Every finding on record at Pruitthealth - Laurel Park, LLC

Based on observations, staff interviews, record review, and review of the facility's policies titled Infection Prevention and Control Surveillance and Infection Prevention - Hand Hygiene, the facility failed to ensure infection control practices were followed for two of two sampled residents (R) (R4 and R5) from a total sample of five residents. This deficient practice had the potential to place R4 and R5 at risk of medical complications. Findings include: Review of the facility's policy titled Infection Prevention and Control Surveillance, reviewed 11/17/2025, revealed the Policy Statement section included, [Name of facility] maintains a surveillance program for the tracking, prevention and follow-up of all partner and patient/resident infections.Review of the facility's policy titled Infection Prevention - Hand Hygiene, reviewed 11/17/2025, revealed the Procedures section included, G. Other Aspects of Hand Hygiene . 4. Perform hand hygiene and change gloves during resident care if moving from contaminated body site to a clean body site.1. Review of the admission Minimum Data Set (MDS) for R4, dated 12/17/2025, revealed that Section GG (Functional Abilities and Goals) documented that R4 required partial/moderate assistance with toileting. Section H (Bladder and Bowel) documented that R4 was incontinent of bowel and bladder.Observation on 12/30/2025 at 9:08 am, of incontinence care for 4, revealed Certified Nursing Assistant (CNA) AA used the same section of the washcloth to wipe more than one area of the perineum and did not use a separate section of the washcloth when cleansing/wiping the perineum. Review of the facility's document Bathing - Perineal Care Female dated 8/1/2025 documented return demonstration checklist for CNA AA to cleanse . Use a different part of the washcloth for each stroke.In an interview on 12/30/2025 at 2:25 pm, Licensed Practical Nurse (LPN) CC stated that during incontinence care, the perineum should be wiped from front to back with a different section of the washcloth or wipes. She stated that the same section should not be used more than once, since the section used was dirty and could cause infections, such as urinary tract infections, among the residents.In an interview on 12/30/2025 at 2:30 pm, the Assistant Director of Nursing (ADON) stated that the washcloth should be folded and a clean section used to wipe each section of the perineum during incontinence care. She stated that if this was not done, the resident would be at risk of infection, such as a urinary tract infection.In an interview on 12/30/2025 at 2:35 pm, CNA AA confirmed she used the same part of the washcloth to wipe more than one area of the perineal area while providing incontinent care for R4. She stated she should not have used the same part of the washcloth to wipe more than one area of the perineum. She further stated the residents could get infections if the washcloth was not folded, and she did not wipe once and then change each section of the washcloth for each wipe. 2. Review of the Quarterly MDS for R5 revealed that Section GG (Functional Abilities and Goals) documented that R5 required substantial /maximum assistance with toileting and partial/moderate assistance for personal hygiene. Section H (Bladder and Bowel) documented that R5 was incontinent of bowel and bladder.Observation on 12/30/2025 at 10:30 am, during observation of incontinence care for R5, revealed CNA BB cleaned bowel movement from R5 and did not change gloves before applying barrier ointment to R5's perineum.Record review of the facility's document Hand Hygiene Competency ValidationSoap & Water; Alcohol Based Hand Rub (ABHR) (60% - 95% alcohol content), dated 8/1/2025, documented annual competency return demonstration was done for CNA BB.In an interview on 12/30/2025 at 2:25 pm, LPN CC stated that during incontinence care, after cleaning bowel movement, gloves should be removed, hands should be sanitized, and a new pair of gloves should be put on. She stated that if this was not done, the residents could get infections.In an interview on 12/30/2025 at 2:30 pm, the Assistant Director of Nursing (ADON) stated that during incontinence care, gloves should be changed when leaving a dirty area for a clean area and after cleaning a bowel movement. She stated that the residents could get infections if this was not done.In an interview on 12/30/2025 at 2:58 pm, CNA BB confirmed she did not change her gloves after cleaning the R5's resident's bowel movement, and she used the same pair of gloves to apply barrier ointment to R5's perineum. She stated that this could transfer bacteria from one area to another and cause infections for residents.

Based on observations, staff and resident representative interviews, record review, and review of the facility policies titled, Enhanced Barrier Precaution (EBP), the facility failed to implement appropriate infection prevention and control practices for one of 62 sampled residents (R) (R134). Specifically, the facility failed to ensure staff consistently used the required personal protective equipment (PPE) in accordance with EBP protocols, failed to follow proper perineal and catheter care techniques, and failed to use facility-specified products for these procedures. The deficient practices placed R134 at increased risk for infection, cross-contamination, and delayed wound healing.Findings include:Review of the facility's policy titled Enhanced Barrier Precautions (EBP) revised 5/27/2025 revealed under Procedure, section 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. The policy further defines EBP as an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. Under Procedure, section 2: EBP refers to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 2. b. Any wound (e.g., chronic wounds such as but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a multidrug-resistant organism.Review of the facility skills checkoff list titled Catheter Care-Foley Catheter and Bathing-Perineal Care Female both undated, revealed both procedures direct staff to use soap and water (cleansing agent and wet washcloth) rather than disposable wipes for perineal hygiene. Further review of the cleanse sections instructed staff to use a clean part of the washcloth for each stroke. Review of the electronic medical record (EMR) revealed R134 was recently hospitalized with severe sepsis from 7/7/2025 to 7/14/2025. Review of hospital records indicated that blood cultures revealed ESBL (Extended-Spectrum Beta-Lactamase) E. coli (Escherichia coli, bacteria that normally live in the intestines of healthy people) bacteremia (the presence of bacteria in your blood), with the likely source identified as a urinary tract infection. The resident was prescribed and receiving intravenous (IV) antibiotic therapy. R134 has pertinent diagnoses including, but not limited to, severe sepsis, acute kidney failure, stage 4 pressure ulcer of the sacral region, urinary tract infection, dysphagia, essential hypertension, morbid obesity, cerebral infarction, metabolic encephalopathy, depression, gastroesophageal reflux disease, and long-term use of antibiotics.Review of R134's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was not completed due to the resident's inability to communicate; staff assessment indicated a score of 0, which represents severe cognitive impairment. Section GG, Functional Status, revealed R134 required extensive assistance with two-person physical help for all activities of daily living (ADLs), including bed mobility, transfers, dressing, personal hygiene, and toileting. R134 remained in bed at all times and was non-ambulatory. Review of the Care Area Assessment (CAA) indicated R134 was identified with cognitive loss related to cerebrovascular accident, communication deficits due to difficulty being understood and expressing needs, impaired activities of daily living and mobility requiring total care, and the use of an indwelling urinary catheter due to a stage 4 sacral pressure ulcer.Review of R134's care plan dated 7/2/2025 indicated a problem related to infection risk due to impaired mobility, presence of an indwelling urinary catheter, and dependence on staff for personal hygiene and toileting. Goals included, but were not limited to, ensuring R134 remained free from signs and symptoms of urinary tract infections and that catheter care would be managed appropriately. Interventions included, but were not limited to, providing catheter care as needed, assessing catheter drainage every shift for color, odor, and leakage, reporting signs of infection such as fever or foul-smelling urine, and assisting the resident with bathing, perineal hygiene, and repositioning to support skin integrity and prevent infection.Review of the Physician's Orders for R134 included but was not limited to: Order dated 6/26/2025 for indwelling urinary catheter care every shift and as needed, including assessment for leakage, dislodgement, obstruction, and monitoring urine characteristics to identify potential infection. Order dated 6/26/2025 to monitor and record intake and output, and to note if a urine specimen is sent to the lab for analysis. Order dated 6/26/2025 to change Foley catheter monthly and as needed per facility protocol. Order dated 7/14/2025 for meropenem 1 gram IV every 8 hours for 5 days, indicating treatment for a current or suspected infection. Order dated 9/14/2024 for Enhanced Barrier Precautions due to gastric tube and sacral ulcer, every shift. Order dated 7/15/2025 for wound care treatments to multiple areas including sacral wound, using antimicrobial dressings such as calcium alginate with silver, with dressing changes ordered multiple times per week and daily condition checks.Observation on 7/15/2025 at 12:59 pm of R134 revealed R134 was not interview able and laying in bed receiving enteral nutrition (also called tube feeding, is a way of providing nutrition directly into the gastrointestinal (GI) tract through an enteral access device (feeding tube) that is placed with its tip in the stomach or small intestine). R134 appeared clinically vulnerable, with documented Stage 4 pressure ulcer. Recent hospitalization from 7/7/2025 to 7/14/2025 for severe sepsis and was receiving IV antibiotic therapy. Interview on 7/17/2025 at 10:40 am with R134's representative revealed concern about her mother's recent hospitalization for sepsis and pneumonia and limited communication from the facility regarding her condition and infection management.Observation on 7/17/2025 at 11:00 am revealed that Certified Nursing Assistants (CNAs) GG and HH provided perineal (the space between the anus and the genitals) and catheter care to R134 without adhering to required Enhanced Barrier Precautions (EBP). Despite signage indicating EBP, both CNAs entered the resident's room without donning (putting on) gowns while delivering direct care to a resident with an active stage 4 pressure ulcer. During the procedure, CNA GG used wet (water) wipes in place of soap and water, contrary to facility protocol. CNA HH was observed using the same wipe for multiple cleansing strokes to the buttocks, increasing the risk of cross-contamination. Additionally, the same incontinence brief was reapplied after care was completed, rather than replacing it with a clean one.Interview with CNA HH on 7/16/2025 at 11:16 am acknowledged she did not wear the required gown while providing care to R134.Interview with CNA GG on 7/16/2025 at 11:22 am admitted she also failed to wear a gown, citing lack of accessible PPE near the R134's room.Interview on 7/16/2025 at 11:43 am with the Registered Nurse Clinical Competency Coordinator (RN CCC) revealed she was still in the process of developing a structured training program.Interview on 7/16/2025 at 11:43 am with the Director of Nursing (DON) confirmed that staff were required to wear gowns for residents on EBP. She acknowledged the nearest PPE cart was across the hallway and verified that facility protocol required the use of soap and water, not wipes, for catheter care.Findings include:Review of the facility's policy titled Enhanced Barrier Precautions (EBP) revised 5/27/2025 revealed under Procedure, section 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. The policy further defines EBP as an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. Under Procedure, section 2: EBP refers to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and glove use during high contact resident care activities. 2. b. Any wound (e.g., chronic wounds such as but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a multidrug-resistant organism.Review of the facility skills checkoff list titled Catheter Care-Foley Catheter and Bathing-Perineal Care Female both undated, revealed both procedures direct staff to use soap and water (cleansing agent and wet washcloth) rather than disposable wipes for perineal hygiene. Further review of the cleanse sections instructed staff to use a clean part of the washcloth for each stroke.Review of the electronic medical record (EMR) revealed R134 was recently hospitalized with severe sepsis from 7/7/2025 to 7/14/2025. Review of hospital records indicated that blood cultures revealed ESBL (Extended-Spectrum Beta-Lactamase) E. coli (Escherichia coli, bacteria that normally live in the intestines of healthy people) bacteremia (the presence of bacteria in your blood), with the likely source identified as a urinary tract infection. The resident was prescribed and receiving intravenous (IV) antibiotic therapy. R134 has pertinent diagnoses including, but not limited to, severe sepsis, acute kidney failure, stage 4 pressure ulcer of the sacral region, urinary tract infection, dysphagia, essential hypertension, morbid obesity, cerebral infarction, metabolic encephalopathy, depression, gastroesophageal reflux disease, and long-term use of antibiotics.Review of R134's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was not completed due to the resident's inability to communicate; staff assessment indicated a score of 0, which represents severe cognitive impairment. Section GG, Functional Status, revealed R134 required extensive assistance with two-person physical help for all activities of daily living (ADLs), including bed mobility, transfers, dressing, personal hygiene, and toileting. R134 remained in bed at all times and was non-ambulatory. Review of the Care Area Assessment (CAA) indicated R134 was identified with cognitive loss related to cerebrovascular accident, communication deficits due to difficulty being understood and expressing needs, impaired activities of daily living and mobility requiring total care, and the use of an indwelling urinary catheter due to a stage 4 sacral pressure ulcer.Review of R134's care plan dated 7/2/2025 indicated a problem related to infection risk due to impaired mobility, presence of an indwelling urinary catheter, and dependence on staff for personal hygiene and toileting. Goals included, but were not limited to, ensuring R134 remained free from signs and symptoms of urinary tract infections and that catheter care would be managed appropriately. Interventions included, but were not limited to, providing catheter care as needed, assessing catheter drainage every shift for color, odor, and leakage, reporting signs of infection such as fever or foul-smelling urine, and assisting the resident with bathing, perineal hygiene, and repositioning to support skin integrity and prevent infection.Review of the Physician's Orders for R134 included but was not limited to: Order dated 6/26/2025 for indwelling urinary catheter care every shift and as needed, including assessment for leakage, dislodgement, obstruction, and monitoring urine characteristics to identify potential infection. Order dated 6/26/2025 to monitor and record intake and output, and to note if a urine specimen is sent to the lab for analysis. Order dated 6/26/2025 to change Foley catheter monthly and as needed per facility protocol. Order dated 7/14/2025 for meropenem 1 gram IV every 8 hours for 5 days, indicating treatment for a current or suspected infection. Order dated 9/14/2024 for Enhanced Barrier Precautions due to gastric tube and sacral ulcer, every shift. Order dated 7/15/2025 for wound care treatments to multiple areas including sacral wound, using antimicrobial dressings such as calcium alginate with silver, with dressing changes ordered multiple times per week and daily condition checks.Observation on 7/15/2025 at 12:59 pm of R134 revealed R134 was not interview able and laying in bed receiving enteral nutrition (also called tube feeding, is a way of providing nutrition directly into the gastrointestinal (GI) tract through an enteral access device (feeding tube) that is placed with its tip in the stomach or small intestine). R134 appeared clinically vulnerable, with documented Stage 4 pressure ulcer. Recent hospitalization from 7/7/2025 to 7/14/2025 for severe sepsis and was receiving IV antibiotic therapy.Interview on 7/17/2025 at 10:40 am with R134's representative revealed concern about her mother's recent hospitalization for sepsis and pneumonia and limited communication from the facility regarding her condition and infection management.Observation on 7/17/2025 at 11:00 am revealed that Certified Nursing Assistants (CNAs) GG and HH provided perineal (the space between the anus and the genitals) and catheter care to R134 without adhering to required Enhanced Barrier Precautions (EBP). Despite signage indicating EBP, both CNAs entered the resident's room without donning (putting on) gowns while delivering direct care to a resident with an active stage 4 pressure ulcer. During the procedure, CNA GG used wet (water) wipes in place of soap and water, contrary to facility protocol. CNA HH was observed using the same wipe for multiple cleansing strokes to the buttocks, increasing the risk of cross-contamination. Additionally, the same incontinence brief was reapplied after care was completed, rather than replacing it with a clean one.Interview with CNA HH on 7/16/2025 at 11:16 am acknowledged she did not wear the required gown while providing care to R134.Interview with CNA GG on 7/16/2025 at 11:22 am admitted she also failed to wear a gown, citing lack of accessible PPE near the R134's room.Interview on 7/16/2025 at 11:43 am with the Registered Nurse Clinical Competency Coordinator (RN CCC) revealed she was still in the process of developing a structured training program.Interview on 7/16/2025 at 11:43 am with the Director of Nursing (DON) confirmed that staff were required to wear gowns for residents on EBP. She acknowledged the nearest PPE cart was across the hallway and verified that facility protocol required the use of soap and water, not wipes, for catheter care.

Based on staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to review and revise the comprehensive care plan for one of 62 sampled residents (R) (R12). This deficient practice had the potential to cause unmet care needs, isolation, and/or a decline in psychosocial well-being. Findings include:Review of the facility's policy titled Care Plans revised 7/27/2023, noted under admission Comprehensive Plan of Care: . The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. Review of R12 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 13, which indicates R12 was cognitively intact. Section B, Hearing, Speech, and Vison revealed R12 usually understood-difficulty communicating some words or finishing thoughts if prompted or given time, usually understands-misses some part/intent of message but comprehends most communication.Review of R12's care plan dated 11/9/2021 and 2/10/2022 indicated problems related to a language barrier, as the resident's primary language is Spanish, which impacted her ability to communicate with staff and fully participate in facility activities. Goals included ensuring the resident would be able to make her needs known and communicate with staff without difficulty, and that staff would continue to encourage her participation in preferred activities such as bingo, music, movies, and card games. Interventions included providing an interpreter daily as needed to assist with completion of activities of daily living (ADLs), using the interpreter line as needed during activities, contacting the resident's son if an interpreter was unavailable, and encouraging her continued participation and socialization with other residents. No changes made to R12's care plan regarding communication.Interview with MDS Coordinator II on 7/17/2025 at 4:15 pm revealed that R12's communication needs had not been reassessed or updated since admission. Although the MDS was completed quarterly and may trigger reviews for issues like pain, communication barriers were only addressed during the initial assessment and not routinely revisited unless staff reported concerns. MDS Coordinator II confirmed that no changes had been made to R12's care plan regarding communication despite her continued difficulty in effectively conveying her needs to staff.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Assistance for Resident with Communication/Language Barriers, the facility failed to ensure consistent, effective two-way communication for one of 62 sampled residents (R) (R12). This deficient practice had the potential to place the R12 at risk for unmet care needs, decreased independence, and potential decline in physical and psychosocial well-being. Findings include:Review of the facility's policy titled Assistance for Resident with Communication/Language Barriers revised 3/16/2023 noted under Procedure: 1. An assessment will be made by the RN/Interdisciplinary Team (IDT) to determine: The specific nature and degree of impairment, resources (persons and equipment) available to and utilized by the client, and present and possible future needs and problems. 2. When the services of qualified interpreters are needed, appropriate agencies will be contacted and utilized, and efforts will be made to help provide for the residents to obtain other aids, such as communication boards, bells, intercoms, etc. 3. The team members will be advised of any special needs the resident has, and the plan of care will be developed to meet these needs.Review of the electronic medical record (EMR) revealed R12 was admitted to the with pertinent diagnoses including but not limited to a primary diagnosis of chronic obstructive pulmonary disease (COPD), schizoaffective disorder, bipolar disorder, depression, anxiety disorder, difficulty in walking, generalized muscle weakness, dysphagia, pain-unspecified, asthma, and insomnia. R12 is of Hispanic, Latino/a, Spanish origin, and speaks and understands only Spanish.Review of R12 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13, which indicates R12 was cognitively intact. Review of R12's care plan dated 11/9/2021 and 2/10/2022 indicated problems related to a language barrier, as the resident's primary language is Spanish, which impacted her ability to communicate with staff and fully participate in facility activities. Goals included ensuring the resident would be able to make her needs known and communicate with staff without difficulty, and that staff would continue to encourage her participation in preferred activities such as bingo, music, movies, and card games. Interventions included providing an interpreter daily as needed to assist with completion of activities of daily living (ADLs), using the interpreter line as needed during activities, contacting the resident's son if an interpreter was unavailable, and encouraging her continued participation and socialization with other residents.Review of progress notes dated 5/12/2025 through 7/14/2025 revealed no documentation that staff utilized the language line or contacted the resident's son to assist with two-way communication. Notes did not include evidence that the resident was provided with routine access to interpretation services to facilitate her ability to initiate communication, express needs, or participate fully in care discussions. Observation and interview on 7/16/2025 at 2:14 pm with R12 in the activity room while she was coloring. The interview was conducted in Spanish, as this Surveyor was fluent in Spanish and able to communicate directly with the resident. R12 stated she was unable to effectively communicate with facility staff, as they did not speak Spanish and she did not understand English. She reported that when she first arrived at the facility, staff occasionally used the Language Line, but it had not been used in a very long time, and she could not recall the last time interpretation services were offered. R12 shared she had been experiencing a recurring white film on her tongue that caused pain, which she brushed away each morning but it returned; she stated she had shown this to nursing staff, but did not believe her concern had been understood due to the language barrier. Additionally, she stated that staff did not make her bed and she had to do it herself, and expressed that she did not know how to communicate her needs or concerns to staff.Observation and interview on 7/17/2025 at 9:30 am R12 in her room revealed that she reported waking up with a white powder on her tongue and mentioned that she used to receive a liquid medication to treat this condition. When asked if she had informed nursing staff about it that morning, R12 confirmed that she had but stated that she did not know if they understood what she was trying to communicate since nothing had been done.Observation and interview on 7/17/2025 at 10:10 am with the Assistant Director of Nursing (ADON) in R12 room revealed that she relied primarily on interpreting the resident's gestures, such as pointing, to guess what the resident was trying to express. Although she mentioned the availability of the language line and contacting R12's son, these methods were not actively in use at the time. When the ADON accompanied the surveyor into R12's room and R12 attempted to explain her concerns about her tongue, the ADON admitted she could not understand what the resident was saying and would probably need to contact the language line or her son. She acknowledged that communication with R12 was difficult and could be better.Interview with the Activities Director (AD) on 7/16/2025 at 2:56 pm revealed a lack of consistent and reliable communication methods in place for R12. She stated she assumed the resident understood some English based on her nodding, without verifying the resident's actual comprehension. The language line was only used when communication became particularly difficult, rather than as a routine method. She also claimed that Registered Nurse (RN) CC translated for the resident; however, a follow-up interview with RN CC revealed he did not speak Spanish and did not provide interpretation for R12. Additionally, the AD admitted she had not recently participated in any care plan meetings for R12. Interview with RN CC on 7/16/2025 at 3:21 pm revealed that he did not speak Spanish and was not involved in translating for R12. He stated that he was Filipino and did not provide interpretation services for Spanish-speaking residents. Interview with RN BB on 7/16/2025 at 4:13 pm, who had been assigned to R12 for the past three days, revealed a lack of adequate measures to support two-way communication. RN BB confirmed that while the language line was available to her, she admitted there was no system in place to allow R12 to independently request its use. There was nothing posted in the resident's room or elsewhere to inform her of the option, and R12 was unable to initiate communication in English. When asked how R12 was expected to communicate her needs, RN BB acknowledged that communication was one-sided and conceded she had not considered the issue from the resident's perspective or recognized the extent of the barrier.Interview with the Director of Nursing (DON) on 7/17/2025 10:10 am confirmed that she had been made aware of R12's ongoing struggles to communicate with staff due to the language barrier. The DON acknowledged that R12 had attempted to report certain concerns but had difficulty conveying this to staff. The DON admitted that the facility had not implemented any tools or systems to support R12's ability to initiate communication, such as signage or a communication board. She stated that she would now begin preparing or purchasing a communication board and creating a sign that R12 could use to indicate when she needed the language line.

Based on observations, staff interviews, record review, and review of the facility policy titled, Discharge and Monthly Deep Cleaning of the Resident Room, the facility failed to maintain a clean, homelike environment related to dirty packaged terminal air conditioner (PTAC) grills, dusty bathroom air vents, and ill-fitting or missing toilet tank lids in four of 15 rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) observed. Findings include: Review of the facility policy titled, Discharge and Monthly Deep Cleaning of the Resident Room, original date October 2020 revealed the following: Procedure: 1. Before beginning the deep/discharge clean, confirm with the Maintenance Director and Housekeeping Supervisor that all Maintenance and Floor Care needs (patch/paint, ceiling tiles, leaky faucets, PTAC units/coils, buffing, scrub/topcoat, strip/topcoat, etc.) have been addressed. 8. Clean and dust A/C [air conditioning] grills and returns in ceiling (daily cleaning and monthly deep cleaning/discharge cleaning) Observations of the 100 Hall on 10/31/2023 revealed the following: 10/31/2023 at 12:16 pm: room [ROOM NUMBER]-dirty PTAC front grill, dusty bathroom air vent, toilet tank cover did not fit. 10/31/2023 at 2:41 pm: room [ROOM NUMBER]-no toilet tank cover; dusty bathroom air vents. 10/31/2023 at 2:53 pm: room [ROOM NUMBER]-dirty PTAC front grill, dusty bathroom air vent, toilet tank cover did not fit. 10/31/2023 at 5:19 pm: room [ROOM NUMBER]-dusty bathroom air vents. Observations of rooms 104, 105, 110, and 112 on 11/1/2023 beginning at 3:45 pm revealed the room conditions had not changed. Interview on 11/1/2023 at 4:30 pm with Housekeeping Aide (HA) BB, he stated he mostly was responsible for cleaning floors and only occasionally cleaned resident rooms; however, he confirmed the bathroom air vent cleaning was the responsibility of the housekeeping staff, but he was not sure about the PTAC front grills. He stated the toilet tank covers were a maintenance task. Observation and interview on 11/02/2023 at 6:08 pm with the Housekeeping Supervisor, he confirmed the observations of dusty bathroom air vents (rooms 104, 105, 110, 112), dirty PTAC front grills (rooms 105, 112), and ill-fitting toilet tank covers (rooms 105, 110, 112). He stated the PTAC front grills and toilet tank covers were tasks for Maintenance, but they have not had a director or supervisor since 10/4/2023. He stated the bathroom air vents should be dusted at least every 30 days on the outside, but Maintenance would have to vacuum inside the air vents when needed. He confirmed the air vents likely had not been dusted for at least 30 days, but he had no documentation to determine the last time the air vents were dusted. Review of the building management platform for senior living electronic logbook documentation revealed PTAC air filters were cleaned on 10/27/2023. There was no documentation related to cleaning the PTAC grills. Interview on 11/2/2023 at 6:09 pm with the Administrator, she stated she was not aware of the housekeeping and maintenance concerns, but the new Maintenance Director would be starting next week.

Based on observation, resident and staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Administration, the facility failed to ensure physician's orders were followed correctly for continuous O2 for one of 16 sampled residents (R) (R30). Findings include: Review of the policy titled Oxygen Administration revised 8/2/2023 revealed the policy's Procedure: 1. Oxygen will be administered by licensed personnel only when ordered by the physician, PA [physician's assistant], or NP [nurse practitioner]. The physician order may be written Pro Re Nata (PRN) or as needed for comfort, or it may specify the number of liters, method of administration and the length of time the oxygen is to be administered. 2. The use of oxygen will be based on the resident's clinical condition, comfort level, and the resident's and/or family's desire for oxygen therapy. 3. A licensed nurse or Respiratory Therapist will assess the resident's respiratory status. Review of the medical record for R30 revealed diagnoses including acute respiratory failure with hypoxia, paroxysmal atrial fibrillation, transient ischemia attacks (TIA), and congestive heart failure (CHF). Review of R30's quarterly Minimum Data Set (MDS) dated [DATE] revealed: section C indicated the Brief Interview for Mental Status (BIMS) score was 13, indicating no cognitive deficit for R30; section GG indicated required substantial maximum assistance with one or two persons with activities of daily living (ADL); section O indicated resident received O2 prior to his admission and since his admission to the facility. Review of R30's care plan dated 12/1/2022 revealed R30 had an ineffective airway clearance related to atrial fibrillation, history of O2 use and current use of O2 at 2 Liters Per Minute (LPM) via nasal cannula (NC). Review of the physician's order revealed an order dated 10/12/2022: Oxygen at 2 LPM via NC to keep O2 Sats [saturation] > [greater] than 92% every shift day, night. Change respiratory circuit supplies weekly once a day on Monday nights. Pulse oximeter check PRN to obtain oxygen saturation rate. Observation and interview 11/1/2023 at 11:45 am revealed R30 sitting up in a wheelchair in his room watching TV. When asked about his sleep last night he nodded his head yes, it was good. R30 asked to change the channel on his television. I informed the nursing staff of R30's request. Observation of the O2 concentrator [machine that converts room air into oxygen] with humidifier bottle revealed no date or label was noted on the O2 tubing or humidifier bottle. The flow meter on the O2 concentrator was set between 2.5 and 3 LPM. The physician's order revealed an order for 2 LPM O2 by NC. Observation 11/2/2023 at 10:15 am revealed R30 sitting up in the chair awake and alert watching TV. O2 through NC was set at 1.5 LPM. Interview 11/2/2023 at 5:30 pm with Registered Nurse (RN) AA revealed the 10/12/2022 O2 order was for 2 LPM through NC as listed on the Medication Administration Record (MAR) 11/2/2023. R30's O2 tubing was off and laying on the bedside table. O2 was ordered continuously day and night, every shift. The nurse replaced the tubing on R30. The flow meter was set at 1.5 LPM and not 2 LPM as verified by RN AA. She had to squat down to eye level to read the dosage set on the flow meter. The nurse confirmed that the doctor's order for O2 was written for 2 LPM continuously and not 1.5 LPM as set on the flow meter of the O2 concentrator. Interview 11/2/2023 at 6:00 pm with the DON revealed that the O2 flow was off because the nurse read it in error. She stated the nurse tried to read the flow meter from a standing position looking downward on the ball, which gives a false reading. She stated the nurse should squat down at eye level and read the flow meter directly from the front view which will give an accurate reading and location of where the ball is. She stated that she would educate staff immediately on the correct position to read the O2 flow meter, and the correct position of the ball on the flow meter. She stated going forward it was the expectation that the nurses will follow the policies that are in place for O2 settings and administration of O2.

Based on record review, facility policy review, observations and interview, it was determined the facility failed to have enough nursing staff available to ensure residents were provided incontinence care in a timely manner, were provided showers timely, and had call lights answered timely. The failure to ensure adequate nurse department staffing affected six of 28 residents selected for review of staffing (Resident (R) #1, #5, R#13, R#14, R#15, and R#16). Findings include: Review of the facility Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property policy revised/reviewed 9/20/19 revealed components which directly addressed staffing included: -The deployment of staff on each shift in sufficient numbers to meet the needs of patients and to see that staff assigned have knowledge of the individual patient's care needs. -The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring patients while providing care, directing patients who need toileting assistance to urinate or defecate in their beds. -The assessment, care planning, and monitoring of patients with needs and behaviors that might lead to conflict or neglect, such as patients .who require heavy nursing care or are totally dependent on staff. -Providers should conduct periodic staffing requirement analysis. 1. R#13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], coded the resident as having a score of 15 for a Brief Interview of Mental Status (BIM), which indicated intact cognition. The MDS coded the resident as needing extensive assistance with toileting and hygiene. The resident was also coded as being incontinent of bowel and bladder. Review of the care plan, dated 5/14/2020, documented under Problems, the resident has self-care deficit due to impaired mobility due to [DIAGNOSES REDACTED]. Approaches listed included to assist with toileting on routine care rounds and as needed. Peri-care per incontinent episodes. Assist with dressing and grooming daily and as needed. The goal for the resident was to maintain/improve ADL functioning. On 10/12/2020 at 2:00 p.m., in an interview with R#13, she stated, Sometimes I have to wait to go to the bathroom. It has been awhile since that happened, but I had to wait about an hour (60 minutes). 2. R#14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], coded the resident as having a BIM score of 15, which indicated intact cognition. The MDS coded the resident as being totally dependent on staff for toileting and needing extensive assistance for personal hygiene. The resident was also coded as being incontinent of bowel and bladder. Review of the care plan, dated 6/20/2020, documented under Problems, ADL Functional/ Rehabilitation Potential, ADL decline due to recent hospitalization . Approaches listed were to set up Resident for ADLs, Physical Therapy/Occupational Therapy (PT/OT) to evaluate and treat. Goals listed were the resident will improve in ADL function to maintain independence. On 10/12/2020, at 2:30 p.m., in an interview with R#14, she stated, The CNAs take a while to answer the call light, sometimes more than an hour (60 minutes). Sometimes I sit in urine for a while. Sometimes they tell me they don't have enough people. 3. R#15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], coded the resident as having a BIM score of 15, which indicated intact cognition. The MDS coded the resident as needing limited assistance with toileting and extensive assistance with hygiene. Review of the care plan, dated 9/25/2020, documented under Problems, ADL Functional/Rehabilitation Potential and ADL decline as a result of a fall at home. Approaches listed were setting up ADLs, provide assistive devices, encourage the resident to do as much as possible. The goal was to improve ADL function to maintain independence. On 10/12/2020, at 2:50 p.m., in an interview with R#15, she stated, They don't answer the call lights very quickly. I am independent, but I have to wait for someone to take me to the shower. Sometimes I wait a long time. 4. R#16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], coded the residents BIM score as 15 indicating intact cognition. The MDS also coded the resident as needing extensive assistance with toileting and hygiene and was also coded a being incontinent of bowel and bladder. On 10/13/2020, at 10:00 a.m., in an interview with R#16, she stated, They don't answer the call lights very quickly. Sometimes I am soaking wet waiting for someone to answer my call light. Sometimes the only have two people on for the 3:00 (p.m.) to 11:00 (p.m.) shifts. There is not always enough help. 5. Review of the medical record of R#5 revealed an original admission date of [DATE] and readmitted [DATE]. Admitting [DIAGNOSES REDACTED]. Observation on 10/13/2020 at 10:35 a.m. of R#5 revealed Certified Nursing Assistant (CNA) AA was in the resident's room providing incontinent care. The resident's incontinent brief was soaked. Immediately after CNA AA completed the incontinent care, interview was conducted with CNA AA. CNA AA revealed being trained to check and change residents every two hours. She revealed the importance of checking and changing residents to prevent skin breakdown. However, due to the extreme workload (performing baths/am personal hygiene care and assisting with two meals) CNA AA stated it was extremely difficult to meet that expectation. CNA AA verbalized fell ow CNAs would assist, but the wait time was still great because of the other CNAs' workloads. CNA AA revealed, due to the high demand of residents' care needs, incontinent care was not provided timely. Interview with CNA BB on 10/14/2020 at 6:20 a.m. revealed the CNA had been employed for two months. The CNA verbalized being responsible to provide care to 20 residents. CNA BB revealed care was difficult to provide due to the caseload. The CNA verbalized residents were not checked and changed every two to three hours. The CNA verbalized all staff were doing their best. 6. Review of the medical record for R#1 revealed an admission date of [DATE] and discharge date of [DATE]. Admitting [DIAGNOSES REDACTED]. Phone interview with Family of R#1 on 10/9/2020 at 12:18 p.m. revealed the resident was admitted to the facility from the hospital. The family member of R#1 stated the resident was only at the facility for four days before being transferred back to the hospital. During the resident's admission, the Family of R#1 revealed while participating in window visits daily (the facility had stopped visitations due to COVID), the resident voiced concerns of not being provided incontinent care on a regular basis. The Family of R#1 voiced this concern to the facility. Interview on 10/13/2020 with CNA AA at 10:05 a.m. revealed being employed since January 2020. The CNA did not recall caring for R#1. However, CNA AA revealed being trained to check and change residents every two hours. She revealed the importance of checking and changing residents to prevent skin breakdown. CNA AA stated it was extremely difficult to meet that expectation. CNA AA validated that residents were not checked and changed timely, due to the high demand of residents' care needs. The Human Resources and Scheduler (HR&S) stated during an interview conducted in her office on 10/13/20 at 9:58 a.m. that she remembered the licensed nurses worked as CNAs in December of 2019. However, she had only worked in the scheduling position since February of 2020. She stated that administrative staff answered residents' call lights and poured water for residents during that time. The HR&S stated she did not remember the cause of the staff shortage. The facility did not use contract or agency staff. However, the headquarters of the company would have alerted the facility if the full-time equivalent staffing numbers were too low and fell below state standards and she stated she had not been alerted. The HR&S stated that she had not been informed of grievances or complaints related to staffing. The HR&S stated that staff did not complain about too few staff. The HR&S stated on this date, there were 68 residents in the facility. Right now, there were two Licensed Practical Nurses (LPNs), one Registered Nurse (RN) and two Certified Nursing Assistants on duty. She stated there were usually three to four nurses on duty depending upon the acuity of the residents. There was also a Wound Care Nurse, the Interim Director of Nursing (IDON), typically there were two Unit Managers (UMs) but one was out on leave and the other had been promoted into the IDON position on last Friday. The HR&S stated the licensed nurses worked 12 hour shifts and there were three nurses on the night shift from 7:00 p.m. to 7:00 a.m. The CNAs were staffed with four to five per day shift and three CNAs on the evening and nights. The HR&S stated that the facility was paying a competitive rate. The staff were given a pay increase last year. Interview with Licensed Practical Nurse (LPN) BB 10/12/20 at 2:30 p.m. in the Nurses' Station revealed that there were three nurses working from seven a.m. until seven p.m. (7-7) today, four certified nursing assistants working seven a.m. to three p.m. (7-3) today. Interview with CNA DD in the dining room on 10/12/20 at 3:45 p.m. revealed that he started working at the facility in May of 2020. The CNA stated that there were 22 residents on his assignment today. The number of residents assigned depends on the number of CNAs on duty. There were some residents on the assignment that required more assistance than others. The CNA stated he knew his residents well. He stated he went to the residents when they needed him. The CNA stated he honestly learned to make it work for him. He told the residents when he was the only aide on the hall. He told the residents the truth. The CNA stated he gathered his supplies as soon as he arrived which included wipes and bed pads. He made rounds, then he passed water and meal trays. CNA DD stated the facility was understaffed, but he was not sure why. Interview with Licensed Practical Nurse DD on 10/13/20 at 12:15 p.m. in the Nurse's Station revealed that she was the Medication Nurse for the 200 and 300 halls. LPN DD stated that her task was medication administration, but she answered call lights and responded to resident emergencies. LPN DD stated there were not enough CNAs. Interview with the facility's Medical Director on 10/15/20 at 10:34 a.m. in the conference room revealed that he was already active as a Physician in the facility prior to accepting the position of Medical Director in July of 2020. He stated that he was in the facility every Monday or Thursday and he lays eyes of the residents. The Medical Director stated an awareness of less clinical staff. He stated that he would like to address the need for clinical staff by participation in job fairs.

Based on observation, interview, record review and review of the facility's policy, the facility failed to provide adequate activities of daily living (ADLs) assistance to three of 28 sampled residents (R) (#1, R#5, and R#19) who required assistance. Findings include: The facility utilized the Lippincott standard of practice for Incontinent Care dated 2017. Lippincott defines urinary incontinence as the involuntary leakage of urine, significant enough to be considered a problem. Incontinence can have a negative impact on the patient's health and quality of life, including complications from moisture and irritation. 1. Review of the medical record of R#5 revealed an original admission date of [DATE] and readmitted [DATE]. Admitting [DIAGNOSES REDACTED]. Review of R#5's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact with a BIMS of 14. The resident was assessed to have no mood or behaviors. The resident required extensive assistance of one staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. The facility assessed the resident to have no limitation with range of motion. R#5 was incontinent of bowel and the bladder was not rated due to the resident having a Foley catheter. Review of the R#5's progress note dated 10/4/20 revealed on 10/4/2020 the resident's Foley catheter was discontinued. The progress note further revealed after the Foley was discontinued the resident would yell out for assistance with incontinent care. Observation on 10/13/2020 at 10:35 a.m. of R#5 revealed Certified Nursing Assistant (CNA) AA was in the resident's room providing incontinent care. The resident's incontinent brief was soaked. Observation of the resident's buttocks revealed a sacral preventive dressing. The resident stated it was applied by the hospital. The resident answered general questions appropriately. During the observation, the resident revealed not being consistently checked or changed by staff. Immediately after CNA AA completed the incontinent care, interview was conducted with CNA AA which revealed the sacral patch was for preventive measures. CNA AA revealed being trained to check and change residents every two hours. She revealed the importance of checking and changing residents to prevent skin breakdown. However, due to the extreme workload (performing baths/am personal hygiene care and assisting with two meals) CNA AA stated it was extremely difficult to meet that expectation. CNA AA verbalized fell ow CNAs would assist, but the wait time was still great because of the other CNAs' workloads. CNA AA revealed, due to the high demand of residents' care needs, incontinent care was not provided timely. Interview with CNA BB on 10/14/2020 at 6:20 a.m. revealed the CNA had been employed for two months. The CNA verbalized being responsible to provide care to 20 residents. CNA BB revealed care was difficult to provide due to the caseload. The CNA verbalized residents were not checked and changed every two to three hours. The CNA verbalized all staff were doing their best. Observation of R#5's peri-area on 10/14/2020 at 9:05 a.m. with the Wound Care Nurse revealed the area was red and excoriated. The Wound Nurse revealed the causes of excoriation was due to increased wetness or feces. She stated all CNAs were trained to check and change residents every two hours. She further stated every resident received, upon admission and as needed, barrier cream and antifungal powder, which should be applied with every brief/incontinent change. 2. Review of the medical record for R#1 revealed an admission date of [DATE] and discharge date of [DATE]. Admitting [DIAGNOSES REDACTED]. Phone interview with Family of R#1 on 10/9/2020 at 12:18 p.m. revealed the resident was admitted to the facility from the hospital. The family member of R#1 stated the resident was only at the facility for four days before being transferred back to the hospital. During the resident's admission, the Family of R#1 revealed while participating in window visits daily (the facility had stopped visitations due to COVID), the resident voiced concerns of not being provided incontinent care on a regular basis. The Family of R#1 voiced this concern to the facility. Review of R#1's General Admission Information dated 9/21/2020 revealed the resident's general health condition was fair. The resident was assessed to be alert and oriented times three and had no problems with memory. The facility assessed the resident to be incontinent of bowel and to have functional urinary incontinence (a form of urinary incontinence in which a person is usually aware of the need to urinate, but for one or more physical or mental reasons, the individual is unable to get to the bathroom on time). The resident had one side limited range of motion (ROM) of the upper and lower extremity. R#1 was assessed to have a red sacral abrasion. Review of the facility's Bowel/Bladder Retraining assessment dated [DATE], revealed R#1 had moderately impaired decision-making. However, the resident was assessed to usually have mental awareness of toileting needs. The resident was totally dependent on staff for toileting. The facility assessed the resident was admitted with a stage one-two buttocks pressure ulcer. Review of Resident #1's 9/21/2020 Progress Note revealed the resident had sacral excoriation which, the facility treated with House Barrier Cream. On 9/25/2020 at 10:09 a.m. the Progress Note revealed R#1's Emergency Contact called the facility to informed them of the resident's complaints of chest pain and being incontinent of bowel. The Progress Note indicated the nurse went to assess the resident. The note identified the resident's pain was triggered from the [DEVICE] (due to metastasis). In addition, the note revealed the resident was incontinence of urine not bowel. The record indicated the resident was transferred to the emergency room . The final progress note indicated the resident would not return to the facility, because the Emergency Contact opted to place the resident on hospice. Interview on 10/13/2020 with CNA AA at 10:05 a.m. revealed being employed since January 2020. The CNA did not recall caring for R#1. However, CNA AA revealed being trained to check and change residents every two hours. She revealed the importance of checking and changing residents to prevent skin breakdown. CNA AA stated it was extremely difficult to meet that expectation. CNA AA validated that residents were not checked and changed timely, due to the high demand of residents' care needs. 3. Health record review revealed that R#19 was admitted into the facility 10/10/08 and had a readmission into the facility on [DATE] from an acute hospital. [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident had unclear speech but usually made herself-understood. R#19 was able to understand others and had moderately impaired vision. R#19 had a BIMS score of 6 which indicated severe cognitive impairment. R#19 was totally dependent on two or more persons for bed mobility and transfers. R#19 was totally dependent on one person for dressing, eating, toilet use, personal hygiene and bathing. R#19 was impaired in ROM to both the upper and both lower extremities and required a wheelchair for mobility. Review of R#19's care plan dated 7/25/19 revealed the resident would have her needs met through next review. Approaches included: Dress/groom daily and as needed. Observation of a bed bath given to R #19 on 10/14/2020 at 5:45 a.m. revealed Certified Nursing Assistant (CNA) FF bathed the resident and when the bath was completed, CNA FF dressed R#19, transferred her to her wheelchair by Hoyer Lift with assistance of two nurses the attempted to brush the resident's hair. R#19 grimaced and softly said, that hurts when the CNA brushed her hair on the back of her head. When asked what was causing the resident pain CNA FF stated that her hair was matted, and it could not be brushed or combed without hurting her. Tightly matted hair about the size of a quarter was observed on the back of R#19's head. After observing the bath on 10/14/2020 at 5:45 a.m., interview with CNA FF was conducted on 10/14/20 at 6:45 a.m. When asked when the resident's hair was washed, CNA FF replied that she was supposed to get showers twice a week and get shampooed at that time; however, even in the shower her hair was matted. Review of the skin assessments by the CNA's dated 9/12/20, 9/26/20, 9/30/20, 10/2/20, 10/4/20, 10/6/20, and 10/8/20 revealed no assessment of R #19's scalp or hair documented. During an observation of R#19 on 10/14/20 at 11:20 a.m., the Staff Development/Infection Preventionist stated R#19's matted hair must be cut away because brushing it caused the resident pain. Review of the Progress Note dated 10/14/2020 at 12:03 p.m. revealed the Family of R #19's was notified of the knot in R#19's hair and gave permission to cut the knot out of the resident's hair if it could not be brushed or combed out.

Based on observation, interview, and record review, the facility failed to ensure one of 28 sampled residents (Resident (R) #9) residents received appropriate treatment and services to prevent Urinary Tract Infections (UTIs). Findings include: Interview with the Interim Director of Nursing (DON), on 10/14/2020 at 9:30 a.m., revealed the facility did not have a policy on perineal care; however, the facility followed the Lippincott Procedures for Perineal Care of the Male Resident. Review of the Lippincott Procedures for Perineal Care of the Male Resident, revised 11/11/16, revealed the procedure to perform perineal care revealed the following: 10. Wet the washcloth with warm water from a running spigot (or from a clean and disinfected bath basin) and apply mild soap. 11. Hold the shaft of the penis with one hand. Clean the meatus with the washcloth. 12. Wash the penis with the washcloth beginning at the tip and working in a circular motion from the center to the periphery, to avoid introducing microorganisms into the urethra. Use a clean section of the washcloth for each stroke to prevent the spread of contaminated secretions or discharge. 13. Wet a washcloth and rinse thoroughly, using the same circular motion. 14. Wash the rest of the penis, using downward [MEDICAL CONDITION] toward the scrotum. If appropriate, rinse well and pat dry with a towel. Record review revealed the facility admitted R#9 on 9/18/2020, with [DIAGNOSES REDACTED]. As the disks dehydrate and shrink, signs of [MEDICAL CONDITION] develop, including bony projections along the edges of bones (bone spurs). Review of the Admission Minimum Data Set (MDS) Assessment, dated 9/23/2020, revealed the facility assessed the resident as always incontinent of bowel and bladder. Further review revealed the facility assessed the resident as requiring extensive assistance with toileting and total dependence for personal hygiene. Observation of perineal care for R#9, on 10/12/2020 at 1:32 p.m., revealed Certified Nurse Aide (CNA) GG wiped stool from the resident's perineal area. Then the CNA placed the soiled washcloth in the bath basin that contained clean water and with the same soiled gloves, obtained a clean washcloth and placed it in the bath basin with the soiled washcloth. Afterwards, CNA GG cleansed the resident's perineal area then placed the soiled washcloth in the bath basin next to the other soiled washcloth. Interview with CNA GG, on 10/14/2020 at 11:49 a.m., revealed she has been a CNA for [AGE] years and had not completed her probation at this facility yet. The CNA further stated she contaminated the clean water by placing the soiled washcloth in the basin after cleansing the resident's perineal area. Continued interview revealed the CNA thought she was finished cleansing R#9 so she accidently placed the soiled washcloth in the basin with clean water. Further interview with the CNA revealed that perineal care was important to prevent skin breakdown and UTIs. Interview with the Clinical Competency Coordinator (CCC) on 10/14/2020 at 8:29 a.m., revealed during new hire orientation, Nurse Aides would shadow another Nurse Aide (preceptor) for three days. The CCC further stated the Preceptor would complete a CNA skills competency checklist form which included peri care. Continued interview revealed CNA GG had not turned in the completed form to her yet. The CCC stated she would review the skills competency form and provide training on the items that the staff performed unsatisfactorily. Further interview revealed she did not have time to provide training to staff on perineal care since she served as the Infection Preventionist too. Interview on 10/14/2020 at 8:51 a.m., with Interim Director of Nursing (DON) revealed she supervised the Nurses and Certified Nurse Aides. The DON stated staff were trained on perineal care upon hire and she expected staff to complete perineal care according to the Lippincott perineal care procedures. Continued interview revealed she did not monitor staff performance of perineal care but would start that process, stating she was new to her role. The Interim DON also stated that she relied on the Nurse Aides to provide perineal care to prevent skin breakdown and UTIs.

Based on interview, record review, and review of the facility's policy, the facility failed to develop a person-centered comprehensive care plan for each resident that included measurable objectives and timeframes to meet the resident's medical and nursing needs identified in the comprehensive assessment for one of eight residents with pressure injury (R#6). Findings include: Review of the facility's policy titled, Care Plans, dated 10/5/17, revealed the baseline care plan would be developed by the admitting nurse and the comprehensive care plan would be developed to include measurable goals and timeframes to meet a resident's nursing, medical and psychosocial needs, the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that were identified in the comprehensive assessment. Review of the clinical record revealed R#6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#6 was discharged on [DATE]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 12/26/19, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated the resident was moderately impaired in cognition. The facility assessed the resident was at risk for developing pressure ulcers, was occasionally incontinent of bladder and frequently incontinent of bowel and required extensive assistance of one person for bed mobility, transfers, toilet use, dressing, and personal hygiene. Review of the Care Area Assessment (CAA), dated 12/31/19, revealed R#6 was at risk for skin breakdown related impaired mobility and incontinent episodes, he needed assistance with activities of daily living (ADLs) and mobility due to muscle weakness from recent hospitalization . Additional review revealed the care plan would be developed to prevent skin breakdown. Review of R#6's physician's orders [REDACTED].>Review of R#6's physician's orders [REDACTED]. Review of R#6's Comprehensive Care Plan, dated 12/22/19, revealed there was no focus area to address the resident's risk for developing pressure ulcers even though it was identified on the Admission MDS assessment, dated 12/19/19 and CAA summary, dated 12/31/19. In addition, the care plan did not include goals or interventions to address the pressure injury that was identified on 1/14/2020. Interview with the MDS Coordinator on 10/15/2020 at 8:36 a.m., revealed she followed the RAI manual to develop care plans and the purpose of the care plan was to implement care and treatment for [REDACTED].#6's Admission MDS and care plan then stated an incontinence and skin integrity care plan should have been developed. Continued interview revealed the Admission Nurse should have developed the baseline care plan with an incontinence and skin integrity focus area and the Wound Care Nurse (WCN) should have developed the pressure ulcer care plan when the pressure ulcer was identified on 1/14/2020. Further interview revealed she would update the care plan after the quarterly MDS assessments were completed. Interview with Licensed Practical Nurse (LPN) DD on 10/15/2020 at 10:19 a.m., revealed the admitting nurse should initiate a care plan and the WCN would develop the pressure ulcer care plan after the skin breakdown was referred to her. Interview with the Wound Care Nurse (WCN), on 10/15/2020 at 9:00 a.m., revealed the admitting nurse should have completed the skin integrity care plan per policy. The WCN stated she was new to her role and did not update R#6's care plan after the development of the pressure injury identified on 1/14/2020. Interview on 10/15/2020 at 1:10 p.m. with the Administrator, revealed she expected staff to follow the care plan policy to establish the baseline care plan for the resident upon admission then develop the comprehensive care plan for the care areas triggered on MDS assessment. Continued interview revealed the purpose of the individualized care plan was for staff to provide appropriate care and treatment to the resident.

Based on observation, interviews, record review and facility policy/procedure review, the facility failed to ensure that bunny boots were applied for one resident (R) (#11) who was at risk for pressure ulcers of 28 sampled residents. Findings include: Review the facility's policy titled, Lippincott Procedures for Pressure Ulcer Prevention Program, dated January 2015, revealed the facility's program was in place to identify residents at risk for developing pressure ulcers which was determined by using the initial risk assessment tool, the Braden Scale for Predicting Score Risk. Completion of the Braden should occur upon admission and readmission, once weekly for four weeks, then quarterly, after a significant change in the resident's condition or upon development of an acquired pressure ulcer. Residents that score an 18 and below would be placed on the pressure ulcer prevention program. The program included the following: inspect skin of residents daily; manage moisture (incontinence care); optimize nutrition and hydration; minimize pressure; and develop care to address interventions when on the pressure ulcer prevention program. R#11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #11, dated 9/9/17, documented a potential for skin breakdown as a result of impaired mobility, incontinence, and impaired safety awareness as a result of impaired cognition. The approaches listed were a low air loss mattress and pressure reducing cushion when the resident was in the chair. Review of a Skin Check Note dated 9/24/2020 documented R#11's skin was intact. The most recent Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental status (BIM) score was 9, indicating moderately impaired cognition. The MDS also indicated the resident was non-ambulatory and had decreased range of motion on both lower extremities. The resident was also coded as needing extensive assistance with toileting, hygiene and bed mobility. The MDS documented the resident had no skin issues but was at risk of developing pressure ulcers and had a pressure reducing device for the chair and bed. A Progress Note dated 9/29/2020, documented, CNA (Certified Nursing Assistant) reported to writer after shower that resident had open area to right inner ankle. Open area noted pink with white center. Dry. No drainage noted. Cleansed with normal saline solution. Patted dry and covered with Opti foam bordered dressing. Positioned resident on left side with heels floated. Daughter made aware. Daughter stated to writer she would like the head nurse to call her tomorrow. A Progress Note dated 9/30/20, documented, Informed by nurse that resident has an open area to right anklebone (Malleolus) wound bed noted with yellow/pink/white in color. No drainage noted. New order received for wound care. Heel protector boots placed to bilateral heels and noted floating and offloading on pillows. Review of the Wound Management Detail Report dated 9/30/20, documented a stage three (3) pressure ulcer on the right ankle. The report indicated, Full thickness wound bed. Patient tolerated skin assessment and treatment well. Voices no complaints pain or discomfort. No s/s (signs or symptoms) of infection noted. Review of the physician's orders [REDACTED]. Pat dry. Skin prep peri area. Apply [MEDICATION NAME] (gel dressing for wounds) to wound bed. Cover with foam dressing. Change dressing daily. Check dressing daily for change in condition. Review of the care plan, dated 9/30/20, documented Resident #11 had a stage three (3) pressure injury to right ankle. The goal was the area would heal. Approaches were to assess and record the condition of the skin surrounding the pressure ulcer, assess the pressure ulcer for location, stage, size, presence, absence of granulation tissue and epithelization, keep clean and dry as possible, and minimize skin exposure to moisture. A Progress Note dated 10/6/2020, documented the wound was noted with progressive healing and the resident tolerated the treatment well. A Progress Note dated 10/12/20, documented by the Wound Nurse read, heel protector boots in place. On 10/14/20, at 11:00 a.m., during a wound care observation, the Wound Care Nurse stated the staff didn't always put the heel protector boots on R#11. She stated, See, she doesn't have them on now. The boots were observed on a chair in the resident's room. The Wound Nurse stated the resident was supposed to have the boots on since she started working there which was about one year ago. On 10/15/20, at 9:00 a.m., R#11 was observed in bed and heel protector boots were in a chair in the corner of the room. On 10/15/20, at 9:30 a.m., in an interview with the Wound Care Nurse about the heel protector boots, she stated the boots were a nursing measure. She stated, We normally don't get orders for boots. If we feel they need them, we put them on.

Based on interview, record review and review of the facility's policy, the facility failed to ensure a grievance for one of 28 sampled residents (Resident (R) #20) was adequately investigated, addressed, the findings reported back to the complainant, with follow up conducted in accordance with facility policy. This created the potential for issues to be ongoing and unresolved. Findings include: Review of the Facility Grievances: Healthcare Centers policy revised on 2/8/18 revealed: It is the policy of the facility to follow an established process whereby patients and/or other customers may have their grievances and complaints resolved in a prompt, reasonable and consistent manner. All partners should take an active part in efforts to resolve grievances and complaints without discrimination or retaliation against a person filing a grievance of complaint. The Administrator of each healthcare center serves as its grievance official and is responsible for the following: overseeing the grievance process; receiving and tracking grievances through to the conclusion; leading necessary investigations; maintaining confidentiality of all information associated with grievances; issuing written grievance decisions to the person who filed the grievance (if known); and coordinating with state and federal agencies as necessary in light of specific allegations. A grievance includes, but is not limited to, complaints with respect to care and treatment that has been furnished to a patient, as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding the patient's facility stay. The Administrator will be responsible for overseeing the grievance process which included tracking the grievance and referral of the grievance to the appropriate department for investigation. Once the referral was made to the responsible discipline, the responsible discipline would make prompt efforts to resolve the grievance. The Administrator or designee was responsible for follow-up with the patient, authorized individual or other representative to determine the grievance has been resolved and to ensure the grievance process was understood. The Administrator or designee would document whether the problem was resolved and document reactions to the resolution. The Grievance/Complaint should be resolved within three business days. Review of the handwritten (by the former Administrator) Grievance/Complaint Form that was received from the Family of R#20 dated 12/30/19 revealed: Patient admitted to us on 12/21/19. Since admission, the Family member is here daily to see him. Since admission she has found him not cared for appropriately, but for three days. Every time she visits, he is soaking wet in urine and has bowel movement (BM) all over him. She continues to find him in the same clothes. He never has a brief on and is lying in the bed with a chuck pad (incontinence pad) only. All the clothes she gets has BM all the way down to his legs. She has had to change him because no one would assist. She had pictures of his bed and clothing with BM everywhere. Last Friday he complained of chest pain to day shift nurse. When the second shift nurse arrived, she told the (Family of R #20) she was not aware that he had chest pain. She states there is no communication here. She stated he is red between his legs due to urine and BM staying on him for so long. This last weekend she went to the Registered Nurse supervisor, she voiced her concern and was told that it would be best to talk to the Administrator or Director of Health Services on Monday (12/30/19). Her father was licking his fingers because he had pudding on them. When he stopped, she realized he had BM on his fingers as well. She took pictures of his nails and he did have BM on them. She has been washing his nails. She also stated his teeth are not being brushed. Lastly, when she turns the corner to walk down 100 hall-she can smell him from there. She brings food but cannot eat with him due to the smell. Continued review of the Grievance/Complaint Form dated 12/30/19 indicated the Steps Taken to Investigate were: Spoke to the nurse who was taking care of the resident as well as the Certified Nursing Assistant (CNA). Reviewed the notes for 12/21/19 which was R#20's date of admission. Did not see any complaint of chest pain. Review of the Summary of the grievance revealed: Spoke to the CNA and the staff and multiple staff relate that resident is not always compliant in following directions. Family member of Resident comes in and changes dressing and states that she's a nurse and knows about order. Summarize (sic)- the CNA and nurse will notify a supervisor when they attempt care and resident refuse so someone else will try. According to the Summary of the grievance the Administrator documented review of the admission notes for R#20 dated 12/21/19. The Family of R#20 referred to 12/27/19 when the resident reported chest pain to a visiting member of his family. There was no evidence that the Family of R#20 was informed of the results of the investigation. In addition, there was no evidence the issues of the resident being soiled with urine, feces and the failure of staff to provide assistance with oral care and personal hygiene were addressed. Review of the Face Sheet for R#20 revealed admission into the facility post-hospitalization on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) for R#20 dated 12/26/19 revealed in the following sections: C- Brief Interview Mental Status (BIMS) score of 01; the resident was severely cognitively impaired. E- R #20 had no behaviors. G- R #20 required extensive assistance of two or more persons for assistance with bed mobility, and transfers. R #20 required extensive assistance of one person for mobility on and off of the unit, dressing, toilet use, hygiene and bathing. R #20 had impairment of range of motion of one upper extremity and required a wheelchair for mobility. H- Resident was frequently incontinent of urine and bowel. Review of the Discharge MDS Assessment for R#20 dated 1/31/20 revealed the resident was discharged to the community on 1/31/2020. A telephone interview was conducted with the Family of R#20 on 10/13/20 at 3:45 p.m. She stated her father had dementia. She stated R#20 was discharged from the hospital to the facility on [DATE]. Each time the Family of R#20 visited there was feces on the resident, his bedding and under his nails. Also, he was often wet with urine. The Family of R #20 stated that when she spoke to the Director of Nursing (DON) about her father's lack of care and appearance the DON remarked that the facility was short of staff. The Family of R #20 stated she visited on weekdays and weekends. One weekend she found her father with urine and feces on him and asked to speak to the weekend supervisor. After waiting for one and one-half hours, the weekend supervisor came into her father's room to give medication. She asked her if she was the weekend supervisor and she responded, yes. The Family of R#20 then asked the Supervisor if they were aware that she needed to talk to them about her father. The Supervisor told her that she was busy. The Supervisor told the Family of R#20 to talk to the Director of Nursing (DON) or the Assistant (DON). The former DON and former Administrator that were employed at the time of the grievance were unavailable to interview during the survey week. A group interview was conducted with the Administrator, Interim Director of Nursing (IDON), Wound Care Nurse and the Infection Preventionist/ Staff Development Nurse in the conference room on 10/14/20 at 9:45 a.m. The IDON stated that usually, if there was a grievance or concern or trend in skin breakdown the facility would stop and collaborate on that issue. She added that every now and then a resident might complain of not getting a shower. She would arrange to have the shower done. She would first try to determine what and why it was happening. The Administrator stated there was not a large amount of concern brought to her attention about residents not being changed (incontinence care). Lack of incontinence care was not reported to the degree that she identified it as a huge concern. The Administrator stated that she was unaware of the grievance filed by the Family of R#20. None of the individuals in the meeting made specific comments related to the grievance filed by R#20's family.

Based on interview, record review, and review of the facility's policy, the facility failed to implement written policies related to reporting and investigating allegations of abuse for one of 28 sampled residents (R#23). Findings include: Review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised 9/20/19, revealed providers were to identify, correct and intervene in situations in which abuse, neglect, mistreatment or exploitation may occur that included the following analysis: preadmission screening processes; features of the environment that could make abuse, neglect and mistreatment, or exploitation more likely to occur; deployment of staff on each shift in sufficient numbers to meet the needs of patients and to ensure staff have knowledge of the patient's care needs; supervision of staff to identify inappropriate behaviors; assessment, care planning and monitoring of patients with needs and behaviors that might lead to conflict or neglect, such as patients with a history of aggressive behaviors; organizational processes such as staff competencies and grievance processes; and not employ staff found guilty by a court of law for abuse. Providers were to assure that patients, families, patient representatives, and staff are provided information on how and to whom they may report concerns, occurrences, and grievances without fear of retribution, and to provide feedback regarding the concerns that have been expressed. Continued review of the abuse policy revealed if there was an occurrence of or an allegation involving patient abuse, neglect, exploitation, mistreatment or misappropriation of property, the following investigation procedures would be followed: a complaint form should be completed if a patient, partner, of family member made an allegation of abuse. Documentation of the investigation should include the following: date and time of the alleged occurrence; patient's full name and room number; names of accused and any witnesses; name of staff who investigated the allegation; any physical evidence and description of emotional state of the patient; details of the alleged incident and injury; signed statements from pertinent parties; cognitive status of the victim and patient who are witnesses; information gathered from the investigation; action taken by provider; the conclusions reached by the investigator; name, address, and phone number of the responsible party and relatives of the victim; and any other police or ombudsman reports or other documentation related to the investigation. Additionally, if the alleged perpetrator is a CNA or a licensed staff person, the following would be included in the documentation of the investigation: initial employment application; certification letter; copies of any personnel action taken by the provider, if applicable; current address and phone number; social security number; and professional license number. A written report of the investigation and follow-up would be submitted to the appropriate agency within five working days of the occurrence. The patient, the legal representative, and/or responsible party would be notified of the investigation results. If indicated, the Ombudsman and the law enforcement agency would be notified of the investigation results. Review of the facility's Abuse Investigations revealed no documented evidence of an investigation related to allegations of physical abuse by CNA HH towards R#23, which were reported by CNA HH and LPN EE to the Night Shift Unit Supervisor on 7/25/2020. Review of R#23's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 7/7/2020, revealed R#23 had a Brief Interview for Mental Status (BIMS) score of four (4) out of 15 indicating the resident was severely impaired in cognition. R#23 had not exhibited behaviors and staff assessment of her mood was a four (4) out of 30 which indicated the resident had minimal depression; no interventions were required. Review of the nurse's progress note, dated 7/25/2020, revealed LPN EE wrote at 12:14 a.m.: Resident alert with confusion and informed family that she was hit in the face by her caregiver. CNA and witness informed nurse that the resident was transferred from the wheelchair to the bed without incident. Skin assessment done, no swelling or discoloration noted to face. Denies pain or discomfort during assessment. Supervisor and Responsible party notified of resident's statement. Family member spoke to resident via phone. There was no documented evidence the facility implemented their written abuse policies related to completing a thorough investigation after R#23 accused Certified Nurse Aide (CNA) HH of hitting her in the face when she was transferred from the wheelchair to the bed on 7/25/2020. The Night Shift Unit Supervisor failed to report the allegation of physical abuse to the Administrator after CNA HH and Licensed Practical Nurse (LPN) EE reported it to her. In addition, there was no documented evidence the facility implemented their written abuse polices related to reporting the alleged violation to the State Agency (SA). Interview with the family of R#23 on 10/13/2020 at 5:45 p.m., revealed that her mother stated a CNA hit her in the face on 7/25/2020. The resident did not indicate when it happened or the name of the CNA. The Nurse called her back and stated that a CNA did not hit her mother. However, the family of R#23 stated she was not notified of the results of the allegation of abuse investigation. Interview with Certified Nursing Aide (CNA) HH on 10/14/2020 at 7:44 p.m., revealed on 7/25/2020 around 8:45 p.m., she transferred R#23 from the wheelchair to the bed then R#23 stated, you hit me, you [***] . The CNA further stated that LPN EE walked into the room to administer R#23's medications at the time R#23 called and reported to the family that she hit her in the face. Continued interview revealed R#23 gave her the phone so she could report that she transferred R#23 to the bed but didn't harm her. CNA HH also stated R#18, R#23's roommate, witnessed the transfer from the wheelchair to the bed. Further interview revealed CNA HH provided care for the residents on the 200 hall for the remainder of her shift and was not sent home. Interview with Licensed Practical Nurse (LPN) EE on 10/14/2020 at 7:51 p.m., revealed that around 9:00 p.m. on 7/25/2020 she walked into the R#23's room to administer medications and saw CNA HH standing by the bed listening to R#23 on the phone with her family. LPN EE stated she overheard R#23 report that CNA HH hit her in the face after being transferred from the wheelchair to the bed. Continued interview revealed that she interviewed CNA HH about allegation of abuse then interviewed R#23. Further interview revealed R#23 was confused and stated that CNA HH hit her when she changed her brief. LPN EE performed a skin assessment on R#23 which revealed no physical signs of abuse and no complaints of pain from the resident. LPN EE stated she reported the allegation of abuse to the Night Shift Unit Supervisor then reported her findings to R#23's family via phone. Further interview revealed LPN EE did not initiate the written abuse allegation form and was not interviewed by anyone regarding the incident. Interview with the Night Shift Unit Supervisor, on 10/14/2020 at 7:56 p.m., revealed LPN EE reported that R#23 accused CNA HH of hitting her in the face while being transferred from the wheelchair to the bed on 7/25/2020. Continued interview revealed R#18, R#23's roommate, stated she witnessed CNA HH transfer the resident to the bed and CNA HH didn't harm R#23. Further interview revealed that she didn't report it to the Administrator because she didn't consider it abuse since nothing happened, but she should have reported it immediately and completed the written abuse allegation form since R#23 made the allegation of physical abuse. Per interview, she failed to implement the abuse policy for conducting the investigation and as a result there was no documented evidence of staff interviews, witness statements, resident interviews or body audits. Interview with the Administrator on 10/14/2020 at 7:15 p.m., revealed she was the Abuse Coordinator and was responsible for reporting and investigating abuse allegations; however, she was unable to do so since she was not made aware of the allegation until the Surveyor requested the investigation related to R#23. The Administrator stated she didn't implement the abuse policy (reporting the allegation and ensuring an investigation was completed); she expected staff to report allegations of abuse to her immediately and complete the written abuse allegation form.

Based on observations, record review and staff interviews, facility failed to follow Physician's Orders related to daily weights for three residents (R) (R#72, R#73 and R#300) with weight loss. The sample size was 47 residents. Findings Include: 1. Record review of residents (R) R#72's weight, revealed a Physician Order, dated 5/10/19, for daily weights due to significant weight loss of 10 percent within 30 days on 5/29/19. There was no evidence that weights were preformed for eight days from 7/16/19 to 7/23/19. An interview on 7/25/19 at 1:00 p.m. with Licensed Practical Nurse (LPN) AA, revealed that R #72 had a significant weight loss of 10 percent in (MONTH) 2019 and that the Physician Ordered daily weights which was assigned to night shift nursing. LPN AA further revealed that the night shift Certified Nurse Assistant (CNA) does the weight; and couldn't explain why they were not done. An interview on 7/24/19 at 1:45 p.m. with CNA FF revealed that R #72 had a poor appetite, and is encouraged to take a dietary supplement (Ensure Plus) due to weight loss. She further revealed that the night shift was assigned to do resident's weights and has no clue why they were not done. An interview on 7/25/19 at 3:00 p.m. with LPN DD who revealed that she was in charge to monitor all residents' weight, but did not know how she missed one-week weights for resident (R) R#72. An interview on 7/25/19 at 3:30 p.m. with the Registered Dietitian revealed that she visited the facility once a week. On 7/23/19, she realized that one week of daily weights were missing for R#72 and notified LPN DD on 7/23/19. She confirmed that R #72 lost 11 percent weight within 30 days on (MONTH) 5/29/19 and that the Physician Ordered daily weights and she had added Ensure Plus supplement to the resident's diet. An interview on 7/25/19 at 3:45 p.m. with the Director of Nursing (DON) and the Administrator revealed that the night shift staff are responsible for daily weights and they have no clue as to why it was not done. 2. Review of medical record for R #73 revealed admission on 6/5/19 and has [DIAGNOSES REDACTED]. Resident experience a weight loss of 8.23 % between 6/5/19 and 6/21/19. Further review revealed an order for [REDACTED]. 3. Review of medical record for R #300 revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED].#300 experienced a 6.12% weight loss from 7/12/19 (83.3 pounds (lbs.)) to 7/24/19 (78.2 lbs.). An interview on 7/24/19 at 12:44 p.m. with Registered Nurse (RN) Unit Manager JJ who confirmed that R#300 had a Physician's Order to receive daily weights and that there are no daily weights documented. Further interview with RN Unit Manager JJ reported that night shift staff are responsible for obtaining the daily weights for residents.

Based on observation, record review, family and staff interview, the facility failed to develop a baseline care plan after admission that included pressure ulcer risk for one resident (R) (R R). The sample size was 47 residents. Findings include: Review of R R's electronic health record revealed that he was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED].(cancer that has spread to other parts of the body). Review of R R's Admission Minimum Data Set (MDS) revealed that it was in process, and not completed yet. Review of R R's baseline care plans revealed that one had not been developed for pressure ulcer risk. Review of an Admission Observation report dated 7/15/19 revealed that R R had no alterations in skin. Review of R R's Braden Scale for Prediction of Pressure Sore Risk (Acuity) dated 7/16/19 and completed by the Wound Care Nurse revealed that she assessed the resident as not being at risk for pressure ulcer development. However, review of the Plan of Care section of this assessment revealed that Initiate Plan of Care had been selected. During interview with a family member of R R on 7/22/19 at 2:16 p.m., she stated that the resident had developed a pressure ulcer to his buttocks that she was first aware of that day. Review of a Wound Management Wound Information report revealed that R S developed a pressure ulcer to his sacrum on 7/22/19, with measurements of 1.6 cm (centimeters) long by 1.4 cm wide. Observation of wound care performed by the Registered Nurse (RN) Wound Care Nurse on 7/25/19 at 9:50 a.m. revealed that R R had a shallow wound to the inner right and left buttocks that the nurse measured as 2.0 cm long and 2.0 cm wide. During interview with the RN Wound Care Nurse on 7/25/19 at 9:58 a.m., she verified that she had completed the Braden assessment on 7/16/19, and made the notation to initiate a plan of care for pressure sore risk. She verified during continued interview that none of the baseline care plans developed for R R mentioned the potential for or actual skin breakdown until 7/24/19, when a baseline care plan for Nutritional Status was developed that mentioned a wound. The Wound Care Nurse stated that it was usually the admitting nurse that developed a plan of care for skin breakdown potential, but when she did the Braden score on 7/16/19 she should have ensured one was done, but did not do this. She verified she assessed R R as not being at risk for pressure ulcer development on this Braden assessment, but that repositioning and nutrition interventions would have been appropriate for him since admission. During interview with RN MDS Coordinators HH and II on 7/25/19 at 2:22 p.m., they stated that the Treatment Nurse would be responsible for doing a baseline care plan for potential for skin breakdown, since she was the one that did the Braden assessment. Cross-refer to F 686.

Based on observation, record review, and staff interview, the facility failed to ensure that their medication error rate was less than 5% by not giving medications per Physician order [REDACTED].#19). A total of 30 medication administration opportunities were observed with four nurses on three of three units. Three errors were observed made by one nurse, for an medication error rate of 10%. Findings include: On 7/24/19 at 8:56 a.m., Licensed Practical Nurse (LPN) GG was observed preparing medications for R#19. Included in this medication pass observation was potassium chloride oral solution, which was poured directly into a medicine cup to measure a total of 15 mL (milliliters), and the potassium was not diluted with any liquid. Further observation revealed that one of the medications prepared was [MEDICATION NAME] (a diuretic) 10 mg (milligrams), two tablets. The nurse verified the number of medications that she had prepared for R#19, and stated that was all of the medications that the resident got for that time of day. Continued observation at this time revealed that LPN GG took the medications into R#19's room, and the resident swallowed the pills first. LPN GG was not observed to check the resident's blood pressure prior to giving her these pills. Before giving the resident the medicine cup with the undiluted potassium solution, LPN GG explained what the medicine was, and the resident said ohhhh and made a face, and said she knew she had to take it. After consuming the potassium in two swallows, the resident again made a face and said uhhhh. The nurse gave R#19 approximately 50 mL of water to drink after swallowing the potassium. Review of R#19's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#19's physician's orders [REDACTED]. Review of R#19's Search Vitals Report revealed that the last blood pressure recorded was 7/23/19 at 8:05 a.m. During interview with LPN GG on 7/24/19 at 11:14 a.m., she verified that she did not give the [MEDICATION NAME] eye drops during the observed medication pass for R#19, and verified it was scheduled to be given along with the other medications observed that morning. During continued interview, LPN GG verified the physician ordered to hold the [MEDICATION NAME] for a systolic BP less than 100, and stated that she usually just looked at the previous shift's BP. LPN GG verified when reviewing R#19's vital signs in the electronic health record, that the last BP taken was on 7/23/19 at 8:05 a.m. During interview with LPN GG on 7/24/19 at 11:22 a.m., she verified that she gave R#19's potassium solution undiluted. The LPN verified a precautionary statement on the manufacturer's labeling on the front of the bottle of potassium bordered with lines on all sides and in all capital letters which read: DILUTE PRIOR TO ADMINISTRATION. During further interview at this time, LPN GG stated that she had never noticed that caution on the label before, and always gave potassium solution undiluted. During interview with R#19 on 7/25/19 at 10:19 a.m., she was asked if she preferred to take her potassium supplement diluted or undiluted, and she made a face and stated ew, it is strong, I don't want it straight. She further stated that there was no good way to take that drug. Review of R#19's Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 10 (a BIMS score between 8 and 12 indicates moderate cognitive impairment). Review of PAR Pharmaceutical's (the company that produced the potassium chloride solution given to R#19) instructions for administration revealed: Administration: Dilute the potassium chloride solution with at least 4 ounces of cold water (see Warnings and Precautions (5.1)). Warnings and Precautions: 5.1 Gastrointestinal Irritation May cause gastrointestinal irritation if administered undiluted. Increased dilution of the solution and taking with meals may reduce gastrointestinal irritation. Review of the facility's policy: Medication Administration: General Guidelines revised 4/6/18 revealed: Medications are administered as prescribed, in accordance with good nursing principles and practices 9. At the end of each medication pass, the person administering the medications reviews the paper MAR (Medication Administration Record) or the electronic version of e-MAR (electronic MAR) to ascertain that all necessary doses were administered. 10. Medications are administered within 60 minutes before or after scheduled time.

Based on observation, record review, family, physician and staff interview, the facility failed to provide the necessary services and treatment for [REDACTED]. Findings include: Review of R R's electronic health record (EHR) revealed that he was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED].(cancer that has spread to other parts of the body). Review of R R's Admission Minimum Data Set (MDS) revealed that it had not been completed yet. Review of R R's baseline care plans revealed that one had not been developed for pressure ulcer risk. Review of an Admission Observation report dated 7/15/19 revealed that R R had no alterations in skin. Review of a Braden Scale for Prediction of Pressure Sore Risk (Acuity) dated 7/16/19 revealed that R R was assessed with [REDACTED]. However, review of the Plan of Care section of this assessment revealed that Initiate Plan of Care had been selected. During interview with a family member of R R on 7/22/19 at 2:16 p.m., she stated that when a staff member was cleaning up the resident after an incontinent bowel movement, the resident hollered out and she looked to see why. She further stated that she saw three open areas on his buttocks, that she did not know if he was admitted to the facility with a pressure ulcer, and that today was the first day that she was aware of the wounds. The family member stated during further interview that she couldn't believe that staff would not have seen these open areas prior to today when they were providing care. Review of a Wound Management Wound Information report revealed that R R developed a Stage II pressure ulcer to his sacrum on 7/22/19, that the wound was present on admission, and had measurements of 1.6 cm (centimeters) long by 1.4 cm wide by 0 cm deep with irregular edges. Further review of this wound report revealed that an [MEDICATION NAME] dressing was applied to the wound. During interview with the Registered Nurse (RN) Wound Care Nurse on 7/23/19 at 3:51 p.m., she stated that R R's pressure ulcer dressing was changed yesterday, and was due to be changed every three days. She verified during continued interview that the Wound Management report dated 7/22/19 indicated that the wound was present on admission, and stated that this was an error as the wound was identified for the first time yesterday. Observation on 7/24/19 at 7:59 a.m. revealed that R R was alert, and had a Foley catheter. Further observation revealed that he refused the breakfast that had been served. During interview with a family member of R R on 7/24/19 at 11:17 a.m., she stated that the resident's dressing had to be changed around 10:00 p.m. last night after the resident had an incontinent bowel movement, and that the wound looked worse. Review of R R's nursing Progress Notes and Wound Management records revealed no documentation of a dressing change the night of 7/23/19. Review of physician's orders [REDACTED]. Review of the Wound Management Wound Information report dated 7/22/19 revealed no evidence that the Physician was notified of the development of the pressure ulcers. Review of the nursing Progress Notes revealed no evidence that the physician was notified of the development of the pressure ulcers. During observation of wound care done by the Wound Care Nurse on 7/25/19 at 9:50 a.m., there was no dressing over the pressure wounds, and a thick white paste identified by the nurse as barrier cream was noted on R R's buttocks, including over the open areas. During interview with a family member of R R at this time, she stated that when she came to visit him between 6:30 a.m. and 7:00 a.m. today, that there was no dressing over his wounds when she watched staff change his incontinent brief, and that the night shift nurse told her she would apply a new dressing but never did. When the Wound Care Nurse gently cleansed the open areas on the resident's left and right inner buttocks, he expressed mild discomfort as she tried to remove the paste that had been applied over the wounds. Further observation revealed that the wounds were shallow, and measured by the nurse as 2.0 cm by 2.0 cm to the left buttock, and 1.5 cm by 1.5 cm to the right buttock. The nurse applied an [MEDICATION NAME] dressing over the wounds at the end of the treatment. During interview with the Wound Care Nurse on 7/25/19 at 9:58 a.m., she stated that when a wound was identified, she called the Physician or Nurse Practitioner to notify them. She stated that she had notified the attending Physician of R R's wounds, but failed to document this notification and forgot to write the treatment order. She verified that she had completed R R's Braden assessment on 7/16/19, had made the notation to initiate a plan of care for pressure sore risk, but that no baseline care plan for potential for skin breakdown was developed. The Wound Care Nurse verified that she assessed R R as not being at risk for pressure ulcer development on 7/16/19, but that repositioning and nutrition interventions would have been appropriate for him since admission. She further stated that she put all of her wound and treatment documentation under Wound Management in the EHR, and that a paper or electronic TAR (Treatment Administration Record) was not used. She stated that the nurses would put any dressing changes or wound observations that they did in the Nurse's Notes, and verified that there was no documentation of a dressing change done around 10:00 p.m. on 7/24/19 (as observed by R R's family member). The Wound Care Nurse further stated that if a dressing came off (as observed at 9:50 a.m. today), that the charge nurse should replace it. Review of a Wounds/Skin--Braden Scale for Prediction of Pressure Sore Risk (Acuity) dated 7/25/19 revealed that the Wound Care Nurse reassessed R R to have a Total Braden Scale Score of 0 (a score of 9 or less indicates very high risk for skin breakdown). During interview with R R's attending physician on 7/25/19 at 1:13 p.m., he stated that he had been notified of RR's pressure ulcer, and that the Wound Care Nurse was responsible for writing the treatment order. He further stated that all pressure ulcers were preventable, but because of R R's immobility and poor nutrition it would be difficult to prevent and/or heal wounds. Review of the facility's Wound Observation and Assessment Documentation policy reviewed (MONTH) (YEAR) revealed: Documentation: The wound observation and documentation form is completed with each dressing change. Review of the Wound Assessment procedure revised 11/11/16 revealed: You should complete a comprehensive wound assessment during every dressing change, and compare the results to previous assessments so that you can monitor, communicate, treat, and document wound healing progression or complications. Review the patient's medical record .for the treatment plan. Apply the appropriate wound care treatments and dressing, as indicated and ordered. Document the procedure.

Based on record review, resident and staff interview, the facility failed to obtain an adequate supply of the medication [MEDICATION NAME] (an immunosuppressive drug used to prevent rejection after an organ transplant) for one resident (R) (R S), so that she received all of her scheduled doses. The sample size was 47 residents. Findings include: Review of R S's electronic health record revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of R S's Admission Minimum Data Set ((MDS) dated [DATE] revealed that it had a status of In Process. Review of her 14-Day MDS dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score between 13 and 15 indicates no cognitive impairment). During interview with R S on 7/23/19 at 11:10 a.m., she stated that the second weekend that she was in the facility, the nurse on that Friday said there was only two [MEDICATION NAME] pills left (in the medication cart). She further stated that she had a kidney transplant [AGE] years ago, and has taken three [MEDICATION NAME] capsules in the morning and three at night since then. R S stated during continued interview that she did not receive the [MEDICATION NAME] at all on Saturday or Sunday, because nobody reordered it and they had run out. R S stated that she had talked to the Case Manager and the Administrator about it on Monday, and they assured her that she would have the medication by the 5:00 p.m. dose that day. She stated that she asked a family member to go to her house Monday evening as she had still not gotten her [MEDICATION NAME], and she took her own supply of the drug about 9:00 p.m. that night. R S further stated that a nurse came in her room with the facility-obtained [MEDICATION NAME] around 9:20 p.m. Monday night, and she informed the nurse that she had already taken the medication from her home supply. R S stated that in [AGE] years, she had never missed more than one day at a time of taking the [MEDICATION NAME]. Review of R S's Physician order [REDACTED]. Review of R S's Medication Administration Record [REDACTED] 7/3/19 at 5:00 p.m.: The administration area was blank, indicating no evidence that it was given. 7/4/19 at 9:00 a.m.: Documented that given but charted late. 7/5/19 at 5:00 p.m.: Documented that given but charted late. On 7/6/19 and 7/7/19 (Saturday and Sunday) , the [MEDICATION NAME] was documented as given as ordered both days. On 7/8/19 (Monday) at 9:00 a.m.: Notation that not administered: drug/item unavailable. Comment: pharmacy was called, they said they will send the med stat, not received yet. 7/8/19 5:00 p.m.: Not administered: Comment: will be delivered tonight. On 7/8/19, there was documentation that the drug was given at 9:00 p.m. During interview with the Corporate Nurse Consultant on 7/25/19 at 11:36 a.m., she stated that she did not know why the [MEDICATION NAME] was not available on 7/8/19. Review of R S's MAR indicated [REDACTED]. Review of R S's Nursing Progress Notes revealed: 7/08/2019 at 9:10 PM (Recorded as Late Entry on 7/09/2019 at 5:48 AM) Medication [MEDICATION NAME] Modified 25 mg, 12 tablets delivered by carrier. Physically took medication to show resident and son at bedside of delivery. Placed medication in nurse's chart (sic). Resident stated that when son arrived she took the medication from home. During interview with Registered Nurse (RN) Unit Manager JJ on 7/25/19 at 2:06 p.m., she stated that she was not aware that R S had not received her [MEDICATION NAME] over the weekend until the resident went to the Administrator to complain. RN JJ stated during continued interview that R S was alert and oriented, and she would take the resident's word for it that she did not receive her [MEDICATION NAME] over the weekend. During interview with the Corporate Nurse Consultant on 7/25/19 at 2:44 p.m., she stated that she had talked to the facility's Consultant Pharmacist, and he told her he did not know why the resident would have run out of the [MEDICATION NAME]. She further stated that [MEDICATION NAME] was not available in the Cubex system (an automated dispensing system containing various frequently-used medications). During interview with the Administrator on 7/25/19 at 3:00 p.m., she stated that the Senior Nurse Navigator wrote up a grievance for R S on 7/8/19, and that the resident's son also reported that the resident had not been receiving her [MEDICATION NAME]. The Administrator further stated that if they could get an order sent to the pharmacy by 5:00 p.m., the pharmacy courier could deliver the medication at the next drop-off around 8:00 p.m. that same night. She stated during continued interview that if the medication was not in the Cubex, that the nurse should call the back-up pharmacy who was available 24 hours a day. During interview with Licensed Practical Nurse (LPN) KK on 7/25/19 at 3:12 p.m., she stated that she gave R S her scheduled doses of [MEDICATION NAME] on Saturday 7/6/19 at 9:00 a.m. and 5:00 p.m., and on Sunday 7/7/19 at 9:00 a.m. from the resident's own supply of the drug, which she stated was on the medication cart. Observation of the box of [MEDICATION NAME] provided by LPN KK at this time revealed that it did not have a pharmacy label on it, and the manufacturer's box was labeled as: [MEDICATION NAME] Capsules (Soft Gelatin Capsules) 25 mg (package of 30 capsules). This box of [MEDICATION NAME], identified by LPN KK as R S's own supply, was compared to the [MEDICATION NAME] packaged in a plastic bag that was labeled for R S by the facility's pharmacy and sent on 7/22/19, and the manufacturer and medication was identical to R S's home supply. LPN KK stated that she did not know the facility policy on having medications from home checked and/or labeled by the facility's pharmacy, but she knew how important this medication was for the resident, and that she needed to receive it. Review of the Grievance/Complaint Form: Healthcare Centers with date of grievance 7/8/19 revealed: Name of Person Taking the Grievance: (Senior Nurse Navigator LL) Person Filing the Grievance: (R S and R S's son) Grievance: (R S) stated she has not received her [MEDICATION NAME] for the last 3 days. Son called stating his mom has not received [MEDICATION NAME] x 3 days. Steps Taken to Investigate: Reviewed MAR. Summary: Pharmacy contacted-stated 30 tabs sent on 6/29/19. Pt (patient) takes 6 tabs per day. Promised to send medication stat. Checked back with pharmacy stated medication will have to come in from back up pharmacy tonight. During interview with Senior Nurse Navigator LL on 7/25/19 at 4:54 p.m., she stated that R S had first reported a grievance to her on 7/8/19 that she had not gotten her [MEDICATION NAME] over the weekend, and her son called later that day with the same concern. She further stated that she looked in the medication cart with the charge nurse after she got the complaint, and neither she nor the charge nurse could find any [MEDICATION NAME] in the cart, including R S's personal supply. Senior Nurse Navigator LL stated during continued interview that she could not explain why the [MEDICATION NAME] was signed out as given over the weekend, if there was no supply of the drug on the medication cart. She stated that she called the facility's pharmacy on 7/8/19 and told them that they did not send a sufficient supply of [MEDICATION NAME] for R S, and they verified this. She further stated that the pharmacy originally sent 30 capsules of [MEDICATION NAME] when the resident was admitted on [DATE], and because she took six capsules a day, this supply would have lasted only five days (enough for through the 9:00 a.m. dose on 7/4/19; however, since there was no evidence the drug was given on 7/3/19 at 5:00 p.m., there would have been enough to last through the 5:00 p.m. dose on 7/4/19). Review of the facility pharmacy's Fill History report revealed that on 6/29/19, a quantity of 30 [MEDICATION NAME] 25 mg capsules were dispensed for R S, and was marked as a 15-day supply. During interview with the Corporate Nurse Consultant on 7/25/19 at 6:01 p.m., she verified that the 30 capsules dispensed on 6/29/19 would have only lasted the resident five days, and not 15 days as on the Fill History report. She further stated that the only [MEDICATION NAME] dispensed by the facility's back-up pharmacy was on 7/8/19, the Monday after the weekend R S alleged she did not receive her medication.

Based on staff interview and review of RAI manual Submission and correction of the MDS Assessments, the facility failed to ensure that Minimum Data Set (MDS) discharge assessments were transmitted within 14 days of discharge to CMS's (Centers for Medicare and Medicaid Services) for two residents (R) (R #3 and R #4). Findings include: A review of Submission and Correction of the MDS Assessments from the RAI manual revealed, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD) (A2300). 1.Review of the electronic medical record of list of completed and transmitted MDS revealed that a discharge assessment had not been completed for R#3. Review of the census confirmed that R#3 was not currently a resident in the facility. R# 3 admitted to the facility on [DATE] and discharged from the facility on 2/13/19. 2.Review of the electronic medical record list of completed and transmitted MDS revealed that a discharge assessment had not been completed for R#4. Review of the census confirmed that R#4 was not currently a resident in the facility. R# 4 admitted to the facility on [DATE] and discharged from the facility on 2/25/19. During an interview with MDS Registered Nurse (RN) HH and MDS RN II on 7/25/19 at 9:22 a.m. it was reported that MDS assessments are done on admission, quarterly, annually, and at discharge. MDS RN II reported that R#3 discharged from the facility on 2/13/19 and confirmed that there was no discharge assessment completed for this resident. MDS RN HH reported that MDS is responsible for completing the discharge assessment and typically the assessment should be opened the same day of the discharge. It was further reported that discharge assessments are typically completed within a few days of discharge. MDS RN II reported that meetings are held at least weekly and residents who will be discharging are discussed. When questioned how the assessments for R#3 and R#4 were missed it was explained that they were just over looked. Both MDS RN HH and MDS RN II reported being responsible for assuring that discharge assessments are completed. It was further reported by MDS RN II reported that a list of missing assessments was received from the nurse consultant this week. MDS RN HH reported that R#4's discharge assessment was completed this morning and she got this information from the list provided by the nurse consultant.

Based on interviews and record reviews and policy review, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) system to oversee the Advance Directive system, to ensure advance directive documentation was maintained and accurate in the clinical record, in an effort to prevent errors or delays in emergency basic life support measures. The facility had a census of 86 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, 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, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility 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 (MONTH) 29, 2019. 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. Findings include: The facility had a Quality Assurance and Performance Improvement policy. The policy documented that the purpose of the Quality Assurance and Performance Improvement (QAPI) program was to continually take a proactive approach to assure and improve the way the facility provided are and engage with patients, partners, and other stakeholders so that the facility may fully realize their vision, mission and commitment to caring pledge. During an interview on [DATE] at 1:50 p.m., the Administrator revealed that she oversees the QAPI committee and they met on a monthly basis, on the third Wednesday of each month. The facility had an Advance Directive: Georgia policy and Do Not Resuscitate Policy: Georgia policy in place to address obtaining and maintaining resident Advance Directive information in the clinical record. However, there was no evidence that this system was routinely monitored through the QAPI process, to ensure that it was accurately and consistently implemented. During an interview on [DATE] at 1:50 p.m., the Administrator stated that she was notified of R#4's death on [DATE]. Further interview the Administrator confirmed that she was not aware of any concerns regarding Advance Directive completion and accuracy in the clinical record prior to R#4's and R#12's deaths. In response to the incident, she interviewed staff, called a Quality Assurance Performance Improvement (QAPI) meeting (on [DATE]), put a plan in place and began auditing residents' Advance Directive status in the clinical records. A review of the plan revealed that it included the following specifics: The facility identified that all residents had the potential to be affected. 1. The DHS and Assistant Director of Health Services (ADHS) would educate all nurses on the Advance Directives policy and procedures. All nurses would also be educated on the facility's electronic clinical record system integration related to Advance Directives. All training was initiated on [DATE] and would be completed by [DATE] with all nurses being educated prior to the start of their next shift. 2. The Administrator or designee would complete a daily audit tool to monitor advance directives for four weeks. The DHS and ADHS would complete a weekly audit tool to monitor compliance for four weeks. A QAPI committee meeting would be held on [DATE] to ensure the audit was correct and that no other issues were identified. However, despite the facility's implemented interventions to ensure the Advance Directives were integrated into the electronic clinical record, they failed to ensure that the Advance Directives status was accurate with supporting Advance Directive documentation. Cross refer to F678 The facility implemented the following actions to remove the Immediate Jeopardy. During Post survey review it was determined that the deficiency should be cited under F687: Facility must maintain a Quality Assurance Performance Improvement committee consisting of the Director of Health Services, Medical Director, Infection Prevention Committee, Administrator must meet quarterly to evaluate activities under the Quality Assurance Performance Improvement program. Root Cause Analysis Facility failed to identify the Advanced Directives on Resident #4 and Resident #12. 1) On (MONTH) 29, 2019 the Facility Administrator, Director of Health Services, Area Vice President, Senior Nurse Consultant, Assistant Director of Health Services, Unit Manager, MDS Coordinators, Housekeeping and Laundry Director, Social Services Director, Activities Director, Admissions Director, Admissions Coordinator, Clinical Competency Coordinator (CCC), Business Office Manager, Human Resources, Medical Records Coordinator, Senior Care Partner, Therapy Director, Wound Nurse (SNC) met in facility conference for immediate Quality Assurance Performance Improvement interventions to the cited incident. The Medical Director participated via phone for the Quality Assurance Performance Improvement and concurred with initial self-imposed interventions as detailed in the below A[NAME]. 2) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 3) Director of Health Services and Social Services completed an audit of all active resident records on [DATE] to ensure the Resident's Advanced Directives were in the medical records. 4) The Advanced Directive Clinical system checklist will be updated daily upon each new admission or change in Advanced Directives orders by DHS, unit managers or Social Worker. The Advance Directive auditing will be on-going. 5) Education compliance related to F655, F658, F678, F835, F842 and F868 (during QA review the deficiency was changed to F867) will be reported to Quality Assurance Performance Improvement by the Clinical Competency Coordinator monthly x3 months and quarterly thereafter as needed. All new staff hired will be educated on Advanced Directives in orientation. Title of Person Responsible for implementing the acceptable plan of correction: The Administrator is responsible for implementing the acceptable plan of correction. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of the sign in sheets of the [DATE] QAPI meeting confirmed the attendance of full committee. The Medical Director attended via telephone. Interviews were conducted on [DATE] at 12:33 p.m. with Clinical Competency Coordinator (CCC) CC, at 1:10 p.m. with the Human Resource (HR) Director and Financial Director, with the DHS at 1:15 p.m., with the Maintenance Director at 1:34 p.m., and with the Housekeeping supervisor at 1:50 p.m. confirming their attendance for the [DATE] QAPI meeting. 2. Review of the QA policy which was signed as reviewed by the Administrator on [DATE]. An interview with the Administrator on [DATE] at 2:32 p.m. to review the policy and confirmed that the policy was reviewed and approved by the QAPI members, then signed by the Administrator on [DATE]. 3. Review of the audit documentation and interview with the DHS on [DATE] at 1:15 p.m. verified the audit of all active resident records to confirm Advanced Directives were in the medical records. 4. Interviews on [DATE] at 1:15 p.m. with the DHS and ADHS verified the daily audit and update of Advanced Directives for new admissions or residents with a change in condition. 5. An interview with CCC CC on [DATE] at 12:33 p.m. verified that education has been completed and the results will be reported to the QAPI meetings, monthly and quarterly thereafter. She confirmed that all new staff hired will be educated upon hire. The facility has had no new hires since [DATE]. An interview with the Administrator on [DATE] at 2:32 p.m. verified that she was responsible for implementing the acceptable plan of correction. She also stated that since the A[NAME] had been written, 100% of staff had now been in-serviced. The QAPI committee had also had additional meetings on [DATE] and [DATE] to review the ongoing process (verified via review of sign-in sheets).

Based on record review, review of the Administrator Job Description and staff interviews, it was determined the facility administration failed to ensure effective monitoring of the Advance Directive system to include accurate code status was available in the electronic record for two residents (R) (#4 and #12) and failed to verify that the Advanced Health Care Directive was available, at the facility, and in the electronic record before declaring one resident (#12) a Do Not Resuscitate (DNR) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, 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, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility 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 (MONTH) 29, 2019. 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. Findings include: The facility had a Job 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 the nursing facility and to establish criteria to assure that care provided meets established standards of quality. The facility had an Advance Directive: Georgia policy and Do Not Resuscitate Policy: Georgia policy in place to address obtaining and maintaining resident Advance Directive documentation in the clinical record. In addition, the facility began using an electronic charting system [DATE]. However, there was no evidence that the Advance Directive system was routinely monitored by the Administrator, to ensure that it was accurately and consistently implemented. During an interview on [DATE] at 1:50 p.m., the Administrator stated that she was notified of R#4's death on [DATE]. In response to the incident, she interviewed staff, called a QAPI meeting (on [DATE]), put a plan in place and began auditing residents' advance directive status in the clinical records. A review of the plan revealed that it included the following specifics: The facility identified that all residents had the potential to be affected. A. The DHS and Assistant Director of Health Services (ADHS) would educate all nurses on the Advance Directives policy and procedures. All nurses would also be educated on the Matrix (the facility's electronic clinical record system) integration related to Advance Directives. All training was initiated on [DATE] and would be completed by [DATE] with all nurses being educated prior to the start of their next shift. B. The Administrator or designee would complete a daily audit tool to monitor advance directives for four weeks. The DHS and ADHS would complete a weekly audit tool to monitor compliance for four weeks. A QAPI committee meeting would be held on [DATE] to ensure the audit was correct and that no other issues were identified. However, despite the facility's implemented interventions to ensure the Advance Directives were integrated into the electronic clinical record, they failed to ensure that the Advance Directives status was accurate with supporting advance directive documentation. During an interview on [DATE] at 1:50 p.m., the Administrator confirmed that she was not aware of any concerns regarding advance directive completion and accuracy in the clinical record prior to R#4's and R#12's deaths. Further interview revealed that she stated she was not aware the supporting documents were not available to confirm the DNR status that had been entered in R#12's electronic record. She stated that she was only checking the code reports with the banner in the electronic records to ensure the correct code status was in the banner. She stated she was not verifying the supporting documents, such as Advanced Health Directives, were in the electronic record to support a DNR status. At this time, the Administrator revealed that the new electronic medical system was begun on [DATE] and that staff were in-serviced on how to use the new system on [DATE] and [DATE] as the specific systems went online. The Administrator supplied the training agenda and sign in sheets for the [DATE] in-service which covered Resident Charting, Resident Banner items, Entering documentation for the DHS, Nurse Leaders and Nurses. Licensed Practical Nurse (LPN) AA was present and signed in for the in-service. The facility implemented the following actions to remove the Immediate Jeopardy: Facility must be administered in a manner that enables it to use its resources effectively and efficiently to maintain the highest practical physical and psychosocial wellbeing of each Resident. Root Cause Analysis Facility failed to identify supporting documentation for Advanced Directives. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions. 1) Current Resident's now have supporting documentation in the electronic medical record for their Advanced Directive. 2) The Director of Health Services and or Unit Manager will monitor this process in clinical stand-up by reviewing all new orders and assuring any DNR or Full Code orders are in the electronic medical record and the banner is correct. This process will be documented on the Advance Directives Checklist by the Director of Health Services or Unit Manager. 3) Senior Nurse Consultant provided training to the facility Administrator on the Advanced Directives policy on [DATE]. The Administrator was educated on [DATE] by the AVP on the Administrator job description and responsibilities. 4) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 5) Results will be communicated by the Director of Health Services or Administrator at QAPI monthly x3 months. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of residents on the resident census list and supporting documentation for those residents specified as having a DNR status confirmed that the status and supporting documentation was correct. 2. An interview with the DHS and LPN PP, Unit Manager, on [DATE] at 1:15 p.m. confirmed that all new orders are reviewed during clinical stand-up meeting and assured that any DNR or Full Code Status are in the electronic medical record and that the banner reading is correct. Review of the Advanced Directives Checklist was reviewed to confirm the DHS or Unit Manager are completing the form. 3. Review of the Administrator education form dated [DATE] confirmed that the Senior Nurse Consultant provided training on Advanced Directives policy and was signed by the Administrator to ensure understanding. 4. Review of the facilities policy revealed a review date of [DATE] and is current. 5. An interview with the DHS on [DATE] at 1:15 p.m. confirmed that the results of the clinical stand-up meeting and the Advanced Directives Checklist will be reviewed during the monthly QAPI meetings.

Based on interviews and record review, the facility failed to accurately assess the Advance Directive status for one resident (#4) and failed to accurately document the Advance Directive status for one resident (#12) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, 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, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility 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 (MONTH) 29, 2019. 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. Findings include: The facility had an Advance Directives: Georgia policy. The policy statement included that the healthcare center recognizes the right of residents to control decisions related to their medical care. The policy procedure included that prior to, or upon admission, the resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directive Checklist will be completed. During an interview on [DATE] at 11:10 a.m., Nurse Consultant UUU stated that the facility went live with using an electronic clinical record system on [DATE] and that the staff was trained on the system as the different components came on line. The facility provided an agenda for the staff training for [DATE] through [DATE] and sign in sheets for the training. 1. R#4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, progress notes documented the resident was status [REDACTED]. A Georgia Advance Directive for Healthcare form and DNR form, were signed by the resident's responsible party on [DATE]. The Georgia Advance Directive for Healthcare form documented that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The DNR form documented that the resident did not have a DNR order or Physician order [REDACTED]. R#4 experienced a change in condition on [DATE]. A nurse's note dated [DATE] at 5:22 a.m., documented that upon entering the resident's room, the resident was unresponsive to verbal and physical stimuli. The note also documented that they were unable to obtain a blood pressure, pulse, respirations or pulse oximetry, and her temperature was 90.3 degrees. The DHS was notified, and a message was left for the on-call physician. There was no evidence that emergency basic life support measures were immediately implemented. The subsequent nurse's note, approximately one hour later, on [DATE] at 6:25 p.m. documented that CPR was started. Further review of nurses' notes entries revealed that EMS personnel were onsite and took over CPR at 6:30 a.m. and continued emergency life support measures, but without success. EMS personnel received a physician's orders [REDACTED]. During an interview on [DATE] at 7:35 a.m., Licensed Practical Nurse (LPN) AA stated that, after finding the resident unresponsive and unable to obtain vital signs, she checked the resident's electronic chart. She stated that she thought she saw DNR on the Advance Directives section of the chart and notified the DHS. However, when she started the paperwork, she could not find DNR information and called the DHS again, who arrived shortly afterward and called 911 and began CPR. LPN AA stated that she would have started CPR immediately, if she had not thought she saw DNR on the electronic chart. During an interview on [DATE] at 4:30 p.m., the DHS confirmed that she received a call from LPN AA the morning of [DATE] regarding resident #4's passing and that the resident was a DNR. The DHS stated while enroute to the facility to pronounce the resident's death, she received another phone call from LPN AA notifying her of that she could not locate DNR information. The DHS stated she arrived shortly afterward, reviewed the chart, and in seeing no Advance Directive status specified, called 911 and initiated CPR. The DHS stated that Advance Directive/Code Status is verified in the electronic clinical record at the top of the computer screen, on the banner. If there is no Advance Directive/Code Status listed there, you assume the resident is a full code (not a DNR). She stated that there is no need to scroll down to the Advance Directive section of the chart because whatever is checked in that section will appear on the banner (at the top of the screen). During an interview on [DATE] at 1:50 p.m., the Administrator stated that she was notified of R#4's death on [DATE]. In response to the incident, she interviewed staff, called a Quality Assurance Plan Improvement (QAPI) meeting (on [DATE]), put a plan in place and began auditing residents' Advance Directive status in the clinical records. A review of the plan revealed that it included the following specifics: The facility identified that all residents had the potential to be affected. A. The DHS and Assistant Director of Health Services (ADHS) would educate all nurses on the Advance Directives policy and procedures. All nurses would also be educated on the facility's electronic clinical record system integration related to Advance Directives. All training was initiated on [DATE] and would be completed by [DATE] with all nurses being educated prior to the start of their next shift. B. The Administrator or designee would complete a daily audit tool to monitor Advance Directives for four weeks. The DHS and ADHS would complete a weekly audit tool to monitor compliance for four weeks. A QAPI committee meeting would be held on [DATE] to ensure the audit was correct and that no other issues were identified. However, despite the facility's implemented interventions to ensure the Advance Directives were integrated into the electronic clinical record, they failed to ensure that the Advance Directives status was accurate with supporting Advance Directive documentation. 2. Review of the Medical record revealed that R#12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#12 was to be a Do Not Resuscitate (DNR). However, review of the electronic medical record revealed there were no supporting documents to validate the resident's DNR status. Review of the Resident Progress Notes dated [DATE] at 3:00 p.m. revealed that at 2:40 p.m. the nurse was notified by a family member that the resident was unresponsive to all stimuli. The note further documented that the resident was assessed by two nurses and found to be without any vital signs. At 2:45 p.m. the funeral home was notified and was awaiting arrival of the funeral home personnel. The resident had an pronouncement of death by RN CC on [DATE] at 2:45 p.m. During an interview with Licensed Practical Nurse (LPN) BB on [DATE] at 11:35 a.m., she stated that the resident's daughter had reported to her the resident was not responding. She stated that she went and got Registered Nurse (RN) CC who got the crash cart and when they entered the room the resident's son told them the resident was a DNR. She stated when she checked the face sheet she saw where the resident was a DNR and they did not do Cardiopulmonary Resuscitation (CPR). During an interview with RN CC on [DATE] at 12:03 p.m., she stated that LPN BB came to her and said the resident was nonresponsive. She grabbed the crash cart while LPN BB got the electronic record to check the resident's code status. As they were entering the room, LPN BB stated the resident was a DNR. She also stated that as they were entering the resident's room, the son asked them what they were doing with the crash cart since his mother was a DNR. She stated she went in the room to assess the resident who did not have a pulse, no respirations, and her pupils were fixed and dilated. She stated that she was the nurse who pronounced the resident's death. During an interview with Nurse Consultant UUU on [DATE] at 10:30 a.m., she provided a copy of the resident's Advanced Health Care Directive which was faxed from the hospital. However, the fax date was [DATE] at 9:22 a.m. She stated that the facility did not have a copy of the Advanced Directive until after surveyor inquiry on [DATE], 25 days after the resident's admitted . She also stated that the family told the facility they would bring a copy of the Advanced Directive on the following Monday, the seventh. She stated the resident should have been a full code until they had a copy of the Advanced Directive. The facility implemented the following actions to remove the Immediate Jeopardy: Personnel will provide basic life support including CPR to a Resident requiring such emergency care before the arrival of emergency medical personnel and subject to related physicians order and Residents Advanced Directive. Root Cause Analysis Nursing staff did not provide CPR on Resident #4 and Resident #12. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1) Clinical Competency Coordinator or designee will ensure all staff know how to confirm the Residents Advanced Directives. 2) All staff were educated on [DATE]. As of [DATE] we trained ,[DATE] activity (100%), ,[DATE] Maintenance (100%), Administration ,[DATE] (100%), Housekeeping & Laundry ,[DATE] (100%), Dietary ,[DATE] (70%), Certified Nursing Assistant ,[DATE] (81%), Licensed Practical Nurses ,[DATE] (88%), Registered Nurses ,[DATE] (100%), Therapist ,[DATE] (75%) by the Director of Health Services and the Clinical Competency Coordinator to verify code status via Resident chart. Staff that have not been trained as of [DATE] will be trained prior to working their next shift. All new hires will be trained on during orientation on basic life support including CPR. Director of Health Services and Administrator completed an audit with all staff on [DATE] to ensure the staff know how to confirm the Residents medical record. 3) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 4) Clinical Competency Coordinator or Director of Health Services will randomly audit 10% of all staff weekly to ensure staff knows how to confirm residents code status by return demonstration. Administrator or designee will audit Advanced Directives in the electronic medical record daily x2 months or until substantial compliance is complete. 5) Findings will be communicated by the Director of Health Services at Quality Assurance Performance Improvement monthly x3 months. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. An interview with Registered Nurse CC (Clinical Care Coordinator) on [DATE] at 12:33 p.m. revealed that staff were in-serviced on [DATE] and any remaining staff were in-serviced before starting their next shift at the facility. 2. The following interviews revealed that all of the staff were able to describe the in-service training for the Advance Directives, Code Status and care planning for Code Status. They stated they have had three to four classes on the topics and then a refresher was done every day where the management would come ask them questions and some had to do a return demonstration to make sure they understood. They were able to describe where to find the resident's Code Status, the banner and in resident electronic documents. They also stated if there was no Code Status on the banner or the documents that the resident would be full code and they would have to start CPR. They stated the resident would be a full code until the proper documents were provided. They also discussed the care plans, where the Code Status would also be included. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) confirming they have attended in-services on [DATE] related to Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: LPN HH at 12:27 p.m., LPN PP, Unit Manager, at 12:39 p.m., LPN RR at 12:47 p.m. and LPN WW at 1:00 p.m. The following Registered Nurses (RN) were interviewed on [DATE] confirming attending in-services regarding the Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status on [DATE]: RN KK at 12:29 p.m., RN DD at 12:34 p.m., RN SS at 12:51 p.m., RN VV (Assistant Director Health Services-ADHS) at 12:53 p.m., RN ZZ at 1:04 p.m., RN HHH (DHS) at 1:21 p.m., RN III at 1:25 p.m. and RN CC at 12:33 p.m. The following Certified Nursing Assistants (CNA) were interviewed on [DATE], confirming they had attended in-services on [DATE] related to Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: CNA II at 12:27 p.m., CNA JJ at 12:29 p.m., CNA MM and CNA NN at 12:36 p.m., CNA OO at 12:39 p.m., CNA QQ at 12:47 p.m., CNA TT and CNA SS at 12:51 p.m., CNA UU at 12:53 p.m., CNA YY at 1:04 p.m., CNA AAA and CNA BBB at 1:09 p.m., CNA CCC at 1:12 p.m. and CNA GGG at 12:21 p.m. The following interviews were conducted on [DATE] related to in-services on [DATE] confirming they had attended in-services on Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: Admission Coordinator LL at 12:34 p.m., Activity Director XX at 1:00 p.m., Social Worker DDD at 1:12 p.m., Front office staff EEE and FFF at 1:18 p.m., Maintenance staff JJJ and KKK at 1:34 p.m., Dietary Aides LLL and MMM at 1:40 p.m., Cooks NNN and OOO at 1:43 p.m., Housekeeping Staff PPP and QQQ at 1:48 p.m. and Housekeeping staff RRR and SSS at 1:50 p.m. and Laundry staff TTT at 1:54 p.m. 3. The Advanced Directive Policy was reviewed and signed by the Administrator on [DATE] and verified with an interview on [DATE] at 2:32 p.m. with the Administrator. 4. Verified via interview [DATE] at 12:33 p.m. with CCC CC, interview [DATE] at 1:15 p.m. with the DHS and review of audit documentation and completed Advance Directive checklists. Also verified via interview [DATE] at 2:32 p.m. with the Administrator who stated she had actually been auditing the lists twice daily. 5. Verified via interview [DATE] at 1:15 p.m. with the DHS confirming that the audit findings will be communicated at the QAPI meetings monthly.

Based on record review and staff interviews, it was determined that the facility failed to ensure the Advance Directive status was accurately reflected on the electronic record face sheet, physician's orders [REDACTED]. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, 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, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility 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 (MONTH) 29, 2019. 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. Findings include: The facility had a Records Management policy. The policy included that it was the facility's policy to apply effective and cost-efficient management techniques to maintain complete and accurate records. The facility had an Advance Directive: Georgia policy and Do Not Resuscitate Policy: Georgia policy in place to address obtaining and maintaining resident Advance Directive documentation in the clinical record. In addition, the facility began using an electronic charting system [DATE]. Review of the Administrator's interview with Licensed Practical Nurse (LPN) XXX, who was assisting LPN AA, dated [DATE] revealed that when reviewing the new electronic record banner for R#4 when she was found unresponsive and without vital signs, the banner contained no Advanced Directive Status. She stated that as a result, LPN AA determined R#4 to be a No Code and did not begin CPR. A post survey interview with the DHS and the Administrator on [DATE] at 11:50 a.m. revealed that R#4's Code Status was not in the banner of the new electronic record, but should have been. The nurses had been trained to look at the banner for the resident's Code Status although if there was no information then it should be assumed that the resident is a full code. During an interview on [DATE] at 1:50 p.m., the Administrator stated that she was notified of R#4's death on [DATE]. Further interview the Administrator confirmed that she was not aware of any concerns regarding advance directive completion and accuracy in the clinical record prior to R#4's and R#12's deaths. In response to the incident, she interviewed staff, called a Quality Assurance Performance Improvement (QAPI) meeting (on [DATE]), put a plan in place and began auditing residents' advance directive status in the clinical records. A review of the plan revealed that it included the following specifics: The facility identified that all residents had the potential to be affected. A. The DHS and Assistant Director of Health Services (ADHS) would educate all nurses on the Advance Directives policy and procedures. All nurses would also be educated on the Matrix (the facility's electronic clinical record system) integration related to Advance Directives. All training was initiated on [DATE] and would be completed by [DATE] with all nurses being educated prior to the start of their next shift. B. The Administrator or designee would complete a daily audit tool to monitor advance directives for four weeks. The DHS and ADHS would complete a weekly audit tool to monitor compliance for four weeks. A QAPI committee meeting would be held on [DATE] to ensure the audit was correct and that no other issues were identified. However, despite the facility's implemented interventions to ensure the Advance Directives were integrated into the electronic clinical record, they failed to ensure that the Advance Directives status was accurate with supporting Advance Directive documentation. Cross refer to F678 The facility implemented the following actions to remove the Immediate Jeopardy: Facility must maintain medical record on each resident that is complete, accurate and readily assessible. Root Cause Analysis Facility failed to maintain Resident's code status in their medical record for Resident #4 and Resident #12. This Immediate Jeopardy was abated on [DATE], at which time the facility has completed the following actions: 1) The admitting nurse is responsible for maintaining accurate information. 2) Director of Health System and Administrator completed an audit of all active resident records on [DATE] to ensure the medical record is complete, accurate and readily assessible. 3) All staff were educated on [DATE]. As of [DATE] we have trained ,[DATE] activity (100%), ,[DATE] Maintenance (100%), Administration ,[DATE] (100%), Housekeeping & Laundry ,[DATE] (100%), Dietary ,[DATE] (70%), Certified Nursing Assistant ,[DATE] (81), Licensed Practical Nurses ,[DATE] (88%), Registered Nurses ,[DATE] (100%), Therapist ,[DATE] (75%) by the Director of Health Services and the Clinical Competency Coordinator to verify code status via Resident chart. Staff that have not been trained as of [DATE] will be trained prior to working their next shift. All new hires will be trained during orientation on maintaining the medical record on each resident that is complete, accurate and readily assessible. 4) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 5) The Director of Health Services and or Unit Manager will monitor this process in clinical stand-up by reviewing all new orders and assuring any Do Not Resuscitate or Full Code orders are in the electronic medical record and the banner is correct. This process will be documented on the Advance Directives Checklist by the DHS or Unit Manager. 6) Results will be communicated by the Director of Health Services or Administrator at Quality Assurance Performance Improvement monthly x3 months. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. This process was confirmed during an interview with Assistant Director of Health Services (ADHS) on [DATE] at 12:53 p.m. and during an interview with the Administrator on [DATE] at 2:32 p.m. 2. Review of the Audit documentation and completed Advanced Directives Checklist verified this process is being done. An interview with the Administrator on [DATE] at 2:32 p.m. verified that all information inputted to the electronic record is accurate. The Administrator revealed that one resident had changed their Advanced Directive and were able to use the new system to ensure that the change was completed accurately. 3. The following interviews revealed that all of the staff were able to describe the in-service training for the Advance Directives, Code Status and care planning for Code Status. They stated they have had three to four classes on the topics and then a refresher was done every day where the management would come ask them questions and some had to do a return demonstration to make sure they understood. They were able to describe where to find the resident's Code Status, the banner and in resident electronic documents. They also stated if there was no Code Status on the banner or the documents that the resident would be full code and they would have to start CPR. They stated the resident would be a full code until the proper documents were provided. They also discussed the care plans, where the Code Status would also be included. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) confirming they have attended in-services on [DATE] related to Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: LPN HH at 12:27 p.m., LPN PP, Unit Manager, at 12:39 p.m., LPN RR at 12:47 p.m. and LPN WW at 1:00 p.m. The following Registered Nurses (RN) were interviewed on [DATE] confirming attending in-services regarding the Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status on [DATE]: RN KK at 12:29 p.m., RN DD at 12:34 p.m., RN SS at 12:51 p.m., RN VV (Assistant Director Health Services-ADHS) at 12:53 p.m., RN ZZ at 1:04 p.m., RN HHH (DHS) at 1:21 p.m., RN III at 1:25 p.m. and RN CC at 12:33 p.m. The following Certified Nursing Assistants (CNA) were interviewed on [DATE], confirming they had attended in-services on [DATE] related to Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: CNA II at 12:27 p.m., CNA JJ at 12:29 p.m., CNA MM and CNA NN at 12:36 p.m., CNA OO at 12:39 p.m., CNA QQ at 12:47 p.m., CNA TT and CNA SS at 12:51 p.m., CNA UU at 12:53 p.m., CNA YY at 1:04 p.m., CNA AAA and CNA BBB at 1:09 p.m., CNA CCC at 1:12 p.m. and CNA GGG at 12:21 p.m. The following interviews were conducted on [DATE] related to in-services on [DATE] confirming they had attended in-services on Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: Admission Coordinator LL at 12:34 p.m., Activity Director XX at 1:00 p.m., Social Worker DDD at 1:12 p.m., Front office staff EEE and FFF at 1:18 p.m., Maintenance staff JJJ and KKK at 1:34 p.m., Dietary Aides LLL and MMM at 1:40 p.m., Cooks NNN and OOO at 1:43 p.m., Housekeeping Staff PPP and QQQ at 1:48 p.m. and Housekeeping staff RRR and SSS at 1:50 p.m. and Laundry staff TTT at 1:54 p.m. 4. Review and interview with the Administrator on [DATE] on 2:32 p.m. of the Records Management policy revealed the Administrator had signed the policy on [DATE]. 5. An interview with the DHS and LPN PP, Unit Manager, on [DATE] at 1:15 p.m. confirmed that all new orders are reviewed during clinical stand-up meeting and assured that any DNR or Full Code Status are in the electronic medical record and that the banner reading is correct. Review of the Advanced Directives Checklist was reviewed to confirm the DHS or Unit Manager are completing the form. 6. An interview with the DHS on [DATE] at 1:15 p.m. confirmed that the results of the clinical stand-up meeting and the Advanced Directives Checklist will be reviewed during the monthly QAPI meetings.

Based on interviews, record review, policy review and review of the Georgia Nurse Practice Act the facility failed to ensure that accepted standards of clinical practice were followed regarding accurately assessing a resident's advance directive status for one resident (#4) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, 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, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility 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 (MONTH) 29, 2019. 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. Findings include: The facility did have an Advance Directives: Georgia policy. Review of the policy statement included that the healthcare center recognizes the right of residents to control decisions related to their medical care. The policy procedure included that prior to, or upon admission, the resident and/or their responsible party will be asked about the existence of any Advance Directives and that the Advance Directive Checklist will be completed. The facility had a Do Not Resuscitate Policy: Georgia policy. The policy statement included that unless an order to withhold life-sustaining treatment is entered on the resident's medical record, life-sustaining treatment will be performed on all residents if it is medically justified. Review of the Rules and Regulations of the State of Georgia, Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurse addressed Rule ,[DATE]-.02 (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or health care facilities in area of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. (f) Performing other specialized tasks as appropriately educated. 2. Responsibility: Each individual is responsible for personal acts of negligence under the law. Licensed practical nurses are liable if the perform functions for which they are not prepared by education and experience and for which supervision is not provided. 1. R#4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, progress notes documented the resident was status [REDACTED]. A GA Advance Directive for Healthcare form and DNR form, were signed by the resident's responsible party on [DATE]. The Georgia Advance Directive for Healthcare form documented that the resident had not executed an Advance Directive and did not wish to discuss Advance Directives further at that time. The DNR form documented that the resident did not have a DNR order or Physician order [REDACTED]. R#4 experienced a change in condition on [DATE]. A nurse's note dated [DATE] at 5:22 a.m., documented that upon entering the resident's room, the resident was unresponsive to verbal and physical stimuli. The note also documented that nursing staff were unable to obtain a blood pressure, pulse, respirations or pulse oximetry, and the resident's temperature was 90.3 degrees. The DHS was notified, and a message was left for the on-call physician. There was no evidence that emergency basic life support measures were immediately implemented. The subsequent nurse's note, approximately one hour later, on [DATE] at 6:25 p.m. documented that CPR was started. Further review of nurses' notes entries revealed that EMS personnel were onsite and took over CPR at 6:30 a.m. and continued emergency life support measures, but without success. EMS personnel received a physician's orders [REDACTED]. During an interview on [DATE] at 7:35 a.m., Licensed Practical Nurse (LPN) AA stated that, after finding the resident unresponsive and unable to obtain vital signs, she checked the resident's electronic chart. She stated that she thought she saw DNR on the Advance Directives section of the chart and notified the DHS. However, when she started the paperwork, she could not find DNR information and called the DHS again, who arrived shortly afterward and called 911 and began CPR. LPN AA stated that she would have started CPR immediately, if she had not thought she saw DNR on the electronic chart. During an interview on [DATE] at 4:30 p.m., the DHS confirmed that she received a call from LPN AA the morning of [DATE] regarding resident #4's passing and that the resident was a DNR. The DHS stated while enroute to the facility to pronounce the resident's death, she received another phone call from LPN AA notifying her that she could not locate the DNR information. The DHS stated she arrived shortly afterward, reviewed the chart, and in seeing no Advance Directive status specified, called 911 and initiated CPR. The DHS stated that Advance Directive/Code Status is verified in the electronic clinical record at the top of the computer screen, on the banner. If there is no Advance Directive/Code Status listed there, you assume the resident is a full code (not a DNR). She stated that there is no need to scroll down to the Advance Directive section of the chart because whatever is checked in that section will appear on the banner (at the top of the screen). 2. Review of the Medical record revealed that R#12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#12 was to be a Do Not Resuscitate (DNR). However, review of the electronic medical record revealed there were no supporting documents to validate the resident's DNR status. Review of the Resident Progress Notes dated [DATE] at 3:00 p.m. revealed that at 2:40 p.m. the nurse was notified by a family member that the resident was unresponsive to all stimuli. The note further documented that the resident was assessed by two nurses and found to be without any vital signs. At 2:45 p.m. the funeral home was notified and was awaiting arrival of the funeral home personnel. The resident had an announcement of death by the Registered Nurse on [DATE] at 2:45 p.m. During an interview with Licensed Practical Nurse (LPN) BB on [DATE] at 11:35 a.m., she stated that the resident's daughter had reported to her the resident was not responding. She stated that she went and got Registered Nurse (RN) CC who got the crash cart and when they entered the room the resident's son told them the resident was a DNR. She stated when she checked the face sheet she saw where the resident was a DNR and they did not do Cardiopulmonary Resuscitation (CPR). During an interview with RN CC on [DATE] at 12:03 p.m., she stated that LPN BB came to her and said the resident was nonresponsive. She grabbed the crash cart while LPN BB got the electronic record to check the resident's code status. As they were entering the room, LPN BB stated the resident was a DNR. She also stated that as they were entering the resident's room, the son asked them what they were doing with the crash cart since his mother was a DNR. She stated she went in the room to assess the resident who did not have a pulse, no respirations and her pupils were fixed and dilated. She stated that she was the nurse who pronounced the resident's death. During an interview with Nurse Consultant UUU on [DATE] at 10:30 a.m., she provided a copy of the resident's Advanced Health Care Directive which was faxed from the hospital. However, the fax date was [DATE] at 9:22 a.m. She stated that the facility did not have a copy of the Advanced Directive until after surveyor inquiry on [DATE], 25 days after the resident's admitted . She also stated that the family told the facility they would bring a copy of the Advanced Directive on the following Monday, the seventh. She stated the resident should have been a full code until they had a copy of the Advanced Directive. The facility had an Advance Directive: Georgia policy and Do Not Resuscitate Policy: Georgia policy in place to address obtaining and maintaining resident Advance Directive documentation in the clinical record. In addition, the facility began using an electronic charting system [DATE]. However, there was no evidence that the Advance Directive system was routinely monitored by the Administrator, to ensure that it was accurately and consistently implemented. During an interview on [DATE] at 1:50 p.m., the Administrator confirmed that she was not aware of any concerns regarding advance directive completion and accuracy in the clinical record prior to R#4's and R#12's deaths. The Administrator revealed that the new electronic medical system was begun on [DATE] and that staff were in-serviced on how to use the new system on [DATE] and [DATE] as the specific systems went online. The Administrator supplied the training agenda and sign in sheets for the [DATE] in-service which covered Resident Charting, Resident Banner items, Entering documentation for the DHS, Nurse Leaders and Nurses. LPN AA was present and signed in for the in-service. Cross refer to F678 The facility implemented the following actions to remove the Immediate Jeopardy: We will ensure that professional care and services are provided according to accepted standards of clinical practice to achieve desired Resident outcomes. Root Cause Analysis The Licensed Practical Nurse failed to provide life sustaining measures for Resident #4. The Licensed Practical Nurse incorrectly identified that the resident was a Do Not Resuscitate. The system that failed was the Full Code status was not entered into the electronic medical record. The Licensed Practical Nurse failed to verify the code status in the resident documents. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1) Senior Nurse Consultant continued education and re-education for all staff on Advance Directives, CPR protocol and explanation of deficient practice. 2) All staff will be educated from [DATE] to completion by the Director of Health Services and Clinical Competency Coordinator to verify code status via Resident chart. As of [DATE], ,[DATE] activity (100%), ,[DATE] Maintenance (100%), Administration ,[DATE] (100%), Housekeeping & Laundry ,[DATE] (100%), Dietary ,[DATE] (70%), Certified Nursing Assistant ,[DATE] (81%), Licensed Practical Nurses ,[DATE] (88%), Registered Nurses ,[DATE] (100%), Therapist ,[DATE] (75%). Staff that have not been trained as of [DATE] will be trained prior to working their next shift. All new hires will be trained during orientation on baseline care plans. Director of Health Services and Administrator completed an audit of all active resident records on [DATE] to ensure the residents Advanced Directive was accurate and in the electronic medical record. 3) The facility follows professional standards of quality. There is no facility policy. The professional standards of quality was reviewed on [DATE]. 4) The Director of Health Services and or Unit Manager will monitor this process in clinical stand-up by reviewing all new orders and ensuring any Do Not Resuscitate or Full Code orders are in the electronic medical record and the banner is correct. This process will be documented on the Advance Directives Checklist by the Director of Health Services or Unit Manager. 5) Findings will be reported in Quality Assurance Performance Improvement by the Director of Health Services or Unit manager x3 months. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of in-service records for [DATE] regarding Advanced Directive: Policy, how to enter Advanced Directives into the electronic record on admission or change in condition, what to do if Code Status changes, reading the full-face sheet in the electronic record, Complete assessments on admission to include Advance Directives and who is responsible for maintaining accurate information. [DATE] DNR policy, Verification of Code Status, Accurate Code Status in the electronic record, Physician order [REDACTED]. Staff were also educated on the [DATE] Immediate Jeopardy results and definitions. All in-services were completed by the Nurse Consultant UUU. 2. Review of in-service sign in sheets to confirm staff attended the in-services. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) confirming they have attended in-services on [DATE] related to Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: LPN HH at 12:27 p.m., LPN PP, Unit Manager, at 12:39 p.m., LPN RR at 12:47 p.m. and LPN WW at 1:00 p.m. The following Registered Nurses (RN) were interviewed on [DATE] confirming attending in-services regarding the Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status on [DATE]: RN KK at 12:29 p.m., RN DD at 12:34 p.m., RN SS at 12:51 p.m., RN VV (Assistant Director Health Services-ADHS) at 12:53 p.m., RN ZZ at 1:04 p.m., RN HHH (DHS) at 1:21 p.m., RN III at 1:25 p.m. and RN CC at 12:33 p.m. The following Certified Nursing Assistants (CNA) were interviewed on [DATE], confirming they had attended in-services on [DATE] related to Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: CNA II at 12:27 p.m., CNA JJ at 12:29 p.m., CNA MM and CNA NN at 12:36 p.m., CNA OO at 12:39 p.m., CNA QQ at 12:47 p.m., CNA TT and CNA SS at 12:51 p.m., CNA UU at 12:53 p.m., CNA YY at 1:04 p.m., CNA AAA and CNA BBB at 1:09 p.m., CNA CCC at 1:12 p.m. and CNA GGG at 12:21 p.m. The following interviews were conducted on [DATE] related to in-services on [DATE] confirming they had attended in-services on Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: Admission Coordinator LL at 12:34 p.m., Activity Director XX at 1:00 p.m., Social Worker DDD at 1:12 p.m., Front office staff EEE and FFF at 1:18 p.m., Maintenance staff JJJ and KKK at 1:34 p.m., Dietary Aides LLL and MMM at 1:40 p.m., Cooks NNN and OOO at 1:43 p.m., Housekeeping Staff PPP and QQQ at 1:48 p.m. and Housekeeping staff RRR and SSS at 1:50 p.m. and Laundry staff TTT at 1:54 p.m. 3. Review of professional standards of quality to confirm review on [DATE] which was signed by the Administrator on [DATE]. 4. Review and interview with the DHS on [DATE] at 1:15 p.m. of completed Advance Directives checklist. 5. Confirmed via interview with the DHS on [DATE] at 1:15 p.m. that the completed Advance Directive checklist will be reviewed by the QAPI committee monthly.

Based on interviews and record review, the facility failed to develop a baseline care plan for the advance directive status for one resident (#4) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, 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, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services (DHS) were notified. While documenting the incident on a Situation, Background, Assessment, Recommendation (SBAR) form in the resident's clinical record the Licensed staff discovered that the resident had a full code status rather than a DNR status. Licensed nursing staff identified the error of the incorrect Advance Directive status approximately one hour after initially finding the resident unresponsive, at which time, the DHS initiated Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) were notified. EMS arrived and continued to provide additional emergency support. However, basic life support measures were not successful, and the DHS pronounced R#4's death on (MONTH) 19, (YEAR) at 6:53 a.m. 2. R#12 experienced a change in condition on (MONTH) 5, 2019. The resident was found in bed, unresponsive to all stimuli and without vital signs. The resident's Advance Directive status was listed in the electronic clinical record as DNR, therefore, licensed nursing staff did not provide emergency basic life support measures and R#12's death was pronounced at the facility on (MONTH) 5, 2019 at 2:45 p.m. However, the DNR status in the clinical record was inaccurate. There was no supporting physician's orders [REDACTED]. Immediate Jeopardy was identified on (MONTH) 29, 2019 and determined to exist on (MONTH) 19, (YEAR) in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plans, F655; 42 CFR: 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658; 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678; 42 CFR 483.70 Administration, F835; 42 CFR: 483.20 (f)(5), 483.70 (i)(1)-(5) Resident Records-Identifiable Information, F842; 42 CFR 483.75(d) Quality Assurance and Performance Improvement Activities, F867, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR: 483.24 (a)(3) Cardio-Pulmonary Resuscitation (CPR), F678. A Credible Allegation of Compliance was received on (MONTH) 29, 2019. Based on interviews, record reviews, and review of facility 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 (MONTH) 29, 2019. 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. Findings include: R#4 was admitted to the facility on [DATE]. A review of the Georgia Advance Directive for Healthcare and DNR forms, signed by the resident's responsible party on [DATE] revealed that the resident had not executed an Advance Directive and did not have a DNR order. A base line care plan was developed that included problems with dates of [DATE] and [DATE] and [DATE]. However, the care plan did not include the resident's Advance Directive status. During an interview on [DATE] at 4:30 p.m., the DHS stated that the Advance Directive/Code Status is verified in the electronic clinical record at the top of the computer screen, on the banner. If there is no Advance Directive/Code Status listed there, you assume the resident is a full code (not a DNR). She stated that there is no need to scroll down to the Advance Directive section of the chart because whatever is checked in that section will appear on the banner (at the top of the screen). The DHS confirmed that the Advanced Directive status was not included on the Baseline Care Plan for R#4 which should have been completed by the admitting nurse and was not completed. Cross refer to F678 The facility implemented the following actions to remove the Immediate Jeopardy: Each Resident must have a Resident centered baseline care plan, followed by a comprehensive care plan developed following completion of the Minimum Data Set and Care Area assessment portion of the comprehensive assessment according to the Resident Assessment Instrument manual and the Resident's choice. Root Cause Analysis The facility failed to develop a Baseline Care Plan to reflect current code status for Resident #4. This Immediate Jeopardy was abated on [DATE], at which time the facility completed the following actions: 1) MDS Nurses, 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 and Full Code Advance Directives. 2) Resident #4 and Resident #12's Care Plan was updated to reflect their Advanced Directives. Director of Health Services and Administrator completed an audit of all active resident records on [DATE] to ensure the residents care plans were accurate. There were no other Residents identified during the audit with inaccurate Care Plans. 3) Care Plan Coordinator/MDS Nurse educated by Senior Nurse Consultant on [DATE] to initiate Advanced Directives/Do Not Resuscitate/Full Code Care Plan once an order is received. As of [DATE] we have trained ,[DATE] activity (100%), ,[DATE] Maintenance (100%), Administration ,[DATE] (100%), Housekeeping & Laundry ,[DATE] (100%), Dietary ,[DATE] (70%), Certified Nursing Assistant ,[DATE] (81%), Licensed Practical Nurses ,[DATE] (88%), Registered Nurses ,[DATE] (100%), Therapist ,[DATE] (75%). Staff that have not been trained as of [DATE] will be trained prior to working their next shift. All new hires will be trained during orientation on baseline care plans for an Advanced Directive. The Director of Health Services and/or Unit Manager will monitor this process in clinical stand-up by reviewing all new orders and ensuring any Do Not Resuscitate or Full Code orders are carried through to the care plan. This process will be documented on the Advance Directives Checklist by the Director of Health Services or Unit Manager. 4) The facilities policy has been reviewed and is current. The policy was reviewed on [DATE]. 5) Findings will be reported in Quality Assurance Performance Improvement Committee by the Director of Health Services or Unit manager x3 months. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. An interview and record review with the Minimum Data Set (MDS) Coordinator on [DATE] at 12:45 p.m. revealed that chart audits have been completed daily for Advance Directives and corresponding care plans from [DATE] through [DATE]. She further stated that as of [DATE] the audits include that the correct Code Status and that the corresponding paper work is included in the resident's record. 2. Review and verification of the facility's audit documents, care plans and Advance Directive documentation for residents with a DNR is specified in the resident's chart. 3. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) confirming they have attended in-services on [DATE] related to developing a Base Line Care Plan for Code Status: LPN HH at 12:27 p.m., LPN PP, Unit Manager, at 12:39 p.m., LPN RR at 12:47 p.m. and LPN WW at 1:00 p.m. The following Registered Nurses (RN) were interviewed on [DATE] confirming attending in-services regarding the development of Base Line Care Plans for Code Status on [DATE]: RN KK at 12:29 p.m., RN DD at 12:34 p.m., RN SS at 12:51 p.m., RN VV (Assistant Director of Health Services-ADHS) at 12:53 p.m., RN ZZ at 1:04 p.m., RN HHH (DHS) at 1:21 p.m., RN III at 1:25 p.m. and RN CC at 12:33 p.m. The following Certified Nursing Assistants (CNA) were interviewed on [DATE], confirming they had attended in-services on [DATE] related to developing a Base Line Care Plan for Code Status and their role in the process: CNA II at 12:27 p.m., CNA JJ at 12:29 p.m., CNA MM and CNA NN at 12:36 p.m., CNA OO at 12:39 p.m., CNA QQ at 12:47 p.m., CNA TT and CNA SS at 12:51 p.m., CNA UU at 12:53 p.m., CNA YY at 1:04 p.m., CNA AAA and CNA BBB at 1:09 p.m., CNA CCC at 1:12 p.m. and CNA GGG at 12:21 p.m. The following interviews were conducted on [DATE] related to in-services on [DATE] confirming they had attended in-services on Advanced Directives Policy, responsibilities for maintaining the resident's record and confirming the Code Status in the electronic record and to confirm the accuracy of the resident's code status: Admission Coordinator LL at 12:34 p.m., Activity Director XX at 1:00 p.m., Social Worker DDD at 1:12 p.m., Front office staff EEE and FFF at 1:18 p.m., Maintenance staff JJJ and KKK at 1:34 p.m., Dietary Aides LLL and MMM at 1:40 p.m., Cooks NNN and OOO at 1:43 p.m., Housekeeping Staff PPP and QQQ at 1:48 p.m. and Housekeeping staff RRR and SSS at 1:50 p.m. and Laundry staff TTT at 1:54 p.m. 4. Per interview and review of the Care Plan Policy, confirmed that the facility Baseline Care Plan Policy was reviewed and approved on [DATE] with input from the Medical Director and Nursing. The policy was signed by the Administrator on [DATE]. 5. Record review and interviews with the Administrator and DHS on [DATE] at 1:15 p.m. and 2:32 p.m. which confirmed that a QA meeting was held on [DATE] after the death of R#4 to put a plan into place which included an audit of all resident's records for Advanced Directive Status. Additionally, a QA meeting was held on [DATE], which included the Medical Director (via telephone) to update the plan to address the Advance Directive error and review the affected policies of the facility, which included Base Line and Comprehensive Care Plans.

Based on observation, interview, record review and review of facility data, the facility failed to follow the care plan related to activities of daily living (ADL) and mobility for one resident, Resident (R) F and failed to ensure the comprehensive care plan was completely developed within the required time frame for one resident, Resident (R) C. Actual harm was identified on 3/25/18 when the R F was being assisted by one Certified Nursing Assistant (CNA), rather than by two persons per the care plan, and fell out of bed resulting in a femur fracture. The sample size was 40 residents. Findings Include: 1. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] for R F revealed a Brief Interview for Mental Status (BIMS) of 12 which indicates the resident was moderately impaired. Section G of the MDS revealed that the resident was assessed for extensive assist by two plus person for bed mobility, transfer, dressing and toilet use. The resident was assessed as total dependence for care. Review of the care plan up-dated 9/14/17 with a problem onset dated 12/11/14 for at risk of falls. Approaches included R F requires the assistant of two people, via mechanical lift for transfers although the care plan does not include the assistance with all care. Continued review of the care plan revealed R F was at risk for decline in Range of Motion (ROM) and muscle strength related to decreased mobility, obesity, chronic pain and [MEDICAL CONDITION] up-dated 9/14/17 revealed an approach for Restorative nursing for bed mobility, rolling side to side using bed rail with max assist X 2 (by two persons). Review of the CNA care intervention record form revised 1/14/15 revealed under transfer and repositioning that the resident requires the assist of two. Record review revealed that R F was originally admitted to the facility on [DATE] then readmitted on [DATE] after a fall/fracture, with the [DIAGNOSES REDACTED]. An interview was conducted with on 4/30/18 at 1:34 p.m. with R F family revealed that the resident's care plan implemented for her mother requires the assistance of two staff. The family revealed that on 3/25/18 one nursing assistant provided care for R F without assistance of another staff and that the resident fell out of the bed to the floor resulting in a fractured of her left femur. An interview conducted on 4/30/18 at 4:10 p.m. with Certified Nursing Assistant (CNA) LL assigned to R F on 3/25/18 revealed that the resident requires the assistance of two people when providing care. CNA LL further revealed that she provided care to R F on 3/25/18, without assistance, and that while providing care to R F, the resident fell out of the bed on to the floor. A post survey telephone interview with the Interim Administrator and the Director of Nursing, conducted on 5/15/18 at 2:45 p.m., revealed that she had started this position in mid (MONTH) (YEAR) and was not aware of staffing issues before starting the position. She revealed that the previous Administrator had put a Performance Improvement Plan in place and that the staff had been in-serviced to follow all resident's care plans. The facility failed to follow the resident care plan by providing care without the assistance of two staff. This resulted in R F having a fall with an injury. Cross refer to F656 2. An interview was conducted during the initial pool process on 4/30/18 at 2:36 p.m. with R C who revealed that she attends therapy, but has missed three days with no explanation. The resident further revealed that when she asked a therapist about missing therapy, the resident was told that she wasn't on the schedule. The resident stated that the Certified Nurse Assistants (CNAs) don't know when she is scheduled and don't have her ready for physical therapy (PT) and that the therapists must come back several times to see if she is are ready. An observation of R C was conducted on 5/01/18 at 3:00 p.m. revealed the resident was observed in the therapy gym participating in exercises, with a pleasant affect. The resident appeared in good spirits, was dressed appropriately, wearing socks and shoes. When asked about having any pain, no complaints were voiced. A review of the Minimum Data Set (MDS) admission assessment, dated 3/15/18, indicated the resident had a Brief Interview for Mental Status (BIMS) with a summary score of 15 indicating no cognitive impairment; a functional assessment indicated the resident required a one person assist; that extensive assistance was needed for mobility and transfers. Medications included an opioid and a diuretic; that for the section for special treatments indicated a therapy start date of 3/10/18. On 5/01/18 at 2:00 p.m. an interview was conducted with the Physical Therapy Outcome Coordinator who provided a copy of the schedule for the PTs, where the residents are scheduled by the number of minutes of therapy for the day and indicate who is the assigned therapist. She explained that for the short-term rehabilitation residents on 100-Hall, the therapist goes to the resident's room and will ask the resident if they want to be seen in the morning or afternoon; they offer this because the residents have other appointments too and are busy. The therapist then will tell the CNAs and the resident when they will be back, approximately, so they can be ready for therapy. She confirmed that the residents do not receive a schedule from PT and revealed that this has been the process since she started in (MONTH) (YEAR). The PT Coordinator further explained that if some resident refuses or misses an appointment that it logged in their computer system; but offered that often a resident does not remember how many times they have been to therapy that week. She confirmed they see residents seven days a week, that residents don't get therapy each day of week, but the amount of days/week the Physician orders [REDACTED]. She confirmed the resident was seen 4/21/18, 4/22/18, 4/24/18, 4/25, 4/26/18, 4/27/18, 4/29/18 and 4/30/18 with days not scheduled on purpose for muscle rest, building up of endurance, or other scheduled appointments the resident may have. She stated that R C was very anxious to go back home, but needs time to build up strength. An interview on 5/01/18 at 2:20 p.m. with day shift CNA EE revealed that they do not have a PT schedule provided to them, that the therapist comes to the room and talks to the resident and will let them know if they have morning or afternoon therapy. During the resident's record review, the record revealed the resident was initially admitted on [DATE] from an acute hospital with a [DIAGNOSES REDACTED]. Review of the Physician PT Orders/Treatments indicated an order for [REDACTED]. A review of the PT notes in the facility's electronic system, revealed the resident was ordered PT, and had been receiving PT five times a week. Review of the form entitled Baseline Care Plan dated 3/10/18, reflected that R C was at risk for falls (fall 3/12/18) and that the care plan was updated for falls; she was care planned for a decline in Activity of Daily Living (ADL) related to a lower back sprain, impaired mobility, and was at risk for pain related to wound on her buttocks, dated 3/12/18; she was at risk for impaired skin integrity, at risk for [DIAGNOSES REDACTED]/[MEDICAL CONDITION] symptoms related to diabetes; at risk due to use of an anti-anxiety medication; has potential social isolation related to being a new patient/short stay resident; care planned for discharge planning, and other devices- family and resident education occurred on the risks of using half side rails for bed mobility and transfers. Review of the form Comprehensive Care Plan undated, revealed that three care plan areas were completed as follows: for an advanced directive status, activities of interest, and for nutrition, these were dated 3/15/18 and 3/16/18 for problem onset. The care plan did not include other resident centered care areas or services being provided, nor was the resident care planned for potential areas of risks, goals or specific interventions. During an interview on 5/2/18 at 3:50 p.m. with MDS Coordinator/Case Mix Director DD at the nurse's station, revealed after review of the two provided care plans for R C, with the surveyor, confirmed that the baseline care plan was completed 3/10/18 by the admitting floor nurse. She confirmed the comprehensive care plan was not finished. The MDS Coordinator DD stated that the comprehensive care plan was expected to be done 21 days after the baseline care plan with the date of 3/10/18, and was due 3/30/18, she confirmed she had not yet met with the resident to complete the comprehensive care plan. On 5/2/18 at 4:00 p.m. a review was conducted of the provided facility policy entitled Care Plans revision date of 10/5/17; reflecting that it is the policy of the health care center for each patient/resident to have a person centered baseline care plan followed by a comprehensive care plan, developed following completion of the MDS and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident's choice. Admission Comprehensive Plan of Care: reflects a comprehensive person center care plan will be developed by the interdisciplinary team for each patient/resident within seven days after the completion of the comprehensive assessment. The comprehensive person-centered care plan is developed to include measurable goals and time frames to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interviews, and review of the facility documents, the facility failed to ensure a safe and secure environment related to accidents, which resulted in actual harm to resident (R) F who had a fall out of the bed while being assisted by one Certified Nursing Assistant (CNA), rather than two as per the care plan which resulted in a fractured femur. In addition, R J experienced a fall, without injury, due to staff not responding to R J's request for assistance to the bathroom; also the facility failed maintain locked medication carts on two of three halls. The facility census was 86. Findings Included: 1. Record review revealed that R F was originally admitted to the facility on [DATE] then readmitted on [DATE] after a fall/fracture. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed R F had a Brief Interview for Mental Status (BIMS) score of 12 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for extensive assist by two plus person for bed mobility, transfer, dressing and toilet use. The resident was assessed as total dependence for care. Review of the care plan, up-dated 9/14/17, with a problem onset dated 12/11/14 for at risk of falls. Approaches for R F requires the assistant of two people, via mechanical lift for transfers although the care plan does not include the assistance with all care. Review of the care plan for at risk for decline in Range of Motion (ROM) and muscle strength related to decreased mobility, obesity, chronic pain and [MEDICAL CONDITION] up-dated 9/14/17 revealed an approach for Restorative nursing for bed mobility, rolling side to side using bed rail with max assist X 2 (by two persons). Review of the CNA care intervention record form revised 1/14/15 revealed under transfer and repositioning that the R F requires the assist of two. Review of the facility's SBAR (Situation, Background, Assessment, Recommendation) communication form dated 3/25/18 at 22:45 (military time) revealed that the Certified Nursing Assistant (CNA) was providing care to R F unassisted and the resident fell out of the bed onto the floor. The Physician and family were notified and the resident was transferred to the hospital for evaluation due to complaints of pain. Review of the Physician order [REDACTED]. Review of the hospital History and Physical for R F dated 3/26/18 revealed an x-ray of the left knee, which demonstrated a left femur fracture. The resident was admitted to the hospital then readmitted back to the facility on [DATE]. An interview was conducted on 4/30/18 at 4:10 p.m. with CNA LL, assigned to R F on 3/25/18, which revealed that CNA LL was aware that R F requires the assistance of two people when providing care although she confirmed providing care to R F on 3/25/18 without assistant and that the resident fell out of the bed, on to the floor. A post survey telephone interview with the Interim Administrator on 5/15/18 at 2:45 p.m. revealed that she had placed the Fall Prevention and Intervention into a Performance Improvement Plan (PIP) on 4/28/18. Review of the staff inserviced revealed that staff had been in-serviced on 3/26/18 related to Use of two person assist with residents that can not turn self. Review of the in-service sign in sheets dated 3/26/18, supplied by the facility, does not reveal that CNA LL was in-serviced. 2. Review of the admission MDS assessment dated [DATE] for R J revealed the resident had a BIMS summary score was 10 which indicates the resident was moderately impaired. Review of Section [NAME] revealed the resident was not assessed as having behaviors. Review of Section G revealed the resident was assessed for extensive assist by one person for bed mobility, dressing, toilet use, and personal hygiene and extensive assist by two plus person for transfers. The resident is assessed as having impairment for upper extremities on one side, uses a walker/wheelchair for mobility. An interview conducted on 5/1/18 at 9:43 a.m. with family of R J revealed that R J had a fall on 4/30/18. The family stated that R J revealed that the resident put the light on, and no one answered the light and he got up because he was tired of waiting. The family stated the resident had a fall while self transferring. An interview conducted on 5/3/18 at 11:05 a.m. with rehabilitation tech (RT) KK revealed that on 4/30/18 around 8:30 a.m. a family member of another resident stopped her in the hall and informed her someone was yelling for help. Upon walking into the room of R J the resident was lying on the floor in the bathroom. RT KK also stated the bathroom call light was on. Record review of the nurses notes dated 4/29/18 revealed the resident was receiving antibiotics for a urinary tract infection [MEDICAL CONDITION] with [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) and was on contact precautions. The resident was a little confused and safety precautions were in place. A post survey telephone interview with the Director of Health Services (DHS) on 5/8/18 at 12:30 p.m. revealed that the facility has been experiencing staffing shortages and is actively attempting to hire additional staff. The facilty failed to have proper supervision of the resident by not answering the call light. The resident had a fall without injury trying to self transfer. 3. Observation on 5/2/18 at 7:25 a.m. revealed a medication cart for the 300 hall, at the nurses station, unlocked and not under direct observation of authorized staff in an area where residents could access it. No residents were observed near the medication cart at this time. An interview and observation were conducted on 5/2/18 at 7:33 a.m. with the Director of Health Services (DHS) and with Licensed Practical Nurse (LPN) NN which confirmed that 300 hall medication cart was unlocked and should not be left unlocked. Observation on 5/2/18 at 8:02 a.m. revealed the medication cart, for the 200 hall in front of room [ROOM NUMBER], was unlocked and was not under direct observation of authorized staff in an area where residents could access it, although no residents were observed near the medication cart at this time. An interview and observation were conducted on 5/2/18 at 8:08 a.m. with the DHS and LPN OO, who confirmed that 200 hall medication cart was unlocked and should be locked.

Based on resident and staff interviews and record reviews, the facility failed to provide staff in sufficient numbers to care for the needs of eight Residents (R) F, R H, R J, R E. R K, R A, R B, and R D. Actual harm was identified on 3/25/18 when the R F was being assisted by one Certified Nursing Assistant (CNA), rather than by two persons per the care plan, and fell out of bed resulting in a femur fracture. The facility census 86. Findings include: 1. Review of R F quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 which indicates the resident's cognition was moderately impaired. Continued review of the MDS revealed in Section G that the resident was assessed for extensive assist by two plus person for bed mobility, transfer, dressing and toilet use. The resident was assessed as total dependence for care. Review of the care plan up-dated 9/14/17 with a problem onset dated 12/11/14 for at risk of falls. Approaches for R F included the resident requires the assistance of two people, via mechanical lift for transfers. Continued review of the care plan revealed R F at risk for decline in Range of Motion (ROM) and muscle strength related to decreased mobility, obesity, chronic pain and [MEDICAL CONDITION] up-dated 9/14/17 revealed an approach for Restorative nursing for bed mobility, rolling side to side using bed rail with max assist X 2 (by two persons). Review of the CNA care intervention record form revised 1/14/15 revealed under transfer and repositioning that the resident requires the assist of two. Review of the facility's SBAR (Situation, Background, Assessment, Recommendation) communication form dated 3/25/18 at 22:45 (military time) revealed that the Certified Nursing Assistant (CNA) was providing care to R F unassisted and the resident fell out of the bed onto the floor. The Physician and family were notified and the resident was transferred to the hospital for evaluation due to complaints of pain. Review of the Physician order [REDACTED]. Review of the hospital History and Physical for R F dated 3/26/18 revealed an x-ray of the left knee, which verified a left femur fracture. The resident was admitted to the hospital then re-admitted to the facility on [DATE]. An interview was conducted on 4/30/18 at 4:10 p.m. with CNA LL, assigned to R F on 3/25/18, which revealed that CNA LL was aware that R F requires the assistance of two people when providing care although she confirmed providing care to R F on 3/25/18 without assistance and that the resident fell out of the bed, on to the floor. A post survey telephone interview with the Interim Administrator on 5/15/18 at 2:45 p.m. revealed that she had placed the Fall Prevention and Intervention into a Performance Improvement Plan (PIP) on 4/28/18. Review of the in-serviced sign in sheets dated 3/26/18, supplied by the facility, related to Use of two person assist with residents that can not turn self, did not contain a signature for CNA LL who had assisted the resident without assistance. An Interview conducted on 4/30/18 at 1:53 p.m. with Licensed Practical Nurse (LPN) BB,in charge of the care of R F, confirmed that R F has not had any of her 9:00 a.m. medications or pain medication. An observation and interview on 4/30/18 at 2:08 p.m. of LPN BB administering medications to R F, confirmed that the medications that the resident was receiving were her 9:00 a.m. medications except for the scheduled antibiotic and that the medications were being given late. An observation and interview on 5/1/18 at 11:42 a.m. LPN FF preparing medications for R F revealed that the medications that she was preparing was for the resident were the 9:00 a.m. medications. LPN FF confirmed that the medications were being given late and revealed that she was busy, working alone, and orientating a new nurse. An Interview was conducted on 5/3/18 at 1:53 p.m. with Licensed Practical Nurse (LPN) BB revealed that there is not sufficient staff to take care of the resident, to complete the necessary paperwork that is required when incidents/accidents happen or to pass medication on time. Cross refer to F689 2. Review of the admission MDS assessment dated [DATE] for R J revealed the resident had a BIMS summary score of 10 which indicates the resident's cognition was moderately impaired. Despite a BIMS score of ten, the resident was alert and oriented times three (people, place, and time) and could answer screening questions appropriately. Review of Section [NAME] revealed the resident was not assessed as having behaviors. Review of Section G revealed the resident was assessed for extensive assist by one person for bed mobility, dressing, toilet use, and personal hygiene and extensive assist by two plus person for transfers. The resident was assessed as having impairment for upper extremities on one side, uses a walker/wheelchair for mobility. An interview conducted on 5/1/18 at 9:43 a.m. with family of R J revealed that there is not sufficient staff to provide nursing related services to meet the needs of the residents in the facility. The family revealed there are long wait times before a call light is answered sometimes the wait can be up to 45 minutes. The family stated R J had a fall on 4/30/18. The family stated that R J told her he put the light on, and no one answered the light and he got up because he was tired of waiting. Neither the family or the resident could specify how long the resident had waiting, that night (4/30/18), for staff before attempting to toilet himself. The family reports there was no injury to the resident. An interview conducted on 5/3/18 at 11:05 a.m. with rehabilitation tech (RT) KK. which revealed that on 4/30/18 around 8:30 a.m. a family member of another resident stopped her in the hall and informed her someone was yelling for help. Upon walking into the room of R J the resident was lying on the floor in the bathroom. RT KK also stated the bathroom call light was on. Cross refer to F689 3. Review of the admission MDS assessment dated [DATE] revealed that R H was assessed with [REDACTED]. Despite an admission BIMS score of ten, the resident was alert and oriented times three (people, place, and time) and could answer screening questions appropriately. Record review of the physician's orders [REDACTED]. An interview conducted on 5/1/18 at 10:14 a.m. with R H, and his family member, revealed there is not sufficient staff in the facility to meet the needs of the residents. Resident H stated on 4/30/18 he put his light on around 7:00 p.m. for something for pain and no one answered the light. Resident stated that around 8:30 p.m. he called his wife and told her he pushed his call bell for something for pain and it had been over an hour and no one would answer the light. The family member revealed that she then called the nurses station and asked the person answering the phone to give R H the pain medication that was requested several hours ago and had not been received. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. 4 . A record review for R B revealed the resident was a new admission on 4/25/18 for a short-term rehabilitation stay. The Minimum Data Set (MDS) Admission Assessment was not yet due/available. The resident was alert, but unable to answer initial pool screening interview questions. An interview was conducted on 5/2/18 at 1:00 p. m. with a family member of R B, regarding some concerns for the resident's care. The family member revealed that they were unhappy with the facility's services; that when the resident was admitted she was never introduced to the nurse or the aide or orientated to the room. The family had waited eight days for a room to be available for admission. She stated that yesterday while visiting the resident from 3:00 p.m. to 7:15 p.m., the family put the call light on, waited for 20 minutes, no one answered, so they went out to the nurse's station to help find someone to help them. The family member stated that by the time the CNA came to the room the resident was incontinent of both urine and bowel, that she usually isn't incontinent with her bowels. 5. A record review for R D revealed the resident was admitted on [DATE] for a short-term rehabilitation stay after surgery. The Admission MDS Assessment was not yet due/available. The resident was alert and able to answer initial pool screening interview questions. An interview was conducted on 5/1/18 at 10:50 a.m. when R D stated that staffing was much better when she was at the facility back in October. She stated now she is seeing less staff. The resident revealed that the 11:00 p.m. to 7:00 a.m. shift seems short, she must wait a long time for help. She stated she needs to be ready by 10:30 a.m. three times per week for [MEDICAL TREATMENT] and they hurry her, they seem short of help during the day shift too. 6. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R [NAME] had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. Review of Section G revealed the resident was assessed for extensive assistance, by one person, for bed mobility, dressing, and eating. The resident was assessed for extensive assistance, by two people, for toilet use and transfer. The resident was assessed for functional limitations of both upper extremities and one side for lower extremities. During an interview on 4/30/18 at 12:17 p.m., R [NAME] revealed she frequently waits for 30-plus minutes for staff to respond when she presses her call button for assistance. On more than one occasion, she urinated in her clothing while waiting for staff to respond to take her to the bathroom because her family advised her not to attempt to hold it when this happens. Staff failure to respond to her call for assistance in a timely manner happens most often on the night shift. During a subsequent interview with R [NAME] on 5/1/18 at 8:45 a.m. revealed that she was waiting for staff to get her showered and dressed for the day. She preferred to start her day much earlier, but she had agreed to have the CNAs get her up and dressed around 9:00 a.m. each day because there was not enough staff for them to get to her before that time. 7. Review of the Quarterly MDS assessment dated [DATE] revealed R K had a BIMS score of 15, indicating that the resident was cognitively intact. Review of Section G revealed the resident was assessed for extensive assistance by one person for bed mobility, eating, and personal hygiene. The resident was assessed for extensive assistance by two persons for transfers, dressing and toilet use. During an initial interview on 4/30/18 at 11:10 a.m., R K asked to be interviewed later in the day because she was still waiting for staff to get her up and dressed for the day. During an interview on 4/30/18 at 1:42 p.m., R K said she likes to stay up late, but the CNA's or nurses sometimes encourage her to go to bed early - before 9:00 p.m - or make some excuse to get her up early in the day when they are short of staff in an effort to care for her needs and move on to other residents. On other occasions, she has to wait much later in the day to get up, because there are not enough staff available to get everyone up on time. Sometimes, when she calls, staff will promise to return, claiming that they are working with another resident. However, they may not return for another two hours, if at all. It typically takes one to two hours for staff to respond when she presses her call button. When she complained, they told her the average time during which they are expected to respond to call lights is two hours. She could not remember the name (s) of staff members who told her this, but was adamant that this is what she was told. Earlier in the day, she knew there were not enough CNAs working on her hall because the CNA that came to her room informed her that the residents would need to be patient because the CNA was working on her own on the resident's hallway and it would take her some time to respond to each resident's needs. 8. Review of the Significant change MDS assessment dated [DATE] for R A revealed a BIMS score of 99, indicated the severe cognitive impairment. Review of Section G revealed the resident was assessed for extensive assistance by one person for bed mobility, eating and personal hygiene. The resident was assessed for extensive assistance by two persons for transfer, dressing and toilet use. During an interview with family member of R A on 4/30/18 at 4:36 p.m., it was revealed that there was usually not enough staff to provide for the needs of all the residents at meal times. The family member of the resident revealed that staff leave the hallways to provide assistance to residents in the dining room during mealtimes. Sometimes R A needs to go to the bathroom and has to wait more than 30 minutes for staff to take her. The resident cannot go to the bathroom on her own because she is at risk for falls. Review of resident council minutes for the past year revealed residents voiced the following concerns related to insufficient staffing during their monthly meetings: June (YEAR) - water was not being passed on every shift; July (YEAR) - not enough staff, especially on nights and weekends - the administration responded that they were having staffing interviews and had just hired 5 new CNAs and 1 nurse; August (YEAR) - water was still not being passed on each shift and sufficient staffing continued to be an issue; September (YEAR) - insufficient staffing was still a concern; residents were waiting 30-45 minutes for call lights to be answered; the administration responded that they were still recruiting; October (YEAR) - the residents said there was not enough staff on the weekends, especially on the 3:00 p.m. to 11:00 p.m. shift; the administration response was that they were still recruiting; November (YEAR) - the residents were concerned that sufficient staffing was an issue; they were concerned with not being able to get up when they wished; December (YEAR) - the residents said staffing was better, but still not adequate; February (YEAR) - staffing continued to be a problem; the administration responded that all CNA positions were filled, but the facility still have nurse vacancies and were recruiting; March (YEAR) - staffing was still a problem; there was not enough staff on the weekends; administration responded: staffing has been at 3.73 average PPD or higher which means that even though people have called out, they have been replaced . we do have vacancies and are currently interviewing/hiring for these positions; April (YEAR) - water was not being passed consistently; During a resident group interview on 5/1/18 at 3:30 p.m. with members of the resident council the following was revealed: Most of the residents attending the group interview said it was not unusual to wait at least an hour after turning on your call light. Two residents said they did not experience long wait times after pressing their call lights for assistance. They attributed this to the fact that they required little to no assistance from staff to obtain drinking water or use the bathroom. Review of the Facility's Assessment for the period 10/31/16 to 10/31/17 revealed the facility cared for a daily average of 84 residents during that period. It also documented that the facility cared for high levels (60.6 % and 22.6% respectively) of residents that were considered to have low and moderate levels of functioning in the area of activities of daily living (ADLs) when compared to the national benchmark. 87.2 % of the facility's residents needed the assistance of one or more persons when receiving daily care (excluding bathing) and 73.2% needed the help of two or more persons. These averages were considered very high when compared to the national benchmark. A review of the April/May schedule for licensed nursing staff (4/22/18 to 5/19/18) revealed there were 10 out of a possible 28 days on which only one nurse was scheduled on the 7:00 p.m. to 7:00 a.m. shift. and only four CNAs were scheduled on the 7:00 a.m. to 3:00 p.m. shift on 4/22/18, with three CNAs working on 5/5/18 and 5/19/18. During an interview on 5/3/18 at 9:02 a.m. with CNA GG, it was revealed that she assists with completing and posting the schedule of licensed staff that are scheduled to work each day. The monthly schedule that is now completed by the Director of Health Services (DHS), she completes the daily census list. The daily census list of licensed staff usually has three or four nurses on the 7:00 a.m. to 7:00 p.m. shift; and three to four on 7:00 p.m. to 7:00 a.m. shift. The schedule usually has seven CNAs - two for each of three hallways and one who splits the upper part of hallways 3 and 2. Seven CNAs are also usually scheduled on the 3:00 p.m. to 11:00 p.m. shift., and five CNAs for the 11:00 p.m. to 7:00 a.m. shift. Each CNA is assigned to a certain number of rooms, depending on how many residents are present in the facility. Observation on 5/3/18 at 11:00 a.m. of the posted staff schedule for the day revealed there were 10 CNAs scheduled for the 7:00 a.m. to 3:00 p.m. shift that day. During an interview on 5/3/18 at 11:06 a.m. with CNA HH it was revealed that the staff usually work with two CNAs on each hallway during the day. That means that each CNA is assigned to work with 16 residents and must give about 4 showers during their shift. Such an arrangement makes it difficult to get through with the care that needs to be provided to each resident; care such as checking/changing residents every two hours, assisting residents to the bathroom, assisting with meals, etc. The residents complain to the CNAs that it takes too long for their call lights to be answered, but what can the CNAs do? If the CNAs are in a room assisting another resident for 30 minutes then they cannot know that another resident is calling and, even if they do, they cannot leave the resident they are attending to if it is not safe to do so. Occasionally, there are three CNAs on the hall during a shift. When that happens, the workload is much easier. However, most workdays there are only two. During an interview with the Director of Health Services (DHS) on 5/3/18 at 11:33 a.m., it was revealed that she completes the staff schedule every 30 days. She schedules staff based on acuity. This means that she usually staffs for a minimum of three nurses on the floor per shift; one on each hall. The CNAs work three shifts - a day, an evening, and a night shift. There are at least six CNAs scheduled on the day shift (7:00 a.m. to 3:00 p.m.) most days, an average of five on the evening shift, and an average of four on the night shift. These averages are scheduled seven days a week. When staff call in sick, she first tries to call in an alternative or will shift the existing CNAs to provide coverage based on the residents' needs. The minimum numbers of CNAs the facility staffs, is sufficient (e.g. six on days) for the needs of the residents. The numbers that are needed were chosen based on the PPD (per patient per day). The minimum number needed for each shift has not been revised recently to her knowledge; however, on some days, based on patient load, they may have extra CNAs and extra licensed practical nurses (LPNs). During the interview on 5/3/18 at 12:52 p.m. with CNA, II, it was revealed that she was scheduled to work on the evening shift. However, she was called to come in on the earlier shift where she was working alongside two other CNAs on one of the hall. During an interview on 5/3/18 at 2:06 p.m. with CNA JJ, it was revealed that the CNAs usually work with a maximum of two CNAs per hallway. This means each CNA is responsible for an average of 16 residents during their shift. They do their best to provide the care the residents need, but it is often difficult to get to everyone and residents must wait. When staff are in a resident's room, they cannot see if another resident down the hall is calling. The CNAs occasionally work with 3 CNAs on their hallway. When this happens, it is much easier to provide for the needs of the residents in their care. A post survey telephone interview with the Interim Administrator on 5/15/18 at 2:45 p.m. revealed that she had been at the facility since mid (MONTH) (YEAR). She felt there was enough staff but that she felt they may not be used efficiently. She was not aware there was a staffing issue before coming to the facility, but after reviewing the Resident Council minutes she was concerned. She met with the Resident Council, at which time the Ombudsman was also present. She is monitoring the staffing issues. A post survey telephone interview with the DHS on 5/18/18 at 12:30 p.m. revealed that she is not new to this position, but at the time of R F's fall she was working nights due to staffing shortage. She was not aware of the fall with fracture until a week later. She revealed that the facility does have a staffing shortage but is interviewing for new staff. She stated the salaries are competitive but is more about the workload than the salary.