procedure related to physician notification of resident status change, and on the accompanying Change of Condition Notification form to be utilized by nursing staff to clearly explain resident condition and to document physician contact. As of June 5, 2014, of the facility's current 113 nursing staff employees, 112 had received this training. The remaining nursing staff employee was currently unavailable for training at that time, and will receive training upon returning to work. In addition, all newly hired employees will receive in-service training regarding these policies and procedures as part of the orientation program conducted upon hire. G. On June 5, 2014, the facility implemented a procedure by which the DON, ADON, or designated Nursing Supervisor would conduct a weekly audit of sampled resident clinical records to ensure timely follow-through for all therapy recommendations. This weekly resident record audit will also monitor staff compliance with the identification of, and follow-up for, resident changes in condition. The QA Audit Tool will be utilized to document this weekly resident record audit. H. On June 5, 2014, the facility implemented a procedure by which the results of facility management staffs' monitoring of staff compliance with the newly implemented policies and procedures regarding physician notification of changes in resident status and follow-up on therapy recommendations, via the QA Audit Tool, would be presented at the monthly Quality Assessment (QA) Committee meetings. Additionally, the QA Committee reviewed and approved all of the newly implemented interventions the facility had put into place, including the Procedure: Follow Up of Therapy Recommendations policy, the new Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy, and the newly revised procedure related to physician notification of resident status change involving the Change of Condition Notification form. The QA Committee will continue the review process, during monthly QA Committee meetings, related to management staffs' findings of facility nursing staff compliance with these newly implemented policies and procedures, to ensure that the QA Committee provides for the ongoing monitoring and oversight of facility nursing staff compliance with these new procedures, and to allow the Committee to identify any future need for policy modification and/or additional staff training. During this complaint survey, on the following referenced dates, each newly developed and implemented policy, procedure, and system included in the facility's credible allegation of jeopardy removal, as referenced above, was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On June 5, 2014, the facility's newly implemented procedure entitled Procedure: Follow Up of Therapy Recommendations was reviewed, and it was found that the facility had implemented this procedure related to actions to be taken upon receipt of a therapy recommendation, including the involvement of the DON, ADON, or Nursing Supervisor to ensure follow-up. - On June 5, 2014, the facility's newly developed and implemented Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy was reviewed and found to address the process of obtaining payor source approval and funding for resident therapy, including both residents with Medicare, Health Maintenance Organization coverage, or other insurance, and private pay residents. - On June 5, 2014, the facility's reviewed and revised procedure for physician notification regarding resident changes in status or physician notification of treatment recommendations was reviewed, and was found to address these issues, including the staff responsible for the notification. - On June 6, 2014, a review was conducted to ensure completion of the facility's 100 percent resident clinical record audit which had been completed on June 5, 2014 by the DON to ensure that resident care recommendations had been identified and addressed. - On June 6, 2014, a review was conducted to ensure completion of the resident chart audit, as indicated on the facility's credible allegation of jeopardy removal, which was conducted on June 5, 2014, by the TPM for residents currently on the therapy caseload to ensure follow-up on therapy recommendations. - On June 6, 2014, the nursing staff in-service training regarding the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the revised procedure for physician notification of resident status change was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On June 6, 2014, it was confirmed via procedural review that the DON/ADON/Nursing Supervisor would conduct weekly audits of sampled resident clinical records to monitor for timely follow-through for all therapy recommendations and significant changes in resident condition. - On June 6, 2014, it was confirmed via procedural review that the results of management staffs' monitoring of staff compliance with the new policies and procedures involving physician notification and follow-up on therapy recommendations using the QA Audit Tool would be presented at the monthly Quality Assessment (QA) Committee meetings to ensure the QA Committee's ongoing monitoring and oversight of staff compliance with these procedures. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to timely follow-up on recommendations for therapy services and significant changes in resident status, was removed on June 6, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had developed, implemented, and/or revised policies and procedures, such as the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the procedure for physician notification of a change in resident status, and had conducted nursing staff in-service training on these policies and procedures. As of June 5, 2014, the facility had provided this in-service training to 112 of the facility's 113 current nursing staff employees, with the remaining nursing staff employee to receive this in-service training upon the return to work. Additionally, the facility had indicated that all newly hired employees were to receive in-service training upon hire. A future review will be necessary to determine the completion of the indicated staff in-service training on these policies and procedures for the remaining current employee, and any new employees hired after the June 6, 2014 exit date of this complaint survey. In addition, the facility had implemented a procedure involving a DON/ADON/Nursing Supervisor weekly audit of sampled resident clinical records to ensure follow-through for therapy recommendations and accurate identification of resident changes in status. However, this new weekly audit procedure had been implemented on June 5, 2014, with the first weekly resident chart audit to be completed the week following the June 6, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with the completion of these weekly resident chart audits will need to be evaluated by way of a future review. To allow for the further evaluation of scheduled nursing staff in-service training regarding the newly implemented policies and procedures and of facility supervisory staffs' ongoing weekly resident chart audits, the noncompliance continues, with the scope and severity decreased to the "D" level.

Based on clinical record review, Bedside Swallow Assessment review, County EMS report review, County EMS Medical Necessity Form For Transportation By Ambulance form review, hospital History and Physical form review, hospital Physician Documentation Sheet review, hospital Radiology Department Computed Tomography review, hospital Emergency Department Record Physician order [REDACTED].#1), who the Speech Language Pathologist assessed to have moderate to severe Oropharyngeal Dysphagia and to be at risk for aspiration pneumonia, on the total survey sample of eight (8) residents. Resident #1 was later noted with coughing with crackles, altered mental status, and respiratory distress, was transferred to the hospital and found to have atelectasis and partial left lower lobe collapse, was diagnosed with [REDACTED]. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on June 4, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on April 3, 2014 (the date the facility failed to immediately consult with Resident #1's physician regarding the resident's signs and symptoms of aspiration identified to be a gurgly/wet voice, watery eyes and nose, and an unproductive cough/clear, and regarding the resident being at risk for aspiration and aspiration pneumonia without skilled speech therapy intervention), continued through June 5, 2014, and was removed on June 6, 2014. On June 5, 2014, the facility implemented a credible allegation of jeopardy removal. During an interview conducted on June 3, 2014 at 1:50 p.m., the Administrator acknowledged a delay in the provision of speech therapy services to Resident #1, and interview with the DON conducted on 06/06/2014 confirmed that speech therapy services were not provided to the resident. An allegation of jeopardy removal was received on June 5, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on June 6, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of evaluating, on an ongoing basis, the effectiveness the modified Policy for physician Change of Condition Notification, the newly implemented Procedure for Follow-Up of Therapy Recommendations, and the newly implemented Policy and Procedure for Obtaining Pay Source Verification and Funding For Therapy Services. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's procedures regarding physician notification and obtaining rehabilitation therapy services to meet the needs of residents. Resident records were reviewed to ensure that physicians were notified of significant changes in resident status, and that rehabilitation therapy services were provided in accordance with the assessed needs of residents. Findings include: Resident #1's Admission Minimum Data Set (MDS) assessment of 04/09/2014 documented an Entry Date of 04/01/2014. MDS Section I - Active [DIAGNOSES REDACTED]. The Admission Nursing Assessment for Resident #1's 04/01/2014 admission identified in the Communication Section that the resident was Dysphagic and mumbled her words, and the Eating/Nutrition Section indicated that the resident received a regular, puree diet. This Admission Nursing Assessment did not, however, assess Resident #1 to have swallowing difficulties or to be in need of eating/swallowing training and practice. The admission Nurse's Notes entry of 04/01/2014 at 11:55 a.m. for Resident #1 documented that upon facility admission, the resident had no shortness of breath or respiratory distress. A subsequent 04/02/2014, 1:20 p.m. Nurses Notes entry documented that Resident #1 had experienced one (1) episode of vomiting a moderate amount of undigested food. A therapy screening form for Resident #1 signed by Certified Occupational Therapy Assistant (COTA) "AA", also dated 04/02/2014, then documented that Resident #1 had been referred to speech therapy for screening due to a wet, gurgly voice. A 04/03/2014 Bedside Swallow Assessment for Resident #1 conducted by the Speech Language Pathologist revealed moderate to severe Oropharyngeal Dysphagia and Pharyngeal Phase deficits which included a delayed swallow trigger with evidence of pharyngeal residue post-swallow. The Speech Language Pathologist documented Resident #1 to demonstrate signs and symptoms of aspiration including a gurgly/wet voice, watery eyes/nose, and an unproductive cough and clear, and specified two (2) required interventions: a Modified [MEDICATION NAME] Swallow Study, and skilled therapy to rehabilitate the resident's swallow function and safety, with a caution that without skilled intervention, Resident #1 was at risk for aspiration and aspiration pneumonia. However, further record review for Resident #1 revealed no evidence to indicate that the attending physician was consulted by therapy services staff or facility staff regarding the Speech Language Pathologist's observations, referenced on the 04/03/2014 Bedside Swallow Assessment referenced above, of Resident #1 demonstrating signs/symptoms of aspiration including a gurgly/wet voice, watery eyes/nose, and an unproductive cough/clear, even though these symptoms represented a significant change in status for this resident. There was also no evidence of physician consultation regarding the Modified [MEDICATION NAME] Swallow Study and the initiation of skilled speech therapy for Resident #1, even though the Speech Language Pathologist had indicated both interventions to be required due to Resident #1 being at risk for aspiration and aspiration pneumonia. Record review also revealed no evidence to indicate that the Modified [MEDICATION NAME] Swallow Study or skilled speech therapy had been provided for Resident #1. During a 06/03/2014, 12:30 p.m. interview, the Speech Language Pathologist acknowledged that during the 04/03/2014 Bedside Swallow Assessment, she had noted Resident #1 to have the swallowing problems outlined in Assessment summary, and acknowledged that the resident was at risk for aspiration, but stated she did not recall speaking with Resident #1's physician about the Assessment or the needed interventions. During a 06/03/2014, 12:45 p.m. interview, COTA "AA" stated he had not contacted Resident #1's physician regarding the Modified [MEDICATION NAME] Swallow and speech therapy services specified in the 04/03/2014 Bedside Swallow Assessment, but that the Assessment had been provided to the facility's Business Office while awaiting a price quote for the services. During an interview with the attending physician of Resident #1 conducted on 06/04/2014 at 2:00 p.m., the attending physician stated that he had not been made aware of Resident #1 having swallowing problems or of the Speech Language Pathologist's 04/03/2014 recommendations for Resident #1, which included the Modified [MEDICATION NAME] Swallow Study. The physician further stated that generally when contacted regarding Speech Language Pathologist recommendations for residents, he honored their requests for services. A 05/03/14, 1:20 p.m. Nurse's Notes entry for Resident #1 then documented that Resident #1 had coughing with crackles and course sounds in the left and right lower lobes, and that an order had been received to send the resident to the emergency room . A Nurse's Notes entry of 05/03/2014 at 1:30 p.m. documented Emergency Medical Services (EMS) arrival to transport Resident #1 to the hospital (Hospital A). The 05/03/2014 County EMS report documented that Resident #1 was in sinus [MEDICAL CONDITION] oxygen saturation of 68 % on room air, had pale, cool skin and constricted pupils, and was placed on high flow oxygen. A 05/03/2014 Radiology Department Computed Tomography (CT) report of Hospital A documented findings for Resident #1 which included debris in the left lower lobe bronchi which could reflect aspiration pneumonia or mucus plugging with partial left lower lobe [MEDICAL CONDITION] collapse. An Emergency Department Record Physician order [REDACTED].#1 to a second hospital (Hospital B), and the 05/04/2014 County EMS Medical Necessity Form For Transportation By Ambulance form documented medical conditions which included Aspiration Pneumonia, indicating Resident #1 was being transported from Hospital A to Hospital B due to the need for ventilator care. The History and Physical (H&P) of Hospital B documented Resident #1's 05/04/2014, 3:00 a.m. admission. The H&P Physical Examination Section documented that Resident #1 had coarse rhonchi on the left and was mechanically ventilated, and the Assessment and Plan Section documented [DIAGNOSES REDACTED]. The Physician Documentation Sheet of Hospital B for Resident #1 documented the ED Final [DIAGNOSES REDACTED].#1 was being admitted to Critical Care in serious condition. Based on the above, despite Resident #1 experiencing a significant change in status from exhibiting no documented signs of aspiration or respiratory distress at the time of her 04/01/2014 admission to being observed on 04/03/2014 to demonstrate signs and symptoms of aspiration including a gurgly/wet voice, watery eyes/nose, and an unproductive cough and clear, there was no evidence to indicate that the physician was consulted regarding this 04/03/2014 significant change in the resident's status involving signs/symptoms of aspiration. In addition, despite Resident #1 being assessed on a 04/03/2014 Bedside Swallow Assessment by the Speech Language Pathologist to have moderate to severe Oropharyngeal Dysphagia and to require a Modified [MEDICATION NAME] Swallow Study and skilled therapy to rehabilitate swallow function and safety, there was no evidence to indicate that the attending physician was consulted regarding the assessed need to initiate the new form of treatment involving speech therapy services. Resident #1 subsequently experienced respiratory distress, was transferred to the hospital and found to have atelectasis and partial left lower lobe collapse, was diagnosed with [REDACTED]. Cross refer to F406 for more information regarding Resident #1. The immediate jeopardy was removed on June 6, 2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: A. On June 4, 2014, the facility developed and implemented a procedure entitled Procedure: Follow Up of Therapy Recommendations. This new Procedure specified that upon receipt of a therapy recommendation, the Therapy Program Manager (TPM) would provide a copy of the therapy recommendation to facility nursing staff to obtain a physician's orders [REDACTED]. B. On June 4, 2014, the facility developed and implemented a new policy entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services. This new Policy and Procedure allowed for obtaining payor source approval and funding approval, if necessary, for all residents when skilled therapy services are provided. This Policy and Procedure specified that when therapy services are required for a resident, the TPM would verify the payor source with the Business Office Manager (BOM). The BOM would then approve the payor source for residents having Medicare, Health Maintenance Organization coverage, or other insurance coverage. For residents who were responsible for privately paying for the cost of care, or who had a conservator or power of attorney, the Policy and Procedure outlined multiple steps, including coordination between the BOM and therapy staff, immediate contact with the responsible party with treatment cost information, immediate notification by the BOM of therapy company management staff, and involvement of the facility Administrator in cases where funding is in question. This process is to ensure the timely receipt of funding for treatment to ensure the timely provision of treatment. C. On June 4, 2014, the facility reviewed and revised the existing procedure for physician notification of a change in resident status and consulting with the physician regarding treatment recommendations. This procedure specified who was responsible for identifying and confirming significant changes of resident status, as well as other circumstances requiring physician consultation, such as a need to alter treatment significantly, and included the use of a Change of Condition Notification form upon which nursing staff were to document an explanation of the resident's condition and the contact information of the physician who was consulted. The procedure also specified the maintenance of a Change of Condition Flow Sheet at the nurse's station for review and for presentation at Patient At Risk Committee meetings for monitoring and discussion. D. On June 4, 2014, the facility's DON conducted a complete resident chart review of 100 percent of resident charts to ensure that all recommendations regarding resident care were had been identified and addressed. E. On June 5, 2014, the TPM conducted a resident chart audit on residents currently on the therapy caseload to ensure that follow-up was completed for therapy care recommendations. F. On June 5, 2014, the facility continued the process of conducting nursing staff in-service training regarding the newly implemented procedure related to therapy recommendations, entitled Procedure: Follow Up of Therapy Recommendations; provided staff training on the newly implemented policy and procedure for the procurement of therapy payor source, entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services; additionally, staff training was provided on the revised procedure related to physician notification of resident status change, and on the accompanying Change of Condition Notification form to be utilized by nursing staff to clearly explain resident condition and to document physician contact. As of June 5, 2014, of the facility's current 113 nursing staff employees, 112 had received this training. The remaining nursing staff employee was currently unavailable for training at that time, and will receive training upon returning to work. In addition, all newly hired employees will receive in-service training regarding these policies and procedures as part of the orientation program conducted upon hire. G. On June 5, 2014, the facility implemented a procedure by which the DON, ADON, or designated Nursing Supervisor would conduct a weekly audit of sampled resident clinical records to ensure timely follow-through for all therapy recommendations. This weekly resident record audit will also monitor staff compliance with the identification of, and follow-up for, resident changes in condition. The QA Audit Tool will be utilized to document this weekly resident record audit. H. On June 5, 2014, the facility implemented a procedure by which the results of facility management staffs' monitoring of staff compliance with the newly implemented policies and procedures regarding physician notification of changes in resident status and follow-up on therapy recommendations, via the QA Audit Tool, would be presented at the monthly Quality Assessment (QA) Committee meetings. Additionally, the QA Committee reviewed and approved all of the newly implemented interventions the facility had put into place, including the Procedure: Follow Up of Therapy Recommendations policy, the new Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy, and the newly revised procedure related to physician notification of resident status change involving the Change of Condition Notification form. The QA Committee will continue the review process, during monthly QA Committee meetings, related to management staffs' findings of facility nursing staff compliance with these newly implemented policies and procedures, to ensure that the QA Committee provides for the ongoing monitoring and oversight of facility nursing staff compliance with these new procedures, and to allow the Committee to identify any future need for policy modification and/or additional staff training. During this complaint survey, on the following referenced dates, each newly developed and implemented policy, procedure, and system included in the facility's credible allegation of jeopardy removal, as referenced above, was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On June 5, 2014, the facility's newly implemented procedure entitled Procedure: Follow Up of Therapy Recommendations was reviewed, and it was found that the facility had implemented this procedure related to actions to be taken upon receipt of a therapy recommendation, including the involvement of the DON, ADON, or Nursing Supervisor to ensure follow-up. - On June 5, 2014, the facility's newly developed and implemented Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy was reviewed and found to address the process of obtaining payor source approval and funding for resident therapy, including residents with Medicare, Health Maintenance Organization coverage, or other insurance, and private pay residents. - On June 5, 2014, the facility's reviewed and revised procedure for physician notification regarding resident changes in status or physician notification of treatment recommendations was reviewed, and was found to address these issues, including the staff responsible for the notification. - On June 6, 2014, a review was conducted to ensure completion of the facility's 100 percent resident clinical record audit which had been completed on June 5, 2014 by the DON to ensure that resident care recommendations had been identified and addressed. - On June 6, 2014, a review was conducted to ensure completion of the resident chart audit, as indicated on the facility's credible allegation of jeopardy removal, which was conducted on June 5, 2014, by the TPM for residents currently on the therapy caseload to ensure follow-up on therapy recommendations. - On June 6, 2014, the nursing staff in-service training regarding the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the revised procedure for physician notification of resident status change was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On June 6, 2014, it was confirmed via procedural review that the DON/ADON/Nursing Supervisor would conduct weekly audits of sampled resident clinical records to monitor for timely follow-through for all therapy recommendations and significant changes in resident condition. - On June 6, 2014, it was confirmed via procedural review that the results of management staffs' monitoring of staff compliance with the new policies and procedures involving physician notification and follow-up on therapy recommendations using the QA Audit Tool would be presented at the monthly Quality Assessment (QA) Committee meetings to ensure the QA Committee's ongoing monitoring and oversight of staff compliance with these procedures. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to timely follow-up on recommendations for therapy services and significant changes in resident status, was removed on June 6, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had developed, implemented, and/or revised policies and procedures, such as the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the procedure for physician notification of a change in resident status, and had conducted nursing staff in-service training on these policies and procedures. As of June 5, 2014, the facility had provided this in-service training to 112 of the facility's 113 current nursing staff employees, with the remaining nursing staff employee to receive this in-service training upon the return to work. Additionally, the facility had indicated that all newly hired employees were to receive in-service training upon hire. A future review will be necessary to determine the completion of the indicated staff in-service training on these policies and procedures for the remaining current employee, and any new employees hired after the June 6, 2014 exit date of this complaint survey. In addition, the facility had implemented a procedure involving a DON/ADON/Nursing Supervisor weekly audit of sampled resident clinical records to ensure follow-through for therapy recommendations and accurate identification of resident changes in status. However, this new weekly audit procedure had been implemented on June 5, 2014, with the first weekly resident chart audit to be completed the week following the June 6, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with the completion of these weekly resident chart audits will need to be evaluated by way of a future review. To allow for the further evaluation of scheduled nursing staff in-service training regarding the newly implemented policies and procedures and of facility supervisory staffs' ongoing weekly resident chart audits, the noncompliance continues, with the scope and severity decreased to the "D" level.

Based on clinical record review, Bedside Swallow Assessment review, hospital Radiology Department Computed Tomography form review, hospital Emergency Department Record Physician order [REDACTED].#1) who was assessed by the Speech Language Pathologist to have Oropharyngeal Dysphagia and to be at risk for aspiration pneumonia, but for whom the facility failed to obtain a Modified [MEDICATION NAME] Swallow Study and to provide skilled speech therapy which the Speech Language Pathologist indicated to be required interventions, on the total survey sample of eight (8) residents. Resident #1 had significantly decreased meal intake after facility admission and experienced a fourteen (14) percent weight loss, was then found to have coughing with crackles and respiratory distress, was transferred to the hospital and noted to have left lower lobe volume loss with associated atelectasis, was diagnosed with [REDACTED]. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on June 4, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on April 3, 2014 (the date the facility failed to notify the physician of Resident #1 having demonstrated signs and symptoms of aspiration and being at risk for aspiration pneumonia without skilled speech therapy intervention), continued through June 5, 2014, and was removed on June 6, 2014. On June 5, 2014, the facility implemented a credible allegation of jeopardy removal. During an interview conducted on June 3, 2014 at 1:50 p.m., the Administrator acknowledged a delay in Resident #1 obtaining the services which had been specified by the Speech Language Pathologist via the speech therapy evaluation, further stating, during a later interview conducted on June 6, 2014 at 9:20 a.m., that treatment had been awaiting a price quote. An allegation of jeopardy removal was received on June 5, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on June 6, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of evaluating, on an ongoing basis, the effectiveness the modified Policy for physician Change of Condition Notification, the newly implemented Procedure for Follow-Up of Therapy Recommendations, and the newly implemented Policy and Procedure for Obtaining Pay Source Verification and Funding For Therapy Services. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's procedures regarding physician notification and obtaining rehabilitation therapy services to meet the needs of residents. Resident records were reviewed to ensure that physicians were notified of significant changes in resident status, and that rehabilitation therapy services were provided in accordance with the assessed needs of residents. Findings include: Record review for Resident #1 revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 04/09/2014 which documented, in Section C - Cognitive Patterns, that Resident #1 had a Brief Interview for Mental Status Summary Score of 99, indicating severe cognitive impairment. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident #1 had required the extensive assistance of staff with eating during the look-back period, and Section K - Swallowing/Nutritional Status documented that Resident #1 received a mechanically altered diet. The April 2014 admission orders [REDACTED]. This admission orders [REDACTED]. A 04/03/2014 memo form documented an evaluation of Resident #1 by the Speech Language Pathologist, in the form of a Bedside Swallow Assessment. The Speech Language Pathologist documented that this Bedside Swallow Assessment of Resident #1 revealed moderate to severe Oropharyngeal Dysphagia, and revealed findings which included, but were not limited to, poor bolus manipulation and control with poor anterior-posterior propulsion, and a swallow trigger delay with evidence of pharyngeal residue post-swallow. The Speech Language Pathologist specified that based on this Bedside Swallow Assessment, Resident #1 required interventions which included a Modified [MEDICATION NAME] Swallow Study and, in addition, skilled therapy to rehabilitate the resident's swallow function and safety three (3) times per week for eight (8) weeks. However, further record review for Resident #1 revealed no evidence to indicate that the Modified [MEDICATION NAME] Swallow Study was done, or that the resident received skilled speech therapy, even though the Speech Language Pathologist had indicated that both the Modified [MEDICATION NAME] Swallow Study and skilled speech therapy were required interventions related to the resident's swallow function and safety. There was also no evidence of physician contact regarding approval or denial of these interventions for Resident #1 either on or after the 04/03/2014 date of completion of the Bedside Swallow Assessment which identified these interventions to be required. During interview on 06/06/2014 at 9:50 a.m., the DON acknowledged that the Speech Language Pathologist's interventions for speech therapy services for Resident #1 had not been done. Review of Resident #1's April 2014 Diet Intake Percentage form revealed that during the period of April 1, 2014 through April 28, 2014, Resident #1 had low a low percentage of meal consumption, ranging from twenty (20) percent to fifty (50) percent, on seventeen (17) days for the breakfast meal. Resident #1 also had a low percentage of meal consumption, ranging from twenty (20) percent to fifty (50) percent, for the lunch meal on twelve (12) days during the same twenty-eight (28) day period in April 2014. Review of Resident #1's April 2014 Monthly Weight Record revealed a documented weight of 149 pounds on the resident's 04/01/2014 admitted . This Monthly Weight Record documented that by 04/07/2014, Resident #1's weight had declined to 144 pounds, and that the resident's weight continued to decline to 137 pounds on 04/14/2014, and 131 pounds on 04/21/2014. The Monthly Weight Record documented that by 04/28/2014, Resident #1's weight had declined to 128 pounds. Resident #1's weight loss from a weight of 149 on 04/01/2014 to a weight of 128 on 04/28/2014 represented a weight loss of twenty-one (21) pounds, or fourteen (14) percent, during the twenty-eight (28) day period. A Nutrition Assessment was completed for Resident #1 by the Registered Dietician (RD), and dated as having been done on 04/29/2014. In the Nutritional Assessment, the RD noted Resident #1's 04/01/2014 admission weight of 149 pounds and the current weight of 128 pounds as of 04/29/2014, and noted that the resident had experienced an unintentional weight loss of greater than ten (10) percent. The RD noted that Resident #1 had poor oral intake, and also had chewing/swallowing difficulties. In the Nutritional [DIAGNOSES REDACTED].#1 that Resident #1 had unintentional weight loss, and documented that the etiology of the weight loss was related to decreased oral intake. Recommendations by the RD included that Resident #1 receive the supplement Medpass. During an interview with the RD conducted on 06/05/2014 at 11:15 a.m., the RD stated she did not specifically recall Resident #1, but stated that for any resident who received a puree diet such as Resident #1, she would automatically assume that the resident had some type of chewing/eating problem. The RD also stated she would assume that Resident #1 would have received speech therapy services, due to the resident being on a puree diet. Continued review Resident #1's April 2014 Diet Intake Percentage Sheet referenced above revealed that on 04/29/2014, the same date the RD assessed the resident, the resident continued with poor oral intake, consuming only forty (40) percent of both the breakfast and lunch meals. Review of Resident #1's May 2014 Diet Intake Percentage Sheet revealed that the resident continued to have a low percentage of meal consumption, ranging from thirty (30) to forty (40) percent for the breakfast, lunch, and dinner meals of 05/01/2014 and 05/02/2014. A Nurse's Notes entry of 05/03/2014 at 1:20 p.m. documented Resident #1 was noted to have coughing with crackles and course sounds in the left and right lower lobes, and a 05/03/2014, 1:30 p.m. Nurse's Notes entry documented that Emergency Medical Services had arrived to transport the Resident to the hospital (Hospital A). A 05/03/2014 Radiology Department Computed Tomography report of Hospital A documented findings for Resident #1 which included debris within the left lower lobe bronchi which could reflect aspiration pneumonia or mucus plugging, and a Radiology Department X-ray report dated 05/04/2014 documented findings which included partial left lower lobe collapse which was concerning for aspiration pneumonia. The Emergency Department Record Physician order [REDACTED].#1 ordered to transfer the resident to Hospital B on 05/04/2014, and the History and Physical (H&P) form of Hospital B documented that Resident #1 was mechanically ventilated with [DIAGNOSES REDACTED]. The Hospital B Physician Documentation form for Resident #1 documented the Emergency Department Final [DIAGNOSES REDACTED].#1 was being admitted to Critical Care in serious condition. Based on the above, despite Resident #1 requiring a pureed diet and being assessed on 04/03/2014 by the Speech Language Pathologist to have Oropharyngeal Dysphagia, poor bolus manipulation and control with poor anterior-posterior propulsion, and a swallow trigger delay, and despite the Speech Language Pathologist specifying that Resident #1 required a Modified [MEDICATION NAME] Swallow Study and skilled therapy to rehabilitate the resident's swallow function and safety, the facility failed to obtain the Modified [MEDICATION NAME] Swallow Study and to provide the resident with skilled speech therapy. Resident #1 experienced a low percentage of meal consumption, ranging from twenty (20) percent to fifty (50) percent on seventeen (17) days for the breakfast meal, and on twelve (12) days for the lunch meal, during the twenty-eight (28) day period from April 1, 2014 through April 28, 2014. During this period, Resident #1 experienced a significant weight loss, declining from 149 pounds to 128 pounds, representing a fourteen (14) percent weight loss, during that period. The resident was then noted on 05/03/2014 to have coughing with crackles and course sounds in the left and right lower lobes of the lungs, was transported initially to Hospital A, then to Hospital B, where she was diagnosed with [REDACTED]. The immediate jeopardy was removed on June 6, 2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: A. On June 4, 2014, the facility developed and implemented a procedure entitled Procedure: Follow Up of Therapy Recommendations. This new Procedure specified that upon receipt of a therapy recommendation, the Therapy Program Manager (TPM) would provide a copy of the therapy recommendation to facility nursing staff to obtain a physician's orders [REDACTED]. B. On June 4, 2014, the facility developed and implemented a new policy entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services. This new Policy and Procedure allowed for obtaining payor source approval and funding approval, if necessary, for all residents when skilled therapy services are provided. This Policy and Procedure specified that when therapy services are required for a resident, the TPM would verify the payor source with the Business Office Manager (BOM). The BOM will then approve the payor source for resident's having Medicare, Health Maintenance Organization coverage, or other insurance coverage. For residents who were responsible for privately paying for the cost of care, or who had a conservator or power of attorney, the Policy and Procedure outlined multiple steps, including coordination between the BOM and therapy staff, immediate contact with the responsible party with treatment cost information, and immediate notification by the BOM of therapy company management staff, and involvement of the facility Administrator in cases where funding is in question. This process is to ensure the timely receipt of funding for treatment to ensure the timely provision of treatment. C. On June 4, 2014, the facility reviewed and revised the existing procedure for physician notification of a change in resident status and consulting with the physician regarding treatment recommendations. This procedure specified who was responsible for identifying and confirming significant changes of resident status, as well as other circumstances requiring physician consultation, such as a need to alter treatment significantly, and included the use of a Change of Condition Notification form upon which nursing staff were to document an explanation of the resident's condition and the contact information of the physician who was consulted. The procedure also specified the maintenance of a Change of Condition Flow Sheet at the nurse's station for review and for presentation at Patient At Risk Committee meetings for monitoring and discussion. D. On June 4, 2014, the facility's DON conducted a complete resident chart review of 100 percent of resident charts to ensure that all recommendations regarding resident care were had been identified and addressed. E. On June 5, 2014, the TPM conducted a resident chart audit on residents currently on the therapy caseload to ensure that follow-up was completed for therapy care recommendations. F. On June 5, 2014, the facility continued the process of conducting nursing staff in-service training regarding the newly implemented procedure related to therapy recommendations, entitled Procedure: Follow Up of Therapy Recommendations; provided staff training on the newly implemented policy and procedure for the procurement of therapy payor source, entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services; additionally, staff training was provided on the revised procedure related to physician notification of resident status change, and on the accompanying Change of Condition Notification form to be utilized by nursing staff to clearly explain resident condition and to document physician contact. As of June 5, 2014, of the facility's current 113 nursing staff employees, 112 had received this training. The remaining nursing staff employee was currently unavailable for training at that time, and will receive training upon returning to work. In addition, all newly hired employees will receive in-service training regarding these policies and procedures as part of the orientation program conducted upon hire. G. On June 5, 2014, the facility implemented a procedure by which the DON, ADON, or designated Nursing Supervisor would conduct a weekly audit of sampled resident clinical records to ensure timely follow-through for all therapy recommendations. This weekly resident record audit will also monitor staff compliance with the identification of, and follow-up for, resident changes in condition. The QA Audit Tool will be utilized to document this weekly resident record audit. H. On June 5, 2014, the facility implemented a procedure by which the results of facility management staffs' monitoring of staff compliance with the newly implemented policies and procedures regarding physician notification of changes in resident status and follow-up on therapy recommendations, via the QA Audit Tool, would be presented at the monthly Quality Assessment (QA) Committee meetings. Additionally, the QA Committee reviewed and approved all of the newly implemented interventions the facility had put into place, including the Procedure: Follow Up of Therapy Recommendations policy, the new Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy, and the newly revised procedure related to physician notification of resident status change involving the Change of Condition Notification form. The QA Committee will continue the review process, during monthly QA Committee meetings, related to management staffs' findings of facility nursing staff compliance with these newly implemented policies and procedures, to ensure that the QA Committee provides for the ongoing monitoring and oversight of facility nursing staff compliance with these new procedures, and to allow the Committee to identify any future need for policy modification and/or additional staff training. During this complaint survey, on the following referenced dates, each newly developed and implemented policy, procedure, and system included in the facility's credible allegation of jeopardy removal, as referenced above, was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On June 5, 2014, the facility's newly implemented procedure entitled Procedure: Follow Up of Therapy Recommendations was reviewed, and it was found that the facility had implemented this procedure related to actions to be taken upon receipt of a therapy recommendation, including the involvement of the DON, ADON, or Nursing Supervisor to ensure follow-up. - On June 5, 2014, the facility's newly developed and implemented Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy was reviewed and found to address the process of obtaining payor source approval and funding for resident therapy, including both residents with Medicare, Health Maintenance Organization coverage, or other insurance, and private pay residents. - On June 5, 2014, the facility's reviewed and revised procedure for physician notification regarding resident changes in status or physician notification of treatment recommendations was reviewed and was found to address these issues, including the staff responsible for the notification. - On June 6, 2014, a review was conducted to ensure completion of the facility's 100 percent resident clinical record audit which had been completed on June 5, 2014 by the DON to ensure that resident care recommendations had been identified and addressed. - On June 6, 2014, a review was conducted to ensure completion of the resident chart audit, as indicated on the facility's credible allegation of jeopardy removal, which was conducted on June 5, 2014, by the TPM for residents currently on the therapy caseload to ensure follow-up on therapy recommendations. - On June 6, 2014, the nursing staff in-service training regarding the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the revised procedure for physician notification of resident status change was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On June 6, 2014, it was confirmed via procedural review that the DON/ADON/Nursing Supervisor would conduct weekly audits of sampled resident clinical records to monitor for timely follow-through for all therapy recommendations and significant changes in resident condition. - On June 6, 2014, it was confirmed via procedural review that the results of management staffs' monitoring of staff compliance with the new policies and procedures involving physician notification and follow-up on therapy recommendations using the QA Audit Tool would be presented at the monthly Quality Assessment (QA) Committee meetings to ensure the QA Committee's ongoing monitoring and oversight of staff compliance with these procedures. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to timely follow-up on recommendations for therapy services and significant changes in resident status, was removed on June 6, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had developed, implemented, and/or revised policies and procedures, such as the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the procedure for physician notification of a change in resident status, and had conducted nursing staff in-service training on these policies and procedures. As of June 5, 2014, the facility had provided this in-service training to 112 of the facility's 113 current nursing staff employees, with the remaining nursing staff employee to receive this in-service training upon the return to work. Additionally, the facility had indicated that all newly hired employees were to receive in-service training upon hire. A future review will be necessary to determine the completion of the indicated staff in-service training on these policies and procedures for the remaining current employee, and any new employees hired after the June 6, 2014 exit date of this complaint survey. In addition, the facility had implemented a procedure involving a DON/ADON/Nursing Supervisor weekly audit of sampled resident clinical records to ensure follow-through for therapy recommendations and accurate identification of resident changes in status. However, this new weekly audit procedure had been implemented on June 5, 2014, with the first weekly resident chart audit to be completed the week following the June 6, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with the completion of these weekly resident chart audits will need to be evaluated by way of a future review. To allow for the further evaluation of scheduled nursing staff in-service training regarding the newly implemented policies and procedures and of facility supervisory staffs' ongoing weekly resident chart audits, the noncompliance continues, with the scope and severity decreased to the "D" level.

Based on clinical record review, Bedside Swallow Assessment review, County EMS report review, hospital Radiology Department Computed Tomography report review, hospital Emergency Department Record Physician order [REDACTED]. form review, therapy company Area Manager interview, Certified Occupational Therapy Assistant interview, Speech Language Pathologist interview, and facility staff interview, the facility failed to provide the necessary skilled speech therapy services and a related Modified [MEDICATION NAME] Swallow Study, both designated via a Bedside Swallow Assessment as required interventions, for one (1) resident (#1), who was assessed to have moderate to severe Oropharyngeal Dysphagia and to be at risk for aspiration and aspiration pneumonia, and failed to obtain a Modified [MEDICATION NAME] Swallow Study as requested by the Speech Language Pathologist for one (1) resident (#6) who was assessed to have oral deficits representing a risk for aspiration, on the total survey sample of eight (8) residents. Resident #1 was then found to have coughing with crackles, was examined by the attending physician and noted to have altered mental status and respiratory distress, was transferred to the hospital and noted to have left lower lobe volume loss with associated atelectasis and partial left lower lobe collapse, was diagnosed with [REDACTED]. The facility's failure to provide the necessary services regarding Resident #1's assessed risk for aspiration and aspiration pneumonia resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on June 4, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on April 3, 2014 (the date the facility failed to notify the physician of Resident #1 having demonstrated signs and symptoms of aspiration characterized by a gurgly/wet voice, watery eyes and nose, and an unproductive cough/clear, and of the resident being at risk for aspiration and aspiration pneumonia without skilled speech therapy intervention), continued through June 5, 2014, and was removed on June 6, 2014. On June 5, 2014, the facility implemented a credible allegation of jeopardy removal. During an interview conducted on June 3, 2014 at 1:50 p.m., the Administrator acknowledged awareness of a delay in Resident #1 obtaining the services as specified on the speech therapy evaluation due to attempts to obtain a price quote for approval of these services. During a subsequent interview conducted on June 6, 2014 at 9:20 a.m., the Administrator again acknowledged being made aware of the Speech Language Pathologist's screen of Resident #1 and that treatment was awaiting a price quote; however, the Administrator further stated that she was not told of Resident #1's assessed problems outlined in the speech therapy screen, and that these problems should have been brought to her attention. An allegation of jeopardy removal was received on June 5, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on June 6, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of evaluating, on an ongoing basis, the effectiveness the modified Policy for physician Change of Condition Notification, the newly implemented Procedure for Follow-Up of Therapy Recommendations, and the newly implemented Policy and Procedure for Obtaining Pay Source Verification and Funding For Therapy Services. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's procedures regarding physician notification and obtaining rehabilitation therapy services to meet the needs of residents. Resident records were reviewed to ensure that physicians were notified of significant changes in resident status, and that rehabilitation therapy services were provided in accordance with the assessed needs of residents. Findings include: 1. Record review for Resident #1 revealed an Admission Minimum Data Set (MDS) assessment reflecting an Assessment Reference Date of 04/09/2014 and a facility Entry Date of 04/01/2014. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #1 had required the extensive assistance of staff with eating during the look-back period. The Admission Record form for Resident #1 also documented the resident's facility admission date of [DATE], documented the resident to be [AGE] years of age, and documented the resident to be Private Pay status. A Nurse's Notes entry of 04/01/2014 at 11:55 a.m. documented that upon admission, Resident #1 was talkative and cooperative, with no shortness of breath or respiratory distress noted. The Admission physician's orders [REDACTED].#1's 04/01/2014 facility admission ordered that the resident receive a regular, puree diet and that the resident be evaluated by physical therapy, occupational therapy, and speech therapy; the resident's Care Plan specified that speech therapy was to treat if warranted/ordered. A therapy screening form, signed by Certified Occupational Therapy Assistant (COTA) "AA" and dated 04/02/2014, for Resident #1 documented that upon evaluation, it had been determined that no physical therapy or occupational therapy evaluation was warranted at that time, but that Resident #1 had been referred to speech therapy for further screening due to a wet, gurgly voice. A memo dated 04/03/2014, signed by the Speech Language Pathologist and addressed to the Power of Attorney for Resident #1, documented that a Bedside Swallow Assessment of the resident had revealed moderate to severe Oropharyngeal Dysphagia. Oral Phase deficits were assessed to be decreased lingual and labial coordination, poor bolus manipulation and control with poor anterior-posterior propulsion, and oral residue throughout the oral cavity post-swallow. The Pharyngeal Phase deficits were assessed to be premature spillage into the pharyngeal mechanism secondary to a delayed swallow trigger, a swallow trigger delay with evidence of pharyngeal residue post-swallow, decreased laryngeal elevation/excursion, and a weak spontaneous and volitional cough and clear. The Speech Language Pathologist noted Resident #1's current diet of puree foods with thin liquids, and documented that Resident #1 demonstrated the signs and symptoms of aspiration, characterized by a gurgly/wet voice, watery eyes and nose, and an unproductive cough and clear. The Speech Language Pathologist also specified in this memo that based on the Bedside Swallow Assessment, one required intervention for Resident #1 was a Modified [MEDICATION NAME] Swallow Study which was necessary for radiological determination of penetration and/or aspiration, parameters of deficits, therapeutic interventions to increase swallow function/safety, and a recommendation for the least restrictive diet level. Another required intervention involved skilled therapy to rehabilitate the resident's swallow function and safety three (3) times per week for eight (8) weeks. The Speech Language Pathologist specifically cautioned that without skilled intervention, Resident #1 was at risk for aspiration and concomitant health issues such as aspiration pneumonia. Nurse's Notes entries of 04/05/2014 at 12:15 p.m. and 04/11/2014 at 5:00 a.m. for Resident #1 documented that staff continued to provide meal tray setup and assistance at mealtimes, and a Nurse's Notes entry of 04/22/2014 at 1:00 p.m. documented that Resident #1 was not holding food in her mouth, but rather would spit it out while falling asleep during mealtimes. Further record review, however, revealed no evidence to indicate that the facility had either obtained the Modified [MEDICATION NAME] Swallow Study and initiated skilled speech therapy, or had contacted the physician regarding the resident's assessed "required" need for these services, at that time. This was despite the fact that the Speech Language Pathologist had indicated in the 04/03/2014 Bedside Swallow Assessment referenced above that the Modified [MEDICATION NAME] Swallow Study was necessary for reasons which included the determination of penetration and/or aspiration for Resident #1, the resident's deficit parameters, and the therapeutic interventions needed to increase the resident's swallow function/safety, and despite the Speech Language Pathologist cautioning that without skilled intervention, Resident #1 was at risk for aspiration and aspiration pneumonia. A Nurse's Notes entry of 04/30/2014 at 10:40 a.m. documented that staff continued to assist Resident #1 with meals, with no distress noted, and a Nurse's Notes entry of 05/03/2014 at 3:00 a.m. documented that Resident #1 continued to exhibit no signs or symptoms of discomfort and had even, non-labored respirations of eighteen (18) per minute. Further record review for Resident #1, however, continued to reveal no evidence to indicate that Modified [MEDICATION NAME] Swallow Study had been obtained or that skilled speech therapy had been provided, both of which had been determined by the Speech Language Pathologist to be required interventions based on the 04/03/2014 Bedside Swallow Assessment referenced above, due to Resident #1's assessed risk for aspiration and aspiration pneumonia. A Nurse's Notes entry of 05/03/2014 at 1:20 p.m. for Resident #1 then documented that the resident had been examined by her attending physician. This Nurse's Notes entry documented that Resident #1 had coughing with crackles and course sounds in the left and right lower lobes of the lungs, and that the physician had given an order to send the resident to the emergency room via Emergency Medical Services (EMS). A Nurse's Notes entry of 05/03/2014 at 1:25 p.m. documented that EMS had been notified, that the resident's respiration rate had increased to twenty-two (22) per minute, and that the resident's Peripheral Capillary Oxygen Saturation level was 86% on four (4) liters of oxygen per minute. A subsequent Nurse's Notes entry of 05/03/2014 at 1:30 p.m. documented that EMS had arrived to transport Resident #1 to the hospital. A physician's assessment form dated 05/03/2014 for Resident #1 documented the assessment of the resident by the physician to be an emergency visit due to the resident's respiratory distress and altered mental status. The physician documented that Resident #1 had labored respirations and an increased respiratory rate, and was noted with rhonchi and crackles. The physician ordered on this assessment form that Resident #1 be sent to the emergency room (of Hospital A). The County EMS report of 05/03/2014 for Resident #1 documented that EMS staff arrived at the nursing facility on 05/03/2014 at 1:29 p.m. This EMS report documented that upon arrival, Resident #1 was in sinus [MEDICAL CONDITION] with an oxygen saturation of 68%. Resident #1 was documented to have pale and cool skin and to have constricted pupils. EMS staff documented that Resident #1 was placed on high flow oxygen at fifteen (15) liters per minute. EMS staff documented that they left the nursing facility transporting Resident #1 to the hospital at 1:47 p.m. on 05/03/2014, and documented that while in route at 1:52 p.m., Resident #1's oxygen saturation had increased to 95% while receiving high flow oxygen at fifteen (15) liters per minute. Review of hospital documents of Hospital A for Resident #1 revealed a Radiology Department Computed Tomography (CT) report of Hospital A dated 05/03/2014, timed at 8:43 p.m., which documented findings in the Findings Section which included volume loss throughout Resident #1's left lower lobe of the lung with associated airspace disease, and documented debris within the left lower lobe bronchi which the CT report indicated could reflect aspiration pneumonia or mucus plugging with partial left lower lobe [MEDICAL CONDITION] collapse. A subsequent Radiology Department X-ray report dated 05/04/2014, timed at 12:03 a.m., for Resident #1 documented left lower lobe volume loss with associated atelectasis and partial left lower lobe collapse. The Impression Section of this X-ray report documented that Resident #1 had left lower lobe lung airspace disease and partial left lower lobe collapse, which the X-ray report indicated was concerning for aspiration pneumonia. The 05/03/2014 Emergency Department Record Physician order [REDACTED].#1 ordered to transfer the resident to a second hospital (Hospital B). The County EMS Medical Necessity Form For Transportation By Ambulance form documented Resident #1's 05/04/2014 transfer to Hospital B, documented medical conditions which included, but were not limited to, Aspiration Pneumonia, and indicated that the resident was being transported from the original hospital to Hospital B due to the need for ventilator specialty care. The History and Physical (H&P) of Hospital B for Resident #1 documented the resident's 05/04/2014, 3:00 a.m. admission. This H&P documented in the History of Present Illness Section that the resident had presented in transfer from Hospital A for respiratory distress, having originally transferred to Hospital A on 05/03/2014 from the skilled nursing facility with increased respiratory rate and work of breathing and suspected aspiration. This Section of the H&P documented that upon Resident #1's arrival at Hospital B, she had a systolic blood pressure of 60 and a diastolic blood pressure of 35, and that the Intensive Care Unit (ICU) was contacted for admission. The Physical Examination Section of this H&P of Hospital B documented that Resident #1 had coarse rhonchi on the left, was clear on the right side, and was mechanically ventilated. Resident #1 was documented as awake, but not following commands. The Assessment and Plan Section of this H&P of Hospital B documented [DIAGNOSES REDACTED]. The Plan Section of this H&P referenced interventions for Resident #1 which included, but were not limited to, antibiotic coverage with [MEDICATION NAME] and [MEDICATION NAME] for aspiration pneumonia. The Physician Documentation Sheet of Hospital B for Resident #1 documented the ED (Emergency Department) Final [DIAGNOSES REDACTED].#1 was being admitted to Critical Care in serious condition. During an interview conducted on 06/03/2014 at 12:30 p.m. with the Speech Language Pathologist, she stated that she had evaluated Resident #1 via the 04/03/2014 Bedside Swallow Assessment referenced above at the request of COTA "AA". She stated that during the assessment, she had noted that Resident #1, who received a puree diet, was having swallowing problems as outlined in the Assessment summary. The Speech Language Pathologist stated that Resident #1's Bedside Swallow Assessment had been done by observing the resident while consuming a puree duet with thin liquids, and that the swallowing problems and signs and symptoms had placed the resident at risk for aspiration. She stated that Resident #1's oral problems involved getting ready to swallow and manipulating food for bolus, but added that the Modified [MEDICATION NAME] Swallow identified in the Bedside Swallow Assessment would have been the only way to actually assess the resident's deficits. She further stated that she did not recall personally speaking with Resident #1's physician about the Assessment. During an interview with COTA "AA" conducted on 05/21/2014 at 4:10 p.m., COTA "AA" was questioned regarding the 04/03/2014 Bedside Swallow Assessment which had been completed by the Speech Language Pathologist on 04/03/2014. COTA "AA" acknowledged that the Bedside Swallow Assessment screen, as documented in the Speech Language Pathologist's 04/03/2014 memo referenced above addressed to Resident #1's Power of Attorney, had determined that further evaluation of Resident #1 was warranted, but further stated that no further evaluation of Resident #1 could be completed without approval of a payor source. COTA "AA" stated that the therapy department was accustomed to dealing with reimbursement for therapy services via insurance rather than via private payment, as would be needed in Resident #1's case due to the resident's private pay status. COTA "AA" stated that upon notification of the request for the 04/03/2014 Bedside Swallow Assessment with the referenced [MEDICATION NAME] Swallow and skilled therapy intervention requirements for Resident #1, he had contacted the therapy company's area manager (Area Manager "BB") on two (2) occasions to obtain a quote for payment of these therapy interventions. COTA "AA" stated that the therapy area manager had informed him that the requests had been forwarded to the therapy company's corporate management staff who was then to follow-up with either the area manager or the nursing facility's Business Office staff to provide a quote for payment of these therapy interventions for Resident #1 to allow for the identification of a payor source to pay for the therapy services. COTA "AA" acknowledged that a quote for these therapy services for Resident #1 had not been provided to the facility by the therapy company corporate staff, and therefore the Bedside Swallow Assessment memo completed by the Speech Language Pathologist for Resident #1 had been held in the facility, and the evaluation for the resident had not been done. During a subsequent interview with COTA "AA" conducted on 06/03/2014 at 12:45 p.m., COTA "AA" stated that he had not personally made Resident #1's physician aware of the Speech Language Pathologist's required interventions of the Modified [MEDICATION NAME] Swallow and speech therapy services specified in the 04/03/2014 Assessment. During an interview with therapy company Area Manager "BB" conducted on 06/03/2014 at 1:35 p.m., Area Manager "BB" stated that COTA "AA" had contacted her and about a price quote for Resident #1's speech therapy, and she had then forwarded the price quote request via text message to therapy company management staff. Area Manager "BB" stated that she had not received a follow-up telephone call from therapy company management staff after forwarding the price quote request, but that the therapy company staff would have contacted the facility's Business Office staff for confirmation. Area Manager "BB" stated that normally, responses for requests for price quotes took only a day or two. During an interview with the facility's Business Office Manager (BOM) conducted on 06/03/2014 at 1:20 p.m., the BOM stated that the 04/03/2014 Bedside Swallow Assessment memo for Resident #1 had been brought to her by COTA "AA" to hold while COTA "AA" was obtaining a price quote from the therapy company corporate staff for the therapy services. The BOM stated that a price quote was not obtained, and therefore she had kept the Bedside Swallow Assessment memo. She stated she had not notified anyone of the Assessment memo remaining in the Business Office, and had thought that the issue had been resolved with some other treatment. During an interview with the DON conducted on 06/06/2014 at 9:50 a.m., the DON acknowledged awareness of the Speech Language Pathologist's screened interventions for speech therapy services for Resident #1, but further acknowledged that these speech therapy services had not been performed for Resident #1. Based on the above, despite Resident #1 receiving a regular, pureed diet; despite the Speech Language Pathologist assessing Resident #1 to have Oropharyngeal Dysphagia, oral residue throughout the oral cavity post-swallow, a delayed swallow trigger, and to demonstrate signs and symptoms of aspiration; despite the Speech Language Pathologist specifying a Modified [MEDICATION NAME] Swallow Study and skilled speech therapy 3 times per week for 8 weeks; and despite the Speech Language Pathologist cautioning that without skilled intervention, Resident #1 was at risk for aspiration pneumonia, the facility failed to obtain the Modified [MEDICATION NAME] Swallow Study and failed to provide skilled speech therapy to the resident. Resident #1 was then found in respiratory distress, transferred to the hospital and with left lower lobe volume loss with atelectasis and partial left lower lobe collapse, diagnosed with [REDACTED]. 2. Record review for Resident #6 revealed an Admission MDS with an Assessment Reference Date of 04/28/2014 which documented the resident's Entry Date of 04/17/2014. This MDS documented in Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status indicated that Resident #6 had required extensive assistance with eating during the look-back period, and Section K - Swallowing/Nutritional Status documented that the resident received a mechanically altered diet. Review of Resident #6's Physician's admission orders [REDACTED]. A Physician's Telephone Orders form for Resident #6 dated 05/07/2014 then specified that a speech therapy evaluation be completed and that speech therapy be provided as indicated. The Speech Language Pathologist's Initial Assessment of 05/07/2014 for Resident #6, which was documented on the resident's Speech Therapy Plan of Care form, indicated the resident currently received a pureed diet with nectar thickened liquids, and that the resident presented with Oropharyngeal Dysphagia characterized by decreased oral stage function. The Speech Language Pathologist assessed Resident #6 to have decreased bolus formation/manipulation, labial leakage due to labial weakness, oral holding, and a mild swallow trigger delay. The Speech Language Pathologist documented that the oral deficits of Resident #6 placed the resident at risk for possible aspiration, and requested a Modified [MEDICATION NAME] Swallow Study to ascertain pharyngeal integrity, the occurrence of penetration or aspiration, the least restrictive diet consistency, and therapeutic interventions to improve swallow safety and function. The Speech Language Pathologist indicated on this Speech Therapy Plan of Care that Resident #6 required skilled speech therapy services three (3) times a week for four (4) weeks. A Physician's Telephone Orders form of 05/07/2014 then specified that Resident #6 receive skilled speech therapy services three (3) times weekly for four (4) weeks, and also ordered a Modified [MEDICATION NAME] Swallow Study as indicated. The Speech Therapist (ST) - Therapist Progress notes for Resident #6, which were dated 05/13/2014 and electronically signed by the Speech Language Pathologist, documented that the resident had received skilled speech therapy as ordered. Subsequent ST - Therapist Progress notes entries dated 05/20/2014 and 05/27/2014, also electronically signed by the Speech Language Pathologist, continued to document that Resident #6 received skilled speech therapy services as ordered, but both the 05/20/2014 and 05/27/2014 Progress notes entries also noted that the Speech Language Pathologist was awaiting scheduling of the Modified [MEDICATION NAME] Swallow Study (originally requested on the Speech Language Pathologist's Initial Assessment of 05/07/2014, and ordered on the 05/07/2014 Physician's Telephone Orders form, both referenced above) to ascertain the resident's pharyngeal integrity, the occurrence of penetration or aspiration, the therapeutic exercises to improve swallow function and safety, and the least restrictive diet consistency. Further record review for Resident #6 revealed no evidence to indicate that the Modified [MEDICATION NAME] Swallow, originally requested and ordered on [DATE] as referenced above, was actually obtained during the month of May 2014, but rather that this Modified [MEDICATION NAME] Swallow Study for Resident #6 was obtained on 06/05/2014, after the initiation of this complaint survey. This represented a twenty-nine (29) day delay (from the 05/07/2014 order date to 06/05/2014) in obtaining Resident #6's Modified [MEDICATION NAME] Swallow Study which the Speech Language Pathologist had requested on her 05/07/2014 Speech Language Pathologist's Initial Assessment to ascertain pharyngeal integrity, the occurrence of penetration or aspiration, the least restrictive diet consistency, and therapeutic interventions to improve the swallow safety and function of Resident #6. During an interview with the Speech Language Pathologist on 06/06/2014 at 12:00 p.m., the Speech Language Pathologist acknowledged that she had requested a Modified [MEDICATION NAME] Swallow Study for Resident #6 on 05/07/2014. She stated that she requested Modified [MEDICATION NAME] Swallow Studies on all residents for whom she provided treatment, because these studies told the deficits and identified what helped, and identified the least restrictive diet. The Speech Language Pathologist acknowledged that the Modified [MEDICATION NAME] Swallow Study for Resident #6 had not been obtained by the facility until the 06/05/2014. Based on the above, despite Resident #6 having Oropharyngeal Dysphagia; despite the Speech Language Pathologist assessing Resident #6 on 05/07/2014 to have decreased oral stage function, decreased bolus formation/manipulation, labial leakage and weakness, oral holding, and a mild swallow trigger; despite the Speech Language Pathologist indicating that these oral deficits placed the resident at risk for possible aspiration and requesting a Modified [MEDICATION NAME] Swallow Study to ascertain pharyngeal integrity, the occurrence of penetration/aspiration, the least restrictive diet consistency, and therapeutic interventions to improve swallow safety and function; and despite a physician's orders [REDACTED]. The immediate jeopardy was removed on June 6, 2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: A. On June 4, 2014, the facility developed and implemented a procedure entitled Procedure: Follow Up of Therapy Recommendations. This new Procedure specified that upon receipt of a therapy recommendation, the Therapy Program Manager (TPM) would provide a copy of the therapy recommendation to facility nursing staff to obtain a physician's orders [REDACTED]. B. On June 4, 2014, the facility developed and implemented a new policy entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services. This new Policy and Procedure allowed for obtaining payor source approval and funding approval, if necessary, for all residents when skilled therapy services are provided. This Policy and Procedure specified that when therapy services are required for a resident, the TPM would verify the payor source with the Business Office Manager (BOM). The BOM will then approve the payor source for resident's having Medicare, Health Maintenance Organization coverage, or other insurance coverage. For residents who were responsible for privately paying for the cost of care, or who had a conservator or power of attorney, the Policy and Procedure outlined multiple steps, including coordination between the BOM and therapy staff, immediate contact with the responsible party with treatment cost information, immediate notification by the BOM of therapy company management staff, and involvement of the facility Administrator in cases where funding is in question. This process is to ensure the timely receipt of funding for treatment to ensure the timely provision of treatment. C. On June 4, 2014, the facility reviewed and revised the existing procedure for physician notification of a change in resident status and consulting with the physician regarding treatment recommendations. This procedure specified who was responsible for identifying and confirming significant changes of resident status, as well as other circumstances requiring physician consultation, such as a need to alter treatment significantly, and included the use of a Change of Condition Notification form upon which nursing staff were to document an explanation of the resident's condition and the contact information of the physician who was consulted. The procedure also specified the maintenance of a Change of Condition Flow Sheet at the nurse's station for review and for presentation at Patient At Risk Committee meetings for monitoring and discussion. D. On June 4, 2014, the facility's DON conducted a complete resident chart review of 100 percent of resident charts to ensure that all recommendations regarding resident care were had been identified and addressed. E. On June 5, 2014, the TPM conducted a resident chart audit on residents currently on the therapy caseload to ensure that follow-up was completed for therapy care recommendations. F. On June 5, 2014, the facility continued the process of conducting nursing staff in-service training regarding the newly implemented procedure related to therapy recommendations, entitled Procedure: Follow Up of Therapy Recommendations; provided staff training on the newly implemented policy and procedure for the procurement of therapy payor source, entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services; additionally, staff training was provided on the revised procedure related to physician notification of resident status change, and on the accompanying Change of Condition Notification form to be utilized by nursing staff to clearly explain resident condition and to document physician contact. As of June 5, 2014, of the facility's current 113 nursing staff employees, 112 had received this training. The remaining nursing staff employee was currently unavailable for training at that time, and will receive training upon returning to work. In addition, all newly hired employees will receive in-service training regarding these policies and procedures as part of the orientation program conducted upon hire. G. On June 5, 2014, the facility implemented a procedure by which the DON, ADON, or designated Nursing Supervisor would conduct a weekly audit of sampled resident clinical records to ensure timely follow-through for all therapy recommendations. This weekly resident record audit will also monitor staff compliance with the identification of, and follow-up for, resident changes in condition. The QA Audit Tool will be utilized to document this weekly resident record audit. H. On June 5, 2014, the facility implemented a procedure by which the results of facility management staffs' monitoring of staff compliance with the newly implemented policies and procedures regarding physician notification of changes in resident status and follow-up

Based on clinical record review and staff interview, facility administration failed to ensure the provision of skilled speech therapy services deemed to be required by the Speech Language Pathologist. This resulted in the failure of the facility to obtain a Modified [MEDICATION NAME] Swallow Study and/or skilled speech therapy services for two (2) residents (#1 and #6), and the failure to ensure adequate food intake for one (1) resident (#1), on the total survey sample of eight (8) residents. For Resident #1, who was diagnosed with [REDACTED].#1 was then noted to have altered mental status and respiratory distress, was transferred to the hospital and diagnosed with [REDACTED]. In addition, Resident #1 experienced a decreased meal intake and a 14 percent weight loss after the failure of the facility to provide skilled speech therapy services as required. Additionally, for Resident #6, who was diagnosed with [REDACTED]. This failure resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on June 4, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on April 3, 2014 (the date the facility failed to notify the physician of Resident #1 having demonstrated signs and symptoms of aspiration characterized by a gurgly/wet voice, watery eyes and nose, and an unproductive cough/clear, and of the resident being at risk for aspiration and aspiration pneumonia without skilled speech therapy intervention), continued through June 5, 2014, and was removed on June 6, 2014. On June 5, 2014, the facility implemented a credible allegation of jeopardy removal. During an interview conducted on June 3, 2014 at 1:50 p.m., the Administrator acknowledged an awareness of there being a delay in Resident #1 obtaining the services identified by the speech therapy evaluation, but acknowledged the absence of follow-up to ensure the provision of these services in a timely manner. An allegation of jeopardy removal was received on June 5, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on June 6, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of evaluating, on an ongoing basis, the effectiveness the modified Policy for physician Change of Condition Notification, the newly implemented Procedure for Follow-Up of Therapy Recommendations, and the newly implemented Policy and Procedure for Obtaining Pay Source Verification and Funding For Therapy Services. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's procedures regarding physician notification and obtaining rehabilitation therapy services to meet the needs of residents. Resident records were reviewed to ensure that physicians were notified of significant changes in resident status, and that rehabilitation therapy services were provided in accordance with the assessed needs of residents. Findings include: Cross refer to F325. Based on clinical record review, staff interview, and hospital document review, the facility failed to maintain acceptable parameters of nutritional status, related to body weight, for Resident #1 who was assessed to have Oropharyngeal Dysphagia and to be at risk for aspiration. The facility failed to obtain a Modified [MEDICATION NAME] Swallow Study and to provide skilled speech therapy for Resident #1 as required by the Speech Language Pathologist. Resident #1 then had decreased meal intake and a 14 percent weight loss, was found in respiratory distress, transferred to the hospital and diagnosed with [REDACTED]. Cross refer to F406. Based on clinical record review, staff interview, and hospital document review, the facility failed to provide skilled speech therapy and/or a Modified [MEDICATION NAME] Swallow Study, per Speech Language Pathologist recommendation, for Resident #1 and Resident #6, who were both assessed to have Oropharyngeal Dysphagia and to be at risk for aspiration. Resident #1 was then found in respiratory distress, transferred to the hospital and noted with partial left lower lobe collapse, Acute [MEDICAL CONDITION] Secondary [MEDICAL CONDITION] and Likely Aspiration Pneumonia. Resident #1 received antibiotic coverage for aspiration pneumonia and was admitted to Critical Care in serious condition and mechanically ventilated. During an interview with the Administrator conducted on 06/03/2014 at 1:50 p.m., the Administrator was questioned about the facility's failure to obtain the Modified [MEDICATION NAME] Swallow Study and skilled speech therapy services for Resident #1. The Administrator stated that the Speech Language Pathologist recommended Modified [MEDICATION NAME] Swallow Studies for most residents. In relation to Resident #1, the Administrator stated that the resident had a conservator during her stay in the facility. The Administrator stated that the procedure for obtaining payment for services involving Resident #1 had been different than for the majority of facility residents, because Resident #1 had been of private pay status while a resident of the facility, thus requiring approval of the conservator before monies could be provided for the payment for services. The Administrator stated that she had been made aware of the Speech Language Pathologist having made recommendations for treatment for [REDACTED]. The Administrator stated that she had been aware that therapy service staff was attempting to obtain a price quote for the speech therapy services indicated for Resident #1 so that the resident's conservator could be made aware of the cost to allow the conservator to approve the release of money for payment. The Administrator stated that since efforts were being made to obtain approval for payment for speech therapy services and the Modified [MEDICATION NAME] Swallow Study for Resident #1, and since there had been no further discussion of the issue, she had assumed the issue had been resolved and thus had made no further inquiries related to this issue prior to this complaint survey. She further stated that if she had known these speech therapy services and Modified [MEDICATION NAME] Swallow Study had not been provided for Resident #1 related to payment, she would have approved facility payment for the services and settled payment with the conservator at a later date. Based on the above, facility administration failed to ensure the provision of a Modified [MEDICATION NAME] Swallow Study and skilled speech therapy services to Resident #1, even though the Speech Language Pathologist had deemed these services to be necessary due to the resident's [DIAGNOSES REDACTED]. This resulted in a failure of Resident #1 to receive these required services. The immediate jeopardy was removed on June 6, 2014, at which time the facility had implemented the following credible allegation of jeopardy removal to remove the immediacy of the deficient practice: A. On June 4, 2014, the facility developed and implemented a procedure entitled Procedure: Follow Up of Therapy Recommendations. This new Procedure specified that upon receipt of a therapy recommendation, the Therapy Program Manager (TPM) would provide a copy of the therapy recommendation to facility nursing staff to obtain a physician's orders [REDACTED]. B. On June 4, 2014, the facility developed and implemented a new policy entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services. This new Policy and Procedure allowed for obtaining payor source approval and funding approval, if necessary, for all residents when skilled therapy services are provided. This Policy and Procedure specified that when therapy services are required for a resident, the TPM would verify the payor source with the Business Office Manager (BOM). The BOM will then approve the payor source for resident's having Medicare, Health Maintenance Organization coverage, or other insurance coverage. For residents who were responsible for privately paying for the cost of care, or who had a conservator or power of attorney, the Policy and Procedure outlined multiple steps, including coordination between the BOM and therapy staff, immediate contact with the responsible party with treatment cost information, immediate notification by the BOM of therapy company management staff, and involvement of the facility Administrator in cases where funding is in question. This process is to ensure the timely receipt of funding for treatment to ensure the timely provision of treatment. C. On June 4, 2014, the facility reviewed and revised the existing procedure for physician notification of a change in resident status and consulting with the physician regarding treatment recommendations. This procedure specified who was responsible for identifying and confirming significant changes of resident status, as well as other circumstances requiring physician consultation, such as a need to alter treatment significantly, and included the use of a Change of Condition Notification form upon which nursing staff were to document an explanation of the resident's condition and the contact information of the physician who was consulted. The procedure also specified the maintenance of a Change of Condition Flow Sheet at the nurse's station for review and for presentation at Patient At Risk Committee meetings for monitoring and discussion. D. On June 4, 2014, the facility's DON conducted a complete resident chart review of 100 percent of resident charts to ensure that all recommendations regarding resident care were had been identified and addressed. E. On June 5, 2014, the TPM conducted a resident chart audit on residents currently on the therapy caseload to ensure that follow-up was completed for therapy care recommendations. F. On June 5, 2014, the facility continued the process of conducting nursing staff in-service training regarding the newly implemented procedure related to therapy recommendations, entitled Procedure: Follow Up of Therapy Recommendations; provided staff training on the newly implemented policy and procedure for the procurement of therapy payor source, entitled Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services; additionally, staff training was provided on the revised procedure related to physician notification of resident status change, and on the accompanying Change of Condition Notification form to be utilized by nursing staff to clearly explain resident condition and to document physician contact. As of June 5, 2014, of the facility's current 113 nursing staff employees, 112 had received this training. The remaining nursing staff employee was currently unavailable for training at that time, and will receive training upon returning to work. In addition, all newly hired employees will receive in-service training regarding these policies and procedures as part of the orientation program conducted upon hire. G. On June 5, 2014, the facility implemented a procedure by which the DON, ADON, or designated Nursing Supervisor would conduct a weekly audit of sampled resident clinical records to ensure timely follow-through for all therapy recommendations. This weekly resident record audit will also monitor staff compliance with the identification of, and follow-up for, resident changes in condition. The QA Audit Tool will be utilized to document this weekly resident record audit. H. On June 5, 2014, the facility implemented a procedure by which the results of facility management staffs' monitoring of staff compliance with the newly implemented policies and procedures regarding physician notification of changes in resident status and follow-up on therapy recommendations, via the QA Audit Tool, would be presented at the monthly Quality Assessment (QA) Committee meetings. Additionally, the QA Committee reviewed and approved all of the newly implemented interventions the facility had put into place, including the Procedure: Follow Up of Therapy Recommendations policy, the new Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy, and the newly revised procedure related to physician notification of resident status change involving the Change of Condition Notification form. The QA Committee will continue the review process, during monthly QA Committee meetings, related to management staffs' findings of facility nursing staff compliance with these newly implemented policies and procedures, to ensure that the QA Committee provides for the ongoing monitoring and oversight of facility nursing staff compliance with these new procedures, and to allow the Committee to identify any future need for policy modification and/or additional staff training. During this complaint survey, on the following referenced dates, each newly developed and implemented policy, procedure, and system included in the facility's credible allegation of jeopardy removal, as referenced above, was reviewed by survey staff to ensure completion and/or implementation, with the findings as follow: - On June 5, 2014, the facility's newly implemented procedure entitled Procedure: Follow Up of Therapy Recommendations was reviewed, and it was found that the facility had implemented this procedure related to actions to be taken upon receipt of a therapy recommendation, including the involvement of the DON, ADON, or Nursing Supervisor to ensure follow-up. - On June 5, 2014, the facility's newly developed and implemented Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services policy was reviewed and found to address the process of obtaining payor source approval and funding for resident therapy, including both residents with Medicare, Health Maintenance Organization coverage, or other insurance, and private pay residents. - On June 5, 2014, the facility's reviewed and revised procedure for physician notification regarding resident changes in status or physician notification of treatment recommendations was reviewed, and was found to address these issues, including the staff responsible for the notification. - On June 6, 2014, a review was conducted to ensure completion of the facility's 100 percent resident clinical record audit which had been completed on June 5, 2014 by the DON to ensure that resident care recommendations had been identified and addressed. - On June 6, 2014, a review was conducted to ensure completion of the resident chart audit, as indicated on the facility's credible allegation of jeopardy removal, which was conducted on June 5, 2014, by the TPM for residents currently on the therapy caseload to ensure follow-up on therapy recommendations. - On June 6, 2014, the nursing staff in-service training regarding the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the revised procedure for physician notification of resident status change was reviewed for completion, as indicated on the facility's credible allegation of jeopardy removal. - On June 6, 2014, it was confirmed via procedural review that the DON/ADON/Nursing Supervisor would conduct weekly audits of sampled resident clinical records to monitor for timely follow-through for all therapy recommendations and significant changes in resident condition. - On June 6, 2014, it was confirmed via procedural review that the results of management staffs' monitoring of staff compliance with the new policies and procedures involving physician notification and follow-up on therapy recommendations using the QA Audit Tool would be presented at the monthly Quality Assessment (QA) Committee meetings to ensure the QA Committee's ongoing monitoring and oversight of staff compliance with these procedures. Based on the corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to timely follow-up on recommendations for therapy services and significant changes in resident status, was removed on June 6, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had developed, implemented, and/or revised policies and procedures, such as the Procedure: Follow Up of Therapy Recommendations Policy, the Policy and Procedure: Obtaining Pay Source Verification and Funding for Therapy Services Policy, and the procedure for physician notification of a change in resident status, and had conducted nursing staff in-service training on these policies and procedures. As of June 5, 2014, the facility had provided this in-service training to 112 of the facility's 113 current nursing staff employees, with the remaining nursing staff employee to receive this in-service training upon the return to work. Additionally, the facility had indicated that all newly hired employees were to receive in-service training upon hire. A future review will be necessary to determine the completion of the indicated staff in-service training on these policies and procedures for the remaining current employee, and any new employees hired after the June 6, 2014 exit date of this complaint survey. In addition, the facility had implemented a procedure involving a DON/ADON/Nursing Supervisor weekly audit of sampled resident clinical records to ensure follow-through for therapy recommendations and accurate identification of resident changes in status. However, this new weekly audit procedure had been implemented on June 5, 2014, with the first weekly resident chart audit to be completed the week following the June 6, 2014 exit date of this complaint survey; therefore, the facility's ongoing compliance with the completion of these weekly resident chart audits will need to be evaluated by way of a future review. To allow for the further evaluation of scheduled nursing staff in-service training regarding the newly implemented policies and procedures and of facility supervisory staffs' ongoing weekly resident chart audits, the noncompliance continues, with the scope and severity decreased to the "D" level.

Based on record review, staff interview, facility report review, facility policy review, and hospital History and Physical review, it was determined that the facility failed to prevent resident neglect for one (1) resident, Resident #1, who had eloped, on a survey sample of three (3) residents. Facility staff failed to ensure a thorough search was conducted when the fence alarm could not be silenced. Resident #1 had eloped and become entangled in an exterior fence. This failure resulted in the resident remaining outside and exposed to an extreme low environmental temperature for approximately 2-3 hours, thus experiencing hypothermia requiring hospitalization and admission to the Intensive Care Unit. It was therefore determined that an immediate and serious threat to resident health and safety existed on December 8, 2010, and was removed as of December 9, 2010, at which time the facility had implemented a plan to remove the immediate jeopardy. Findings include: Cross refer to F323 for more information regarding Resident #1. Review of the clinical record for Resident #1 revealed a Nurse's Note of 12/08/2010 at 7:45 a.m., and a 12/08/2010 Incident Report, which documented that staff notified the Licensed Practical Nurse (LPN) that Resident #1 was outside, hanging over the fence in the D-Wing back yard. This Note documented that staff responded and found the resident to be very cold, hanging upside down, with swelling noted to the facial area. A Nurse's Note of 12/08/2010 at 7:55 a.m. documented that Emergency Medical Services (EMS) was called, and a Nurse's Note of 12/08/2010 at 8:10 a.m. documented that the resident was transported to the hospital. The 12/08/2010 hospital History and Physical documented that it was estimated Resident #1 had been outside for about 3 hours, and documented an assessment of Hypothermia and multiple puncture wounds from the fence. During interview with Resident #1's physician conducted on 12/09/2010 at 1:45 p.m., this physician stated that this incident had been discussed with another physician and that the best estimate regarding the time the resident was outside was approximately two (2) hours. A weather report was obtained for the city in which the facility was located and the outside temperature on 12/08/2010 was recorded to be 23 degrees Fahrenheit. A review of the facility procedures and safeguards in place revealed that the facility had a fence that was six (6) feet high, with three (3) cables that ran across the top. One cable was 4 inches and the other two were 4 and 1/2 inches apart and were pointed inward. This represented a total of thirteen (13) inches of cabling that pointed inward and a total of sixteen (16) inches of bracketing that held the cables. The fence posts extended above the fence links, with the points of the fence covered by a top support pole. On the fence posts were mounted laser devices which provided a beam that ran from one device to another and served as a fence alarm. The alarm would not sound unless something was obstructing the laser beam. Further review revealed there was no specific policy for the use of the fence alarms. During an interview with Maintenance Staff "LL" conducted on 12/08/2010 at 2:20 p.m., this staff member stated that the facility's fence alarm was triggered by a beam which ran from corner-to-corner of the fence. Staff "LL" stated that a loud alarm would sound and could be reset, but that the alarm would continue to chime until the sensor, which was part of the alarm, was cleared. Only then could the chime be turned off. An interview conducted on 12/08/2010 at 1:05 p.m. with Licensed Practical Nurse (LPN) "CC", who was working at the time of the incident involving Resident #1, revealed that she had last observed the resident at approximately 5:15 a.m on 12/08/2010. She further stated that at approximately 5:30 a.m., the fence alarm sounded and she observed a female resident coming in from outside. She further stated that although the alarm continued to chime even after the loud alarm was silenced and she could not turn the chiming off, she assumed the female resident had set the alarm off and conducted no more follow-up. During a telephone interview conducted with Certified Nursing Assistant (CNA) "BB" on 12/10/2010 at an unknown time, the CNA stated that the alarm had sounded between 5:00 a.m. and 5:30 a.m. Interview with CNA "DD" conducted on 12/08/2010 at 1:37 p.m. revealed that she made rounds at 1:00 a.m., 3:00 a.m., and 5:00 a.m. and last recalled seeing the resident at around 3:00 a.m. on that date. She stated that she was unsure of the resident's location at 5:00 a.m. The CNA stated the fence alarm sounded and the loud alarm was turned off, but she continued to hear the chime and tried to turn it off. She stated that when the female resident was observed coming in from outside, she thought that resident had triggered the alarm. She stated that in addition, the alarm had chimed in this annoying way in the past and then had just gone off. During further telephone interview conducted on 12/09/2010 at 1:35 p.m., this CNA stated that the alarm had sounded at around 5:00 a.m. on 12/08/2010. Further record review revealed that, despite these multiple facility staff members noting that the chiming alarm continued to sound, there was no evidence to indicate that facility staff made additional efforts to determine the cause of the continued alarm, or to ensure the alarm sensor was clear, when the alarm sounded at approximately 5:00 a.m. During an interview with CNAs "MM" and "NN" conducted on 12/08/2010 at 2:20 p.m., both CNAs stated that on 12/08/2010, they had responded when another facility resident had observed, and made staff aware, of Resident #1 hanging on the fence as the smoke break was beginning. These CNAs stated that it was at that point that they solicited assistance from other facility staff to remove the resident from the fence. During an interview with Nurse "JJ" conducted on 12/08/2010 at 5:00 p.m., this nurse stated that during orientation, all staff are trained about facility policy regarding the fence alarm. During an interview with Nurse "EE", a facility Unit Manager, conducted on 12/08/2010 at 5:15 p.m., this nurse stated she had been trained that when alarms sound, staff are to go to the door, walk the fence perimeter, and if no one was there, to come into the facility and to do a head count until found. During an interview with Nurse "II" conducted on 12/08/2010 at 6:00 p.m., this nurse stated that when an alarm sounds staff were to go out the front and back of the facility and walk the fence line until the problem was found. During an interview with Nurse "FF" conducted on 12/08/2010 at 5:45 p.m., this nurse stated that when an alarm sounded, staff were to go outside of both the front and the back of the facility to find the problem. During an interview with CNA "HH" conducted on 12/08/2010 at 5:45 p.m., this CNA stated that when an alarm sounded, staff were to go out the front and back of the facility to make sure no one was outside. During an interview with CNA "GG" conducted on 12/08/2010 at 5:10 p.m., this CNA stated she had been trained that when the fence alarm sounded, she was to go outside and check the fence. However, based on the above, Resident #1 exited the building at approximately 5:00 a.m. to 5:30 a.m. on 12/08/2010 without the knowledge of staff. Resident #1 was found at 7:45 a.m., only after being observed by another resident, hanging upside down and entangled in the fence. Resident #1 was taken to the hospital, found to be hypothermic, and admitted to the Intensive Care Unit. An alarm had sounded between 5:00 a.m. and 5:30 a.m., however staff did not investigate the alarm when it could not be totally silenced. Instead of conducting a thorough outside search of the facility, to include searching the outside fence perimeter as indicated by facility procedure, staff stated that they assumed a female resident who had come in from the outside had triggered the alarm. Staff did not follow the facility's procedure that had been provided in orientation indicating if the alarm could not be silenced, the perimeter of the fence should be checked and a head count of residents should be done. Thus, Resident #1 remained outside exposed to a below-freezing temperature for between 2 to 3 hours. On 12/08/2010 at 2:00 p.m., a serious threat to resident health and safety was identified and facility staff was notified. During an interview with the Administrator conducted on 12/08/2010 at 1:55 p.m., the Administrator stated there was a good system in place, but acknowledged that staff just did not follow it and that was the reason the chime would not stop sounding on the alarm system. It was determined that the immediate jeopardy was removed as of 12/09/2010, by which time the facility had completed the following actions: 1. On 12/8/2010, the facility identified residents who have exhibited wandering behaviors or elopement potential were monitored every hour. 2. On 12/8/2010, all building exits, without door locks were monitored by a staff member and documented every hour. 3. On December 8th all available staff was educated via RN/LPN Supervisor on the proper procedure for responding to emergency devices. 4. All other staff will be educated via RN/LPN Supervisor, on the proper procedure for responding to emergency devices before being allowed to work their scheduled shift. 5. On December 8th a staff member was assigned to all exit doors. A staff member will remain at exit doors until residents are accustomed to the system change. 6. On [DATE]th an alarm was installed on all exit doors that did not have an existing alarm by Maintenance. As of [DATE]th all exiting doors that has exit to the outside has a working alarm. 7. On [DATE]th Charge nurse will check door alarms every shift to ensure in place and functioning properly, Maintenance will check door alarms 3 times a week. These will be ongoing. 8. On [DATE]th Maintenance Supervisor will check all other emergency devices 3 times a week. This will be on going. 9. On [DATE]th the Procedure for responding to alarms was implemented. 10. On [DATE]th a Policy and Procedure for when residents could go outside was implemented. A. No resident will be allowed outside unsupervised during inclement weather such as: - Extreme outside weather temperatures, hot and or cold outside temperatures - Any other critical weather conditions such as but not limited to: Hurricanes, Tornados, Lighting Storms, Blizzards, Icy conditions B. No resident will be allowed outside unsupervised from the hours 9:00 p.m. to 6:00 a.m. 11. On [DATE]th rounds were made every hour by Licensed Personal to ensure all residents are accounted for. Rounds will continue every hour by Licensed Personal X 4 Weeks then every 2 hours thereafter. 12. On [DATE]th the emergency device system changes will be monitored by Administer /RN daily and all or any discrepancies will be addressed immediately and discussed in QA. 13. On [DATE]th A Emergency Resident Council Meeting was held and those resident ' s in attendance were notified of the emergency device system changes by SW/Admin. 14. On [DATE]th residents and responsible parties were being notified of the emergency device system changes and will continue until all responsible parties are reached by SW. 15. On [DATE]th the facility Medical Director was notified of the system changes on the emergency device system 16. On [DATE]th bids are being obtained for a different security system by Admin. 17. On [DATE]th all new hires will be oriented and educated on the facility emergency devices upon orientation and prior to performing any resident care by RN/LPN Supervisor. 18. On [DATE]th Education on emergency device systems will be ongoing to all staff by RN/LPN Supervisor. 19. On [DATE]th An Emergency device drill was conducted by Admin/DON. 20. On [DATE]th the facility will have random emergency device drills as well as having one completed monthly on each shift by Maintenance Supervisor. Random Drill ' s were held on 12/8, 12/9 and 12/10 and will continue on going. 21. On [DATE]th all resident ' s were re-assessed for being at risk for elopement via RN/LPN Supervisor 22. On [DATE]th all available staff was educated via RN/LPN Supervisor on the facility ' s elopement procedure. 23. All other staff will be educated via RN/LPN Supervisor, on the proper procedure for responding to emergency devices before being allowed to work their scheduled shift. 24. On [DATE]th Emergency Device System was added to QA and all deficiencies will be discussed in weekly QA. QA Meeting was held via telephone on 12/8,12/9 with Admin, DON and Medical Director. Facility ' s QA Meeting is scheduled for 12/16/10. The above issues will be addressed again on 12/16/10. If any discrepancies in the above are identified Admin, DON and Medical Director will hold another QA meeting via telephone. 25. On 12/8/2010, the facility had inserviced a total sixty-seven (67) of the ninety-one (91) employees in the proper usage of the fence alarms, the process for determining that the residents in the secured unit were safe and unharmed, the procedure for searching the area of the alarm, searching the fence perimeter, and the actual count of the residents in the unit. An additional door alarm was placed at each exit on 12/08/2010 at 9:00 p.m., with ongoing inservices. Inservices were ongoing, with twelve (12) employees inserviced on 12/09/2010. There remained a total of twelve (12) employees requiring inservices on 12/10/10. Those employees would not be allowed to provide patient care until an inservice was completed. 26. On 12/8/2010, staff hiring and orientation policies were modified to include specific training regarding alarms, emergency devices and the related Policy and Procedures. This will be performed by documentation being maintained in the new hire's employment file including the date of training. 27. On 12/8//2010, the members of the QA Committee had been notified of the incident referenced in this deficiency, and of ongoing and subsequent investigation by telephone or in person. An additional QA meeting will be held on 12/16/10. Based on these corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice had been removed on December 9, 2010. However, the effectiveness of these corrective plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented the interventions referenced above and conducted staff inservice training on the modified policies and practices, but the facility will conduct inservice for new staff in an ongoing process. Monitoring will be required to assure that this training is ongoing and has resolved the identified problems for new and existing staff. Interventions were scheduled to be reviewed at the next scheduled QA meeting to be held on December 16, 2010. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.

Based on record review, staff interview, facility report review, Emergency Medical Services report review, and hospital History and Physical review, it was determined that the facility failed to develop a system to ensure adequate supervision for one (1) resident (#1), on the survey sample of (3) residents, who were identified to be at risk for elopement and/or exposure to extreme weather conditions, such as a below-freezing environmental temperature. This failure resulted in serious harm to one (1) resident, Resident #1, who exited the facility without the knowledge of staff, became entangled in an exterior fence, and remained outside exposed to an extremely low environmental temperature resulting in hypothermia, transfer to the hospital, and admission to the Intensive Care Unit. It was therefore determined that an immediate and serious threat to resident health and safety existed on December 8, 2010, and was removed by December 9, 2010, at which time the facility implemented a plan to abate the immediate jeopardy. Findings include: Review of the clinical record for Resident #1 revealed a facility Standard Admission Record and Agreement (Admission Record) which documented an admitted to the facility of 11/26/2010. This Admission Record documented that the resident was a [AGE] year male who had primary [DIAGNOSES REDACTED]. The Cumulative [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set (MDS), which was completed on 12/04/2010, revealed the resident was assessed as having poor recall with a total on the Brief Interview for Mental Status section of three (3) out of a possible fifteen (15). The resident was further assessed on this MDS to have wandering behaviors, but also documented no evidence of the resident frequently trying to elope from the facility. Review of the Nurse's Notes of 12/08/2010 at 7:45 a.m., and a 12/08/2010 Incident Report, revealed that staff notified the Licensed Practical Nurse (LPN) that Resident #1 was outside, hanging over the fence in the D-Wing back yard. This Note documented that staff were called to go outside and assist the resident off the fence. This Nurse's Note further documented that the resident was found to be alert and verbal but very cold, hanging upside down, with swelling noted to the facial area. This Note documented that the resident was assisted off the fence, blankets were wrapped around the resident, and staff members remained at his side. A Nurse's Note of 12/08/2010 at 7:55 a.m. documented that Emergency Medical Services (EMS) was called, and a Nurse's Note of 12/08/2010 at 8:05 a.m. documented that the ambulance had arrived at the facility. A Nurse's Note of 12/08/2010 at 8:10 a.m. documented that the resident was transported to the hospital, and a Nurse's Note of 12/08/2010 at 8:22 a.m. documented that the family was notified of the incident and condition of the resident, and that the resident was transported to the hospital. The EMS report of 12/08/2010 documented that Resident #1 had gotten stuck on the fence and also documented that the resident was noted with severe hypothermia which was life-threatening. This report also documented that the resident had been last seen at 5:00 a.m. The 12/08/2010 hospital History and Physical documented that Resident #1 had been found hanging on the fence after having wandered away from the nursing facility, and documented it was estimated that the resident had been outside for about 3 hours. This History and Physical documented a body temperature of 89 degrees Fahrenheit, and documented an assessment of Hypothermia. This History and Physical also documented that multiple puncture wounds from the fence were noted on the resident's hands, left upper extremity and left lower extremity. The Emergency Department/Nursing Record dated 12/08/2010 at 8:14 a.m. documented that the resident was warmed with blankets and warm air, and was then transferred to the Intensive Care Unit. A weather report was obtained for the city in which the facility was located and the outside temperature on 12/08/2010 was recorded to be 23 degrees Fahrenheit. An interview conducted on 12/08/2010 at 1:05 p.m. with Licensed Practical Nurse (LPN) "CC", who was working at the time of the incident involving Resident #1, revealed she had last observed the resident when medications were being administered to the roommate at approximately 5:15 a.m on 12/08/2010. Nurse "CC" stated that at approximately 5:30 a.m., the fence alarm sounded, she observed a female resident coming in from outside, and she thought that resident had set off the alarm. This nurse stated that there was a light in the area, but the fence could not be observed. This nurse stated that the alarm continued to chime even after the loud alarm was silenced, and that she could not turn the chiming off, but that she assumed the female resident had set the alarm off and conducted no more follow-up. Interview with Certified Nursing Assistant (CNA) "BB" conducted on 12/08/2010 at 1:33 p.m. revealed that Resident #1 usually sat close to her at night. This CNA stated that the resident did not go to bed on her shift, and from 11:00 p.m. - 7:00 a.m., the resident stayed in the common room changing chairs. The CNA stated the resident was last observed in the common area at approximately 6:20 a.m., but was not certain of the time, and that she did not see the resident go outside. During a telephone interview conducted on 12/10/2010 at an unknown time, when the CNA returned the Administrator's call, the CNA stated that the alarm had sounded between 5:00 a.m. and 5:30 a.m. Interview with CNA "DD" conducted on 12/08/2010 at 1:37 p.m. revealed that she last recalled seeing Resident #1 at around 3:00 a.m. on that date. During further telephone interview conducted on 12/09/2010 at 1:35 p.m., this CNA stated that the alarm had sounded at around 5:00 a.m. on 12/08/2010. During interview with Resident #1's physician conducted on 12/09/2010 at 1:45 p.m., this physician stated that this incident had been discussed with another physician and that the best estimate that could be provided regarding the length of time the resident was outside, based on his body temperature, was approximately two (2) hours. As indicted above, another physician was consulted and he also agreed that a two (2) hour period was probable. Based on the above, Resident #1 exited the building at approximately 5:00 a.m. to 5:30 a.m. on 12/08/2010 without the knowledge of staff. The resident was found at 7:45 a.m., hanging upside down and entangled in the fence. An alarm had sounded, however staff did not investigate the alarm when it could not be totally silenced. Instead of conducting a thorough outside search of the facility, staff stated they assumed a female resident who had just come in from the outside had triggered the alarm. This resulted in Resident #1 remaining outside of the facility exposed to a below-freezing temperature for between 2 to 3 hours. The resident was subsequently taken to the hospital, found to be hypothermic, and admitted to the Intensive Care Unit. On 12/08/2010 at 2:00 p.m., a serious threat to resident health and safety was identified and facility staff was notified. It was determined that the immediate jeopardy was removed as of 12/09/2010, by which time the facility had completed the following actions: 1. On 12/8/2010, the facility identified residents who have exhibited wandering behaviors or elopement potential were monitored every hour. 2. On 12/8/2010, all building exits, without door locks were monitored by a staff member and documented every hour. 3. On December 8th all available staff was educated via RN/LPN Supervisor on the proper procedure for responding to emergency devices. 4. All other staff will be educated via RN/LPN Supervisor, on the proper procedure for responding to emergency devices before being allowed to work their scheduled shift. 5. On December 8th a staff member was assigned to all exit doors. A staff member will remain at exit doors until residents are accustomed to the system change. 6. On [DATE]th an alarm was installed on all exit doors that did not have an existing alarm by Maintenance. As of [DATE]th all exiting doors that has exit to the outside has a working alarm. 7. On [DATE]th Charge nurse will check door alarms every shift to ensure in place and functioning properly, Maintenance will check door alarms 3 times a week. These will be ongoing. 8. On [DATE]th Maintenance Supervisor will check all other emergency devices 3 times a week. This will be on going. 9. On [DATE]th the Procedure for responding to alarms was implemented. 10. On [DATE]th a Policy and Procedure for when residents could go outside was implemented. A. No resident will be allowed outside unsupervised during inclement weather such as: - Extreme outside weather temperatures, hot and or cold outside temperatures - Any other critical weather conditions such as but not limited to: Hurricanes, Tornados, Lighting Storms, Blizzards, Icy conditions B. No resident will be allowed outside unsupervised from the hours 9:00 p.m. to 6:00 a.m. 11. On [DATE]th rounds were made every hour by Licensed Personal to ensure all residents are accounted for. Rounds will continue every hour by Licensed Personal X 4 Weeks then every 2 hours thereafter. 12. On [DATE]th the emergency device system changes will be monitored by Administer /RN daily and all or any discrepancies will be addressed immediately and discussed in QA. 13. On [DATE]th A Emergency Resident Council Meeting was held and those resident ' s in attendance were notified of the emergency device system changes by SW/Admin. 14. On [DATE]th residents and responsible parties were being notified of the emergency device system changes and will continue until all responsible parties are reached by SW. 15. On [DATE]th the facility Medical Director was notified of the system changes on the emergency device system 16. On [DATE]th bids are being obtained for a different security system by Admin. 17. On [DATE]th all new hires will be oriented and educated on the facility emergency devices upon orientation and prior to performing any resident care by RN/LPN Supervisor. 18. On [DATE]th Education on emergency device systems will be ongoing to all staff by RN/LPN Supervisor. 19. On [DATE]th An Emergency device drill was conducted by Admin/DON. 20. On [DATE]th the facility will have random emergency device drills as well as having one completed monthly on each shift by Maintenance Supervisor. Random Drill ' s were held on 12/8, 12/9 and 12/10 and will continue on going. 21. On [DATE]th all resident ' s were re-assessed for being at risk for elopement via RN/LPN Supervisor 22. On [DATE]th all available staff was educated via RN/LPN Supervisor on the facility ' s elopement procedure. 23. All other staff will be educated via RN/LPN Supervisor, on the proper procedure for responding to emergency devices before being allowed to work their scheduled shift. 24. On [DATE]th Emergency Device System was added to QA and all deficiencies will be discussed in weekly QA. QA Meeting was held via telephone on 12/8,12/9 with Admin, DON and Medical Director. Facility ' s QA Meeting is scheduled for 12/16/10. The above issues will be addressed again on 12/16/10. If any discrepancies in the above are identified Admin, DON and Medical Director will hold another QA meeting via telephone. 25. On 12/8/2010, the facility had inserviced a total sixty-seven (67) of the ninety-one (91) employees in the proper usage of the fence alarms, the process for determining that the residents in the secured unit were safe and unharmed, the procedure for searching the area of the alarm, searching the fence perimeter, and the actual count of the residents in the unit. An additional door alarm was placed at each exit on 12/08/2010 at 9:00 p.m., with ongoing inservices. Inservices were ongoing, with twelve (12) employees inserviced on 12/09/2010. There remained a total of twelve (12) employees requiring inservices on 12/10/10. Those employees would not be allowed to provide patient care until an inservice was completed. 26. On 12/8/2010, staff hiring and orientation policies were modified to include specific training regarding alarms, emergency devices and the related Policy and Procedures. This will be performed by documentation being maintained in the new hire's employment file including the date of training. 27. On 12/8//2010, the members of the QA Committee had been notified of the incident referenced in this deficiency, and of ongoing and subsequent investigation by telephone or in person. An additional QA meeting will be held on 12/16/10. Based on these corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice had been removed on December 9, 2010. However, the effectiveness of these corrective plans could not be fully assessed to ensure ongoing application and completion. The facility had implemented the interventions referenced above and conducted staff inservice training on the modified policies and practices, but the facility will conduct inservice for new staff in an ongoing process. Monitoring will be required to assure that this training is ongoing and has resolved the identified problems for new and existing staff. Interventions were scheduled to be reviewed at the next scheduled QA meeting to be held on December 16, 2010. Therefore, the noncompliance continues, with the scope and severity level of the deficiency decreased to the "D" level.