Every finding on record at Pruitthealth - Eastside

Based on observations, staff interview, and review of the facility policy titled Hand Hygiene Policy, the facility failed to ensure staff properly performed hand hygiene and peri care for one of three residents (Resident (R)11) observed receiving care. This deficient practice had the potential to place R11 at increased risk of infection. Findings include:Review of the facility policy titled Hand Hygiene Policy, dated 2022, revealed:Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene policy. Between resident contacts. [and] after handling contaminated objects. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.Observation on 1/11/2026 at 3:03 pm revealed Certified Nurse Aide (CNA) 2 wearing gloves while assisting the wound care nurse with a dressing change for R11. After the dressing change was completed, CNA2 removed the gloves and exited the room briefly to obtain supplies. CNA2 was not observed performing hand hygiene prior to re-entering the room and donning (putting on) gloves without performing hand hygiene. CNA2 observed that R11 had a bowel movement and was wearing an adult brief. While wearing the same gloves, CNA2 touched the bed covers, removed R11's pants and adult brief, and proceeded to provide peri care. CNA2 wiped the resident's rectal area, using three wipes bunched together, wiping the area four times without folding the wipes or obtaining clean wipes. CNA2 did not spread the labia during peri care and continued to wipe with the same soiled wipes. After removing the soiled adult brief and placing it in the trash, CNA2 did not perform hand hygiene and, with the same gloves on, applied a clean adult brief and clean pants to the resident. During an interview with CNA2 on 1/11/2026 at 4:39 pm, CNA2 stated, This is the way we do care to clean up the residents.During an interview with the Interim Assistant Director of Nursing/Infection Preventionist (ADON/ICP) on 1/12/2026 at 2:55 pm, she stated her expectation was that staff perform hand hygiene before entering a resident's room, before and after donning gloves, immediately after glove removal, and after removal of soiled adult protectors. She confirmed that hand hygiene should be performed immediately after removing gloves.

Based on observations, staff interviews, and review of the facility policy titled Medication Delivery, the facility failed to ensure medications were stored securely and inaccessible to unauthorized individuals in two of four medication carts. This deficient practice created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart. The facility census was 83 residents. Findings include:Review of the facility's policy titled Medication Delivery, dated 2022, revealed that medications are to be secured at all times and in the presence of licensed staff qualified to administer medications.During an observation on 1/12/2026 at 9:37 am, a medication cart located in the East Hallway, outside of residents' rooms 117-116, was observed unlocked and unattended, with the key present and medications placed on top of the cart. The cart contained multiple labeled prescription medications and medication administration supplies. No licensed staff were observed in the immediate area for approximately five minutes.During an interview with Licensed Practical Nurse (LPN) 3 on 1/12/2026 at 9:45 am, she revealed that she was the Unit Manager on East Hall and had walked away from the medication cart to take care of something, leaving it unattended and unlocked.During an observation on 1/13/2026 at 9:18 am, a medication cart located in the [NAME] Hallway, outside resident room [ROOM NUMBER], was observed to be unlocked and unattended for three minutes. The cart contained scheduled and non-scheduled medications. The cart remained unlocked while Registered Nurse (RN) 2, assigned to the cart, was observed inside a resident room with the door closed. During the observation, RN 2 returned to the cart and observed the surveyor standing beside it. She reached for the lock and stated, Oh, I was not supposed to do that, referring to leaving the cart unlocked.During an interview on 1/14/2026 at 4:05 pm, the Director of Nursing (DON) confirmed that facility policy required all medication carts to remain locked when unattended. The DON acknowledged that leaving medication carts unlocked is not an acceptable practice and places residents at risk.

Based on record review, staff interviews, and review of the facility policy titled Medication Administration: Insulin Injections, the facility failed to ensure insulin was provided according to the blood sugar parameters on the sliding scale insulin physician order for one of five residents (Resident (R) 4), reviewed for unnecessary medications. This deficient practice had the potential to place R4 at increased risk of uncontrolled blood sugar levels. Findings include: Review of the facility's policy titled Medication Administration: Insulin Injections, reviewed 7/28/2025, revealed Check the resident's MAR [medication administration record] or EMAR [electronic MAR] for current orders. Determine what is required according to the prescriber's orders and gather supplies needed.Document administration on the paper MAR or within the e-MAR or use numeric code.Review of R4's Face Sheet, located under the Face Sheet section of the electronic medical record (EMR), revealed the resident was admitted [DATE] and readmitted [DATE] with diagnoses to include type two diabetes mellitus. Review of R4's Orders, listed under the Orders section of the EMR, revealed the following: -Start date 8/6/25, Humalog U-100 Insulin (Insulin lispro) solution; 100 unit/mL [milliliter]; amt [amount]: Per Sliding Scale; if Blood Sugar is less than 65, call MD [Medical Doctor]. If Blood Sugar is 150 to 200, give 2 units.Before Meals and At Bedtime 06:30 AM, 11:30 AM, 04:30 PM, 0900 PM. Review of the medications administration history, provided by the facility and dated 12/1/2025-12/31/2025, revealed missing documentation for blood sugar results or insulin administration for 12/9/2025 at 9:00 pm, 12/10/2025 at 9:00 pm, 12/14/2025 at 11:30 am and 9:00 pm, 12/15/2025 at 6:30 am, 12/18/2025 at 11:30 am, 12/27/2025 at 9:00 pm, 12/28/2025 at 6:30 am and 9:00 pm, and 12/29/2025 at 6:30 am. There was a blood sugar result documented on 12/19/2025 at 6:30 am for 155 with zero units of insulin provided to the resident. Review of the medications administration history, provided by the facility and dated 01/01/2026-1/12/2026, revealed missing documentation for blood sugar results or insulin administration for 1/2/2026 at 6:30 am and 9:00 pm, 1/3/2026 at 6:30 am, 1/10/2026 at 9:00 pm, and 1/11/2026 at 6:30 am. There was a blood sugar result documented on 1/6/2026 at 9:00 pm for 188 with zero units of insulin provided to the resident.During an interview and record review on 1/13/2026 at 3:13 pm, the Unit Manager, Licensed Practical Nurse (LPN)3, stated that the staff were not following the scale. She stated R4 should have received two units of insulin per the physician's order on 12/19/2025 at 6:30 am and 1/6/2026 at 9:00 pm. For the blank sections, she said the insulin was not given and that if it is not documented, then it was not done. She stated the staff should have ensured R4 received the insulin coverage she needed. During an interview on 1/13/2026 at 3:13 pm, the Corporate Consultant stated the expectation was to follow the policy.

Based on staff and responsible party (RP) interviews, record review, and review of the facility's document titled Charge Nurse Workflow, the facility failed to notify one resident's (R) (R1) RP of a change in condition and transfer to the hospital. This failure had the potential to affect one of three residents reviewed for notification of change. Findings include:Review of the facility's document titled Charge Nurse Workflow, updated on 4/19/2022, revealed that when a change of condition is identified, the resident's RP would be notified.Review of the Face Sheet for R1 revealed an original admission date of 3/31/2025. The Face Sheet documented that the primary contact for R1 was Other-Guardian with a name and telephone number listed, and was listed as 1 in the Call Order column. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 6/24/2025, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition.Review of a document titled Into to Admission revealed that a Department of Human Services representative was documented as R1's responsible party. Review of R1's Progress Note, dated 7/1/2025 at 12:21 pm, revealed that R1 was noted with increased psychosis. He is threatening to knock over the computer monitors and hit other residents. Resident is yelling and cursing throughout facility. 'LCSW' [Licensed Clinical Social Worker] is in-house and wrote a 10-13 order, NP [Nurse Practitioner] notified. RP notified of situation and transport decision and stated ok.In an interview on 7/14/2025 at 3:57 pm, the Director of Health Services (DHS) revealed she called the resident's RP when he was exhibiting those behaviors on 7/1/2025. When asked who the RP was, the DHS stated she spoke to R1's Daughter. The DHS stated the emergency contact on R1's dashboard was the contact information she used. When the DHS was asked if she knew that the DHS representative was the RP, not R1's daughter, the DHS stated that normally the resident's RP was noted on the resident's dashboard under emergency contact, so that's who she called for the notification. During an interview on 7/16/2025 at 9:39 am, R1's RP stated she received a phone call on 7/9/2025 from R1's daughter asking for an update on R1. She further stated that was the first time R1's RP was made aware of R1 being sent to the hospital.

Based on observation, staff interviews, record review, and review of the facility policies titled Infection Control Precautions for Dressing Change, Clean Procedures, and Using the Treatment Cart and Infection Prevention-Hand Hygiene, the facility failed to ensure infection control practices were followed during wound care for one of two residents (R) (R28) reviewed for wound care. The deficient practice had the potential to increase the probability of R28 contracting an infection in his current wound. Findings include: A review of the facility's undated policy titled Infection Control Precautions for Dressing Change, Clean Procedures, and Using the Treatment Cart revealed the Procedure section included 15. Wash your hands (or use an alcohol cleaner) after removing and discarding the existing dressing. A review of the facility policy titled Infection Prevention-Hand Hygiene, dated 8/22/2024, revealed the Procedures section included D. Indications Requiring Hand Wash or Hand Rub 5. After contact with blood, body fluids or excretions, mucous membranes, non-in-tact skin, and wound dressings. 6. When hands move from a contaminated body site to a clean body site during resident care. A review of the medical record revealed that R28's diagnoses included but were not limited to venous insufficiency (chronic) (peripheral) and cutaneous abscess. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 13 (indicating little to no cognitive impairment) and section M (Skin Conditions) documented R28 had one unstable deep tissue injury with applications of ointments/medications. A review of the Physician Order Report revealed an order dated 7/15/2024 of Clean left heel with normal saline and pat dry. Apply skin prep to surrounding skin and apply AMD [Antimicrobial Foam Dressing] foam. Cover with foam dressing. Once a day PRN [as needed]. Wound care observation on 9/21/2024 at 3:18 pm revealed Skin Integrity Coordinator (SIC) Licensed Practical Nurse (LPN) knocked on R28's door and asked for permission to complete wound treatment to left heel with surveyor observation. After permission was granted, the nurse proceeded to gather supplies. SIC LPN cleaned and sanitized R28's bedside table with germicidal bleach wipes and allowed it to air dry. She then covered the table with a clean trash bag before placing gathered supplies on the table. SIC LPN donned a plastic gown, sanitized hands, and applied clean gloves. R28 was repositioned to the left side, and the old bandage was removed and placed in a trash bag resting on the resident's bed. SIC LPN removed her gloves and donned clean gloves without washing or sanitizing her hands between the glove change. In an interview on 9/21/2024 at 3:30 pm, SIC LPN revealed she received training for wound care from the wound care company that is contracted with the facility. She acknowledged that she did not wash or sanitize her hands during wound care and revealed that during the training she received, it was disclosed that it was not necessary to sanitize or wash your hands between glove changes during wound care. In an interview on 9/22/2024 at 8:19 am, the Director of Health Services (DHS) revealed that during wound care, the nurse should be performing hand hygiene between glove changes for infection control purposes. She stated the expectation was for all nursing staff to know when it is appropriate to wash and sanitize hands, and an in-service would be conducted.

Based on observations, staff interviews, and review of the facility policies titled Foodborne Illnesses, Labeling, Dating, and Storage, Pot/Pan Washing and Sanitation, and Food Temperatures, the facility failed to thaw meat properly to prevent a foodborne illness, failed to clean a floor fan to prevent food contamination, failed to label and date opened food items, failed to discard leftover foods by the use by date, failed to demonstrate the proper usage of the three-compartment sink to prevent foodborne illness, and failed to properly maintain all food items on the steam table above 135 degrees Fahrenheit (F) to prevent bacteria growth. The deficient practices had the potential to place 78 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. The facility census was 79. Findings include: 1. A review of the facility policy titled Foodborne Illnesses, reviewed 1/8/2021, revealed the Procedure section included .7. Meats will be thawed and cooked to appropriate internal temperature to prevent foodborne illnesses. Thaw meats under refrigeration at or below 41 degrees Fahrenheit in a drip-proof container or submerged in a solid bottom pan under cold running water. Observation on 9/20/2024 at 8:27 am of the food preparation sink revealed the water faucet was running a stream of water into a large rectangle steam table pan filled with pork chops. The pork chops were piled high in the pan, and only half of them were completely submerged in water. In an interview on 9/20/2024 at 8:27 am, the Assistant Dietary Manager (ADM) confirmed the pork chops were in the process of being thawed and confirmed that not all of the pork chops were submerged in water. The ADM was unable to state the reason behind completely submerging food items in water when thawing. 2. A review of the facility policy titled Labeling, Dating, and Storage, reviewed 11/11/2022, revealed the Procedure section included 1. Food and beverage items will have an identifying label as well as a received date and opened date, as applicable, for items prepared onsite, a use by date will also be indicated. Observation on 9/20/2024 at 8:35 am of the dry storage area revealed a large, tall, white plastic container containing rainbow pasta with no label or date. Continued observation revealed a large, tall, clear plastic container containing egg noodles with no label or date. Further observation revealed an opened 48-ounce jar of grape jelly with no open date. In an interview on 9/20/2024 at 8:35 am, the ADM confirmed that both large plastic containers containing pasta had no labels or dates, and the opened jar of grape jelly had no open date. The ADM revealed that dietary staff should have dated any food item that was opened and stored. Observation on 9/20/2024 at 8:40 am of the two-door reach-in refrigerator, located in a back room of the kitchen, revealed a square clear plastic container labeled Ravioli prep date 9/14 and discard date 9/18. In an interview on 9/20/2024 at 8:40 am, the ADM confirmed that the clear plastic container of food was labeled with a discard date of 9/18. The ADM revealed that she had been off of work and, since returning, had not had the opportunity to go through the refrigerator. The ADM revealed that dietary staff should have reviewed leftover food items in her absence and discard if needed. 3. Observation on 9/20/2024 at 9:15 am of the large floor fan in the kitchen by the fryer revealed the fan housing had a layer of dust and lint. The fan was turned on, and the airflow was directed into the food preparation area. Observation on 9/21/2024 at 12:40 pm of the large floor fan in the kitchen revealed it continued to have a layer of dust and lint. A large rectangular steam table pan containing flour was on the top of a cart, and the cart was next to the fryer. The airflow from the fan was directly in the path of the pan containing flour and in the food preparation area. Observation on 9/22/2024 at 9:40 am of the large floor fan in the kitchen revealed it continued to have a layer of dust and lint. The airflow from the fan was directed into the food preparation area, where the dietary staff was prepping food for the lunch meal. In an interview on 9/22/2024 at 9:40 am, the ADM confirmed the large floor fan in the kitchen had a layer of dust and lint build-up and that the fan was blowing directly into the food preparation area. The ADM stated that due to the heat in the kitchen the fan helps keep staff cool. The ADM revealed that dietary staff have assigned cleaning tasks, and the fan was to be cleaned once a week. The ADM further revealed that she does expect dietary staff to clean the fan when dust and lint are noted. 4. A review of the facility policy titled Pot/Pan Washing and Sanitation, reviewed 11/16/2020, revealed the Procedures section included Chemical Sanitizers: Items need to be immersed for 60 seconds in the Quaternary. Review of the chemical sanitizing Product Specification Document revealed to expose all surfaces to the sanitizing solution for a period of not less than one minute. Observation on 9/21/2024 at 11:30 am of Dietary [NAME] AA washing the food processor bowl, lid, and blade revealed she washed the dishware items with soapy water, rinsed, swished the items in the sanitizing solution for two seconds, then placed the items on the drying rack. In an interview on 9/21/2024 at 11:30 am, Dietary [NAME] AA confirmed the dishes she cleaned were only in the sanitizing solution a few seconds before being placed on the drying rack. Dietary [NAME] AA revealed that she had not been trained on how long dishware items needed to be submerged in the sanitizing solution. She further confirmed that the poster titled Pot & Pan Procedure, which hung on the wall over the 3-compartment sink, stated to submerge in the sanitizing sink for one minute. In an interview on 9/21/2024 at 11:35 am, the ADM revealed the facility uses a quaternary sanitizer solution for the three-compartment sink. The ADM revealed she could not recall when the last in-service was conducted using the three-compartment sink. She further stated that she expected the dietary staff to have dish items in the sanitizing solution for at least one minute. 5. A review of the facility policy titled Food Temperatures, revised 2/24/2023, revealed the Procedure section included 1. All hot foods served from the steam table must be held at or above 135 degrees. Steam table temperatures were completed on 9/21/2024 at 12:35 pm with Dietary [NAME] AA assisting and using the facility's calibrated food thermometer. Observation revealed the steamed beets had a temperature of 126 degrees Fahrenheit (F). In an interview on 9/21/2024 at 12:35 pm, Dietary [NAME] AA confirmed the beets had a temperature of 126 degrees F. In an interview on 9/21/2024 at 12:35 pm, Dietary Aide BB, who was assisting Dietary [NAME] AA, revealed that foods on the steam table should be at 135 degrees F or hotter. In an interview on 9/21/2024 at 12:45 pm, the Dietary Manager (DM) revealed that she expects dietary staff to have food items on the steam table at least maintained at 135 degrees F.

Based on record review, staff interviews, and review of the facility policy titled Nutritional Screening and Assessments/Food Preferences, the facility failed to ensure the Registered Dietitian completed an annual nutritional assessment for one of 30 sampled residents (R) (R53). The deficient practice had the potential to place R53 at risk of unmet nutritional needs. Findings include: A review of the facility policy titled Nutritional Screening and Assessments/Food Preferences, revised 3/28/2024, revealed the Nutrition Assessment will be completed at a minimum of annually for each patient/resident. A review of the medical record revealed R53's diagnoses included, but were not limited to, Alzheimer's disease, dysphagia, feeding difficulties, and stage 3 pressure ulcer. A review of R53's Physician Orders revealed a diet order for regular mechanical soft, no red sauce. A review of the medical record revealed the last nutritional assessment completed by the Registered Dietitian was 6/23/2023. In an interview on 9/22/2024 at 12:05 pm, the facility's Corporate Nurse Consultant (CNC) confirmed the last nutrition assessment completed by the Registered Dietitian was in June 2023. The CNC revealed that the facility has recently transitioned to a new Dietitian, and R53's annual nutritional assessment was likely missed. In an interview on 9/22/2024 at 1:05 pm, the Administrator revealed the facility had a new Dietitian who had only been with them for one month. The Administrator revealed the previous Registered Dietitian should have completed an annual nutritional assessment for R53. The Administrator further stated the Dietitian was expected to complete nutritional assessments on residents at admission and at least annually.

Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for three of 10 residents (R) who received oxygen (R64, R54, and R29). The deficient practice had the potential to place R64, R54, and R29 at an increased risk of respiratory complications and infection. Findings include: A review of the facility policy titled Oxygen Administration, revised 8/3/2023, revealed the internal filters would be changed by a contracted company, and the exteriors of the concentrators would be cleaned weekly. 1. A review of R64's Quarterly Minimum Data Set (MDS) dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment) and section O (Special Treatments and Programs) documented R64 received oxygen. A review of R64's medical record revealed an order dated 12/26/2023 for oxygen at 3 liters per minute (LPM) via nasal cannula continuous. An observation of R64's oxygen concentrator on 9/20/2024 at 9:17 am and 9/21/2024 at 9:05 am revealed the interior filter, exterior of the concentrator, and air intake cover were covered with visible dust and debris. During an observation of R64's oxygen concentrator on 9/21/2024 at 9:29 am, the Administrator and Infection Control Preventionist (ICP) verified the interior filter, exterior of the concentrator, and air intake cover were covered with visible dust and debris. During an interview on 9/20/2024 at 9:20 am, R64 revealed that a staff member would usually change the filters and clean the concentrator weekly. However, it had been at least 30 days since she had seen staff change the filter or clean the oxygen concentrator. 2. A review of R54's Quarterly MDS dated [DATE] revealed section O (Special Treatments and Programs) documented that R54 received oxygen. A review of R54's medical record revealed an order dated 10/21/2023 for oxygen at 2 LPM via nasal cannula continuous. An observation of R54's oxygen concentrator on 9/20/2024 at 9:17 am and 9/21/2024 at 9:05 am revealed the exterior air intake cover/vent was covered with visible dust and debris. During an observation of R54's oxygen concentrator on 9/21/2024 at 9:29 am, the Administrator and (ICP) verified the exterior air intake cover/vent was covered with visible dust and debris. An observation of R54's oxygen concentrator on 9/22/2024 at 9:22 am revealed the exterior air intake cover/vent continued to be covered with visible dust and debris. 3. A review of R29's Annual MDS dated [DATE] revealed section O (Special Treatments and Programs) documented that R29 received oxygen. A review of R29's medical record revealed an order dated 8/1/2024 for oxygen at 2 LPM via nasal cannula as needed. An observation of R29's oxygen concentrator on 9/20/2024 at 9:22 am and 9/21/2024 at 9:18 am revealed the exterior air intake cover/vent was covered with visible dust and debris. During an observation of R29's oxygen concentrator on 9/21/2024 at 9:32 am, the Administrator and ICP verified the oxygen concentrator air intake cover was covered with visible dust and debris. An observation of R29's oxygen concentrator on 9/22/2024 at 9:01 am revealed the oxygen concentrator air intake cover continued to be covered with visible dust and debris. During an interview with the ICP on 9/21/2024 at 9:29 am, she stated that ensuring the oxygen concentrators and oxygen filters were clean fell under infection control, but she did not know how often the filters and concentrators needed to be cleaned. The ICP acknowledged R64's, R54's, and R29's oxygen concentrator air intake cover and R64's oxygen filter were covered with visible dust and debris and should have been cleaned. During an interview with the Administrator on 9/21/2024 at 9:30 am, she stated it was her expectation for the oxygen filters and concentrators to be cleaned per the manufacturer's instructions and facility policy, and when observed to be visibly dirty. The Administrator acknowledged R64's, R54's, and R29's oxygen concentrator air intake cover and R64's oxygen filter were covered with visible dust and debris and should have been cleaned.

Based on observations, staff interviews, and resident interviews, the facility failed to ensure a functioning call system for one of 30 sampled residents (R) (R39). This failure placed R39 at risk of accident, injury, and/or unmet needs related to an inability to call for staff assistance. Findings include: A review of R39's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 10 (indicating moderate cognitive impairment), and section GG (Functional Abilities and Goals) documented no upper extremity impairment. Observations of R39's call light on 9/20/2024 at 9:51 am and 9/21/2024 at 8:57 am revealed the call light was not working. When the call light was unplugged from the wall, the call light was triggered outside the room, but when the call light was plugged in, and the call light was depressed, the call light did not trigger outside the resident's room. An interview with R39 on 9/20/2024 at 9:56 am revealed he was unaware the call light was not working, and he had no idea when it had stopped working. He stated he could not remember when the staff had last checked his call light. An observation of R39's call light with the Administrator and Assistant Maintenance Director (AMD) on 9/21/2024 at 9:37 am revealed the call light was not working. The Administrator and AMD acknowledged that when the call light was unplugged from the wall, the call light triggered outside the room, but when the call light was plugged in, and the call light was depressed, the call light did not trigger outside the resident's room. During an interview with the ADM on 9/21/2024 at 9:38 am, he said he checked the resident's call lights every other day but had not checked R39's call light recently because he had been busy with different tasks. He could not remember the last time he had checked the call light in R39's room. During an interview with the Administrator on 9/21/2024 at 9:39 am, she stated the resident's call lights were supposed to be checked regularly and fixed or replaced if they were found to be non-functioning. She said R39's light should have been checked, fixed, or replaced. The Administrator further stated the facility had no policy or written procedure indicating who was responsible for monitoring the call light system or how the system would be assessed for functional ability.

Based on observations, staff interviews, and a review of the facility's policies titled, Labeling, Dating, Leftovers, Food Temperatures, Refrigeration/Freezer Temperatures, and Storage, and Pot/Pan Washing and Sanitation, the facility failed to ensure food items in the refrigerator were properly labeled, dated, and discarded; failed to ensure the dish machine had a final rinse temperature at or above 180 degrees for proper sanitization; failed to properly wash food processor bowl, lid, and blade between pureed food items to prevent cross contamination; failed to properly use the three-compartment sink to properly sanitize dishware; failed to ensure all food items on the steam table were held at or above 135 degrees to prevent foodborne illness; and failed to ensure all refrigerators containing food items had an internal temperature of 41 degrees or below to prevent bacterial growth. The facility census was 75, with 73 residents consuming an oral diet. These failures had the potential to support bacterial growth associated with foodborne illness. Findings include: 1. Review of the policy titled Labeling, Dating, and Storage revealed that Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared onsite, a 'use by' date will also be indicated. Review of the policy titled Leftovers revealed that leftovers must be used within 72 hours (3 days). Observation on 5/19/2023 at 8:49 a.m. of the reach-in refrigerator located in the back room of the kitchen revealed the following: - One gallon container of French Dressing opened with no date. - One gallon container of Creamy Italian Dressing opened with no date. - 4.6-pound container of Maraschino Cherries opened with no date. - 48-ounce Smucker's Grape Jelly opened with no date. - A clear plastic container labeled gravy with preparation date 5/11/2023 and use by date 16. - A clear plastic container labeled zucchini squash with no preparation date and use by date of 5/17/2023. - A clear plastic container labeled mashed potatoes with no preparation date and use by date 5/17/2023. - A clear plastic container labeled beans with no preparation date and use by date of 5/17/2023. - A clear plastic container labeled veggie soup with no preparation date and use by date 5/10/2023. - A clear plastic container labeled corn with preparation date 5/10/23 and use by date 5/17/2023. - A clear plastic container labeled corn on the cob with no preparation date and use by date 5/12/2023. Interview on 5/19/2023 at 9:20 a.m. with Assistant Dietary Manager (ADM) confirmed that all the food items found in the refrigerator in the back room of the kitchen were either not labeled or dated or should have been discarded. The ADM revealed that the labels on leftover foods should be used or discharged seven days after the initial preparation day. The ADM revealed that she is responsible for ensuring that all refrigerator food items are properly labeled, dated, and discharged if needed. 2. Observation on 5/20/2023 at 8:58 a.m. of the dish machine revealed that the facility had a high-temperature machine. The temperature gauge for the final rinse towards the top of the dish machine revealed a sticker stating: rinse 180F (min). The first attempt at capturing the final rinse temperature read 170 degrees. Four additional attempts were made to review the final rinse temperature, which were 171, 170, 165, and 175 degrees. Interview on 5/20/23 at 8:58 a.m. with dietary aide BB confirmed all the final rinse temperatures. The dietary aide stated that the final rinse temperature should be between 175-180 degrees. Interview on 5/20/2023 at 9:05 a.m. with Dietary Manager (DM) confirmed that the dish machine had a final rinse temperature of 170 degrees and should be at least 180 degrees to sanitize dishes properly. The DM stated that they will use paper products until the dish machine is repaired. Review of the Dish Machine Temperature Log Form revealed that dietary staff documented the wash and final rinse temperature three times during the day, at each mealtime. The log sheet for 5/20/2023 revealed that the rinse temperature was at 171 degrees. 3. Observation on 5/20/2023 at 9:43 a.m. of dietary cook CC washing the food processor bowl, lid, and blade after pureeing roast pork revealed she brought the items to the three-compartment sink and rinsed only the visible food particles. Continued observation revealed that dietary cook CC did not properly sanitize the food processor bowl, lid, and blade before pureeing the next food item, asparagus. Interview on 5/20/2023 at 9:52 a.m. with dietary cook CC confirmed that she did not properly sanitize the food processor bowl, lid, and blade between the puree roast pork and pureed asparagus. Dietary cook CC revealed that she did not properly wash the food processor, bowl, lid, and blade in the three-compartment sink due to the wash sink was full of other pots and pans, and there was no room to wash the food processor bowl, lid or blade with soapy water and then sanitize. Interview on 5/20/2023 at 10:00 a.m. with DM revealed that she expects staff to wash the food processor bowl, lid, and blade between each puree food item. 4. Review of the policy titled Pot/Pan Washing and Sanitation revealed that pots, pans, and utensils must be sanitized in the sanitizer sink according to one of the following methods - Quaternary concentration is to be 200-300ppm with a water temperature above 75 degrees or as specified by the manufacture. Items need to be immersed for 60 seconds in the Quaternary. Observation on 5/20/2023 at 9:55 a.m. of dietary cook CC using the three-compartment sink to wash the food processor bowl, lid, and blade revealed dish items were washed in soapy water, rinsed, then placed in the sanitizing solution for four seconds before placing on drying rack. Continued observation revealed that the facility was using EcoLab Quaternary sanitizing solution. Interview on 5/20/2023 at 9:55 a.m. with dietary cook CC revealed that dish items only needed to be in the sanitizing solution for about two seconds. Interview on 5/20/2023 at 10:00 a.m. with DM revealed she expects staff to use the three-compartment sink correctly when washing dish items which include placing dishes in the sanitizing solution for 60 seconds. 5. Review of the policy titled Food Temperatures revealed that all hot foods served from the steam table must be held at or above 135 degrees. Observation on 5/20/2023 at 12:30 p.m. revealed steam table temperatures were completed; dietary aide BB assisted and used the facility's calibrated thermometer. The fried pork chop had a temperature of 118 degrees, and the baked pork chop had a temperature of 124 degrees. During an interview on 5/20/2023 at 12:30 p.m. with dietary aide BB confirmed that the fried pork chop was 118 degrees, and the baked pork chop was 124 degrees. Continued interview with dietary aide BB revealed she was not able to state the proper holding temperature for food items in the steam table and was not able to state the re-heat temperature for food items below 135 degrees. Interview on 5/20/2023 at 12:30 p.m. with dietary cook CC was not able to state the proper holding temperature for food items on the steam table and was not able to state the proper re-heat temperature for the food items not held at the proper temperature. Interview on 5/20/2023 at 12:30 p.m. with DM revealed that food items on the steam table should be held at 135 degrees or above, and staff needs to reheat the pork chops to 165 degrees. 6. Review of the policy titled Refrigeration/Freezer Temperatures revealed that refrigeration temperatures will be maintained at or below 41 degrees; freezer temperatures will be maintained at or below 0 degrees Observation on 5/21/2023 at 8:50 a.m. of the reach-in refrigerator located in the food preparation area revealed that warm air was felt coming from inside when the doors were opened. The internal thermometer read 70 degrees. This refrigerator contained poured beverages for lunch, individual juice containers, one carton of whole milk, three clear plastic resealable bags containing leftover breakfast food items, and two clear plastic containers of apple slices that were warm to the touch. Interview on 5/21/2023 at 8:50 a.m. with DM confirmed that warm air came from inside the refrigerator and that the internal thermometer read 70 degrees. The DM stated that this refrigerator is only used to hold beverages. The DM confirmed that the containers of apple slices were warm to the touch. The DM could not explain why other food items that needed to refrigerate at 41 or below were in the refrigerator.

Based on staff interviews, record review, and review of the facility policy titled Nutritional Screening and Assessment/Food Preferences, the facility failed to complete a Comprehensive Nutritional Assessment for six of 27 residents (R) (R#72, R#37, #46, #36, #65, and #69) sampled. Findings included: A review of the facility policy, Nutritional Screening and Assessments/Food Preferences, revised 11/21/2016, revealed that the in-house Registered Dietician (RD) or consulting RD would complete a nutritional assessment and recommend interventions to optimize the resident's nutritional status. Additionally, the Nutrition Assessment Form would be completed within 14 days. 1. Record review of the Minimum Data Set (MDS) OBRA Admission Assessment for R#72, dated 4/23/2023, revealed that R#72 required supervision and set-up assistance for eating. Record review of the care plan for R#72 revealed a focus area of altered nutrition related to CVA, diabetes mellites with hyperglycemia, multiple pressure ulcers, and a surgical incision. The goal was for R#72 to consume adequate nutrition and hydration to maintain a stable weight without significant weight loss. Interventions included were to provide supplements with meals, monitor for malnutrition, assessing for dehydration, encourage compliance with the prescribed diet, consult the Registered Dietician, and notify the MD as needed. Record review of physician's orders for R#72 included (not all-inclusive) revealed orders for Consistent Carbohydrate Diet (CCHO) for Diabetes, Decubi Vite (a supplement to support wound healing) once per day, Juven (a therapeutic nutrition powder) once per day and Ensure (a nutritional supplement) three times per day. Record review of the Electronic Medical Record (EMR) for R#72 revealed an admission weight of 123 pounds on 4/19/2023. On 5/15/2023, the resident weighed 107.2 pounds, reflecting a weight loss of 12.76%. Record review of the EMR revealed that a Comprehensive Nutritional Assessment was completed on 5/19/2023, 30 days after the resident's admission to the facility. 2. Record review of the Minimum Data Set (MDS) OBRA Admission Assessment for R#37, dated 2/17/2023, revealed that R#37 required limited assistance with eating. Record review of the care plan for R#37 revealed a focus area of therapeutic diet related to hypertension and diabetes mellites. The goal was for R#37 to not experience significant weight loss. Interventions included assessing weights routinely, offering food substitutes, monitoring labs, monitoring malnutrition, assessing dehydration, praising diet compliance, and obtaining a dietary consult when needed. Record review of physician's orders for R#37 included (not all-inclusive) revealed orders for Consistent Carbohydrate Diet (CCHO) for Diabetes, Juven (a therapeutic nutrition powder) and Ensure (a nutritional supplement) once a day, and a Nutrition Shake twice a day. Record review of the Electronic Medical Record (EMR) revealed R#37 had an admission weight of 218 pounds on 2/15/2023. On 5/15/2023, R#37 weighed 176.2 pounds, reflecting a weight loss of 19.7%. Record review of the EMR for R#37 revealed that a Comprehensive Nutritional Assessment was completed on 4/19/2023, 62 days after the resident's admission to the facility. Interview on 5/19/2023 at 2:31 p.m. with Director of Health Services (DHS), she acknowledged R#72 had not had a nutritional assessment. However, she added that the Registered Dietician (RD) should have completed a Comprehensive Nutritional Assessment for R#72 within 14 days of admission. During a follow-up interview on 5/21/2023 at 10:21 a.m. with the DHS, she explained it was her expectation for the RD to complete a Comprehensive Nutritional Assessment for each new admission, change in condition, and annually within the required 14 days. The DHS explained that the regional RD was following the facility residents until a new RD was hired. The DHS further revealed that the regional RD had taken over almost one month ago. The DHS acknowledged that the RD had not completed a Comprehensive Nutritional Assessment for R#72 and R#37 within 14 days of admission. The DHS stated that the RD was notified about new admissions through the Observation Reports and e-mail. Nurses would typically let the Dietary Manager (DM) and physician (MD) know if there were nutritional concerns, and the MD or DM would consult the RD. The DHS stated that the RD received updates about each resident during the weekly Patient at Risk (PAR) meetings and by reviewing the clinical record 42464 3. Record review of the Admission Minimum Data Set (MDS) for R#69 dated 2/8/2023 revealed that section G indicated required set-up assistance for eating; section K indicated weight was 138, there was no significant weight loss or gain, and was on a therapeutic diet. Record review of the Significant Change MDS for R#69 dated 5/3/2023 revealed section K revealed weight was 141, there was no significant weight loss or gain, and was on a therapeutic diet. Record review of the Physician's orders for R#69 included an order dated 2/1/2023 for a Consistent Carbohydrate Diet (CCHO)/ No Added Salt (NAS) diet. Record review of the care plan review for R#69 dated 4/27/2023 revealed weight loss; a goal of R#69 will maintain current body weight; approaches of encouraging oral intake of foods and fluids, monitor, and record weight and notify the physician of significant weight change. Review of weights since admission revealed R#69 did not have a significant weight loss or gain. A clinical record review revealed there was not a documented comprehensive dietary assessment since admission, and there were no dietary progress notes. Interview on 5/21/2023 at 10:30 a.m. with Director of Health Service (DHS) and Regional Nurse Consultant (RNC) revealed the facility did not have a full-time Registered Dietician (RD) for the last month and relied on the Regional RD to complete the required resident nutritional assessments. She revealed that the Regional RD received notification through an observation order when there were new admissions or significant changes. The DHS further revealed that her expectations were for comprehensive nutritional assessments to be completed and documented by an RD within 14 days of admission or a significant change in the resident's status. 4. Record review of the admission MDS for R#65 dated 4/25/2023 revealed that section G indicated required supervision of one person for eating; section K indicated no swallowing concerns and no weight loss; section O indicated R#65 received dialysis. Record review of the physician's orders for R#65 included an order dated 5/19/2023 for a CCHO/ NAS regular diet with thin liquids and large portions of meat and eggs at meals. Record review of the care plan for R#65 dated 5/9/2023 required a therapeutic diet with a goal of R#65 will verbalize understanding of dietary regime and restrictions. Approaches included obtaining a dietary consult and following recommendations. A review of the clinical record weights section revealed that R#65 did not have significant weight loss. On 04/19/2023, the resident weighed 160 lbs. On 05/15/2023, the resident weighed 169.2 pounds, a 5.75 % Gain. A clinical record review revealed that a nutritional assessment was completed by a Registered Dietician (RD) on 5/19/2023, 30 days after R#65 was admitted to the facility. 46691 5. A review of the weight record for R#36 revealed that on 12/6/2022, the resident weighed 191 lbs. (pounds). On 5/1/2023, R#36 weighed 156 lbs., an 18.32% weight loss in 6 (six) months. Further review of the electronic medical record (EMR) revealed that a Nutritional Screen was done by the Registered Dietician after admission on 8/8/2022. There was no other Nutritional Screen or evidence Registered Dietician was notified of the resident's weight loss. or anytime thereafter. Further review of the EMR revealed that resident weight loss was not addressed until 5/8/2023 by the Nurse Practitioner. An order was written on 5/18/2023 to add a nutritional supplement drink, but there is no documentation that the weight loss was addressed prior to this order. 6. R#46 was admitted to the facility with diagnoses including but not limited to adult failure to thrive. A review of the weight record for R#46 revealed that 2/20/2023, the resident weighed 162 lbs. On 5/15/2023, the resident weighed 139.6 lbs., a 13.83 % loss in 3 (three months). Further review revealed there was no Nutritional Screen done by the Registered Dietician after admission or anytime thereafter. Interview on 5/20/2023 at 2:33 p.m. with Dietary Manager revealed that residents with weight loss were discussed during weekly meetings with the Interdisciplinary Team (IDT). Confirmed residents were not referred to the Registered Dietician, and a Nutritional Screen was not completed. She stated that there was not a Registered Dietician available for the facility until approximately 1 (one) week ago. Interview on 5/20/2023 at 2:36 p.m. with Corporate Nurse Consultant revealed there is a corporate Registered Dietician available for all facilities. She stated that residents should have been referred to the corporate Registered Dietician, and a Nutritional Screen should have been done on admission and when there was a significant change in weight.

Based on observations, staff interviews and a review of the policy titled Medication Storage in the Healthcare Setting, the facility failed to ensure that all drugs and biologicals were securely stored and not accessible by residents, unauthorized staff or visitors, specifically the facility failed to ensure that two of four medication carts were locked and secured when left unattended and out of eyesight of the nurse (West Wing Long Hall and East Wing A Hall carts); failed to ensure that all drugs and biologicals were appropriately labeled with an opened or discard date, specifically one tuberculin purified protein derivative 10 dose vial (an injectable solution used in a skin test to help diagnose tuberculosis); failed to ensure that all drugs and biologicals were discarded on the discard date, specifically one Novolog Flex Pen 100units/milliliter (ml) 3ml pre-filled pen, (an injectable medication used to treat diabetes); failed to ensure that drugs and biologicals were stored at the proper temperature to preserve their integrity, specifically one Novolog Flex Pen 100units/ml 3ml pre-filled pen to be unopened and not stored under refrigeration. This failure placed residents, staff, and visitors at risk of having unauthorized access to residents' medications. In addition to the potential use of ineffective medications by not being properly stored. Findings include: Review of the policy titled Medication Storage in the Healthcare Setting dated 4/1/98 and revised 9/15/17 revealed a policy statement that medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier; the medication supply is accessible only to licensed nursing personnel and pharmacy personnel. The Procedure section revealed: 2. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access. 9. Medications requiring refrigeration are stored at a temperature between 2 degrees Celsius (C) (36 degrees Fahrenheit (F)) and 8 degrees C (46 degrees F) and are kept in a refrigerator with a thermometer to allow temperature monitoring. 11. multi-dose containers of injectables, ophthalmic and optic preparations, and inhalers are to be dated (when opened). Observation on 5/20/2023 at 8:40 a.m., during a medication pass for a resident (R) in room [ROOM NUMBER], an observation revealed Registered Nurse (RN) DD left the [NAME] Wing Long Hall medication cart unlocked and unattended and parked against the wall between rooms [ROOM NUMBERS] with the drawers facing the hallway. Further observation revealed one Advair Diskus (a prescription orally inhaled medication used to control the symptoms of asthma and chronic obstructive pulmonary disease) sitting on top of the cart. At 8:42 a.m., one resident was observed propelling in a wheelchair past the cart. From 8:40 a.m. to 8:46 a.m., two housekeeping staff were observed walking past the cart several times as they passed meal trays to residents in the hallway. RN DD was out of sight of the cart in room [ROOM NUMBER] with the curtain drawn and administering medication to a resident. At 8:46 a.m. RN DD approached the medication cart and verified she had left it unlocked, unattended, and out of her eyesight. She further verified that the Advair Diskus inhaler was left on the cart. She revealed that she normally does not leave medication sitting on the medication cart or unattended. She was just nervous and forgot to secure the medication and lock the medication cart. Observation on 5/20/2023 at 9:05 a.m. of the East Wing A Hall medication cart revealed the cart to be located against a wall next to room [ROOM NUMBER] with the drawers facing the hallway, unlocked and unattended. At 9:13 a.m., one ambulatory resident (R#46) was observed walking past the medication cart, turned around, and walked past it a second time at 9:16 a.m. Licensed Practical Nurse (LPN) EE approached the medication cart and locked it. LPN EE revealed that LPN FF was responsible for the medication cart and was in room [ROOM NUMBER] assisting a resident with eating. Interview on 5/20/2023 at 9:40 a.m. with LPN EE revealed she was responsible for the East Wing A Hall medication cart. She verified that she had left the medication cart unlocked and unattended while checking on a resident and assisting another resident with eating. She revealed that she should have locked the medication cart before leaving it unattended and out of her eyesight and that she just forgot to. Observation on 5/20/2023 at 8:50 a.m. of the [NAME] Wing Long Hall medication cart with RN DD revealed one Novolog Flex Pen 100units/ml (milliliter) 3ml pre-filled pen to have a discard date of 5/19/2023 and one Novolog Flex Pen 100units/ml 3ml pre-filled pen to be unopened and stored in the medication cart. The pharmacy label on the Novolog Flex Pen indicated that the medication should be stored under refrigeration until opened. Interview on 5/20/2023 at 8:53 a.m. with RN DD verified the Novolog Flex Pen to have a discard date of 5/19/2023 and the Novolog Flex Pen to be unopened and stored at room temperature in the medication cart. She revealed that all insulin, including Novolog Flex Pen pre-filled pens, should be discarded on the discard date and that Novolog Flex Pen pre-filled pens should be stored under refrigeration until opened. Observation on 5/20/2023 at 11:00 a.m. of the medication storage room located behind the nursing station at the East Wing Nursing Unit with LPN JJ revealed one tuberculin purified protein derivative 10 dose vial was opened and without an open or discard date on the vial or the box. LPN JJ verified there was not an open or discard date on the opened vial of tuberculin purified protein derivative 10 dose vial and verified there was no way to know how long the vial had been opened or to ensure the integrity of the solution. She discarded the medication into a sharps container. Interview on 5/21/23 at 10:30 a.m. with Director of Health Services (DHS) and Regional Nurse Consultant (RNC) revealed their expectations were for the medication carts to be locked and secured when out of the eyesight of a nurse. The DHS further revealed her expectations were for injectable medications to be stored according to manufacturers' recommendations and for opened injectable medications to be labeled with an open and discard date once opened. The DHS revealed that she planned to provide education to licensed nursing staff to ensure medication carts were not left unlocked and unattended and to label and store medications properly.

Based on observations, staff interviews, and a review of the facility policy titled Infection Prevention and Control Plan, the facility failed to ensure resident basins and bedpans were labeled and covered for three of 54 rooms. These failures had the potential to expose patients to infections due to cross-contamination. Findings included: Review of the facility policy titled Infection Prevention and Control Plan, revised 3/11/2021, revealed that the Infection Prevention and Control program would provide oversight of procedures related to the disinfection of equipment used in the care of residents. Observation of room [ROOM NUMBER] on 5/19/2023 at 8:45 a.m., which housed two residents (R#225 and R#59), revealed an unlabeled basin on the floor under the sink. The basin was not stored in a bag and sat directly on the floor. Interview on 5/19/23 at 8:50 a.m. with Licensed Practical Nurse (LPN) BB revealed that she could not indicate which patient the basin belonged to. She stated that all basins should be labeled with the patient's name and room number and stored in a bag. Observation of room [ROOM NUMBER] on 5/19/2023 at 8:53 a.m., which housed two residents (R#72 and R#71), revealed two unlabeled basins under the sink. The basins were not stored in bags and sat directly on the floor. Interview on 5/19/2023 at 8:57 a.m. with the Director of Health Services (DHS) revealed that she could not indicate which patient the basins belonged to. She stated that the staff was supposed to label all basins in the patient rooms. Observation of room [ROOM NUMBER] on 5/19/2023 at 9:10 a.m., which housed two residents (R#14 and R#29), revealed two unlabeled basins and one bedpan sitting under the sink. The basins and bedpan were not stored in bags and sat directly on the floor. Interview on 5/19/2023 at 9:12 a.m. with LPN BB revealed that she could not indicate which patient the basins or bedpan belonged to. She stated that all basins were supposed to be labeled. Observation on 5/20/23 at 8:09 a.m. of rooms [ROOM NUMBER] revealed that no basins were present in the rooms. Interview on 5/20/23 at 12:17 p.m. with the Infection Preventionist (IP), she stated her expectation of staff was to label each resident's basin and bedpans. She added that the basins and bedpans were to be stored in clear plastic bags and discarded when dirty. The IP acknowledged that the basins were not labeled or stored properly.

Based on observation, staff interviews, and recipe review, the facility failed to ensure that dietary staff followed recipes for preparing pureed foods to avoid compromising the nutritive value, flavor, or appearance. This affected six of 73 residents receiving an oral diet. Findings include: A review of the recipe for regular Buttered Asparagus Spears revealed in the notes: Puree Level 4 - smooth texture, no lumps, the liquid must not separate from solid, may not be sticky, cannot be drunk from a cup or sucked through a straw. Shows some very slow movement under gravity, but cannot be poured, hold the shape of a spoon & fall off the spoon in a single spoonful. A continued review of the recipe revealed that the ingredients listed included margarine solids, salt, and frozen asparagus spears. A review of the recipe for Puree Green Beans revealed that the only ingredient listed is green beans. Observation on 5/20/2023 at 9:45 a.m. of dietary cook CC puree asparagus revealed no recipe was available or used as a reference during puree production. Dietary cook CC placed eight slices of white bread in the food processor bowl and an unmeasured amount of cooked asparagus. The cook then pureed to the proper consistency. Interview on 5/20/2023 at 9:45 a.m. with dietary cook CC revealed that she knows by experience how to puree food items. The dietary cook stated that she was trained to add slices of bread when pureeing asparagus. The dietary cook was not able to state if a recipe for puree asparagus was available or if a recipe was reviewed prior to completion. Interview on 5/20/23 at 3:35 p.m. with the Dietary Manager (DM) revealed that the cook using eight slices of bread for the unmeasured amount of cooked asparagus was not appropriate. The DM stated that the cook should have used about four slices of bread. The DM revealed that she could not locate an actual recipe for pureed asparagus and provided a recipe for pureed green beans since they were similar vegetables. The DM verified that the puree green bean recipe did not indicate any bread to be added. The DM revealed that as long as it tastes good, the method and steps the cook took to puree the asparagus were acceptable.

Based on observations, staff interviews, and record review, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of seven residents (R) (R#69) who had an indwelling urinary catheter. This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: The Regional Nurse Consultant (RNC) revealed there was not a policy for dignity, nor a policy related to urinary catheter dignity or privacy. Observation on 5/19/2023 at 10:02 a.m. of R#69 in a wheelchair in a resident day room with other residents. Further observation revealed a urinary catheter drainage bag attached to the wheelchair without a privacy bag covering the bag, allowing the urine to be seen by other residents, staff, and visitors. Record review of the Significant Change Minimum Data Set (MDS) for R#69 dated 5/3/2023 revealed in section C indicated a Brief Interview for Mental Status (BIMS) of 12 (indicating was cognitively intact); section H indicated had an indwelling catheter. Interview on 5/20/2023 at 8:15 a.m. with R#69 revealed he did not remember the urinary catheter drainage bag being in a privacy bag and would like to have it covered so other residents did not see his urine. Observation on 5/20/2023 at 11:50 a.m. of R#69 with the Regional Nurse Consultant (RNC) revealed the resident to be sitting on his bed in his room with the urinary drainage bag lying in his wheelchair and not in a privacy bag. The RNC verified that the urinary drainage bag was not in a privacy bag and revealed that it should have been. Interview on 5/21/2023 at 10:30 a.m. with the Director of Health Services (DHS) and the RNC revealed their expectations were for urinary drainage bags always to be contained in a privacy bag unless care was being provided that required the bag to be exposed.

Based on staff interviews, record review, and a review of the facility's policy, Significant Weight Changes, the facility failed to update the care plan with appropriate interventions for one resident (R) (#36) with significant weight loss. This failure had the potential for residents to not receive treatment and/or care according to their needs and place residents in a position for adverse consequences. Findings include: Review of facility policy 'Weight Monitoring Program' last revised 6/13/2018 revealed 'Significant Weight Changes: 2. The Weight Team will evaluate these changes and determine if the change is either: Significant Weight Loss (SWL): Update care plan Interventions will be added as needed. R#36 was admitted to the facility on [DATE] with diagnoses including but not limited to dysphasia following cerebral infarction, cholelithiasis with obstruction, diabetes, gastroesophageal reflux disease, and cholecystitis. A review of R#36's weight record revealed that on 12/6/2022, R#36 weighed 191 lbs. (pounds). On 5/1/2023, R#36 weighed 156 lbs., which is an 18.32% weight loss in 6 (six) months. Record review of the care plan for R#36, last revised on 3/8/2023, revealed no update to the care plan to address the significant weight loss. Interview on 5/21/2023 at 11:13 a.m. with Care Plan Coordinator revealed that the Dietary Manager is responsible for updating care plans related to weight changes. Interview on 5/21/2023 at 11:31 a.m. with Dietary Manager (DM) revealed that she is over the weight program and updating care plans to address weight loss. The DM confirmed that R#36's care plan was not updated to reflect a significant weight loss. Interview on 5/21/2023 at 12:34 p.m. with Director of Health Services revealed it is her expectation for the care plan to be updated to reflect weight loss.

Based on staff interviews, and record review, the facility failed to provide appropriate care and services for one resident (R) (#61) with a diagnosis of Post-Traumatic Stress Disorder (PTSD). This failure had the potential to increase the risk for a resident with a mental illness diagnosis from not receiving specialized services. Findings include: R#61 was admitted to the facility on [DATE] with a diagnosis of PTSD. Record review of the Admission Minimum Data Set (MDS) for R#61 dated 1/3/2023 revealed in section A-Identification Information, A1500 Preadmission Screening and Resident Review (PASRR) is not checked. Section D-Mood revealed little interest or pleasure in doing things for 12-14 days of the look back period and feeling tired or having little energy seven-11 days of the look back period. Section I-Active Diagnosis revealed I6100 PTSD was checked. Section N-Medications revealed resident received antipsychotic and antidepressant medications. Section O-Special Treatments and Programs E. Psychological Therapy revealed none received. Record review of the Electronic Medical Record (EMR) for R#61 revealed resident was previously seen by a psychiatrist while in the community, however since admission resident has not received any psychological therapy. There was no documentation regarding the residents' diagnosis of PTSD or triggers. Interview on 5/21/2023 at 11:50 a.m. with Social Services Director (SSD) revealed she does not do a resident history on admission. She stated that she does not fill out any observations concerning psychosocial needs. The SSD further revealed that she does not know what the resident's PTSD is related to. She revealed that the facility is awaiting PASRR Level 2 screening results for approval for a psychological evaluation because it was not done on admission. Interview on 5/21/2023 at 12:07 p.m. with Director of Health Services (DHS) revealed Social Services Director should have found out from the resident, the resident's family, or prior Physician cause of the resident's PTSD. The DHS confirmed that R#61 should be receiving psychological therapy.

Based on resident and staff interviews, record review, and a review of the facility's policy Care Plans, the facility failed to develop and implement a care plan for one resident (R) (#61) related to a diagnosis of post-traumatic stress disorder and one resident (R) (#69) related to use of catheter dignity bag. This failure had the potential for residents to not receive treatment and/or care according to their needs and place residents in a position for adverse consequences. Findings include: 1. Review of the policy titled 'Care Plans' effective 12/31/1996 revealed: 'Admission Comprehensive Care Plan 3. The comprehensive person-centered care plan is developed to include measurable goals and time frames to meet a patient/resident's measurable goals, medical, nursing, and psychosocial needs, the services that are furnished to attain or maintain the resident's highest practicable physical, and mental and psychosocial needs that are identified in the comprehensive assessment.' Record review of the comprehensive care plan for R#61, last reviewed 4/4/2023, did not reveal a person-centered care plan to address the resident's post-traumatic stress disorder. Interview on 5/21/2023 at 11:06 a.m. with MDS Coordinator revealed R#61 does not have a person-centered care plan to address the post-traumatic stress disorder. The MDS Coordinator further revealed that the resident should have specific interventions for her specific needs. She stated that the Social Services Director is responsible for ensuring those care plans are in place. Interview on 5/21/2023 at 11:50 a.m. with Social Services Director revealed that a person-centered care plan to address the resident's post-traumatic stress disorder was not developed on admission. Interview on 5/21/2023 at 12:07 p.m. with the Director of Health Services (DHS) revealed that the care plan should be person centered on addressing the resident's post-traumatic stress disorder. The DHS confirmed that the resident did not have a care plan in place. 46691 2. Observation on 5/19/2023 at 2:35 p.m., and 5/20/2023 at 8:15 a.m. of R#69 revealed him to be sitting in a wheelchair with a urinary catheter drainage bag attached to the wheelchair without a privacy bag. The urine in the drainage bag was visible to other residents, staff, and visitors. Interview on 5/20/2023 at 10:40 a.m. with Certified Nursing Assistant (CNA) HH revealed CNAs were responsible for ensuring urinary catheter drainage bags were kept in privacy bags. She further revealed that she was unaware of what interventions were in the care plans. Interview on 5/20/2023 at 10:45 a.m. with LPN GG revealed that urinary drainage bags should be kept in privacy bags to prevent other residents and visitors from observing a resident's urine. She revealed that the CNAs were primarily responsible for ensuring privacy bags were in place, but that nurses should also ensure privacy bags were in place. LPN GG stated that care plan approaches should be followed by nursing staff. Interview on 5/21/2023 at 10:30 a.m. with the Director of Health Services (DHS) and the RNC revealed their expectations were for nursing staff to follow care plan approaches.

Based on staff interviews, and record review, the facility failed to accurately code one of 27 resident (R) (#52) Quarterly Minimum Data Set (MDS) sampled. This failure has the potential to cause the Resident's medical record to reflect inaccurate data related to MDS coding. Findings include: Record review of the most recent Quarterly MDS Assessment for R#52 dated 3/16/23 revealed in section P that R#52 was assessed as having a restraint used in chair or out of bed - chair prevents rising. Record review of the Electronic Medical Record (EMR) revealed no progress note or assessment regarding a restraint being used. Interview on 5/19/2023 at 12:40 p.m. with Director of Health Services (DHS) revealed that the facility is restraint-free, and no resident has a restraint. The DHS stated that R#52 does not use a restraint. Interview on 5/21/2023 at 10:45 a.m. with Minimum Data Set (MDS) Coordinator revealed she completed R#52 quarterly MDS dated [DATE] and confirmed that section P indicated that the resident used a restraint. The MDS coordinator revealed that it was an error; she was going too fast when completing the assessment. The MDS Coordinator stated that there are no restraints used in the facility.

Based on observation, record review, staff and resident interview, the facility failed to maintain a working hot water heater on one of two halls, the West Hall. Findings include: Interview with the Ombudsman on 3/22/22 at 11:58 a.m. revealed that during the resident council meeting, residents complained about not having hot water for over a month. During a walkthrough of the West Hall with the Maintenance Supervisor on 3/24/22 starting at 11:45 a.m., random hot water temperatures were checked in the shower and sink of resident rooms and were verified using the facilities calibrated thermometer. Water temperatures were in degrees Fahrenheit as follows: Room (Rm) 148- 65 Rm 149- 67 Rm 150- 66 Rm 151- 67 Rm 154- 67 Rm 152- 67 Rm 134- 67 Rm 136- 67 Rm 137- 68 Rm 141- 67 Rm 140- 68 West Hall Shower room sink- 67 West Hall Shower- 68 Interview on 3/22/22 at 3:15 p.m. with the Treatment Nurse revealed the facility has been out of hot water one or two months and was told they are waiting on a part. Interview on 3/22/22 at 3:48 p.m. with the Maintenance Supervisor confirmed there has been no hot water on the West Hall since January 2022. There is a hole in the bottom of the hot water heater. He found it leaking and turned it off. He got a quote from the same plumbing company they used last year when they replaced the hot water heater on East Hall. The quote was $11,000.00. The Administrator and his superior signed off on it and sent it up to Corporate. Two weeks ago, the district manager revealed that Corporate had not signed off on it. Interview on 3/23/22 at 11:12 a.m. with R#17 revealed, We need some hot water. The hot water has been out about a month and a half. Interview on 3/23/22 at 3:19 p.m. with R#18 revealed he had a shower a few days ago on the other hall (East Hall) and confirmed they do not have hot water on this side (West Hall). Interview on 3/24/22 at 8:05 a.m. with Certified Nursing Assistant (CNA) LL confirmed the hot water on the West Hall had been out since she started working at the facility in February 2022. Residents have complained about the hot water being out. Interview on 3/24/22 at 2:20 p.m. with the Administrator confirmed the facility did not have hot water on West Hall. He was made aware of it in January 2022. Any purchase over $500 dollars must be approved. The request was placed the first or second week in February 2022 for approval. It's a commercial gas hot water heater. The Ombudsman approached him about it when she was at the facility the prior week and he informed her that he got a quote to get it fixed but big-ticket items are hard to get, and it takes time. The Administrator expected the equipment would be delivered today or tomorrow and would be installed and working by early next week.

Based on interview, record review, facility document review, and review of the facility's policy titled, Prevention of Patient, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure residents were free from physical abuse from Resident (R) (#79) for three of seven sampled residents reviewed for abuse (R13, R19, and R6). An altercation between R79 and R13 resulted in actual harm to R13 when he sustained an eyebrow laceration requiring repair and an orbital floor closed fracture. Findings include: Review of the facility's policy titled, Prevention of Patient, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised 10/27/20, indicated, It is the policy . to actively preserve each patient's right to be free from verbal, sexual, physical and mental abuse . 1. Review of the Face Sheet found in the electronic medical record (EMR) revealed R79 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Against Medical Advice [AMA] Release from Responsibility for Discharge indicated R79 left the facility AMA on 12/29/21. Review of R79'S Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/15/21 revealed R79 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. The MDS indicated R79 exhibited physical behavioral symptoms toward others that occurred one to three days in the assessment period. Review of the Care Plan, located in EMR under the Care Plan tab, revealed a Psychosocial Wellbeing care plan with a start date of 6/11/21 that indicated, Monitor for psychosocial changes. Observe and report any changes in mental status, mood, behavior, caused by situational stressor. A Behavioral Symptoms care plan with a start date on 9/9/21 indicated, Encourage [R79] to utilize acceptable coping mechanisms if feeling stressed. [R79] will accept medication as ordered . [R79] will verbalize his frustration to staff when feeling frustrated . An update to the Behavioral Symptoms care plan with a start date of 12/3/21 indicated, Resident exhibited socially inappropriate disruptive behavioral symptoms. 12/2/21- physical altercation with another resident, hitting head against wall, refusing care . Approaches indicated, Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Divert resident's behavior. When resident becomes physically abusive, keep distance between resident and others. When resident becomes physically abusive, move resident to a quiet, calm, environment. 2. Review of R13's Face Sheet, located under the Face Sheet tab in the EMR revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R13's Quarterly MDS with an ARD of 10/8/21 revealed R13 had a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. The MDS indicated R13 didn't exhibit any physical or verbal behavioral symptoms toward others. Review of the facility's Incident Report Form, dated 9/9/21 and provided by the facility, revealed On 9/9/21 at 11:50 a.m., [R13] pushed [R79] because he was talking bad about some of the female residents. In the process of [R79] being pushed, [R79] took a swing and hit [R13] by his eye. [R13] was sent to the ER [emergency room ] for stitches. Review of the Situation Background Communication Form dated 9/9/21 revealed the physician was notified that R13 was involved in an altercation with another resident and sustained a laceration above the left eye that may require suturing. Emergency medical transport was initiated. Review of the Emergency Department Provider Report dated 9/9/21 revealed chief complaint: assault victim, nursing home pt (patient) was punched by another resident, lac (laceration) above left eye. Clinical impression included closed injury of head, eyebrow laceration (with repair), and orbital floor (blow-out) closed fracture. Interview with R13 on 1/17/22 at 11:29 a.m. revealed R79 hit him in the face in the day room which resulted in a laceration over his left eye after he stood up to tell R79 to stop talking about his girlfriend. R13 also stated he was sent to the ER and stitches were placed above his left eye. R13 indicated R79 no longer resided in the facility. 3. Review of the Resident Face Sheet, undated and located in the EMR under the Home tab, revealed R19 was admitted to the facility on [DATE]. R19's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS with an ARD of 10/13/21 revealed R19 was moderately impaired in cognition with a BIMS of eight out of 15 (score of eight - 12 indicates moderate cognitive impairment). R19 exhibited verbal behavioral symptoms towards others four to six days out of the seven-day assessment period. R19 required extensive assistance of one person for transfers, dressing, and hygiene. R19 had not walked during the assessment period and used a wheelchair for mobility. Review of the Care Plan, dated 11/27/19 and located in the EMR under the Resident Assessment Instrument (RAI) tab, revealed a problem of, Behavioral Symptoms. [R19] has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . verbal altercation leading to physical aggression with injury from another resident on 12/3/21. The goal was for R19 to not threaten, scream at, or curse at other residents, visitors, and/or staff . Interventions included, Notify the MD [Medical Doctor] as needed . psych services . Assess whether the behavior endangers the resident and/or others. Intervene if necessary . Convey an attitude of acceptance toward the resident . Follow familiar routines with resident . Maintain a calm environment and approach to the resident . Review of the Nurse's Note, dated 12/3/21 at 1:10 p.m. and located in the EMR under the Progress Notes tab, revealed Resident was involved in altercation in the day room. Resident [R19] was attacked by another resident [R79] after a verbal altercation. The other resident [R79] punched him [R19] in the head and neck area several times. He [R19] was knocked out of his wheelchair and landed on the floor on his right side. Staff assisted resident [R19] off floor. Resident [R19] assessed for pain and injuries. Resident [R19] had a skin tear to right lower leg. Bleeding stopped, and dressing applied. 911 and MD [Medical Doctor] notified. [R19's family] called and aware. Review of the Follow-up for [number of incident], undated paper document provided by the facility, revealed The incident on 12/3/21 took place between [R19] . male age 57 BIMS score of 8 and [R79] [AGE] year-old . male who has a BIMS of 13 . [R19] rolled his wheelchair by [R79] and asked him what time smoke break was. [R79] replied it's the same time it is every day why are you asking me that. [R19] replied back it's just a stupid f (---) ing question cracker. This upset [R79] and he stood up and took a swing at [R19] and pushed him out of his wheelchair. There was some commotion and yelling in the common ground until staff rushed in and separated the two men. [R79] was standing over ([19] on the ground in an attack like position and was separated, the [name] sheriff's office was notified, the physician notified and both responsible parties . The decision was made to 1013 [initiate transportation to an emergency receiving mental health facility due to imminent risk] [R79] . He [R79] was sent to a behavior health center for stabilization (resident was hospitalized from 12/3/21 through 12/14/21 at inpatient psychiatric facility) . [R19] was evaluated for any injuries and had none to report. [R19] has returned back to his normal baseline routine. During an interview on 1/18/22 at 6:56 p.m., the Administrator stated R79 was sent out on a 1013 after he punched R19 in the head and neck. The Administrator stated R79 hit R19 after R19 called R79 a cracker. During an interview on 1/19/22 at 10:31 a.m., the Social Services Director (SSD) stated R19 was sporadically verbally aggressive towards residents and staff. She stated there were no patterns to this behavior and indicated the incident between R19 and R79 was started by R19. The SSD indicated R19 had used a derogatory name towards R79 on 12/3/21; R79 then punched R19 in the face two or three times. The SSD stated R19 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The SSD stated R19 did not have a history of being physically abusive towards other residents. During an interview on 1/20/22 at 12:53 p.m., Licensed Practical Nurse (LPN) 9 stated R19 upset other residents by cussing and fussing at them. R19 had to be redirected by staff. LPN9 stated anything could tick R19 off. During an interview on 1/20/22 at 1:34 p.m., the Medical Director, also R19's physician, stated R19 had dementia. He stated R19 was usually calm, he had not witnessed any verbally aggressive behaviors, and in general R19 was doing well. The Medical Director stated he was notified of the incident on 12/3/21. He stated staff should be monitoring residents on a one-to-one basis after aggressive behaviors were exhibited for 24 to 48 hours. He stated residents were sent on a 1013 if they were at risk of harming themselves or others. 4. Review of R6's Face Sheet, located under the Face Sheet tab in the electronic medical record (EMR) revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's Quarterly MDS with an ARD of 10/8/21 revealed a BIMS score of 10 out of 15, which indicated R6 was moderately cognitively impaired. The MDS indicated R6 exhibited verbal behavioral symptoms toward others that occurred one to three days during the assessment period. Review of the facility's Incident Report Form, dated 12/27/21 and provided by the facility, revealed On 12/27/21 at 5:00 p.m., [R6] was rolling by in her wheelchair and mumbled something to [R79] calling him a bastard and [R79] called [R6] a whore then according to witnesses stood up and kicked [R6] and [R6] fell out of her wheelchair. Staff were notified [and] separated the two and did an injury assessment on [R6]. The police department was called for assistance. They called back after an hour saying they couldn't do anything and to call back to dispatch if further assistance was needed. Review of the facility's Follow Up Report, undated and provided by the facility revealed The incident that took place on 12/27/21 between [R6 and R79] .[R79] was watching [television] and [R6] who is verbally impaired rolled by [R79] who was blocking the view of the TV [television]. [R6] mumbled to [R79] get out of the way you bastard. [R79] proceeded to stand up and yelled back at [R6] shut up your [sic] whore. Then [R79] kicked [R6's] wheelchair and [R6] slid out of the chair. Staff rushed in and separated the residents and cleared out the common area. A pain assessment was done on [R6] and the physician and family was [sic] notified. After the incident took place [R79] went and spoke with the social services director and told them he wanted to leave the facility and go back to his brother's home in [city]. [R79's] brother was working on finding a room for him to rent prior to this incident. Later that evening an uber was called and [R79] signed himself out AMA [against medical advice] to return back to his home in [city] GA. [R6] has since returned back to her normal routine. Interview with R6 on 1/18/22 at 9:49 a.m. revealed R79 kicked her wheelchair and she slid out of it in the dayroom. R6 also stated staff assessed her and she didn't have any injuries. R6 indicated that R79 didn't reside in the facility any longer. Interview with the Administrator on 1/20/22 at 5:34 p.m. revealed he protected the residents from abuse per the facility's abuse policy by clearing the common area where the incident took place, sending R6 and R79 to their rooms. The Administrator also stated he paused the smoke break temporarily and R79 signed out AMA on 12/29/21. Interview with the Nurse Consultant, along with the Administrator, Director of Nursing (DON), and Social Worker on 1/18/22 at 6:00 p.m. revealed the facility would not accept the resident back if he wanted to come back. The Nurse Consultant stated the resident was not a good fit for the facility and that he was danger to himself and others. Interview with the Administrator on 1/18/22 at 6:44 p.m. revealed that he didn't know R79's medical history and would not have admitted him if had known about his violence. Regarding R79, the facility got a referral from the hospital, prior history of behaviors was not known. The Administrator stated after admission they learned R79 had been living with his brother in the past and the brother kicked him out due to drug abuse. R79 had been shot multiple times and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review for R79, R13, R19, and R6 from 9/9/21 through 1/20/22 revealed residents were receiving appropriate behavioral health services when indicated.

Based on interviews and record review, the facility failed to accurately assess the Advance Directive status and provide continued Cardiopulmonary Resuscitation (CPR) for one resident (A) and failed to ensure the Advance Directive status was accurately reflected on the physician's orders for two residents (#2 and #3), from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which 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. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. RA experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of Physician's Order to stop resuscitative efforts. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: The facility had a Do Not Resuscitate Policy: Georgia. The policy included that a written list of all residents who have DNR orders would be kept in the front of the current MAR book. The Social Worker (SSD) would be responsible for keeping the list updated. The facility also had a Cardiopulmonary Resuscitation (CPR), one-person policy. The policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's Advance Directive or in the absence of Advance Directives or a DNR order. 1. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The resident had a Physician's Order since at least [DATE] for oxygen to be administered continuously at two liters per minute via nasal cannula. R A was care planned for being at risk for falls, use of a wheelchair for mobility and able to ambulate short distances. A care plan was also in place, dated [DATE], for being at risk for respiratory complications. The care plan problem included that the resident would adjust his own oxygen setting and refuse to wear oxygen at times. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent nurse's note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m. and that the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. However, the DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. There was no evidence that an attempt was made to verify the accuracy of the DNR form maintained in the MAR book and Resident A's Advance Directive status, through a review of his clinical record, prior to the cessation of CPR. During interviews on [DATE] at 4:24 p.m. with Licensed Practical Nurse (LPN) OO and on [DATE] at 7:28 a.m. with LPN PP, both of whom were present and responded to the resident's change in condition on [DATE], both confirmed that they did not look for Advance Directive information in the resident's chart. In addition, there was no evidence that the DHS verified R A's Advance Directive status prior to pronouncing his death on [DATE] at 7:09 a.m. During an interview on [DATE] at 1:45 p.m., the DHS confirmed that she did not verify the resident's Advance Directive status prior to pronouncing his death on [DATE]. During an interview on [DATE] at 11:47 a.m., the Medical Director stated that he would have expected the nurses, including the nurse who pronounced the resident's death, to have look at the resident's clinical record for the Advance Directive status. Review of the State of Georgia, State Office of Vital Records, Pronouncement of Death dated time of death [DATE] at 7:09 a.m. and signed by the DHS. Review of the Georgia Death Certificate Worksheet-Medical Record form revealed the following cause of death, [MEDICAL CONDITION], Chronic [MEDICAL CONDITION] Fibrillation, and Chronic Systolic Heart Failure which was signed by the MD on [DATE]. 2. Resident #2 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form for Adult Patient/Resident With Decision -Making Capacity: Georgia form was signed by Resident #2 on [DATE] and by the physician on [DATE]. However, a review of the clinical record revealed that the Advance Directive status was inaccurately documented on the (MONTH) (YEAR) Physician order for [REDACTED]. 3. Resident #3 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form For Adult Patient/Resident Without Decision-Making Capability With Durable Healthcare Power of Attorney Only: Georgia was completed on [DATE]. However, a review of the clinical record revealed that the Advance Directive status was inaccurately documented on the (MONTH) (YEAR) POF's. The (MONTH) (YEAR) POF documented that the resident's Advance Directive status as Full Code instead of DNR. The (MONTH) (YEAR) POF's were accurate for the DNR status. A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate Advance Directive status. The audit will include Physician's Order, documentation on the Physician's Order Form (POF), documentation on the list in front of the MAR, appropriate signatures from two physicians if the resident is not competent, responsible party signature if the resident is not competent, documentation on the care plan and on the CNA guide. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of advance directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders it stopped. This may be a facility physician, if the CPR was started in error, or the emergency room physician once the ambulance personnel arrive and call the physician. When looking to confirm an advance directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to Quality Assurance Performance Improvement (QAPI) monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to Advanced Directives: On [DATE] the Facility Administrator, Director of Health Services (DHS), Area Vice President (AVP), Senior Nurse Consultant (SNC) and Senior Vice President of Clinical Services (SVPCS) met via telephone conference for immediate QAPI interventions to the cited incident. The Medical Director was notified of the interventions via phone on [DATE] and concurred with initial self-imposed interventions as detailed in the below A[NAME]. DHS called MD to follow-up on [DATE] to provide additional interventions and plan progress. 1. A review of the Do Not Resuscitate Policy: Georgia by the Area Vice President (AVP) and Senior Vice President of Clinical Services (SVPCS) was conducted on [DATE]. A policy revision was recommended to remove A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping this list updated. Policy revision was completed by corporate office and published on [DATE] reflecting removal of the above referenced section. The new policy was reflected in education listed in #3 below. 2. The Social Worker (SSD) was terminated on [DATE] for failing to ensure accuracy of the DNR list per policy. 3. All licensed and certified staff were educated from [DATE] through [DATE] by the DHS and CCC to verify advance directive/code status via the resident's chart. Fourteen of 14 LPN's were educated as of [DATE] (100%), seven of eight RN's were educated as of [DATE] (87.5%). Twenty-nine of 34 active CNA's completed education as of [DATE] (85%). 4. All newly hired licensed and certified staff will be educated during orientation. Licensed and certified staff who have not received this education, due to scheduled vacation, FMLA, or an as-needed work status will not work until this education is completed. 5. All licensed and certified nursing staff were educated from [DATE] through [DATE] to continue CPR (even if in error) until a physician orders it stopped, or the resident becomes responsive. Fourteen of 14 LPNS were educated as of [DATE] (100%), seven of eight RN's were educated as of [DATE] (87.5%), and 29 of 34 active CNA's completed education as of [DATE] (85%). 6. The facility DHS, Nurse Managers and/or Administrator will conduct mock code drills to ensure compliance weekly for four weeks and monthly for two months. Results will be communicated by the DHS at QAPI monthly meetings for three months. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of the facility policy titled Do Not Resuscitate Policy: Georgia by AVP and SVP of Clinical Services dated [DATE], revealed the section A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping the list updated had been removed. 2. Review of the personnel records for the SSD confirmed separation notice dated [DATE]. 3. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that on [DATE], [DATE] and [DATE] that 100% of the RNs, LPNs, and that 29 CNAs had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart, change in condition, nursing runs the code, that once CPR is started then it cannot be stopped without a doctors order and that mock code procedure had been put into place. The facility provided evidence that four mock drills had been conducted by [DATE], with sign-in sheets and evaluation had been completed. The mock codes drills will continue. 4. An interview with the CCC on [DATE] at 1:20 p.m. confirmed that one new staff member had been hired on [DATE] and verified through sign-in sheets that the new staff person had been educated. The CCC confirmed that any new staff, or any staff, not already in-serviced, would be in-serviced on the new policy and procedure for checking the Advanced Directive Status, change in condition, and nursing runs a code and that once CPR is started it cannot be stopped without a doctor's order chart prior to working. 5. An interview with the CCC on [DATE] at 1:20 p.m. verified per review of the sign-in sheets and in-service records that licensed staff and certified staff were educated to continue CPR (even if in error) until they had MD (physician) orders to stop or if the resident becomes responsive. 6. Observation on [DATE] at 11:50 a.m. of a Code Blue being announced in a resident's room over the intercom. Observation of the mock drill in progress by the surveyor revealed that the DHS and Corporate Nurse Consultant were guiding the nurses and CNA's on roles which included: providing CPR and rescue breathing on CPR mannequin, role delegation, step by step instruction on use of AED (Automated External Defibrillator) use, continuation of CPR until mock EMS arrival to take over, notifying the MD, family and charting afterwards. The DHS made a point to clarify that licensed nurse oversees the code, should be in the room with the resident. The mock drill list was reviewed with staff. Staff present ran smoothly through the drill. Review of the Mock Code Drills education checkoff sheet revealed the following: date, time, number of participants (see sign in sheet), nurse in charge on scene, nurse assigned duties, crash cart present and AED utilized and reviewed, scribe assigned and writing, paged code, chart brought to room or reviewed for code status, 911 called, MD and RP called and documented in chart, crash cart restocked and sealed. Record review of Mock Drill form dated [DATE] and interview with the DHS on [DATE] at 1:45 p.m. confirmed the Mock Drills will be conducted weekly for four weeks then monthly for two months. The DHS confirmed that she will present the findings to the QAPI committee monthly. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the Minimum Data Set (MDS) Coordinator revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill.

Based on interviews and record review, the facility administration failed to ensure effective monitoring of the Advance Directive system and failed to ensure staff were trained to respond appropriately during an emergency situation in an effort to prevent errors or delays in emergency resuscitative efforts. The facility had a census of 64 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which 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. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of Physician's Order to stop resuscitative efforts. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: The facility had a Position Description for the job title of Administrator. The description included that the purpose of the job was to direct the day-to-day functions of the nursing center in accordance with Federal, State, and local regulations that govern long-term care centers, and as may be directed by the Area Vice President, to provide appropriate care for residents. The position description also included a key responsibility of the ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. Review of the facility Quality Assurance and Performance Improvement (QAPI) policy revealed a QAPI meeting reference guide documented that the Administrator was responsible for preparing and/or assigning specific information listed in the agenda for the QAPI meeting. During an interview on [DATE] at 12:46 p.m., the Administrator confirmed that she did oversee the QAPI meetings. Review of the facility policy which was in place to address obtaining and maintaining resident Advance Directive documentation in the clinical record via the Do Not Resuscitate Policy: Georgia and Advance Directive: Georgia policy. However, there was no evidence that this system was routinely monitored by the Administrator, to ensure that it was accurately and consistently implemented. Review of the facility policy which was in place for Cardiopulmonary Resuscitation (CPR), one-person policy revealed that the policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directive or in the absence of advance directives or a DNR order. However, there was no evidence that this system was routinely monitored by the administrator, to ensure that, in an emergency situation, nursing staff could response and implement the policy appropriately. Record review for Resident (R) A revealed the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE] per a Nurse's Note dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula, the note documented that the resident returned to his bed then returned to the bathroom and again turned on the call light. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent Nurse's Note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a Medication Administration Record (MAR) record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., Emergency Management Services (EMS) personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m., the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. However, the DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. A telephone interview with the Administrator, Regional Vice President (VP), and the DHS on [DATE] at 11:00 a.m., during review of the A[NAME] with the State Survey Agency (SSA) Regional Director, revealed that the Medical Director had not been involved in the development of the self-imposed IJ plan of action and that a full QAPI committee meeting had not taken place. Additionally, the facility had not reviewed the current Advanced Directive Policy and Procedures as part of the self-imposed IJ action nor had in-services included the CNAs, rather only the licensed nurses had been in-serviced. Therefore, the self-imposed IJ action plan did not remove the IJ. Cross refer to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate Advance Directive status. The audit will include physician's order, documentation on the Physician's Order Form (POF), documentation on the list in front of the MAR, appropriate signatures from two physicians if the resident is not competent, responsible party signature if the resident is not competent, documentation on the care plan and on the CNA guide. The Advance Directive facility checklist will be used to record the audit. New admissions will have their advance directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders it stopped. This may be a facility physician, if the CPR was started in error, or the emergency room physician once the ambulance personnel arrive and call the physician. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and and order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE], nor had a full QAPI meeting taken place prior to the survey entrance to investigate the complaint. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to ensuring the accuracy of Advanced Directives and the Administrator's oversight of this process: 1. The DHS and Senior Nurse Consultant completed an audit of all active resident records on [DATE] and [DATE] utilizing the Advance Directives facility checklist. 2. Review of the Do Not Resuscitate Policy: Georgia by the Area Vice President (AVP) and Senior Vice President of Clinical Services (SVPCS) completed on [DATE]. Policy revision recommended to remove A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping this list updated. The policy was revised and published on [DATE] to include removal of the above referenced section. 3. The Social Worker (SSD) was terminated on [DATE] for failing to ensure accuracy of DNR list per policy. 4. The Advance Directive Clinical system checklist will be updated upon each new admission or change in advance directive orders by the DHS, Unit Manager or Social Worker (SSD). 5. The Administrator will review the Advance Directive clinical checklist in the QAPI meetings monthly for three months and quarterly thereafter. 6. The Administrator was educated on [DATE] by the AVP on the Administrator job description and responsibilities. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of audit list dated [DATE] and [DATE] confirmed that all active residents medical record were audited utilizing the Advanced Directives facility check list. 2. A review of the Do Not Resuscitate Policy: Georgia by the Area Vice President (AVP) and Senior Vice President of Clinical Services (SVPCS) was conducted on [DATE]. A policy revision was recommended to remove A written list of all patients/residents who have DNR order will be kept in the front of the current MAR book. The Social Worker (SSD) will be responsible for keeping this list updated. Policy revision was completed by corporate office and published on [DATE] reflecting removal of the above referenced section. 3. Review of the personnel records for the SSD confirmed separation notice dated [DATE]. 4. A interview with the DHS on [DATE] at 1:45 p.m. and the Unit Manager, RN FF on [DATE] at 3:45 p.m. revealed the DHS provided evidence that new Physician's Orders and that new admission orders [REDACTED]. Review of the Advanced Directives Clinical system checklist was reviewed on [DATE]. 5. An interview and review of the Advanced Directive Checklist on [DATE] at 12:46 p.m. revealed the Administrator is responsible for review of the checklist and to present the findings to the QAPI meeting monthly for three months then quarterly thereafter. 6. Review of the description with acknowledgment page for the Administrator signed and dated [DATE]. An interview with the AVP on [DATE] at 12:46 p.m. confirmed that he had reviewed the Administrator's job description and responsibilities with the Administrator on [DATE]. An interview with the Administrator on [DATE] at 12:46 p.m. revealed that the DNR policy was reviewed and revised by an ad hoc QAPI committee which including the Medical Director. She confirmed that the Area Vice President (AVP) had reviewed and in-serviced the Administrator on her job description and duties. The Administrator will oversee the A[NAME] plan. She confirmed the SSD and that Licensed Practical Nurse (LPN) OO have been terminated.

Based on interview, record review, and review of the Quality Assurance and Performance Improvement policy, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) system to oversee the Advance Directive system and ensure staff were trained to respond appropriately during an emergency situation in an effort to prevent errors or delays in emergency resuscitative efforts. The facility had a census of 64 residents. An Abbreviated/Partial Extended Survey to investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which 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. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI), F868, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: Review of the facility Quality Assurance and Performance Improvement policy, which was in place, revealed that the policy documented that the purpose of the QAPI program was to continually take a proactive approach to assure and improve the way the facility provided care and engaged with patients, partners, and other stakeholders so that the facility may fully realize their vision, mission, and commitment to caring pledge. The facility's QAPI committee included the Administrator, Medical Director, Director of Health Services (DHS), Clinical Competency Coordinator (CCC), West Wing Unit Manager, Therapy, Admissions, East Wing Unit Manager, Social Services Director (SSD), Activities Director, Business Manager, Maintenance Director, Medical Records Director, Skin Integrity Registerd Nurse (RN), Minimum Data Set (MDS) Coordinator, Dietary Services, Environmental Services and Central Supply/Transportation. The QAPI committee met monthly, at the end of the month. The facility had a system in place to address obtaining and maintaining resident Advance Directive documentation in the clinical record via the Do Not Resuscitate Policy: Georgia and Advance Directive: Georgia policy. However, there was no evidence that this system was routinely monitored through the QAPI process, to ensure that it was accurately and consistently implemented. Review of the facility Cardiopulmonary Resuscitation (CPR), one-person policy, which was in place, revealed that the policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directive or in the absence of advance directives or a DNR order. However, there was no evidence that this system was routinely monitored through the QAPI process, to ensure that, in an emergency situation, nursing staff could respond and implement the policy appropriately. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent Nurse's Note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entries document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m., the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. However, the DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. Cross refer to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate Advance Directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a Physician orders [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. A telephone interview with the Administrator, Regional V.P., and the DHS on [DATE] at 11:00 a.m., during review of the A[NAME] with the State Survey Agency Regional Director, revealed that the Medical Director had not been involved in the development of the self-imposed IJ plan of action and that a full QAPI committee meeting had not taken place. Additionally, the facility had not reviewed the current Advanced Directive Policy and Procedures as part of the self-imposed IJ action nor had in-services included the CNAs, rather only the licensed nurses had been in-serviced. An interview on [DATE] at 11:47 a.m., the Medical Director stated that he would have expected the nurses, including the nurse who pronounced the resident's death, to have look at the resident's clinical record for the Advance Directive status. He further revealed that he had not been involved in developing the facility's self-imposed IJ plan but was involved and approved the facility's A[NAME] plan. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to QAPI: Facility failed to educate all licensed staff according to the self-imposed plan of correction initiated on [DATE]. Facility failed to audit the Advance Directive system for compliance using the Advanced Directive clinical system checklist. 1. On [DATE] the Administrator, DHS, Area Vice President (AVP), Senior Nurse Consultant (SNC) and Senior Vice President of Clinical Services (SVPCS) met via telephone conference for an ad hoc QAPI meeting to establish interventions for the cited incident. The Medical Director was also called by the DHS on [DATE] and communicated the interventions included in this Allegation of Compliance (A[NAME]). The Medical Director concurred with interventions listed in the A[NAME]. 2. Review of active staff listing was completed to ensure accuracy. Terminated employees will be removed and/or identified on the active staff listing. 3. Newly hired licensed and certified staff will be provided with the education prescribed in the self-imposed plan of correction ([DATE]) will be completed with all licensed and certified staff prior to working, by the CCC or DHS. Completion percentages are noted in each section of the A[NAME]. 4. Newly hired licensed and certified staff will be provided with the education prescribed in the self-imposed plan of correction upon orientation. 5. DHS and Senior Nurse consultant completed and audit of all active resident records on [DATE] and [DATE] utilizing the Advance Directive facility checklist. 6. The Advance Directive Clinical System checklist will be updated upon each new admission or change in advance directive orders by the DHS, Unit Manager, or Social Worker (SSD). 7. Education compliance related to F580, F656, F726, F835 and F868 will be reported to QAPI by the CCC monthly for three months and quarterly thereafter as needed. The Administrator is specified as the staff person responsible for implementing the acceptable plan of correction. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. During an interview and record review with the Administrator on [DATE] at 12:46 p.m. confirmed by reviewing emails and meeting signatures dated [DATE] which included the Medical Director's signature that he had approved the A[NAME]. 2. On [DATE] review of the revised active list of employees to verify the correct number of RNs, Licensed Practical Nurses (LPNs) and CNAs have been educated on the new policies and procedures for verifying Advanced Directives and updating with any change in Physician Order, Code process and procedure, use of the Automated External Defibrillator (AED), and care planning. 3. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that as of [DATE] that RNs, LPNs, and CNAs had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart. 4. An interview with the CCC on [DATE] at 12:01 p.m. and the DHS on [DATE] at 1:45 p.m. revealed that both had been educated by the SNC regarding MD notification policy for change of condition on [DATE] and on [DATE]. Review of the sign in sheets confirm the in-services. Verification of sign in sheets for Licensed Nurses confirmed that on [DATE], 20 licensed nursed had completed the in-service on Change of Condition with one nurse on [DATE]. 5. Record review and an interview with the DHS on [DATE] at 1:45 p.m. of the Advance Directives facility checklist dated [DATE] and [DATE] confirmed that all active resident's records had been reviewed to ensure that their Advance Directives were correct. 6. An interview with the DHS on [DATE] at 1:45 p.m. revealed that she currently responsible for updating any new admissions or residents with a change in their Advanced Directives until the new Social Worker (SSD) is hired and educated on the process. 7. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that as of [DATE] that RNs (87.5%), LPNs (100%), and CNAs (88%) had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart, care plan updates, new resident or change in condition reporting, new Advance Directive Policy, responsibilities during a code and use of the Automated External Defibrillator (AED). Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the MDS Coordinator revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed participating in a Mock Code Drill.

Based on interviews and record review, review of the Georgia Board of Nursing Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurses, review of the Standards of Practice for Registered Professional Nurses: ,[DATE]-.01, the facility failed to provide adequate supervision of certified nursing staff regarding the initiation and cessation of cardiopulmonary resuscitation (CPR) during an emergency situation for one resident (A), from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which 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. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: Review of the Georgia Board of Nursing Rule ,[DATE]-.02: Standards of Practice for Licensed Practical Nurses, 1) The practice of license practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not limited to the following: e) Participating in the management and supervision of unlicensed personnel in the delivery of patient care. Review of the Georgia Board of Nursing ,[DATE]-.01: Standards of Practice for Registered Nurses, 2. (a) 3. Plan care which includes goals and prioritized nursing approaches, or measures derived from the nursing diagnoses; (b) 3. Communicate, collaborate and function with other members of the health team to provide optimum care; 8. Assign and supervise only those nursing measures which the nurse knows, or should know, that another person is prepared, qualified, or licensed to perform; 9. Retain professional accountability for nursing care when delegating nursing intervention. The facility had a Do Not Resuscitate Policy: Georgia policy. The policy documented that CPR will be performed on all residents without a DNR order unless it is determined that CPR is not medically justified as determined by two nursing personnel, one of whom must be licensed. Not medically justified is defined to mean that when all of the conditions listed below are true, CPR will not be initiated, even if the resident does not have a DNR order documented on the chart, until the physician is notified, and orders are given to administer CPR. 1. Resident was found with no visible respiratory efforts 2. Resident was found with no vital signs 3. Resident was found unresponsive to verbal or painful stimulation. 4. Resident was found with fixed, dilated, and non-reactive pupils. 5. Resident was found with skin cold to touch. 6. Resident's decline in condition is sudden and not witnessed, and the resident is found without any signs of life. The facility also had a Cardiopulmonary Resuscitation (CPR), one-person policy. The policy documented that the facility provided basic life support, including initiation of CPR, to any resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's Advance Directive or in the absence of Advance Directives or a DNR order. The policy included to administer 30 chest compressions at a rate of 100 to 120 per minute. Push hard and fast. Open the airway and give 2 ventilations. Then find the proper hand position again and deliver 30 more compressions. Continue chest compressions until the emergency response team arrives or another rescuer arrives with a defibrillator or an automated external defibrillator (AED). Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The resident had a physician's orders [REDACTED]. R A was care planned for being at risk for falls, use of a wheelchair for mobility and able to ambulate short distances. A care plan was also in place, dated [DATE], for being at risk for respiratory complications. The care plan problem included that the resident would adjust his own oxygen setting and refuse to wear oxygen at times. During an interview on [DATE] at 12:07 p.m., a family member of R A stated that the resident was a full code and wanted to know why the resident was not sent to the hospital on [DATE]. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent nurse's note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., Emergency Management Services (EMS) personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's Note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m. and that the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. During an interview on [DATE] at 11:37 a.m., CNA HHH stated that R A could get up on his own and would normally get up on his own and then call for assistance with his oxygen. On [DATE] around 5:00 a.m., she responded to the resident's call light. The resident was in the bathroom and said he needed his oxygen, so she applied is oxygen tubing and exited the bathroom. She stated that the resident did not complain of shortness of breath. She responded to his call light a second time when she noticed it on, above his door, when she exited another resident's room. R A was lying in the bed and stated that he had wanted some assistance with pulling up his pants but had already pulled them up and was in the bed. CNA HHH stated that the resident had his oxygen on, did not complain of any shortness of breath and she left the room. CNA HHH stated a little later she responded to his call light a third time. He was in bathroom again, on the commode, and said he needed his oxygen, so she applied his oxygen tubing. She stated that he did not complain of any shortness of breath and that she reminded him that his oxygen tubing would reach into the bathroom, that he did not have to take it off when he went to the bathroom. CNA HHH stated that she exited the room and not even five minutes later, R A turned his call light on again. She went back into the bathroom and observed him lying on the floor beside the toilet, asking for help to get up. CNA HHH stated that she noticed at that time that his right arm was a grayish color and that was different for R A. She stated that she left the resident's room to get Licensed Practical Nurse (LPN) OO. Additional help was also obtained from CNA QQ. CNA HHH stated that the resident remained alert but then became quiet while they were attempting to remove the resident from between the commode and the wall and he was unresponsive when they were able to get him out. CNA HHH stated that LPN OO instructed her to call the code so she left the room to call the code and obtain the crash cart. CNA HHH stated that when she returned to the room LPN OO was trying to obtain vital signs on the resident but there were none, so she (CNA HHH) initiated chest compressions on R A, and that LPN OO left the room to call the code again because LPN PP had not heard the first call, although LPN OO did not return to the resident's room. CNA HHH stated that she continued to provide chest compressions until she overheard LPN PP, who had arrived on the unit, state that the resident was a DNR, and then she stopped providing chest compressions. CNA HHH stated that she did not receive any supervision, guidance or instructions from the LPN's on initiating or stopping CPR. CNA HHH stated that she was not aware that once she started CPR, she could not just stop. The DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. Nurse's Note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled. During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. There was no evidence that R A's condition met the criteria of not medically justified, as documented in the facility's Do Not Resuscitate Policy. There was also no evidence that an attempt was made to assess R A's Advance Directive status prior to CNA HHH initiating CPR and no evidence that supervision and guidance was provided to the CNA by the LPN's regarding initiating and cessation of CPR. In addition, facility staff failed to continue to provide continued chest compressions until EMS arrived, as documented in the facility's CPR, one-person policy. There was no evidence that an attempt was made to verify the accuracy of the DNR form maintained in the MAR book and Resident A's Advance Directive status, through a review of his clinical record, prior to the cessation of CPR. During interviews on [DATE] at 4:24 p.m. with Licensed Practical Nurse (LPN) OO and on [DATE] at 7:28 a.m. with LPN PP, both of whom were present and responded to the resident's change in condition on [DATE], both confirmed that they did not look for Advance Directive information in the resident's chart and neither instructed CNA HHH to begin or stop CPR. In addition, there was no evidence that the DHS verified R A's Advance Directive status prior to pronouncing his death on [DATE] at 7:09 a.m. During an interview on [DATE] at 1:45 p.m., the DHS confirmed that she did not verify the resident's Advance Directive status prior to pronouncing his death on [DATE]. During an interview on [DATE] at 11:47 a.m., the Medical Director stated that he would have expected the nurses, including the nurse who pronounced the resident's death, to have look at the resident's clinical record for the Advance Directive status. Cross refer to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: A facility investigation was initiated on [DATE] and the following concerns were identified: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate advance directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a Physician order [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy per the A[NAME] dated [DATE] related to competency of staff: The facility failed to ensure that all licensed staff were competent regarding the protocol for CPR. The LPN failed to supervise certified staff members during CPR. LPN exited the room where certified staff were performing CPR to page for additional nursing staff, review the DNR listing in the Medication Administration book and call 911 and failed to return. 1. LPN OO will be terminated on [DATE] 2. Licensed and certified staff were educated by the DHS and Clinical Care Coordinator (CCC) from [DATE] through [DATE] including one newly hired staff on [DATE], on Do Not Resuscitate Policy: Georgia and Advance Directives: Georgia. Fourteen of 14 LPN's were educated as of [DATE] (100%), seven of eight RN's (87.5%) were educated as of [DATE], and 29 of 34 active CNA's completed education as of [DATE] (85%). 3. All newly hired licensed and certified staff will be educated during orientation. Licensed and certified staff who have not received this education, due to scheduled vacation, FMLA, and as-needed work status will not work until this education is completed. 4. The facility DHS, Nurse managers and/or Administrator will conduct mock code drills including AED function/usage, and the supervisory role of the nurse during the code, weekly for four weeks and monthly for two months. The results will be communicated by the DHS or Administrator at QAPI monthly for three months. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Record review of the personnel file for LPN OO on [DATE] confirmed a separation noticed dated [DATE]. 2. Review of the in-service sign in sheets with the CCC on [DATE] at 1:20 p.m. revealed that on [DATE], [DATE] and [DATE] that 100 % of the RNs, LPNs, and that 29 CNAs had been in-serviced on the new policy and procedures to verify code status of residents via the resident's chart, change in condition, nursing runs the code, that once CPR is started then it cannot be stopped without a doctors order and that mock code procedure had been put into place. The facility provided evidence that four mock drills had been conducted by [DATE], with sign-in sheets and evaluation had been completed. The mock codes drills will continue. 3. An interview with the CCC on [DATE] at 1:20 p.m. confirmed that one new staff member had been hired on [DATE] and verified through sign-in sheets that the new staff person had been educated. The CCC confirmed that any new staff, or any staff, not already in-serviced, would be in-serviced on the new policy and procedure for checking the Advanced Directive Status, change in condition, and nursing runs a code and that once CPR is started it cannot be stopped without a doctor's order chart prior to working. 4. Observation on [DATE] at 11:50 a.m. of a Code Blue being announced in a resident's room over the intercom. Observation of the mock drill in progress by the surveyor revealed that the DHS and Corporate Nurse Consultant were guiding the nurses and CNA's on roles which included: providing CPR and rescue breathing on CPR mannequin, role delegation, step by step instruction on use of AED (Automated External Defibrillator) use, continuation of CPR until mock EMS arrival to take over, notifying the MD, family and charting afterwards. The DHS made a point to clarify that licensed nurse oversees the code, should be in the room with the resident. The mock drill list was reviewed with staff. Staff present ran smoothly through the drill. Review of the Mock Code Drills education checkoff sheet revealed the following: date, time, number of participants (see sign in sheet), nurse in charge on scene, nurse assigned duties, crash cart present and AED utilized and reviewed, scribe assigned and writing, paged code, chart brought to room or reviewed for code status, 911 called, MD and RP called and documented in chart, crash cart restocked and sealed. Record review of Mock Drill form dated [DATE] and interview with the DHS on [DATE] at 1:45 p.m. confirmed the Mock Drills will be conducted weekly for four weeks then monthly for two months. The DHS confirmed that she will present the findings to the QAPI committee monthly. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the Minimum Data Set (MDS) Coordinator revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They confirmed knowledge that the licensed nurse oversees the code and should not leave the room during the code. They confirmed participating in a Mock Code Drill. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in in-services on the new policy and procedures for verifying a resident's Advance Directive via the resident's chart, not to discontinue CPR once started even if in error, and the process for conducting a code and roles during the code. They were aware that the licensed nurse is in charge of the code and should give direction to them during the code. They confirmed participating in a Mock Code Drill.

Based on interviews and record review, the facility failed to develop a care plan for the advance directive status for four residents (A, #2, #3, and #15) from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which 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. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F868, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the advance directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: 1. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. However, the resident's Advance Directive status was not included in his care plan. R A experienced a change in condition on [DATE]. A Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent Nurse's Note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m. and that the physician was notified at 7:15 a.m. and the resident's responsible party at 7:20 a.m. The DNR status that was documented on the MAR record, referenced in the [DATE] 5:40 a.m. nurse's note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an advance directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. However, there was no evidence in the clinical record that a care plan was developed to include the resident's Advance Directive status on admission or during the care plan updated on [DATE]. During an interview on [DATE] at 11:30 a.m., the Minimum Data Set (MDS) Coordinator stated that prior to [DATE] that only the DNR Advance Directive Status had been added to residents' care plans but now all residents have their advance directive status (Full code or DNR) included in the care plan. She confirmed that R A care plan did not include the Advance Directive Status. Cross refer to F678 2. R #2 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form for Adult Patient/Resident With Decision -Making Capacity: Georgia form was signed by resident #2 on [DATE] and by the physician on [DATE]. However, there was no evidence in the clinical record that a care plan was developed to include the resident's initial Advance Directive status on admission or new advance directive status of DNR in (MONTH) (YEAR). Cross refer to F678 3. R #3 was admitted to the facility on [DATE]. An Advance Directives Checklist form was completed on [DATE] and documented that the resident had not executed an Advance Directive at that time. The resident's Advance Directive status changed when a Physician's DNR Order Form For Adult Patient/Resident Without Decision-Making Capability With Durable Healthcare Power of Attorney Only: Georgia was completed on [DATE]. However, there was no evidence in the clinical record that a care plan was developed to include the resident's initial advance directive status or new advance directive of DNR in (MONTH) (YEAR). Cross refer to F678 4. R#15 was admitted to the facility on [DATE]. A Physician order [REDACTED]. A review of the clinical record revealed no evidence that the resident's DNR status had been included in the care plan. Cross Refer to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate Advance Directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of advance directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for advance directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. The facility conducted an Advance Directive audit on [DATE] of all residents' Advance Directives information. The audit included reviewing the care plan for the inclusion of DNR status. A review of the audit tool dated [DATE] revealed that R#15 was identified as not having a care plan in place for the DNR status. However, there was no evidence in the clinical record that a care plan was developed to address R#15's DNR status, until after surveyor inquiry on [DATE]. During an interview on [DATE] at 12:16 p.m., the DHS confirmed that a care plan for R#15's Advance Directive status had not been developed until after surveyor inquiry on [DATE]. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy related to Advanced Directive care plans: 1. MDS Nurse, DHS and Senior Nurse Consultant Completed an audit of all resident care plans to ensure correct code status on care plan on [DATE]. MDS Nurse completed an audit of resident care plans on [DATE] for residents with DNR Advance Directives. 2. Any care plans identified were corrected and placed on the chart. Two (2) Residents with no care plan for DNR Advanced Directive care plan. Those care plans were printed and placed on the chart on [DATE]. All Active residents will have a care plan indicating Advanced Directive/Code Status. (sic) 3. Care Plan Coordinator/MDS Nurse educated by CCC on [DATE] to initiate Advanced Directives/DNR Care Plan once an order is received. 4. The DHS and or Unit Manager will monitor this process in clinical stand-up by reviewing all new orders and assuring any DNR orders are carried through to the care plan. This process will be documented on the Advance Directives Checklist by the DHS or Unit Manager. 5. Findings will be reported in QAPI by the DHS or Unit manager x3 months, The State Survey Agency (SSA) validated the corrective actions taken by the facility as of [DATE] as follows: 1. An interview with the DHS on [DATE] at 1:45 p.m. and the MDS Coordinator at revealed they had audited all resident care plans to ensure correct code status. Record review of audit list/spread for all resident's care plan was reviewed and completed. 2. Review of the resident's care plans were reviewed to ensure the correct Advanced Directives were in place utilizing audit/spread sheet. An interview with the MDS Coordinator on [DATE] at 11:30 a.m. verified the process of audit has been completed. 3. Record review of in-service sign in sheet verified the MDS Coordinator had been in-serviced on developing an Advanced Directive care plan once a physician's orders [REDACTED]. 4. A interview with the DHS on [DATE] at 1:45 p.m. and the Unit Manager, RN FF on [DATE] at 3:45 p.m. revealed the DHS provided evidence that new physician's orders [REDACTED]. This process was confirmed by the RN FF. 5. Review of the QAPI process revealed that the Audit findings will be presented to the QAPI meeting monthly by either the DHS or Unit Manager, RN FF. This process was confirmed by interview with the DHS and Unit Manager, RN FF on the dates and times listed in #4. An interview on [DATE] at 1:45 p.m. with the DHS revealed that she had participated in in-services related to Advance Directives and having the correct information on each resident's care plan and updating as changes are made by residents or the responsible party. She is overseeing that the MDS Coordinator has reviewed all care plans against the Advance Directives for each resident and that any changes to the Advance Directive is updated timely. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the MDS Coordinator revealed they had all participated in in-services regarding care planning of Advanced Directives and were knowledgeable of the process. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed they had participated in in-services related to care plans for Advanced Directives.

Based on interviews and record review, the facility failed to notify the physician and responsible party in a timely manner, of a change in condition for one resident (A) from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which 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. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's advance directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS was not aware the resident's Advanced Directive status was inaccurate until notified by the family later in the morning of [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F656; 42 CFR 483.24 Quality of Life, F678; 42 CFR 483.35 Nursing Services, F726; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI), F868, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.24 Quality of Life, F678. A Credible Allegation of Compliance was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the Advance Directive system and continued education. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials, policies and records were reviewed. Observation, record review and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: The facility had a Change in Condition policy: When to report to the MD/NP/PA guidance. The form documented that immediate notification should be made of any symptom, sign or apparent discomfort that is acute or sudden in onset and is a marked change in relation to usual symptoms and signs or is unrelieved by measures already prescribed. Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the Advance Directives Checklist form, dated [DATE], revealed that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The resident had a physician's orders [REDACTED]. R A was care planned for being at risk for falls, use of a wheelchair for mobility and able to ambulate short distances. A care plan was also in place, dated [DATE], for being at risk for respiratory complications. The care plan problem included that the resident would adjust his own oxygen setting and refuse to wear oxygen at times. R A experienced a change in condition on [DATE]. Review of a Nurse's Note, dated [DATE] at 5:15 a.m., documented that a Certified Nursing Assistant (CNA) reported that the resident complained of shortness of breath and was sitting on the commode in the bathroom, not wearing his oxygen. The CNA applied the resident's oxygen nasal cannula and the resident returned to bed. The note further documented that the CNA reported that the resident returned to the bathroom and pressed the call light again. The resident again complained of shortness of breath and was not wearing his oxygen. The note continued to document that the CNA replaced his oxygen and exited the bathroom. A subsequent Nurse's Note on [DATE] at 5:20 a.m., documented that the resident was observed on the floor, in the bathroom, between the commode and the wall. The resident stated he could not get up. The note further documented that the resident was moved, by staff, from between the wall and commode and into his room and became unresponsive. The note continued to document that CPR was initiated and an oxygen saturation level and carotid pulse were unable to be obtained. At 5:30 a.m., 911 was notified and an ambulance dispatched while CPR continued to be performed. A 5:40 a.m. Nurse Note entry documented that a MAR record review indicated that the resident was a DNR and CPR was discontinued at that time. At 5:45 a.m., the DHS was notified that R A had expired and at 5:50 a.m., EMS personnel arrived and were notified that the resident was a DNR, therefore they left the facility. Nurse's note entry document that the DHS arrived and pronounced the resident as deceased at 7:09 a.m., notified the physician at 7:15 a.m., and the resident's responsible party at 7:20 a.m. The DNR status that was documented on the MAR record, referenced in the [DATE] at 5:40 a.m. nurse's note entry, was not accurate and was not consistent with the Advance Directives Checklist form that documented that the resident had not executed an Advance Directive. A review of the facility investigation, initiated on [DATE], revealed that the DNR list that was included at the front of the MAR book had been incorrectly labeled by the former Social Service Director (SSD). During an interview on [DATE] at 11:08 a.m., the former SSD, who came into the facility for the interview, confirmed that the DNR list was an error and should have been labeled as the behavior management list. Review of the form used on [DATE] by Licensed Nursing Staff, revealed DNR dated [DATE] with two residents listed, including R A. There was no evidence that licensed nursing staff notified the physician or responsible party timely, of the resident's sudden change in condition, notification of EMS personnel, and initiation and cessation of CPR prior to EMS arrival and departure. During interviews on [DATE] at 1:45 p.m. and [DATE] at 12:46 p.m., the DHS confirmed that she notified the physician and R A's responsible party of his death, after she arrived at the facility. She further stated that when she notified them of the resident's death, she was unaware of the events that had occurred because they had not been reported to her. She stated that she did not become aware of the events that had occurred until Licensed Practical Nurse (LPN) UU entered the 9:30 a.m. morning meeting, on [DATE], and notified all staff, that were present, that R A's family member had called the facility stating the resident was a full code and inquiring about EMS. During an interview on [DATE] at 11:47 a.m., with the physician, he stated that licensed nursing staff did not call him when he would have expected them to call him, which is when the resident's condition is changing. He stated that the call from the DHS was the first call he received regarding R A. Cross reference to F678 A facility investigation was initiated on [DATE] and the following concerns were identified and evidenced through review of Nurse Consultant email dated [DATE] stating Eastside will proceed with a self-imposed jeopardy for the following: 1. Failure to notify the resident's responsible party of a change in condition timely. 2. Failure to continue CPR once started, without a stop order from the physician. 3. Failure to have accurate DNR lists in the front of the MAR. The facility implemented the following actions to address their identified concerns: 1. A complete audit of all residents' charts to confirm the accurate advance directive status. The audit will include physician's orders [REDACTED]. The Advance Directive facility checklist will be used to record the audit. New admissions will have their Advance Directive status verified and documented on admission. New admissions will be verified for accuracy by the DHS or Clinical Care Coordinator (CCC). New admissions will be added to the audit tool and continued until substantial compliance is maintained for three months. Issues identified as a result of the audits will be corrected immediately. 2. Education provided to the Social Worker (SSD) related to the importance of accuracy of Advance Directive status and completeness of all required paperwork including the list of DNR's in front of the MAR. 3. Education to Registered Nurses (RN) that will be on-call to pronounce, that will include coming to the facility immediately even if they are told the resident was a DNR. 4. Education to nurses regarding once CPR is started (even if in error), it cannot be stopped unless a physician orders [REDACTED]. When looking to confirm an Advance Directive status during an emergency, the chart must be opened and reviewed; looking for Advance Directive paperwork and an order on the POF. Never rely on the list in front of the MAR. 5. These audits and education pieces will be brought to daily stand-up meetings and reviewed by the Administrator. Results will be brought to QAPI monthly for three months or until substantial compliance is obtained for three months. Review of the facility's implementation of action related to the self-imposed jeopardy that record review revealed the actions were incomplete, and that residents were still at risk including: Care plans did not accurately reflect Advanced Directives, the survey team identified a resident who had no Advance Directive Sheet in their record and that only Licensed Nurses had been educated. An interview on [DATE] at 3:30 p.m. with the Administrator and the DHS revealed that the facility Policy and procedure titled Do Not Resuscitate Policy had not been reviewed or updated as of [DATE]. Therefore, this action did not remove the IJ related to accuracy or documentation of Advance Directives. The facility implemented the following actions to remove the Immediate Jeopardy related to notification: The facility failed to notify the physician upon change of condition for Resident A. The facility failed to notify the MD at the time of the incident because the LPN incorrectly identified that the resident was a DNR. The system that failed was the DNR system, The Social Worker (SSD) provided a DNR listing that was not accurate and the LPN failed to verify the code status in the resident chart. Although the DNR listing was found to be incorrect, the LPN failed to notify the MD at the time that Resident A had a change of condition. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1. The CCC and DHS were educated by the SNC on [DATE] on MD notification policy for change of condition. CCC and DHS educated active licensed staff of MD notification policy for change of condition on [DATE] and [DATE]. ,[DATE] LPNs have received education as of [DATE] (92%), ,[DATE] RNs completed as of [DATE] (87.5%). 2. Certified staff were educated on [DATE] to report change of condition to Nurse by the Administrator and DHS. ,[DATE] active CNAs completed education as of [DATE] (85%). 3. All newly hired licensed and certified staff will be educated on this policy upon orientation. Licensed and certified staff who have not received this education, due to scheduled vacation, FMLA or PRN (as needed) status will not work until education is completed. 4. 24 hr reports will be reviewed daily x2 weeks by the DHS or Registered Nurse (RN) on call for change of condition to ensure MD notification conducted as required. Findings will be reported by the DHS in the QAPI meeting monthly x3 months. The State Survey Agency (SSA) validated the corrective actions taken by the facility as of [DATE] as follows: 1. An interview with the CCC on [DATE] at 12:01 p.m. and the DHS on [DATE] at 1:45 p.m. revealed that both had been educated by the SNC regarding MD notification policy for change of condition on [DATE] and on [DATE]. Review of the sign in sheets confirm the in-services. Verification of sign in sheets for Licensed Nurses confirmed that on [DATE], 20 licensed nursed had completed the in-service on Change of Condition with one nurse on [DATE]. 2. Review of the CNA sign-in sheets on Notification of Change revealed that on [DATE] and [DATE] that 30 of 34 CNA's had been in-serviced. 3. A interview with the CCC on [DATE] at 1:20 p.m. revealed the facility had one new hire, who was educated on [DATE]. Any staff returning to work or new hire must have the in-services prior to working with residents. 4. Review of the 24-hour report revealed these are reviewed by the DHS and signed as reviewed by the DHS. Interviews were conducted with Licensed Practical Nurses (LPN) and Registered Nurses (RN) on [DATE] at 2:15 p.m. with LPN TT and LPN BB, [DATE] at 2:25 p.m. with LPN EEE and LPN UU, [DATE] at 3:45 p.m. with RN FF and LPN KK, [DATE] at 4:00 p.m. with LPN HH, [DATE] at 11:18 a.m. with LPN MM and on [DATE] at 11:30 a.m. with LPN LLL, the Minimum Data Set (MDS) Coordinator revealed they had all be recently in-serviced on the policy and procedure for notifying the physician if a change in condition should occur, their role in the notification process in a timely manner. Interviews were conducted with Certified Nursing Assistants (CNA) on [DATE] at 2:04 p.m. with CNA XX and CNA ZZ, [DATE] at 2:10 p.m. with CNA GG and CNA VV, [DATE] at 2:35 p.m. with CNA DD and CNA YY, [DATE] at 2:39 p.m. with CNA WW and CNA II, [DATE] at 3:35 p.m. with CNA DDD, [DATE] at 3:40 p.m. with CNA JJ and CNA CCC, [DATE] at 4:00 p.m. with CNA BBB, and [DATE] at 4:05 p.m. with CNA AAA revealed that they had participated in an in-service which included notification and their role in this process.

Based on clinical record review and staff interview, the facility failed to develop a comprehensive Care Plan having interventions which ensured pressure relief to prevent development of a heel pressure ulcer for one (1) resident (# 32), who had a history of [REDACTED]. Resident #32 subsequently developed a pressure sore of the left heel which was unstageable, measuring 3.7 centimeters (cms) by 3.7 cms by Unable to Determine (UTD) Findings include: Record review for Resident #32 revealed an Admission Pressure Assessment (APA) dated 06/25/2012 which documented facility admission on that date, and documented that the resident did not have any open skin areas at the time of admission, but did have scar tissue to the left heel indicating previous ulceration. Resident #32's Minimum Data Set (MDS) of 07/01/2013 documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]., [MEDICAL CONDITION] and [MEDICAL CONDITION]. Section M - Skin Conditions of this 07/01/2013 MDS, and also of a subsequent 12/18/2013 MDS, continued to document that Resident #32 had no unhealed pressure ulcers, but was at risk of developing pressure ulcers. Review of Resident #32's comprehensive Care Plan revealed an identified Problem, originally dated 06/25/2012, which identified that the resident was at risk for skin breakdown related to both bowel and bladder incontinence and requiring the total assistance of staff for Activities of Daily Living care. This Care Plan identified multiple Current Approaches related to Resident #32's risk of pressure ulcer development, including such Approaches as showering the resident per the facility schedule, the provision of incontinence care every two hours and as needed, and assisting the resident with eating as needed. However, further review of Resident #32's Care Plan revealed that, despite Resident #32 having a history of previous ulceration as identified on the 06/25/2012 APA referenced above, and having a continued risk for pressure ulcer development as indicated in the 07/01/2013 and 12/18/2013 MDS assessments referenced above, there was no evidence to indicate that the facility had developed any interventions or Approaches, during the original formulation of or subsequent updates to the comprehensive Care Plan, which addressed Resident #32's risk of heel pressure ulcer development, or which provided pressure relief to the resident's heels. A Nurses Progress Notes entry dated 01/01/2014 documented that Resident #32 was noted by the nurse to have a dark, boggy area to the left heel, and that a physician's orders [REDACTED]. A Treatment Progress Notes (TPN) of 01/02/2014 documented the pressure sore to Resident #32's left heel, describing the pressure sore as maroon in color, unstageable, and measuring 3.7 centimeters (cms) by 3.7 cms by Unable to Determine (UTD). This TPN documented the physician ordered to add a roll gauze to the heel pressure sore. During interview on 01/17/2014 at 10:30 a.m., the Treatment Nurse acknowledged that the facility had not developed interventions to provide pressure relief to Resident #32's heel prior to the development of the left heel ulcer. Cross refer to F314 for more information regarding Resident #32.

Based on observation, record review, facility Policy And Procedure For Shower Documentation review, Shower Documentation form review, and staff interview, the facility failed to provide care and services to promote the prevention of pressure sore development for one (1) resident (# 32), who was identified as high risk for developing pressure ulcers and dependent on staff for care, from a survey sample of thirty-four (34) residents. This resulted in Resident #32 developing a pressure sore of the left heel, which was maroon in color and unstageable, measuring 3.7 centimeters (cms) by 3.7 cms by Unable to Determine (UTD). Findings include: Review of the facility Policy And Procedure For Shower Documentation revealed that shower aides were to report any reddened or broken areas, skin tears or bruises noted on residents' skin to the charge nurse. During interview with the Licensed Practical Nurse (LPN) Treatment Nurse conducted on 01/14/2014 at 9:00 a.m., this nurse acknowledged that resident skin assessments for residents were completed three (3) times weekly by Certified Nursing Assistants (CNAs) on shower days, and if any areas were observed, the LPN was to be notified. During a post-survey interview with the Treatment Nurse, conducted on 1/27/14 at 10:30 a.m. during the Quality Assurance review, this nurse stated that licensed staff did not do skin assessments on the residents routinely, even when residents were known to be high risk for development of pressure ulcers, and further stated that professional staff depended on the shower aides to assess residents' skin three (3) times a week during showers. Record review for Resident #32 revealed the Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 07/01/2013 which documented a facility Entry Date of 06/25/2013, and that the resident had been admitted from another nursing home. Section C - Cognitive Patterns of this MDS documented a Brief Interview for Mental Status (BIMS) Summary Score of 99 for Resident #32, indicating severe cognitive impairment. Section I - Active [DIAGNOSES REDACTED]., [MEDICAL CONDITION] and [MEDICAL CONDITION]. Section H - Bladder and Bowel documented that Resident #32 had always been incontinent of both bladder and bowel during the seven (7) day look-back period, and Section G - Functional Status documented that the resident had required the extensive assistance of staff for bed mobility, transfer and locomotion during the seven (7) day look-back period. Section M - Skin Conditions documented that Resident #32 had no unhealed pressure ulcers at that time, but was at risk of developing pressure ulcers. In addition to the 07/01/2013 MDS referenced above for Resident #32 which indicated that the resident had no unhealed pressure ulcers at that time, review of Resident #32's Admission Pressure Assessment (APA), dated 06/25/2012 and completed upon the resident's original facility admission from another nursing facility, revealed that the resident had not had any reddened or open areas at the time of facility admission. However, this ANPA did document that Resident #32 had been assessed with [REDACTED]. Prior to the completion of the 07/01/2013 MDS referenced above, Norton Scale Pressure Ulcer Risk Evaluations completed for Resident #32 in January of 2013 and April of 2013 had each assessed the resident to have a Total Score of 23, with a score exceeding 12 representing a High Risk for pressure-sore development. Additionally, Norton Scale Pressure Ulcer Risk Evaluations completed for Resident #32 in July of 2013 and December of 2013 had also each assessed the resident to continue to have a Total Score of 23, indicating a continued High Risk of pressure-sore development. A Quarterly MDS for Resident #32 having an Assessment Reference Date of 12/18/2013 documented a BIMS Summary Score of 07, indicating that the resident continued to have severe cognitive impairment. Section H - Bladder and Bowel documented that Resident #32 continued to be incontinent of both bladder and bowel, and Section G - Functional Status documented that the resident continued to require the extensive assistance of staff for bed mobility, and was totally dependent for transfer and locomotion. Section M - Skin Conditions documented that Resident #32, while having no unhealed pressure ulcers at that time, continued to be at risk of pressure ulcer development during the seven (7) day look-back period. Review of the Shower Documentation forms for Resident #32 revealed no evidence to indicate that skin assessments done by the shower aides, per facility Policy and Procedure, had revealed any concerns regarding the resident's skin until a notation of 01/01/2014 documented a bruised area identified on the resident's left heel. Review of a Nurses Progress Notes entry dated 01/01/2014 for Resident #32 revealed that the nurse noted a dark, boggy area to the resident's left heel, having no drainage, and with the surrounding skin intact. The physician was notified and an order was obtained specifying the application of skin prep daily to the left heel, and specifying the application of bunny boots while in bed. Review of a Treatment Progress Notes (TPN) entry dated 01/02/2014 for Resident #32 then revealed a notation documenting a new pressure ulcer to the resident's left heel, indicating that the ulcer was maroon in color and unstageable, and measuring 3.7 centimeters (cms) by 3.7 cms by Unable to Determine (UTD). This Notes entry documented that there were no signs or symptoms of infection, and that when notified, the physician gave a new order to add a roll gauze to the heel. A subsequent TPN entry of 01/09/2014 documented that Resident #32's heel pressure sore measurements had increased to 4.6 cms by 4.6 cms by UTD, and an entry of 01/15/14 documented heel pressure sore measurements of 4.4 cms by 4.3 cms by UTD, with no change in treatment. Observation of Resident #32 conducted on 01/15/2014 at 10:35 a.m., with the Treatment Nurse and Certified Nursing Assistant (CNA) "AA" in attendance, revealed Resident #32's left heel pressure sore to continue be maroon in color and to have intact skin, and also to measure 4.4 cms by 4.3 cms by UTD at that time. However, further review of Resident #32's clinical record revealed that, despite the initial 06/25/2012 APA assessment referenced above which indicated Resident #32 had a previous history of ulceration to the left heel, despite Norton Scale Pressure Ulcer Risk Evaluations of January, April, July and December of 2013 referenced above all indicating that Resident #32 was at high risk for pressure ulcer development, and despite the MDS assessments of 07/01/2013 and 12/18/2013 referenced above which also indicated that Resident #32 was at risk for pressure ulcer development, there was no evidence to indicate that the facility had developed and implemented any methods to provide pressure relief to the resident's heel, prior to the 01/01/2014 physician's order for the bunny boot after Resident #32 had developed a dark, boggy area to the left heel. During an interview with CNA "DD" conducted on 01/17/2014 at 10:45 a.m., CNA "DD" stated that she provided care to Resident # 32 about four (4) days a week, and further acknowledged that resident started wearing bunny boots only about three (3) weeks prior. During an interview with Licensed Practical Nurse (LPN) "EE" conducted on 01/17/2014 at 10:50 a.m., LPN "EE" stated that Resident # 32 had skin assessments, and also that staff were to keep the resident's heels up when he/she was in the chair and were to change his/her position every two (2) hours in bed. However, LPN "EE" acknowledged that the facility had not begun the use of the bunny boots as a treatment until after Resident #32 developed a pressure ulcer on the heel. During an interview with the facility's Treatment Nurse conducted on 01/17/2014 at 10:30 a.m. regarding Resident #32's left heel pressure ulcer, this Treatment Nurse acknowledged that, other than providing skin assessments three (3) times weekly and the use of a pressure-reduction mattress, the facility had not had any other methods of pressure relief in place prior to the development of the resident's left heel ulcer.

Based on record review, staff interview, Hospital Consultation Report review, hospital Adult General Consultation report review, hospital Discharge Summary Review, nursing facility Accident/Incident Report review, and Dietary Manager written statement review, the facility failed to prohibit neglect by failing to ensure adequate supervision and assessment for one (1) resident (#1), who was at risk of choking, required food of a pureed consistency, and had a history of [REDACTED].#1 to gain access to food of a non-pureed consistency. This failure resulted in Resident #1 entering to the unattended Dining Room, obtaining and ingesting food of a non-pureed consistency, choking, and being found unresponsive and cyanotic. The resident was subsequently transferred to the hospital, was determined to have sustained a severe [MEDICAL CONDITION] neurological injury, was diagnosed with [REDACTED]. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Assistant Director of Nursing (ADON) was informed of the Immediate Jeopardy on [DATE], at 4:15 p.m. The situation which caused the Immediate Jeopardy involving the facility's neglect of Resident #1 by the failure to provide a safe environment for, and adequate supervision of, this resident who required food of a pureed consistency was identified to have existed as of [DATE] (the date Resident #1 obtained food of a non-pureed consistency and choked), continued through [DATE], and was removed on [DATE]. During a telephone interview with the Administrator conducted on [DATE] at 3:35 p.m., the Administrator acknowledged awareness of Resident #1 obtaining food of an improper consistency and choking. During a subsequent interview with the ADON conducted on [DATE] at 9:30 a.m., the ADON referenced interventions regarding resident supervision and access to food items which were initiated after the choking incident involving Resident #1, but further acknowledged the lack of a system by which to assess the effectiveness of, and staffs' conformance with, these interventions prior to this complaint survey. A Plan To Abate the IJ Level Deficiency was received from the facility on [DATE]. 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 [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring a safe resident environment by securing resident food access in the dining areas and throughout the facility via newly implemented procedures, and completed a process staff in-service training related to these new procedures. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of the resident environment related to resident access to food items. Findings include: Record review for Resident #1 revealed a [DATE] Quarterly Minimum Data Set assessment which documented, in Section C - Cognitive Patterns, severely impaired cognitive skills for daily decision-making. Section I - Active [DIAGNOSES REDACTED].#1 would at times enter the Dining Room and try to obtain food off of other residents' food trays. A [DATE], 6:25 p.m. Nurse's Notes entry documented that Resident #1 was unresponsive, slumped over in the wheelchair, and cyanotic. The [MEDICATION NAME] Maneuver was initiated and a piece of bread emerged. A 6:39 p.m., [DATE] Nurse's Notes entry documented that Emergency Medical Services (EMS) arrived, and a 6:47 p.m. Nurse's Notes entry documented that the resident was transported to the emergency room (ER). This [DATE], 6:47 p.m. Nurse's Notes entry also documented an incident during which Dietary Aide "AA" had been informed that Resident #1 had earlier eaten a portion of non-pureed sausage. However, further record review for Resident #1 revealed no evidence of any nursing assessment having been conducted for Resident #1 on [DATE] related to the resident having ingested non-pureed food prior to the Nurse's Notes entries referenced above which documented that the resident had choked. A [DATE] Hospital Consultation Report (HCR) for Resident #1 documented that Resident #1 had been found unresponsive, and that upon EMS arrival, meat was removed from the resident's airway. Resident #1 had experienced Pulseless Electrical Activity arrest related to choking on meat. A [DATE] hospital Adult General Consultation report documented that food had become lodged in the resident's esophagus, was later dislodged, and the resident was admitted to the Intensive Care Unit. The hospital Discharge Summary documented that Resident #1 had sustained a severe [MEDICAL CONDITION] neurological injury. Ventilator support was established but later withdrawn, and the resident expired. [DIAGNOSES REDACTED]. A nursing facility Accident/Incident (A/I) Report of [DATE] documented that around 6:25 p.m. on that date, Resident #1 had gone into the Dining Room, taken a sausage and began putting the sausage into his/her mouth. Another resident, Resident "B", called out to Dietary Aide (DA) "AA" who responded and removed the sausage from Resident #1's hand. A written statement dated [DATE] provided by the facility's Dietary Manager (DM) documented that on [DATE], Resident #1 entered the Dining Room with no facility staff in attendance. DA "AA" was informed by Resident "B" that Resident #1 was eating a sausage taken from a meal tray. DA "AA" retrieved part of the sausage but found that Resident #1 had eaten half of the sausage. DA "AA" then informed the Administrator. During a [DATE], 3:35 p.m. telephone interview, the Administrator acknowledged being told by the dietary aide that Resident #1 had been found with sausage. However, the Administrator stated that he did not check the resident's mouth for remaining food, and did not inform nursing staff of the resident having been found with sausage. During an interview with the ADON conducted on [DATE] at 1:30 p.m., the ADON acknowledged the [DATE] choking incident after Resident #1 obtained access to non-pureed sausage. During a subsequent [DATE], 4:30 p.m. interview, the ADON acknowledged that no one informed a nurse that the resident had eaten non-pureed sausage on [DATE] prior to the resident choking. Based on the above, even though Resident #1 required food of a pureed consistency, and even though the resident had a known history of obtaining food of non-pureed consistency from the meal trays of other residents, the facility neglected Resident #1 by failing to provide adequate supervision. Resident #1 subsequently entered the unattended Dining Room on [DATE] without the knowledge of staff, obtained and ingested non-pureed sausage, and choked. The facility also neglected Resident #1 by failing to ensure a timely assessment of the resident after the resident had ingested the non-pureed sausage, even though DA "AA" had been made aware that the resident had eaten a portion of the sausage, and the Administrator had been made aware of the resident having possession of non-pureed sausage. Resident #1 was later found unresponsive and cyanotic, having choked on a piece of meat. Resident #1 was transferred to the hospital and placed on a ventilator, which was later discontinued, and the resident expired. [DIAGNOSES REDACTED]. Cross refer to F323 for more information regarding Resident #1. It was determined that the Immediate Jeopardy had been removed on [DATE], by which time the facility had submitted a Plan To Abate the IJ Level Deficiencies and had implemented the following corrective actions: - On [DATE], the facility completed implementation of a new Dining Protocol by which designated Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) would be assigned to the Main Dining Room and to the Restorative/Solarium dining area to monitor until all residents had completed each meal service, all meal trays were cleared by dietary staff, and meal tray carts had been returned to the Dietary Department. Additionally, unit RNs had been assigned to remain on the halls to supervise those residents who dine in their rooms, from the initiation of meal service until the meal trays had been collected and the dietary tray carts had been returned to the Dietary Department. All staff assignments related to the Dining Protocol are now listed on a typed assignment form for staff reference. - On [DATE], the facility developed and implemented a Nursing Monitoring Tool For Meals form to allow the assigned RN and LPN nursing staff to document resident monitoring during meal service in the resident dining areas as specified by the Dining Protocol, as referenced above. - On [DATE], the facility completed in-service training for all nursing staff, dietary staff, and housekeeping/laundry staff regarding the Dining Protocol. - On [DATE], the facility completed implementation of a new procedure making the Dietary Cook responsible for ensuring that the doors to the Main Dining Room were closed and secured after each meal service to prevent residents from obtaining food items that could cause choking. - On [DATE], the facility developed and implemented a Monitoring Tool form to allow the Dietary Cook to document the securing of the Main Dining Room Doors after each meal service, as referenced above. - On [DATE], the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas, with designated nurses having keys to allow residents to obtain snacks. The snack carts for the 7:00 a.m.-to-3:00 p.m. shift and the 3:00 p.m.-to-11:00 p.m. shift were to be locked in the pantry when the nutrition aide was not actively distributing snacks. This Snack Cart/Pantry Procedure for locking the pantry areas and securing the snack carts will be monitored by the Charge Nurse, who will document this monitoring each shift via the Snack Sign-Off List form upon delivery of the carts, and upon storage. - On [DATE], the facility provided staff in-service training on the new procedure for securing the snack carts. As of [DATE], eighty-nine (89) staff who were on duty received this in-service training, with the remaining sixty-four (64) staff to receive this training upon reporting to the facility for work. - On [DATE], the facility provided staff in-service training regarding the [MEDICATION NAME] Maneuver and the provision of care to an individual with an obstructed airway. As of that date, 122 employees, to include nursing staff, dietary staff, and housekeeping staff, had been trained, with the remaining 31 employees to receive in-service training upon reporting to the facility for work. - On [DATE], the facility began including in the orientation procedures for new employees the requirement that all newly hired staff will receive training upon employment, to include training regarding the Dining Protocol, the Snack Cart/Pantry Procedure, and the [MEDICATION NAME] Maneuver to ensure resident safety. - On [DATE], all residents with mechanically altered diets were assessed for tolerance and safety by Nursing Assessment and Speech Therapy, to ensure accurate assessment. - On [DATE], the facility implemented a procedure by which the ADON would monitor staff conformance with the new Dining Protocol, the Main Dining Room door security procedure, and the Snack Cart/Pantry Procedure by monitoring the Nursing Monitoring Tool For Meals, the Dining Room door Monitoring Tool, and the Snack Sign-Off List form three times weekly for six months. The ADON will then report the results of this monitoring to the Quality Assessment and Performance Improvement (QAPI) Committee for review. - On [DATE], the facility implemented a procedure by which all compliance monitoring via the Nursing Monitoring Tool For Meals, the Dining Room door Monitoring Tool, and the Snack Sign-Off List will be presented by the ADON to the QAPI Committee. The Committee will evaluate staff compliance with these processes, and the effectiveness of the processes. All assigned nursing staff and dietary staff will continue recording on the monitoring tools for the next 6 months, and the QAPI Committee will then evaluate the frequency of monitoring, the need for additional staff training, and the effectiveness of interventions on an ongoing basis. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on [DATE]. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. In order to ensure that residents did not obtain food items which could represent a hazard, the facility had implemented a new Dining Protocol by which designated licensed nursing staff would monitor the Main Dining Room, the Restorative/Solarium dining area, and the halls from the start of each meal service, all the way through completion of meal service and tray removal, to ensure security. The facility had also completed implementation of a new procedure by which the Dietary Cook would ensure that the doors to the Main Dining Room are closed and secured after each meal service. However, both the new Dining Protocol and the process of securing the Main Dining Room doors had not been completed until [DATE], only two days prior to the [DATE] exit date of this survey. In addition, the facility had implemented the use of a Nursing Monitoring Tool For Meals form to monitor compliance with the Dining Protocol and a Monitoring Tool form to monitor compliance with securing Dining Room doors, but had only implemented the use of these monitoring tool on [DATE], two days prior to the survey exit. Also, on [DATE], the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas to allow for the security of snack carts. As of [DATE], eighty-nine (89) staff who were on duty had received this in-service training, but the remaining sixty-four (64) staff would not receive training until they reported for work after the completion of this survey. Additionally, the ADON will be presenting the results of the Nursing Monitoring Tool For Meals, the Main Dining Room Monitoring Tool used for monitoring door security, and the Snack Sign-Off List form used for monitoring the security of the snack carts to the QAPI Committee for the Committee's review, evaluation, and consideration of needed interventions. However, as of the [DATE] exit date of this survey, the QAPI Committee had not yet met to initiate the evaluation of these new interventions to ensure resident health and safety, related to access to inappropriate food items. The QAPI Committee's next scheduled meeting is in January of 2014. Therefore, the non-compliance continues, but the scope and severity level is reduced to a "D" level.

Based on record review, staff interview, Hospital Consultation Report review, hospital Adult General Consultation report review, hospital Discharge Summary Review, nursing facility Accident/Incident Report review, and Dietary Manager written statement review, the facility failed to ensure that services were provided in accordance with the Care Plan, related to monitoring and redirection to address a known behavior of obtaining hazardous food items, for one (1) resident (#1), who was at risk of choking, required food of a pureed consistency, and had a history of [REDACTED]. This failure resulted in Resident #1 gaining access to the unattended Dining Room, obtaining and ingesting food of an un-pureed consistency, choking, and being found unresponsive and cyanotic. The resident was subsequently transferred to the hospital, was determined to have sustained a severe [MEDICAL CONDITION] neurological injury, was diagnosed with [REDACTED]. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Assistant Director of Nursing (ADON) was informed of the Immediate Jeopardy on [DATE], at 4:15 p.m. The situation involving facility staffs' failure to provide a safe environment for, and adequate supervision of, this resident who required food of a modified consistency which caused the Immediate Jeopardy was identified to have existed as of [DATE] (the date Resident #1 obtained food of an un-pureed consistency and choked), continued through [DATE], and was removed on [DATE]. During a telephone interview with the Administrator conducted on [DATE] at 3:35 p.m., the Administrator acknowledged awareness of Resident #1 obtaining food of an improper consistency and choking. During a subsequent interview with the ADON conducted on [DATE] at 9:30 a.m., the ADON referenced interventions regarding resident supervision and access to food items which were initiated after the choking incident involving Resident #1, but further acknowledged the lack of a system by which to assess the effectiveness of, and staffs' conformance with, these interventions prior to this complaint survey. A Plan To Abate the IJ Level Deficiency was received from the facility on [DATE]. 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 [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring resident safety by securing resident food access in the dining areas and throughout the facility via newly implemented procedures, and completed a process of staff in-service training related to these new procedures. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of the resident environment related to resident access to food items. Findings include: Record review for Resident #1 revealed a Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of [DATE] which documented, in Section C - Cognitive Patterns, that the resident had severely impaired cognitive skills for daily decision-making. Section K - Swallowing/Nutritional Status documented that Resident #1 received a mechanically altered diet. Resident #1's Care Plan identified a Problem , originally dated [DATE], indicating that Resident #1 had a gastrostomy tube for flushes and medications, but also received a pureed diet with honey-thickened liquids, and was on the restorative caseload for restorative dining. This Care Plan identified an additional Problem, also originally dated [DATE], which referenced that Resident #1 was dependent on a wheelchair for mobility, and indicated that the resident would put food items in his/her mouth when staff attempted to obtain the food from the resident. An Approach to address this hazard directed staff to monitor and redirect Resident #1 away from the dinning area as he/she was up in the wheelchair. Further record review for Resident #1 revealed a Nurse's Notes entry of [DATE] at 6:25 p.m. which documented that the resident was noted to be slumped over in the wheelchair, and was unresponsive and cyanotic. The [MEDICATION NAME] Maneuver was performed, yielding a piece of bread. A [DATE], 6:39 p.m. Nurse's Notes entry documented that Emergency Medical Services (EMS) had arrived, and a [DATE], 6:47 p.m. Notes entry documented that Resident #1 was taken to the emergency room (ER). A Hospital Consultation Report (HCR) documented that on [DATE], Resident #1 had apparently choked on meat, and that upon EMS arrival, meat was removed from the resident's airway. This HCR documented that the resident had experienced Pulseless Electrical Activity (PEA) arrest in the nursing facility related to choking on meat. A [DATE] hospital Adult General Consultation (AGC) report documented that food had become lodged in the resident's esophagus, and that the resident had gone into [MEDICAL CONDITION]. The food was dislodged, an airway was established, and the resident was stabilized and moved to the Intensive Care Unit on ventilator support. The hospital Discharge Summary (DS) documented that Resident #1 had respiratory arrest with PEA in the nursing facility and was resuscitated, but had sustained a severe neurological [MEDICAL CONDITION] injury. Ventilator support was initiated, but after ventilator withdrawal, the resident expired, with [DIAGNOSES REDACTED]. A nursing facility Accident/Incident (A/I) Report of [DATE] documented that around 6:20 p.m., Resident #1 had gone into the Dining Room, had taken a sausage from a food tray and had begun putting the sausage into his/her mouth. Resident "B" alerted Dietary Aide (DA) "AA", who responded and removed the remaining sausage from Resident #1's hand. In a [DATE] written statement, the Dietary Manager (DM) documented that on the evening of [DATE], no nursing staff or CNAs were in the Dinning Room. The DM documented that on [DATE] at 6:40 p.m., he received a telephone call from DA "AA" who stated that, upon being informed by Resident "B" that Resident #1 was in the Dining Room eating a sausage, she found that Resident #1 had already eaten half of the sausage. DA "AA" stated that she took the remaining uneaten half of the sausage from Resident #1. However, as referenced above in the Nurse's Notes entry of [DATE] at 6:25 p.m., Resident #1 was subsequently found slumped over, unresponsive and cyanotic, with the [MEDICATION NAME] Maneuver yielding a piece of bread. The hospital AGC report documented that food had become lodged in the resident's esophagus and the resident had gone into [MEDICAL CONDITION]. The hospital DS documented that Resident #1 had ultimately expired having [DIAGNOSES REDACTED]. During an interview with the Assistant Director of Nursing (ADON) conducted on [DATE] at 1:30 p.m., the ADON acknowledged that on [DATE], Resident #1 had obtained and ingested non-pureed sausage. Based on the above, despite Resident #1 requiring food of a pureed consistency, despite the resident's Care Plan entry which identified the resident's known risk of obtaining hazardous food items and placing them in the mouth, and despite the Care Plan Approach which specified that staff were to monitor and redirect Resident #1 from the Dining Room to prevent the acquisition of hazardous food items, the facility failed to ensure the adequate monitoring and redirection of Resident #1, as specified in the Care Plan. Rather, staff allowed Resident #1 to enter the Dining Room on [DATE], without the knowledge of staff and while the Dining Room was unattended by staff, and to obtain and ingest non-pureed sausage. The resident was later found unresponsive and cyanotic, with the [MEDICATION NAME] Maneuver revealing a piece of bread. EMS later removed meat from the resident's airway, Resident #1 was then transferred to the hospital and placed on a ventilator, which was later discontinued, and the resident expired. [DIAGNOSES REDACTED]. Cross refer to F323 for more information regarding Resident #1. It was determined that the Immediate Jeopardy had been removed on [DATE], by which time the facility had submitted a Plan To Abate the IJ Level Deficiencies and had implemented the following corrective actions: - On [DATE], the facility completed implementation of a new Dining Protocol by which designated Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) would be assigned to the Main Dining Room and to the Restorative/Solarium dining area to monitor until all residents had completed each meal service, all meal trays were cleared by dietary staff, and meal tray carts had been returned to the Dietary Department. Additionally, unit RN nurses have been assigned to remain on the halls to supervise those residents who dine in their rooms, from the beginning of meal service until the meal trays have been collected and the dietary tray carts have been returned to the Dietary Department. All staff assignments related to the Dining Protocol are listed on a typed assignment form for staff reference. - On [DATE], the facility developed and implemented a Nursing Monitoring Tool For Meals form to allow the assigned RN and LPN nursing staff to document resident monitoring during meal service in the resident dining areas as specified by the Dining Protocol, as referenced above. - On [DATE], the facility completed in-service training for all nursing staff, dietary staff, and housekeeping/laundry staff regarding the Dining Protocol. - On [DATE], the facility completed the implementation of a new procedure making the Dietary Cook responsible for ensuring that the doors to the Main Dining Room were closed and secured after each meal service to prevent residents from obtaining food items that could cause choking. - On [DATE], the facility developed and implemented a Monitoring Tool form to allow the Dietary Cook to document the securing of the Main Dining Room Doors after each meal service, as referenced above. - On [DATE], the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas, with designated nurses having keys to allow residents to obtain snacks. The snack carts for the 7:00 a.m.-to-3:00 p.m. shift and the 3:00 p.m.-to-11:00 p.m. shift were to be locked in the pantry when the nutrition aide was not actively distributing snacks. This Snack Cart/Pantry Procedure for locking the pantry areas and securing the snack carts will be monitored by the Charge Nurse, who will document this monitoring each shift via the Snack Sign-Off List form upon delivery of the carts, and upon storage. - On [DATE], the facility provided staff in-service training on the new procedure for securing the snack carts. As of [DATE], eighty-nine (89) staff who were on duty received this in-service training, with the remaining sixty-four (64) staff to receive this training upon reporting to the facility for work. - On [DATE], the facility provided staff in-service training regarding the [MEDICATION NAME] Maneuver and the provision of care to an individual with an obstructed airway. As of that date, 122 employees, to include nursing staff, dietary staff, and housekeeping staff, had received training, with the remaining thirty-one (31) employees to receive in-service training upon reporting to the facility for work. - On [DATE], the facility included in the orientation procedures for new employees the requirement that all newly hired staff will receive training upon employment, to include training regarding the Dining Protocol, the Snack Cart/Pantry Procedure, and the [MEDICATION NAME] Maneuver, to ensure resident safety. - On [DATE], all residents with mechanically altered diets were assessed for tolerance and safety by Nursing Assessment and Speech Therapy, to ensure accurate assessment. - On [DATE], the facility implemented a procedure by which the ADON would monitor staff conformance with the new Dining Protocol, the Main Dining Room door security procedure, and the Snack Cart/Pantry Procedure by monitoring the Nursing Monitoring Tool For Meals, the door Monitoring Tool, and the Snack Sign-Off List form three times weekly for six months. The ADON will then report the results of this monitoring to the Quality Assessment and Performance Improvement (QAPI) Committee for review. - On [DATE], the facility implemented a procedure by which all compliance monitoring via the Nursing Monitoring Tool For Meals, the Dining Room door Monitoring Tool, and the Snack Sign-Off List will be presented by the ADON to the QAPI Committee. The Committee will evaluate staff compliance with these processes and procedures, and the effectiveness of the processes. All assigned nursing staff and dietary staff will continue recording on the monitoring tools for the next 6 months, and the QAPI Committee will then evaluate the frequency of monitoring, the need for additional staff training, and the effectiveness of interventions on an ongoing basis. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on [DATE]. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. In order to ensure that residents did not obtain food items which could represent a hazard, the facility had completed implementation of a new Dining Protocol by which designated licensed nursing staff would monitor the Main Dining Room, the Restorative/Solarium dining area, and the halls from the start of each meal service, all the way through completion and tray removal, to ensure security. The facility had also completed implementation of a new procedure by which the Dietary Cook would ensure that the doors to the Main Dining Room are closed and secured after each meal service. However, both the new Dining Protocol and the process of securing the Main Dining Room doors had not been completed until [DATE], only two days prior to the [DATE] exit date of this survey. In addition, the facility had implemented the use of a Nursing Monitoring Tool For Meals form to monitor compliance with the Dining Protocol and a Monitoring Tool form to monitor compliance with securing the Dining Room doors, but had only implemented the use of these monitoring tools on [DATE], two days prior to the survey exit. Also, on [DATE], the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas to allow for the security of snack carts. As of [DATE], eighty-nine (89) staff who were on duty had received this in-service training, but the remaining sixty-four (64) staff would not receive training until they reported for work after the completion of this survey. Additionally, the ADON will be presenting the results of the Nursing Monitoring Tool For Meals, the Main Dining Room Monitoring Tool used for door security, and the Snack Sign-Off List form used for security of the snack carts to the QAPI Committee for the Committee's review, evaluation, and consideration of needed interventions. However, as of the [DATE] exit date of this survey, the QAPI Committee had not yet met to initiate the evaluation of these new interventions to ensure resident health and safety, related to access to appropriate food items. The QAPI Committee's next scheduled meeting is in January of 2014. Therefore, the non-compliance continues, but the scope and severity level is reduced to a "D" level.

Based on record review, staff interview, resident interview, Hospital Consultation Report review, hospital Adult General Consultation report review, hospital Discharge Summary Review, nursing facility Accident/Incident Report review, Dietary Manager written statement review, and facility investigation summary review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and failed to ensure adequate supervision, related to monitoring resident access to hazardous food items, so as to prevent one (1) resident (#1), who was at risk of choking, required food of a pureed consistency, and had a history of [REDACTED]. This failure resulted in Resident #1 gaining access to the unattended Dining Room, obtaining and ingesting food of a non-pureed consistency, choking, and being found unresponsive and cyanotic. The resident was subsequently transferred to the hospital, was determined to have sustained a severe anoxic neurological injury, was diagnosed with [REDACTED]. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Assistant Director of Nursing (ADON) was informed of the Immediate Jeopardy on [DATE], at 4:15 p.m. The situation involving facility staffs' failure to provide a safe environment for, and adequate supervision of, this resident who required food of a modified consistency which caused the Immediate Jeopardy was identified to have existed as of [DATE] (the date Resident #1 obtained food of a non-pureed consistency and choked), continued through [DATE], and was removed on [DATE]. During a telephone interview with the Administrator conducted on [DATE] at 3:35 p.m., the Administrator acknowledged awareness of Resident #1 obtaining food of an improper consistency and choking. During a subsequent interview with the ADON conducted on [DATE] at 9:30 a.m., the ADON referenced interventions regarding resident supervision and access to food items which were initiated after the choking incident involving Resident #1, but further acknowledged the lack of a system by which to assess the effectiveness of, and staffs' conformance with, these interventions prior to this complaint survey. A Plan To Abate the IJ Level Deficiency was received from the facility on [DATE]. 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 [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring a safe resident environment by securing resident food access in the dining areas and throughout the facility via newly implemented procedures, and completed a process staff in-service training related to these new procedures. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of the resident environment related to resident access to hazardous food items. Findings include: Record review for Resident #1 revealed a Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of [DATE] which documented, in Section C - Cognitive Patterns, that the resident had severely impaired cognitive skills for daily decision-making, and documented in Section I - Active [DIAGNOSES REDACTED].#1 received a mechanically altered diet. A current physician's orders [REDACTED]. Resident #1's Care Plan identified that, in addition to having memory deficits, the resident also had a [DIAGNOSES REDACTED].#1 received a pureed diet with honey-thickened liquids, per the physician's pureed diet order referenced above. An additional Care Plan Problem, also dated [DATE], indicated that the resident would put food items in his/her mouth upon staffs' attempts to intervene, thereby requiring staff monitoring and redirection from the dining room. Further record review for Resident #1 revealed a Nurse's Notes entry of [DATE] for Resident #1 which documented, as referenced in the Care Plan entry above regarding the resident attempting to obtain and ingest inappropriate food items, that the resident continued after mealtimes to propel himself/herself to the Dining Room after most residents had eaten and try to obtain food, especially bread, off of food trays that were to be picked up. This Nurse's Notes entry indicated that the writer of the note had redirected Resident #1 on several occasions, and indicated that staff would continue to monitor the resident. A Nurse's Notes entry of [DATE] at 6:25 p.m. for Resident #1 documented that a certified nursing assistant (CNA) reported to a nurse that the resident was sitting in the hallway at the East Wing Nurse's Station in the wheelchair and slumped over. The CNA stated she had touched Resident #1 on the shoulder but the resident did not respond. The CNA reported that she lifted the resident's head and noted that the resident was cyanotic, having a blue face. This Nurse's Notes entry documented that the Heimlich Maneuver was initiated, and oxygen was started via nasal cannula, with the resident's color changing from cyanotic to red. A 6:30 p.m. Nurse's Notes entry documented that the Heimlich Maneuver continued for Resident #1 and that a piece of bread was noted to come out. A Nurse's Notes entry of [DATE] at 6:39 p.m. for Resident #1 documented that Emergency Medical Services (EMS) staff had arrived and began to assess the resident for a partial obstruction. A subsequent Nurse's Notes entry of 6:47 p.m. on [DATE] documented that Resident #1 was transported via ambulance to the hospital emergency room (ER) per a physician's orders [REDACTED]. Resident #1 putting a large piece of sausage in his/her mouth, and had called to Dietary Aide (DA) "AA". The Nurse's Notes entry further documented that DA "AA" had given a statement indicating that Resident #1 had been eating a sausage and that she had removed the sausage from the resident's hand. Further record review, however, revealed no evidence, prior to this Nurse's Notes entry of 6:47 p.m., to indicate that facility nursing staff had been made aware of Resident #1, who required pureed food, having eaten a portion of non-pureed sausage approximately twenty (20) minutes before. There was also no evidence of any assessment of Resident #1 after DA "AA" had been initially informed that Resident #1 had been seen eating non-pureed sausage in the Dining Room, until the resident was later noted to be unresponsive and cyanotic at the Nurse's Station. Review of a Physician's Telephone Orders form of [DATE] at 6:25 a.m. for Resident #1 documented an order to send the resident to the ER for a partial airway obstruction and choking. A Hospital Consultation Report (HCR), detailing the hospital ER examination of Resident #1, documented a hospital admission date of [DATE]. This HCR documented, in the History of Present Illness section, that nursing home Resident #1, who was wheelchair-bound, had the behavior of rolling himself/herself around and taking food off of other residents' plates. This HCR documented that on the evening of [DATE], Resident #1 apparently choked on meat and was found unresponsive, with Pulseless Electrical Activity Arrest, and that upon EMS arrival, meat was removed from the resident's airway. The HCR documented the resident was then intubated, with the return of a pulse, and was transported to the hospital ER. The HCR documented that upon arrival at the hospital ER, Resident #1 was originally hypotensive, with a systolic blood pressure of 92 (millimeters of mercury), and was also in Supra[DIAGNOSES REDACTED], with an elevated heart rate of 200 (beats per minute). The HCR documented that Resident #1 was treated with Cordarone and Cardizem, but was documented as being unresponsive, having jerking and twitching movements, and also having fixed pupils. The Assessment portion of this HCR documented that the resident had experienced Pulseless Electrical Activity arrest in the nursing facility related to choking on meat, and that the initial evaluation in the ER suggested an anoxic injury. A hospital Adult General Consultation report of [DATE] for Resident #1 documented in the History of Present Illness Section that the resident had been unable to swallow food and the food had become lodged in the esophagus. Food was then dislodged and an airway was established. The physician documented that the resident had gone into arrest and was without cardiac activity for an unknown, but extended, period of time. The physician further documented that Resident #1 had been brought to the ER and then moved to the Intensive Care Unit. The Exam section of this Consultation report documented that Resident #1 was on a ventilator at that time, and that he/she had episodic myoclonic jerks which were most likely from hypoxia. The hospital Discharge Summary (DS) for Resident #1 documented a discharge date of [DATE]. This DS documented that the resident had been admitted to the hospital from the nursing facility where he/she had sustained respiratory arrest with Pulseless Electrical Activity. The physician documented on this DS that Resident #1 had been resuscitated, but had sustained a severe anoxic injury, which was described as a devastating neurological injury with no significant meaningful recovery. The physician documented that upon the withdrawal of ventilator support, Resident #1 had expired a few hours later. The [DIAGNOSES REDACTED]. The Cause of Death was listed as Respiratory Arrest. A nursing facility Accident/Incident (A/I) Report of [DATE], which referenced the choking incident involving Resident #1 referenced above, documented that around 6:20 p.m. on that date, Resident #1 had gone into the Dining Room where food trays were sitting on the tables, had taken a sausage with both hands and began putting the sausage into his/her mouth. This A/I Report documented that Resident "B", who was entering the Dining Room to return his/her meal tray, called out to Dietary Aide (DA) "AA" who responded and removed the piece of sausage from Resident #1's hand. However, this A/I Report documented that Resident #1 subsequently sustained a partial airway obstruction and choked. During an interview with Resident "B" conducted on [DATE] at 4:00 p.m., the resident who had alerted DA "AA" after having observed Resident #1 obtain food in the Dining Room, Resident "B" stated that he/she was returning his/her meal tray to the Dining Room when he/she saw Resident #1 with a piece of sausage in his/her hand, and also eating some of the sausage. Resident "B" stated that he/she called out to a dietary employee and informed her that Resident #1 was eating a sausage. Resident "B" stated that the dietary employee responded, removed the sausage from Resident #1's hand, and then began to escort Resident #1 out of the dining room. Record review for Resident "B" revealed a Quarterly MDS with an Assessment Reference Date of [DATE] which documented in Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status score of 15, thus indicating that the resident was cognitively intact and was interviewable. During an interview with DA "AA" conducted on [DATE] at 3:10 p.m., DA "AA" acknowledged that she had observed Resident #1 with a sausage in his/her hand and had removed the sausage from the resident's hand. DA "AA" stated that she had then started to remove Resident #1 from the Dining Room, at which time the Administrator walked into the Dining Room. DA "AA" stated that she informed the Administrator that she had removed sausage from Resident #1's hand. In a written statement dated [DATE] provided by the facility's Dietary Manager (DM) as part of the facility's investigation into the [DATE] choking incident of Resident #1, the DM documented that on the evening of [DATE] when the choking incident had taken place, the Dining Room was empty, with no nursing staff or CNAs in the dining area. The DM documented that on [DATE] at 6:40 p.m., he had received a telephone call from DA "AA" who stated she had been informed by a facility resident (Resident "B") that another resident, Resident #1, was eating a sausage in the dining room. The DM documented that Resident #1, who was on a pureed diet and was known to eat food taken from other residents' food trays, had entered the Dining Room after everyone had finished eating and had taken uneaten food which had been left behind on a plate. DA "AA" informed the DM that she went to retrieve the sausage from Resident #1, and found that Resident #1 had already eaten half of the sausage. DA "AA" stated, per the DM's statement, that she took the remaining uneaten half of the sausage from Resident #1 and began to remove the resident from the dining room, at which time she was met by the Administrator and informed the Administrator of what had taken place. The facility's investigation summary of the facility's investigation regarding the [DATE] choking incident of Resident #1 referenced above acknowledged that on [DATE] at approximately 6:25 p.m., Resident #1 had propelled into the Main Dining Room and obtained a sausage off a tray that was sitting on a table. DA "AA" then removed the sausage from Resident #1's hand and rolled the resident into the hallway. Later, staff observed Resident #1, who was at that time seated close to the Nurse's Station, to be unresponsive and cyanotic, with the Heimlich Maneuver removing a piece of food. Resident #1 was suctioned and ventilated via an Ambu bag and supplemental oxygen, and was transported to the hospital via EMS admitted to ICU. Ventilator support was provided, but was later discontinued on [DATE]. The facility acknowledged in this investigation summary that Resident #1 had choked on a piece of sausage. During a telephone interview with the Administrator conducted on [DATE] at 3:35 p.m., the Administrator acknowledged that on the evening of the choking incident involving Resident #1 referenced above, he had been approached by the dietary aide who informed him that Resident #1, who was known to take food off of the dietary trays of other residents, had obtained sausage which was presumed to have come from a food tray in the Dining Room. The Administrator stated that the dietary aide informed him that she had then removed the remaining sausage from the resident's hand. The Administrator stated that Resident #1 did not appear to be in any distress at that time, and stated that he did not look in the resident's mouth for any remaining food. He also acknowledged that a nurse was not informed that Resident #1 had been found with non-pureed sausage. Furthermore, record review for Resident #1, to include review of the resident's clinical record and of the A/I report referenced above, revealed no evidence of any assessment of the physical status of Resident #1 immediately upon the resident being found to have eaten non-pureed sausage. There was also no evidence to indicate that nursing staff had been informed of Resident #1 being found with, or had eaten, non-pureed sausage prior to the resident being found slumped over, unresponsive and cyanotic. Therefore, based on review of Resident #1's clinical record, review of the facility's investigation of the incident, and staff interviews as referenced above, there was no evidence to indicate that nursing staff had been made aware that Resident #1, who required food of a pureed consistency, had obtained and eaten a portion of non-pureed sausage, and thus no evidence to indicate that nursing staff, or any staff, had searched Resident #1's mouth or person to determine the presence or absence of any additional non-pureed food prior to the resident choking. This was despite the fact that Resident #1 had been observed by DA "AA" to be holding a partially uneaten and non-pureed sausage, and after DA "AA" had been told by Resident "B" that Resident #1 had actually eaten a portion of the sausage. This was also despite the fact that DA "AA" had informed the facility's Administrator of the resident being found with a piece of non-pureed sausage in his/her hand. During an interview with the ADON conducted on [DATE] at 1:30 p.m. related to the [DATE] choking incident involving Resident #1, the ADON acknowledged Resident #1 having obtained non-pureed sausage. The ADON stated that the first time nursing staff became aware of Resident #1 having any distress with the airway was when the resident was noted to be slumped over while seated in the wheelchair at the Nurse's Station. The ADON stated that when nursing staff noted the resident to be slumped, the Heimlich Maneuver was initiated. The ADON further stated that it was only upon the initiation of the Heimlich Maneuver that nursing staff checked the resident's mouth and noted the presence of food. During a subsequent interview conducted later in the afternoon of [DATE] at 4:30 p.m., the ADON acknowledged Resident #1's history of obtaining food from other residents' food trays, and further stated that on the evening the resident had obtained and eaten non-pureed sausage and choked, no one had informed a nurse that the resident had eaten sausage until after the resident had choked. Based on the above, despite Resident #1 requiring food of a pureed consistency, and despite the resident's known risk and history of obtaining food of non-pureed consistency from the meal trays of other residents, the facility failed to ensure the adequate supervision of Resident #1, who entered the Dining Room on [DATE] without the knowledge of staff and obtained and ingested non-pureed sausage. Additionally, even though DA "AA" had been made aware of Resident #1 having obtained and eaten a portion of the non-pureed sausage, and DA "AA" then related to the Administrator that the resident had been found with non-pureed sausage, there was no evidence to indicate that facility nursing staff were made aware that Resident #1 had ingested non-pureed sausage, no evidence of any physical assessment of the resident's status upon being found with the sausage, and no evidence of any additional search of the resident's mouth or person for the presence of remaining non-pureed food items, until after the resident was noted to be unresponsive and cyanotic. The Heimlich Maneuver at that time revealed a piece of bread, and EMS later removed meat from the resident's airway. Resident #1 was then transferred to the hospital and placed on a ventilator, which was later discontinued, and the resident expired. [DIAGNOSES REDACTED]. It was determined that the Immediate Jeopardy had been removed on [DATE], by which time the facility had submitted a Plan To Abate the IJ Level Deficiencies and had implemented the following corrective actions: - On [DATE], the facility completed implementation of a new Dining Protocol by which designated Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) would be assigned to the Main Dining Room and to the Restorative/Solarium dining area to monitor until all residents had completed each meal service, all meal trays were cleared by dietary staff, and meal tray carts had been returned to the Dietary Department. Additionally, unit RNs had been assigned to remain on the halls to supervise those residents who dine in their rooms, from the beginning of meal service until the meal trays have been collected and the dietary tray carts have been returned to the Dietary Department. All staff assignments related to the Dining Protocol are listed on a typed assignment form for staff reference. - On [DATE], the facility developed and implemented a Nursing Monitoring Tool For Meals form to allow the assigned RN and LPN nursing staff to document resident monitoring during meal service in the resident dining areas as specified by the Dining Protocol, as referenced above. - On [DATE], the facility completed in-service training for all nursing staff, dietary staff, and housekeeping/laundry staff regarding the Dining Protocol. - On [DATE], the facility completed implementation of a new procedure making the Dietary Cook responsible for ensuring that the doors to the Main Dining Room were closed and secured after each meal service to prevent residents from obtaining food items that could cause choking. - On [DATE], the facility developed and implemented a Monitoring Tool form to allow the Dietary Cook to document the securing of the Main Dining Room Doors after each meal service, as referenced above. - On [DATE], the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas, with designated nurses having keys to allow residents to obtain snacks. The snack carts for the 7:00 a.m.-to-3:00 p.m. shift and the 3:00 p.m.-to-11:00 p.m. shift were to be locked in the pantry when the nutrition aide was not actively distributing snacks. This Snack Cart/Pantry Procedure for locking the pantry areas and securing the snack carts will be monitored by the Charge Nurse, who will document this monitoring each shift via the Snack Sign-Off List form upon delivery of the carts, and upon storage. - On [DATE], the facility provided staff in-service training on the new procedure for securing the snack carts. As of [DATE], eighty-nine (89) staff who were on duty received this in-service training, with the remaining sixty-four (64) staff to receive this training upon reporting to the facility for work. - On [DATE], the facility had provided staff in-service training regarding the Heimlich Maneuver and the provision of care to an individual with an obstructed airway. As of that date, 122 employees, to include nursing staff, dietary staff, and housekeeping staff, had been training, with the remaining thirty-one (31) employees receive in-service training upon reporting to the facility for work. - On [DATE], the facility included in the orientation procedures for new employees the requirement that all newly hired staff received training upon employment, to include training regarding the Dining Protocol, the Snack Cart/Pantry Procedure, and the Heimlich Maneuver to ensure resident safety. - On [DATE], all residents with mechanically altered diets were assessed for tolerance and safety by Nursing Assessment and Speech Therapy, to ensure accurate assessment. - On [DATE], the facility implemented a procedure by which the ADON will monitor staff conformance with the new Dining Protocol, the Main Dining Room door security procedure, and the Snack Cart/Pantry Procedure by monitoring the Nursing Monitoring Tool For Meals, the door Monitoring Tool, and the Snack Sign-Off List form three times weekly for six months. The ADON will then report the results of this monitoring to the Quality Assessment and Performance Improvement (QAPI) Committee for review. - On [DATE], the facility implemented a procedure by which all compliance monitoring via the Nursing Monitoring Tool For Meals, the Dining Room door Monitoring Tool, and the Snack Sign-Off List will be presented by the ADON to the QAPI Committee. The Committee will evaluate staff compliance with these processes, and the effectiveness of the processes. All assigned nursing staff and dietary staff will continue recording on the monitoring tools for the next 6 months, and the QAPI Committee will then evaluate the frequency of monitoring, the need for additional staff training, and the effectiveness of interventions on an ongoing basis. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on [DATE]. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. In order to ensure that residents did not obtain food items which could represent a hazard, the facility had completed implementation of a new Dining Protocol by which designated licensed nursing staff would monitor the Main Dining Room, the Restorative/Solarium dining area, and the halls from the start of each meal service, all the way through completion and tray removal to ensure security. The facility had also completed implementation of a new procedure by which the Dietary Cook would ensure that the doors to the Main Dining Room are closed and secured after each meal service. However, both the new Dining Protocol and the process of securing the Main Dining Room doors had not been completed until [DATE], only two days prior to the [DATE] exit date of this survey. In addition, the facility had implemented the use of a Nursing Monitoring Tool For Meals form to monitor compliance with the Dining Protocol and a Monitoring Tool form to monitor compliance with securing Dining Room doors, but had only implemented the use of these monitoring tools on [DATE], two days prior to the survey exit. Also, on [DATE], the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas to allow for the security of snack carts. As of [DATE], eighty-nine (89) staff who were on duty had received this in-service training, but the remaining sixty-four (64) staff would not receive training until they reported for work after the completion of this survey. Additionally, the ADON will be presenting the results of the Nursing Monitoring Tool For Meals, the Main Dining Room Monitoring Tool used for door security, and the Snack Sign-Off List form used for security of the snack carts to the QAPI Committee for the Committee's review, evaluation, and consideration of needed interventions. However, as of the [DATE] exit date of this survey, the QAPI Committee had not yet met to initiate the evaluation of these new interventions to ensure resident health and safety, related to access to appropriate food items. The QAPI Committee's next scheduled meeting is in January of 2014. Therefore, the non-compliance continues, but the scope and severity level is reduced to a "D" level.

Based on record review, staff interview, and facility Accident/Incident Report review, the facility failed to ensure that the Quality Assessment and Assurance Committee (QA&A) developed and implemented an effective plan of action to address an identified environmental accident hazard, regarding resident access to hazardous food items and the related risk for choking. This failure affected one (1) resident (#1), who was at risk of choking, required food of a pureed consistency, and had a history of [REDACTED]. Resident #1 gained access to the unattended Dining Room on 09/09/2013, obtained and consumed food of a non-pureed consistency, choked, and was found unresponsive and cyanotic. The resident was transferred to the hospital, determined to have sustained a severe [MEDICAL CONDITION] neurological injury, diagnosed with [REDACTED]. However, even after this incident, the facility's QA&A Committee failed to develop and implement interventions to secure the resident environment, complete with mechanisms to monitor the effectiveness of interventions. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Assistant Director of Nursing (ADON) was informed of the Immediate Jeopardy on October 8, 2013, at 4:15 p.m. The situation involving facility staffs' failure to provide a safe environment for, and adequate supervision of, Resident #1 who required food of a pureed consistency which caused the Immediate Jeopardy was identified to have existed as of September 9, 2013 (the date Resident #1 obtained food of a non-pureed consistency and choked), continued through October 9, 2013, and was removed on October 10, 2013. A telephone interview was conducted with the facility's Administrator on 10/10/2013 at 9:15 a.m., and the Administrator was questioned as to the QA&A Committee's oversight of resident environmental safety. The Administrator acknowledged the choking incident involving Resident #1, and acknowledged the QA&A Committee's discussion of this incident, but provided no evidence of QA&A Committee intervention to ensure the security and monitoring of the resident environment, related to resident access to hazardous food items. A Plan To Abate the IJ Level Deficiency was received from the facility on October 9, 2013. 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 October 10, 2013, and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring a safe resident environment by securing resident food access in the dining areas and throughout the facility via newly implemented procedures, and completed a process of staff in-service training related to these new procedures. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of the resident environment related to resident access to food items. Findings include: Cross refer to F323. Record review for Resident #1 revealed a physician's orders [REDACTED]. However, a nursing facility Accident/Incident Report of 09/09/2013 documented an incident involving Resident #1 during which the resident had entered the Dining Room, obtained a sausage (of non-pureed consistency), put the sausage into his/her mouth, and subsequently sustained a partial airway obstruction and choked. During a 10/08/2013, 2:00 p.m. interview with the Assistant Director of Nursing (ADON), the choking incident of 09/09/2013 during which Resident #1, who required pureed food, gained access to non-pureed sausage was discussed. During this interview, the ADON was questioned regarding the facility's response to this incident, and about interventions the facility had developed and implemented to address the issue of residents having access to unsafe food items. The ADON stated that, as a response to Resident #1 having gained access to an unsafe food item, the Director of Nursing had begun the implementation of a New Dining Protocol involving the assignment of designated nursing staff to supervise resident dining areas during each meal service. This New Dining Protocol would also provide supervision, by designated nursing staff, for residents who dine in their rooms. However, the ADON acknowledged that, even though the implementation of the New Dining Protocol had begun, the facility had developed no mechanism to document nursing staff monitoring, nursing staff supervision, and nursing staff compliance with the newly-developed Protocol. The ADON also acknowledged the absence of a mechanism to assess the effectiveness of the new Protocol. During a subsequent telephone interview with the Administrator conducted on 10/10/2013 at 9:15 a.m., the Administrator was questioned about the QA&A Committee's oversight of resident environmental safety, related to access to hazardous food items, and the Committee's response to the choking incident of Resident #1. During this interview, the Administrator acknowledged the QA&A Committee's knowledge of this 09/09/2013 choking incident involving Resident #1. However, during this interview, the Administrator could provide no evidence of a QA&A Committee plan of action which addressed the known risk of resident access to hazardous food items, including mechanisms to evaluate the effectiveness of interventions, staffs' conformance with interventions, and the need to modify established interventions. Based on the above, the facility's QA&A Committee failed to ensure the implementation of corrective actions, related to providing a safe resident environment, which included measures to ensure the ongoing analysis of both the application and effectiveness of corrective interventions, and the need to modify established interventions. It was determined that the Immediate Jeopardy had been removed on 10/10/2013, by which time the facility had submitted a Plan To Abate the IJ Level Deficiencies and had implemented the following corrective actions: - On 10/08/2013, the facility completed implementation of a new Dining Protocol by which designated Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) would be assigned to the Main Dining Room and to the Restorative/Solarium dining area to monitor until all residents had completed each meal service, all meal trays were cleared by dietary staff, and meal tray carts had been returned to the Dietary Department. Additionally, unit RNs had been assigned to remain on the halls to supervise those residents who dine in their rooms, from the beginning of meal service until the meal trays had been collected and the dietary tray carts had been returned to the Dietary Department. All staff assignments related to the Dining Protocol are listed on a typed assignment form for staff reference. - On 10/08/2013, the facility developed and implemented a Nursing Monitoring Tool For Meals form to allow the assigned RN and LPN nursing staff to document resident monitoring during meal service in the resident dining areas as specified by the Dining Protocol, as referenced above. - On 10/08/2013, the facility completed in-service training for all nursing staff, dietary staff, and housekeeping/laundry staff regarding the Dining Protocol. - On 10/08/2013, the facility completed implementation of a new procedure making the Dietary Cook responsible for ensuring that the doors to the Main Dining Room are closed and secured after each meal service to prevent residents from obtaining food items that could cause choking. - On 10/08/2013, the facility developed and implemented a Monitoring Tool form to allow the Dietary Cook to document the securing of the Main Dining Room Doors after each meal service, as referenced above. - On 10/09/2013, the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas, with designated nurses having keys to allow residents to obtain snacks. The snack carts for the 7:00 a.m.-to-3:00 p.m. shift and the 3:00 p.m.-to-11:00 p.m. shift were to be locked in the pantry when the nutrition aide was not actively distributing snacks. This Snack Cart/Pantry Procedure for locking the pantry areas and securing the snack carts will be monitored by the Charge Nurse, who will document this monitoring each shift via the Snack Sign-Off List form upon delivery of the carts, and upon storage. - On 10/09/2013, the facility provided staff in-service training on the new procedure for securing the snack carts. As of 10/09/2013, eighty-nine (89) staff who were on duty received this in-service training, with the remaining sixty-four (64) staff to receive this training upon reporting to the facility for work. - On 10/09/2013, the facility had provided staff in-service training regarding the [MEDICATION NAME] Maneuver and the provision of care to an individual with an obstructed airway. As of that date, 122 employees, to include nursing staff, dietary staff, and housekeeping staff, had been trained, with the remaining thirty-one (31) employees to receive in-service training upon reporting to the facility for work. - On 10/09/2013, the facility included in the orientation procedures for new employees the requirement that all newly hired staff would receive training upon employment, to include training regarding the Dining Protocol, the Snack Cart/Pantry Procedure, and the [MEDICATION NAME] Maneuver to ensure resident safety. - On 10/09/2013, all residents with mechanically altered diets were assessed for tolerance and safety by Nursing Assessment and Speech Therapy, to ensure accurate assessment. - On 10/09/2013, the facility implemented a procedure by which the ADON would monitor staff conformance with the new Dining Protocol, the Main Dining Room door security procedure, and the Snack Cart/Pantry Procedure by monitoring the Nursing Monitoring Tool For Meals, the door Monitoring Tool, and the Snack Sign-Off List form three times weekly for six months. The ADON will then report the results of this monitoring to the Quality Assessment and Performance Improvement (QAPI) Committee for review. - On 10/09/2013, the facility implemented a procedure by which all compliance monitoring via the Nursing Monitoring Tool For Meals, the Dining Room door Monitoring Tool, and the Snack Sign-Off List will be presented by the ADON to the QAPI Committee. The Committee will evaluate staff compliance with these processes, and the effectiveness of the processes. All assigned nursing staff and dietary staff will continue recording on the monitoring tools for the next 6 months, and the QAPI Committee will then evaluate the frequency of monitoring, the need for additional staff training, and the effectiveness of interventions on an ongoing basis. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on October 10, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. In order to ensure that residents did not obtain food items which could represent a hazard, the facility had completed implementation of a new Dining Protocol by which designated licensed nursing staff would monitor the Main Dining Room, the Restorative/Solarium dining area, and the halls from the start of each meal service, all the way through completion and tray removal to ensure security. The facility had also completed implementation of a new procedure by which the Dietary Cook would ensure that the doors to the Main Dining Room are closed and secured after each meal service. However, both the new Dining Protocol and the process of securing the Main Dining Room doors had not been completed until 10/08/2013, only two days prior to the 10/10/2013 exit date of this survey. In addition, the facility had implemented the use of a Nursing Monitoring Tool For Meals form to monitor compliance with the Dining Protocol and a Monitoring Tool form to monitor compliance with securing Dining Room doors, but had only implemented the use of these monitoring tools on 10/08/2013, two days prior to the survey exit. Also, on 10/09/2013, the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas to allow for the security of snack carts. As of 10/09/2013, eighty-nine (89) staff who were on duty had received this in-service training, but the remaining sixty-four (64) staff would not receive training until they reported for work after the completion of this survey. Additionally, the ADON will be presenting the results of the Nursing Monitoring Tool For Meals, the Main Dining Room Monitoring Tool used for door security, and the Snack Sign-Off List form used for security of the snack carts to the QAPI Committee for the Committee's review, evaluation, and consideration of needed interventions. However, as of the 10/10/2013 exit date of this survey, the QAPI Committee had not yet met to initiate the evaluation of these new interventions to ensure resident health and safety, related to access to appropriate food items. The QAPI Committee's next scheduled meeting is in January of 2014. Therefore, the non-compliance continues, but the scope and severity level is reduced to a "D" level.

Based on record review, staff interview, nursing facility Accident/Incident Report review, and facility investigation summary review, the facility administration failed to ensure that the resident environment remained free of accident hazards, and failed to ensure adequate resident supervision, related to resident access to hazardous food items, for one (1) resident (#1), who was at risk for choking, required food of a pureed consistency, and had a history of [REDACTED]. This failure resulted in Resident #1 gaining access to the unattended Dining Room, obtaining and ingesting food of a non-pureed consistency, choking, and being found unresponsive and cyanotic. The resident was subsequently transferred to the hospital, was determined to have sustained a severe [MEDICAL CONDITION] neurological injury, was diagnosed with [REDACTED]. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Assistant Director of Nursing (ADON) was informed of the Immediate Jeopardy on [DATE], at 4:15 p.m. The situation involving facility staffs' failure to provide a safe environment for, and adequate supervision of, this resident who required food of a modified consistency which caused the Immediate Jeopardy was identified to have existed as of [DATE] (the date Resident #1 obtained food of a non-pureed consistency and choked), continued through [DATE], and was removed on [DATE]. During a telephone interview with the Administrator conducted on [DATE] at 3:35 p.m., the Administrator acknowledged awareness of Resident #1 obtaining food of an improper consistency and choking. During a subsequent interview with the ADON conducted on [DATE] at 9:30 a.m., the ADON referenced interventions regarding resident supervision and access to food items which were initiated after the choking incident involving Resident #1, but further acknowledged the lack of a system by which to assess the effectiveness of, and staffs' conformance with, these interventions prior to this complaint survey. A Plan To Abate the IJ Level Deficiency was received from the facility on [DATE]. 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 [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of ensuring a safe resident environment by securing resident food access in the dining areas and throughout the facility via newly implemented procedures, and completed a process of staff in-service training related to these new procedures. Observations were made to assess staff performance related to these new procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of the resident environment related to resident access to food items. Findings include: Cross refer to F323. Record review for Resident #1 revealed a physician's orders [REDACTED]. Resident #1's Care Plan also referenced that the resident received a pureed diet, but further identified a hazard of the resident putting inappropriate food items in his/her mouth, thus requiring staff monitoring and redirection. However, a nursing facility Accident/Incident Report of [DATE] documented that Resident #1 had entered the Dining Room, obtained a sausage from a food tray, and put the sausage into his/her mouth. This Report further documented that Resident #1 subsequently sustained a partial airway obstruction, choked, and was transported to the hospital. The facility's investigation summary documented that Resident #1 had entered the Main Dining Room and obtained a sausage, of which Dietary Aide "AA" had removed a portion from the resident's hand. However, Resident #1 was later observed to be unresponsive and cyanotic, having choked on a portion of the sausage which he/she had eaten. The resident was then transported to the hospital and admitted to the Intensive Care Unit on a ventilator, but was later disconnected from ventilator support and expired. During a telephone interview conducted on [DATE] at 3:35 p.m., the Administrator acknowledged awareness of Resident #1's history of removing food off of other residents' food trays, and acknowledged the [DATE] incident during which Resident #1 had entered the Dining Room and eaten a piece of sausage. The Administrator stated that, during the [DATE] incident, he had been approached by Dietary Aide "AA" who informed him that she had removed sausage from Resident #1's hand. However, the Administrator acknowledged that he neither examined Resident #1's mouth for remaining food at the time of the incident, nor informed a nurse of the incident. The Administrator voiced no information regarding corrective actions taken since the choking incident of Resident #1 to ensure a safe resident environment. During a [DATE], 2:00 p.m. interview with the Assistant Director of Nursing (ADON), the ADON was questioned about corrective actions which had been taken after the [DATE] choking incident involving Resident #1. During this interview, the ADON stated that, while the facility had begun the implementation of a system of assigning nursing staff in the dining areas to provide extra resident supervision during each meal service, she acknowledged that no system had been put into place to document this staff monitoring and to assess compliance with the newly-implemented protocol. During a subsequent telephone interview with the Administrator conducted on [DATE] at 9:15 a.m., during the discussion of interventions which had been in place prior to the [DATE] choking incident and corrective actions which had been taken in response to the incident, the Administrator referenced only the Care Plan intervention of monitoring Resident #1 which had been in place prior to the incident. The Administrator voiced no information regarding corrective actions taken since the choking incident of Resident #1 to ensure a safe resident environment. Based on the above, facility administration had failed to provide a secure environment, related to resident access to hazardous food items, thus allowing Resident #1, who required pureed food but who had a known history of obtaining food of an unsafe, non-pureed consistency, to obtain and ingest a non-pureed sausage. The resident subsequently choked and expired. Additionally, even after this choking incident involving Resident #1, the facility failed to implement a system consisting of both corrective actions to ensure a safe resident environment, and methods to evaluate the application and effectiveness of these corrective actions. This failure had caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. It was determined that the Immediate Jeopardy had been removed on [DATE], by which time the facility had submitted a Plan To Abate the IJ Level Deficiencies and had implemented the following corrective actions: - On [DATE], the facility completed implementation of a new Dining Protocol by which designated Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) would be assigned to the Main Dining Room and to the Restorative/Solarium dining area to monitor until all residents had completed each meal service, all meal trays were cleared by dietary staff, and meal tray carts had been returned to the Dietary Department. Additionally, unit RNs had been assigned to remain on the halls to supervise those residents who dine in their rooms, from the initiation of meal service until the meal trays have been collected and the dietary tray carts have been returned to the Dietary Department. All staff assignments related to the Dining Protocol are listed on a typed assignment form for staff reference. - On [DATE], the facility developed and implemented a Nursing Monitoring Tool For Meals form to allow the assigned RN and LPN nursing staff to document resident monitoring during meal service in the resident dining areas as specified by the Dining Protocol, as referenced above. - On [DATE], the facility completed in-service training for all nursing staff, dietary staff, and housekeeping/laundry staff regarding the Dining Protocol. - On [DATE], the facility completed implementation of a new procedure making the Dietary Cook responsible for ensuring that the doors to the Main Dining Room were closed and secured after each meal service to prevent residents from obtaining food items that could cause choking. - On [DATE], the facility developed and implemented a Monitoring Tool form to allow the Dietary Cook to document the securing of the Main Dining Room Doors after each meal service, as referenced above. - On [DATE], the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas, with designated nurses having keys to allow residents to obtain snacks. The snack carts for the 7:00 a.m.-to-3:00 p.m. shift and the 3:00 p.m.-to-11:00 p.m. shift were to be locked in the pantry when the nutrition aide was not actively distributing snacks. This Snack Cart/Pantry Procedure for locking the pantry areas and securing the snack carts will be monitored by the Charge Nurse, who will document this monitoring each shift via the Snack Sign-Off List form upon delivery of the carts, and upon storage. - On [DATE], the facility provided staff in-service training on the new procedure for securing the snack carts. As of [DATE], eighty-nine (89) staff who were on duty received this in-service training, with the remaining sixty-four (64) staff to receive this training upon reporting to the facility for work. - On [DATE], the facility had provided staff in-service training regarding the [MEDICATION NAME] Maneuver and the provision of care to an individual with an obstructed airway. As of that date, 122 employees, to include nursing staff, dietary staff, and housekeeping staff, had been trained, with the remaining thirty-one (31) employees to receive in-service training upon reporting to the facility for work. - On [DATE], the facility included in the orientation procedures for new employees the requirement that all newly hired staff would receive training upon employment, to include training regarding the Dining Protocol, the Snack Cart/Pantry Procedure, and the [MEDICATION NAME] Maneuver, to ensure resident safety. - On [DATE], all residents with mechanically altered diets were assessed for tolerance and safety by Nursing Assessment and Speech Therapy, to ensure accurate assessment. - On [DATE], the facility implemented a procedure by which the ADON would monitor staff conformance with the new Dining Protocol, the Main Dining Room door security procedure, and the Snack Cart/Pantry Procedure by monitoring the Nursing Monitoring Tool For Meals, the door Monitoring Tool, and the Snack Sign-Off List form three times weekly for six months. The ADON will then report the results of this monitoring to the Quality Assessment and Performance Improvement (QAPI) Committee for review. - On [DATE], the facility implemented a procedure by which all compliance monitoring via the Nursing Monitoring Tool For Meals, the Dining Room door Monitoring Tool, and the Snack Sign-Off List will be presented by the ADON to the QAPI Committee. The Committee will evaluate staff compliance with these processes, and the effectiveness of the processes. All assigned nursing staff and dietary staff will continue recording on the monitoring tools for the next 6 months, and the QAPI Committee will then evaluate the frequency of monitoring, the need for additional staff training, and the effectiveness of interventions on an ongoing basis. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on [DATE]. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. In order to ensure that residents did not obtain food items which could represent a hazard, the facility had completed implementation of a new Dining Protocol by which designated licensed nursing staff would monitor the Main Dining Room, the Restorative/Solarium dining area, and the halls from the start of each meal service, all the way through completion and tray removal to ensure security. The facility had also completed implementation of a new procedure by which the Dietary Cook would ensure that the doors to the Main Dining Room are closed and secured after each meal service. However, both the new Dining Protocol and the process of securing the Main Dining Room doors had not been completed until [DATE], only two days prior to the [DATE] exit date of this survey. In addition, the facility had implemented the use of a Nursing Monitoring Tool For Meals form to monitor compliance with the Dining Protocol and a Monitoring Tool form to monitor compliance with securing Dining Room doors, but had only implemented the use of these monitoring tools on [DATE], two days prior to the survey exit. Also, on [DATE], the facility implemented a Snack Cart/Pantry Procedure by which locks were placed on the resident pantry areas to allow for the security of snack carts. As of [DATE], eighty-nine (89) staff who were on duty had received this in-service training, but the remaining sixty-four (64) staff would not receive training until they reported for work after the completion of this survey. Additionally, the ADON will be presenting the results of the Nursing Monitoring Tool For Meals, the Main Dining Room Monitoring Tool used for door security, and the Snack Sign-Off List form used for security of the snack carts to the QAPI Committee for the Committee's review, evaluation, and consideration of needed interventions. However, as of the [DATE] exit date of this survey, the QAPI Committee had not yet met to initiate the evaluation of these new interventions to ensure resident health and safety, related to access to appropriate food items. The QAPI Committee's next scheduled meeting is in January of 2014. Therefore, the non-compliance continues, but the scope and severity level is reduced to a "D" level.