Every finding on record at Redbanks Colonial Terrace

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of nine (9) sampled residents (Resident #9). Observation on 12/01/2022, revealed Certified Nurse Aide (CNA) #1 failed to wash her hands when providing care to Resident #9. The findings include: Review of the facility's policy titled, Handwashing, undated, revealed handwashing and hand antisepsis should be regarded by the facility as the single most important means of preventing the spread of infection. All personnel should follow the established hand washing and antisepsis procedures to prevent the spread of infection and disease to residents, and visitors. If staff's hands were not visibly soiled, they were to use an alcohol-based hand rub for routinely decontaminating their hands in all other clinical situations; before having direct contact with residents, after contact with inanimate objects in the immediate vicinity of the resident, and after removing gloves. Review of the medical record revealed the facility admitted Resident #9 on 04/02/2022, with diagnoses which included Cerebral Infarction, Unspecified, Hemiplegia and Hemiparesis affecting Right Dominant Side and Muscle Weakness. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 10/20/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated no cognitive impairment. Interview with Resident #9, on 12/01/2022 at 9:41 AM, revealed he/she did not pay much attention when staff washed their hands, but thought they usually wore gloves. Observation on 12/01/2022 at 9:12 AM, revealed CNA #1 entered Resident #9's room and donned gloves without washing her hands, and assisted the resident to the bathroom. Continued observation revealed CNA #1 exited the bathroom with Resident #9 in his/her wheelchair, removed her gloves and tossed them in the trash and did not wash her hands. CNA #1 then assisted Resident #9 to the nurses' station without washing her hands. Interview with CNA #1 on 12/01/2022 at 9:21 AM, revealed she should have washed her hands prior to her gloves on. She stated she should have also washed her hands when she removed the gloves after caring for Resident #9. CNA #1 further stated handwashing helped prevent the spread of infections. Interview with the Assistant Director of Nursing (ADON) on 12/02/2022 at 2:13 PM, revealed she expected all staff to wash their hands before and after resident care and as indicated by the facility policy. She stated all staff had been educated numerous times on handwashing since the COVID pandemic. Interview with the Administrator on 12/02/2022 at 3:10 PM, revealed he expected staff to follow infection control guidelines and wash their hands before and after patient care. He stated handwashing was important to prevent resident infections.

Based on interview, record review, review of facility policy, and the facility's initial investigation documentation, it was determined the facility failed to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of three (3) sampled residents (Resident #2). Interview with the Administrator on 12/01/2022 at 11:14, revealed on 11/27/2022 at 6:40 PM, Resident #2, proceeded to his/her room after a supervised smoke break with staff and went passed his/her room. Resident #2 approached door #1 on the northside of the building on Wing Two (2), where he/she pushed on the door until the magnetic locking system automatically disengaged. Resident #2 then exited the building without staff's knowledge. The findings include: Review of the facility's policy titled, Wandering and Elopement, revised 03/2019, revealed the facility was to identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting, revised 07/2017, revealed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises were to be investigated and reported to the Administrator. Review revealed the Nurse Supervisor or the department director were to promptly initiate and document investigation of the accident or incident. Per review, the Report of Incident/Accident form was to include the date and time the incident/injury took place, the nature of the injury/illness or incident, and the circumstances surrounding the accident or incident. Further review revealed the Report of Incident/Accident form was also to include the names of any witnesses and their account of the accident or incident, the time of Physician notification and response or instructions, and the time of family notification and by whom. In addition, the form was to include the condition of the resident including vital signs, any corrective action taken, and the signature of person completing the report. Review of Resident #2's medical record revealed the facility admitted the resident on 03/09/2021, with diagnoses which included Other Transient Cerebral Ischemic Attacks and related Syndromes, Encephalopathy, and Dementia. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) indicating severe cognitive impairment. Review of the the facility's Wander/Elopement Risk assessment dated [DATE], revealed the facility assessed Resident #2 as with a score of eleven (11). Review revealed a score of eleven (11) or above indicated a high risk for wandering. Further review revealed the facility additionally assessed Resident #2 as ambulatory with the use of a walker and to have a history of wandering; however, with no reported episodes of wandering in the last six (6) months. Review of the Resident #2's Comprehensive Care Plan initiated 03/09/2021 and revised 11/28/2022, revealed Resident #2 was an elopement risk/wanderer related to family concerns of resident stating multiple times that he/she wished to go home. Resident #2's goal was his/her safety would be maintained through 02/07/2023. Continued review of the care plan revealed interventions which included: placement of a Wander Alert Bracelet, initiated on 03/10/2021; identify patterns of wandering, such as wandering purposeful, aimless, escapist, the resident looking for something or the need for more exercise. Per review, Resident #2's interventions also included distracting him/her from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, initiated on 03/09/2021. Further review revealed on 11/28/2022, every fifteen (15) minute checks were implemented at 6:00 AM on 11/28/2022 and were still in progress at the survey exit date. Review of Long-Term Care Facility - Self Reported Incident Form, dated 11/27/2022 at 10:45 PM, completed by the Administrator, revealed the northeast door alarm sounded, and staff responded and noticed Resident #2 approximately sixty (60) feet from the door in a grassy area of the property. Per review, staff assisted Resident #2 back into the facility and a full body audit and assessment was completed, with no injuries noted. Continued review revealed the facility placed Resident #2 on one to one (1:1) care (supervision) by Licensed Practical Nurse (LPN #1). Further review of the document revealed the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Environmental Director arrived at the facility. Review further revealed the Environmental Director assessed the security functions on all the facility's doors and alarms to ensure they were functioning properly. In addition, MDS staff and the ADON performed assessments of all residents with Wander Guard alarms and their care plans updated and revised if applicable. Review of the Health Status Note dated 11/27/2022 at 6:45 PM, revealed the alarm sounding for the side door by office, and staff responded immediately by going to check the door. Review revealed staff observed Resident #2 walking in the field on the side of the facility property. Continued review revealed staff approached Resident #2, and escorted him/her back to the facility without any injuries noted. Per review one to one (1:1) supervision with staff was initiated and the resident's care plan was updated. Further interview revealed staff attempted to notify Resident #2's Power of Attorney; however, were unable to do so, and left a message. In addition, review further revealed the DON, ADON, the Administrator and the Physician were notified. Review of Certified Nursing Assistant (CNA) #3's witness statement dated 11/27/2022, revealed she had been providing care to another resident when the door alarm went off. Continued review revealed CNA #3 proceeded to the door, looked out the window but did not see anything. Further review of the statement revealed she turned the alarm off and CNA #5 went out the front door to check outside and found Resident #2. Observation of Resident #2 on 11/29/2022 at 2:22 PM, revealed the resident was resting on his/her bed with eyes closed. Continued review revealed a wander alert bracelet was present on his/her left ankle and there was a walker at the bedside. Observation of Resident #2, on 11/30/2022 at 2:18 PM and on 12/01/2022 at 8:46 AM, revealed Resident #2 was ambulating on the hallway on Wing one (1) with a walker attempting to located his/her room. Interview with CNA #3 on 11/28/2022 at 8:30 PM, revealed on 11/27/2022 at approximately 6:40 PM, while providing care to another resident she heard the door alarm, so she went to door #1 on the side of the building and looked out the window, but did not see anything. CNA #3 stated there were no residents near the door or on the hall so she turned the alarm off and asked CNA #5 to go out the front door to see if she saw anyone/anything. Continued interview revealed CNA #5 found Resident #2 outside and brought him/her back inside. According to CNA #3, the nurse was aware of the incident as the nurse heard the alarm. CNA #3 revealed the DON, ADON, Administrator and Environmental Director came to the facility and started an investigation of the incident. The CNA stated Resident #2 was placed on 1:1 supervision and staff took turns sitting with him/her throughout the night until 6:00 AM the following morning. Review of CNA #2's witness statement dated 11/27/2022, revealed she was on the back hall on Wing 2 at the computer completing education when the door alarm went off. stated she checked the alarm panel (located at the nurses' station) which listed all the doors and showed when a door was opened, explain what this panel is, does it list all the doors and show when one has been opened and saw that it was door #1. Further review of the document revealed CNA #2 viewed the security cameras located at the nurse's station and saw CNA #3 and CNA #5 were outside bringing Resident #2 back inside. Interview with CNA #2, on 12/01/2022 2:18 PM, revealed she was on the back hall of wing two (2) completing education on the computer. CNA #2 stated she heard the door alarm sound and checked the alarm panel and saw it was door #1. She stated she viewed the security cameras located at the nurse's station and saw Resident #2 walking in the grass on the side of the building just steps from the sidewalk. Continued interview revealed as CNA #2 viewed the camera she saw CNA #5 come around the corner and escorted Resident #2 back inside the building. Further interview with CNA #2 revealed she had never witnessed Resident #2 at the doors attempting to leave, nor had she ever heard him/her make statements about going home. Review of CNA #5's witness statement dated 11/27/2022, revealed she was providing care to another resident when she heard the door alarm going off. Per review, she started looking at the door and nobody was around. Continued review revealed CNA #3 asked her to look outside and she saw Resident #2 standing on the grass and she escorted him/her back to the building. Interview with CNA #5 on 12/01/2022 at 2:38 PM, revealed she was in another resident's room when she heard the door alarm. She stated she immediately went to check and saw CNA #3 at the side door and CNA #3 asked her to go out the front door to look and see if she saw anything. Continued interview revealed she stepped out and saw Resident #2 standing on the grass at the side of the building. Per CNA #5, Resident #2 had been wearing gray jogging pants, a black or gray hooded sweatshirt and tennis shoes at the time. She stated she escorted Resident #2 back into the facility. Further review revealed administrative staff came to the facility, and did a walk through of the incident. Interview with LPN #1 on 12/02/2022 at 10:46 AM, revealed she was the nurse working when Resident #2 eloped from the facility. She stated she was on the phone with Pharmacy when she heard the alarm sounding. Per LPN #1, CNA #2 checked the panel and saw that it was door #1's alarm sounding, then looked at cameras and saw that Resident #2 was outside. Continued interview revealed when she got to the lobby area staff were bringing Resident #2 back inside the facility. She stated she assessed Resident #2 for injury, and none were observed. LPN #1 stated she called the DON and the DON had informed the Administrator. Further interview revealed they all came to the facility to investigate the situation. LPN #1 further stated Resident #2 was placed on 1:1 supervision throughout the night, then every fifteen (15) minute checks were initiated. Additionally, she stated she notified the Physician and attempted to notify the POA; however, was unable to and left a message. Interview with Assistant Director of Nursing (ADON) on 12/02/2022 at 2:13 PM revealed she had received a call from LPN #1 about Resident #2 getting out of the side door. She stated she immediately notified the DON who notified the Administrator. Per the ADON, they all went to the facility and started an investigation of the incident. The ADON stated staff education was initiated on 11/27/2022 following the event, regarding door alarms, Wander Guard system, timing of alarms, policy of door alarms. Further interview revealed the education was initiated that night for staff working, and was still in progress. She further stated an elopement assessment was completed for Resident #2 and the resident's care plan was revised. In addition, the ADON revealed Resident #2 was placed on 1:1 supervision and then on every fifteen (15) minute checks. Interview with the DON on 12/02/2022 at 2:36 PM, revealed she was notified by the ADON that Resident #2 had gotten outside. She stated she informed the Administrator and called the facility to obtain the details from LPN #1. The DON stated she had LPN #1 assess Resident #2, obtain written statements from staff, and initiate 1:1 supervision of the resident. Continued interview revealed she went to the facility, and the ADON, Administrator, and Environmental Services also came to the facility that evening and initiated an investigation. The DON further stated the investigation was currently ongoing. Interview with the Administrator on 12/01/2022 at 11:14 AM, revealed Resident #2's elopement investigation was presently ongoing. He stated he had gone to the facility on [DATE], and the DON, ADON and Environmental Director also came to gather witness statements and check all the facility doors. The Administrator stated the facility determined Resident #2 had missed his/her room and had gone out the first door he/she saw. He further stated the facility's Interdisciplinary Team (IDT) was currently reassessing the Wander Guard elopement system and a corrective action plan was being implemented.

Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to establish a system of records receipt of medications, ensure drug records were in order, and account of all controlled drugs was maintained for two (2) of three (3) sampled residents (Resident #1 and Resident #6). Certified Medication Technician (CMT) #7 and Licensed Practical Nurse #1 failed to follow the facility's policy for counting narcotic medications when they did not count the narcotic medication at change of shift on the evening of 08/16/2022 and again on the morning of 08/17/2022. CMT #7 had Registered Nurse (RN) #1 count with him and they discovered Resident #6 had two (2) missing tablets of his/her Norco (a narcotic pain medication). The facility investigated; however, was unable to determine what happened to the two (2) missing Norco tablets. In addition, the facility failed to secure Resident #1's ninety (90) day supply of Eliquis (an anticoagulant medication) brought to the facility by the resident's daughter at the time of his/her admission. Resident #1's daughter had to obtain the medication for the resident. The findings include: Review of the facility's policy titled, Controlled Substances, dated April 2019, revealed the facility would comply with all laws, regulations and other requirements related to handling and documentation of controlled substances. Per review, controlled substances were to be counted at the end of each shift, by the nurse coming on duty and the nurse going off duty together. Continued review revealed any discrepancies in the controlled substance count were to be documented and reported to the Director of Nursing (DON) services immediately. Further review of the policy revealed the DON investigated all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties and reports the findings to the Administrator. Review of the facility's policy titled, Discrepancies, Loss and or Diversion of Medications, revised 01/2018, revealed all discrepancies, suspected loss and or diversion of medications, irrespective of drug type or class, was to be immediately investigated and a report filed. Continued review revealed immediately upon discovery or suspicion of a discrepancy, suspected loss or diversion, the Administrator, DON, Consulting Pharmacist and/or other determined appropriate parties were notified, and an investigation conducted. Per review, a discrepancy in a drug count, a search for the medication and investigation were to be completed by the designated personnel/staff. The policy review revealed a plan of correction was to be completed by the leadership team or designated personnel. Further review revealed if there was loss of a supply of a medication, a search for the medication and an investigation must be completed by the designated personnel/staff. In addition, the review revealed the appropriate agencies, required by state and federal law, were also to be notified, and the facility would assume financial responsibility for the loss. Review of Resident #6's medical record revealed the facility admitted the resident on 06/17/2020 with diagnosis which included Chronic Kidney Disease, Spinal Stenosis and Pain in Left Leg. Review Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 09/17/2022, revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating Resident #6 was cognitively intact. Review of Resident #6's Physician order dated 08/11/2022, revealed an order for Norco 10/325 (Hydrocodone 10 milligrams [mg] and Acetaminophen 325 mg) one (1) tablet by mouth three (3) times a day for pain. Review of the facility provided, Long-Term Care-Self Reported Incident Form, Initial Report dated 08/17/2022, at 8:55 PM, revealed the CMT counted medications and found two (2) narcotics missing for Resident #6. Per review, Resident #6 did not miss any ordered pain medication and a pain assessment was completed with no complaints of pain from the resident. Continued review revealed LPN #1 and CMT #7 failed to count the controlled substances at change of shift on the evening of 08/16/2022 and again on the morning of 08/17/2022 (as per the facility's policy). Review revealed the Pharmacy, Medical Director, and resident's family were aware of the issue. According to review of the facility's Initial Report, the investigation was completed with no further discrepancies identified, and the resident's missing medication was replaced at no charge to him/her. Further review revealed education was initiated for all CMT's and nurses. Review further revealed an Action Plan was in progress for approval by the facility's Quality Assurance Performance Improvement (QAPI) team to include weekly audits performed by the DON and Assistant Director of Nursing (ADON) to rule out any further discrepancies. In addition, review revealed the facility included the implemented education in the new hire packets for all new nurses and med technicians (techs) regarding the proper medication count procedure. Review of the Controlled Drug Use Record revealed on 08/09/2022 the facility received thirty (30) tablets of Norco 10/325 for Resident #6. Continued review revealed that on 08/17/2022, tablets #20 and #21 had been recorded as missing and a line had been drawn through the date and signature lines. Review of the facility's Corrective Action Report, first warning, dated 08/17/2022, and signed by the former DON, revealed she counseled CMT #7 and LPN #1 for not counting the controlled drugs on the medication carts together before and after change of shift on the evening of 08/16/2022, and on the morning of 08/17/2022. Review of the facility's Performance Improvement (PI) Action Plan dated 08/17/2022, signed by the former DON, revealed the DON and the ADON were to initiate chart audits and count narcotics daily for one (1) week, then weekly for one (1) week, then monthly for one (1) month. However, interview with the ADON on 12/01/2022 at 4:18 PM, revealed the facility was unable to provide evidence the audits were performed and the narcotic counts had been completed as per the PI Action Plan. Interview with Resident #6 on 11/30/2022 at 3:40 PM, revealed she recalled the facility made her aware some time back that a couple of his/her pain tablets were missing. Resident #6 stated it had not bothered him/her, he/she had not missed any medication doses. Interview with CMT #7 on 11/29/2022 at 3:58 PM, revealed he and LPN #1 had not counted the medication cart at the end of the shift on 08/16/2022 or the beginning of the shift on 08/17/2022. He stated he had Registered Nurse (RN) #1 count with him and that was when it was discovered that Resident #6 had two (2) tablets missing. CMT #7 stated the former DON had a meeting that day with the nurses and other CMT's about counting the narcotics together and accepting the medication cart. Further interview revealed CMT #7 stated it was a lesson learned. Interview with RN #1 on 12/01/2022 at 3:05 PM, revealed CMT #7 asked her to count the controlled substances on the medication cart on 08/17/2022, and they discovered Resident #6 was missing two (2) of his/her Norcos. She stated she did not know why CMT #7 had not counted the controlled drugs with LPN #1 that morning and LPN #1 had already left the building. Per RN #1, she reported the missing Norco tablets to the former DON. RN #1 stated all controlled drugs were to be counted at change of shift, and she did not know what happened to the missing doses of the medication. Interview with LPN #1 on 12/02/2022 at 10:46 AM, revealed that on 08/16/2022 and 08/17/2022, she and CMT #7 had not counted the narcotics on the medication cart at change of shift. She stated the former DON called her and informed her that two (2) tablets were missing from Resident #6's Norco card. Continued interview revealed she had no idea what happened to the Norco tablets. According to LPN #1, Resident #6 had an order to receive the medication three (3) times a day and she had administered a dose at bedtime on 08/16/2022. Further interview revealed the DON counseled her and she had also been educated along with the other nurses and medication techs on counting narcotics. LPN #1 further revealed she didn't really have a reason as why she failed to do a count. Interview with the former DON on 12/02/2022 at 11:01 AM, revealed that on 08/17/2022, RN #1 informed her that Resident #6 was missing two (2) doses of his/her narcotics. She stated she spoke with CMT #7 and he admitted to not counting the narcotics at shift change on 08/16/2022 with LPN #1, and again at shift change on 08/17/2022. Continued interview revealed she placed a call to LPN #1 who also admitted to not counting the controlled drugs at shift change. The former DON stated she provided written disciplinary action to CMT #7 and LPN #1 on 08/17/2022. She revealed she and the ADON performed chart audits and counted the narcotics daily, and she left the investigation information in the DON office when she resigned. Further interview revealed she was unable to determine what happened to the two (2) missing narcotic tablets, did not know if the Administrator had notified law enforcement or not. Interview with the ADON on 12/01/2022 at 4:18 PM, revealed she was unable to locate the documentation for the chart audits and the daily narcotic audits she and the former DON had completed. Interview with the former Administrator on 12/02/2022 at 1:44 PM, revealed she could not recall if she reported the missing narcotics to law enforcement or not. She stated the former DON and ADON provided staff education and performed audits of the narcotics after the missing narcotic medication was discovered. Further interview revealed she expected staff to follow the facility's policy and procedures related to counting narcotics. Interview with the current Administrator on 12/02/2022 at 3:28 PM, revealed he had not been the Administrator at the time of the incident; however, he would expect the nurses to follow the facility's policy and count the controlled drugs at change of shift. He further stated he would expect the DON to investigate and also follow the facility's policy. 2. Review of the closed record revealed the facility admitted Resident #1 on 07/27/2022, with diagnoses which included Paroxysmal Atrial Fibrillation, Chronic Kidney Disease, Stage Three (3), and Unspecified Dementia. Review of Resident #1's Admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15) which indicated severe cognitive impairment. Further review of the MDS Assessment revealed Resident #1 was admitted to the facility under Hospice Services and was discharged from the facility on 10/18/2022. Review of Resident #1's Physician order dated 07/27/2022, revealed an order for Eliquis 2.5 mgs to be administered two (2) times daily for anticoagulation. Review of Resident #1's Medication Administration Record (MAR) dated July 2022, revealed the resident had not missed any doses of Eliquis since his/her admission to the facility. Interview with Resident #1's daughter on 11/29/2022 at 8:04 PM, revealed Resident #1 had the medication Eliquis (a blood thinner) ordered from Veterans Affairs (VA). She stated Resident #1 had been under Hospice Care since February 2022 and that Hospice Services had not provided the medication. Resident #1's daughter stated when Resident #1 was admitted to the facility on [DATE], she took a ninety (90) day supply of the Eliquis medication to the facility and gave it to RN #1. Further interview revealed the following day she was made aware by RN #1 that the Eliquis medication could not be found. Further interview revealed as a result of that she had to drive to the VA and obtain another prescription. She additionally stated the facility never found the Eliquis medication Review of a Hospice Visit Note dated 08/11/2022, revealed RN #1 had called a Hospice nurse and stated when Resident #1 was admitted to the facility the family had provided the facility with a bag full of medications including a ninety (90) day supply of Eliquis and the Eliquis medication could not be found. Continued review revealed RN #4 was present when Resident #1 arrived at the facility and recalled RN #1 taking a bag of medications, and saying the facility would take the medications, in case medication did not arrive from the facility's Pharmacy. Per review, RN #4 spoke with the former DON regarding the medications which had not been found. Further review of the Note revealed Hospice Nurse #1 informed the DON that Eliquis was not a covered drug under Hospice. Review further revealed the Hospice team met and felt the facility was ultimately responsible for finding or replacing Resident #1's missing Eliquis medication. Interview with Registered Nurse (RN) #1 on 12/01/2022 at 3:05 PM, revealed she was the nurse working when Resident #1 was admitted to the facility. She stated Resident #1's daughter had brought a ninety (90) day supply of Eliquis to the facility, and she had been the person who accepted the medication. RN #1 revealed she thought she put the Eliquis in the medication cart; however, the next day the CMT #7 informed her the Eliquis was not present in the cart in order for it to be given. Further interview revealed RN #1 called the resident's daughter and informed her and the daughter was upset after being told that. She further stated the resident's daughter worked with the VA to get the medication refilled. In addition, RN #1 revealed she did not know what happened to the Eliquis medication. Interview with the former Director of Nursing (DON) on 12/02/2022 at 11:01 AM, revealed she had been aware of the missing Eliquis medication for Resident #1. She stated the facility had looked for the medication; however, had not performed a formal investigation related to the missing medication. Continued interview revealed the facility should have completed an investigation to attempt to determine what happened to the medication. The former DON further stated the family was able to provide the facility with a refill of the Eliquis medication, and Resident #1 had not missed any doses of the medication. Further interview revealed the facility had covered the cost of the Eliquis. Interview with the former Administrator on 12/02/2022 at 1:44 PM, revealed she expected staff to follow the facility's policy and procedures related to missing medications. She stated the Eliquis medication should have been accounted for on the resident's admission.

Based on observation, interview, record review, and facility policy review, it was determined the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to handwashing/gloving technique during peri-care, for one (1) of two (2) residents (Resident #66). During observation of peri-care, on 06/20/19, Certified Nurse Aide (CNA) #1 failed to wash her hands between glove changes and prior to touching resident's personal items. The findings include: Review of the facility policy Handwashing/Hand Hygiene, last revised (MONTH) (YEAR), revealed the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before and after coming on duty; before and after direct contact with residents; and after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for prevention healthcare-associated infections. Record review revealed the facility admitted Resident #66 on 06/14/16 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #66's cognition as intact with a Brief Interview for Mental Status Score (BIMS) score of fourteen (14), which indicated the resident was interviewable. Observation of peri-care provided by CNA #1, on 06/20/19 at 8:46 AM, revealed she failed to wash her hands between glove changes during peri-care and she did not wash her hands after removing her gloves prior to touching the bedding, the resident's privacy curtain, or after placing the resident's skin cream in the cabinet. Interview with CNA #1 after she provided Resident #66's peri-care revealed she should have washed her hands between glove changes and prior to touching the bedding, privacy curtain, and skin cream. Interview with the Director of Nursing (DON), on 06/20/19 at 1:30 PM, revealed the staff should follow the facility policy regarding proper hand washing and hand hygiene. She stated she expected all staff to follow the facility policy with no exceptions.

Based on observation and interview, it was determined the facility failed to label/date drugs used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, related to one (1) vial of ,[DATE] [MEDICATION NAME] Insulin, with an expiration date of ,[DATE], found in the Emergency Drug Kit refrigerator box on Wing 2. The findings include: Interview with the Director of Nursing (DON), on [DATE] at 3:30 PM, revealed she was unable to provide a policy regarding expiration dates of medications. Observation on [DATE] at 2:43 PM, revealed an unopened vial of ,[DATE] [MEDICATION NAME]which had an expiration date of ,[DATE]. Interview with the Unit Manager (UM), on [DATE] at 2:43 PM, revealed the insulin should have been removed with the weekly delivery of medications by Pharmacy. Interview (Post Survey) with the current Pharmacist from the facility Pharmacy Company, on [DATE] at 2:15 PM, revealed their Pharmacy took over in (MONTH) (YEAR). He stated the insulin was actually medication from the former Pharmacy used prior to (MONTH) (YEAR). The Pharmacist revealed, our Pharmacists go into the facility monthly to check for outdates of medications. He stated, since that medication was in a storage container belonging to the former Pharmacy, we did not check that medication, since it was in the former Pharmacy's container, and therefore, was not dispensed by us. He further revealed the customer service representative had spoken with the facility on the day the surveyor found the expired medication, and the facility was reminded the medications were from the former Pharmacy, and the current Pharmacy does not have any responsibility for those medications. Further interview with the DON, on [DATE] at 3:30 PM, revealed the Pharmacy was responsible to check all medications in the Emergency Drug Kit and remove medications which had expired. She stated the medication should have been discarded before the end of (MONTH) 2019. Additionally, she revealed licensed nurses were responsible to ensure no outdated medications were in the refrigerator.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of twenty (20) sampled residents (Resident #66). The facility care planned for Resident #66 to receive proper peri-care; however, observation of peri-care for Resident #66 by Certified Nurse Aide (CNA) #1 revealed CNA #6 failed to wash her hands when gloves were removed/prior to applying new gloves, and prior to touching items in the resident's room. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, last revised (MONTH) (YEAR), revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical well being. Also, will reflect treatment goals. Record review revealed the facility admitted Resident #66 on 06/14/16 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #indicated the resident was interviewable. Further review of the MDS assessment revealed the resident was always incontinent of urine and required extensive assist of two (2) persons for toileting. Review of Resident #66's Comprehensive Care Plan for Potential for Urinary Tract Infection [MEDICAL CONDITION], dated 05/29/18, revealed an intervention to provide proper peri-care. However, observation of peri-care provided by CNA #1, on 06/20/19 at 8:46 AM, revealed she failed to wash her hands between glove changes during peri-care. Further observation revealed she also did not wash her hands after removing her gloves prior to touching the bedding, the resident's privacy curtain, or after placing the resident's skin cream in the cabinet. Interview with CNA #1, following the observation, revealed she should have washed her hands between glove changes and prior to touching the bedding, privacy curtain and skin cream. She stated the resident's Comprehensive Care Plan included using proper peri-care and should be followed. Interview with the Director of Nursing (DON), on 06/20/19 at 1:30 PM, revealed the staff should follow the facility policy regarding proper hand washing and hand hygiene. She stated she expected all staff to follow the Comprehensive Care Plans as written. She revealed all CNA's have a copy of the resident's care plans available, and she expected all staff to follow the facility policy and care plans as written with no exceptions.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the medical record was complete and accurately documented in accordance with accepted professional standards of practice for one (1) of six (6) sampled residents (Resident #1). Resident #1 exhibited symptoms of a weak cough, congestion and complaints of not feeling well on 11/16/18 and 11/17/18. On 11/18/18, Resident #1's oxygen (O2) saturation level began dropping and O2 was initiated. However, review of the Nurses' Notes revealed there was no documented evidence of the resident's declining condition and ongoing assessments until 11/18/18 at 8:34 PM when the on-call Physician was notified. At that time, an order for [REDACTED]. In addition, further record review revealed there was no documented evidence of ongoing assessments of the resident's condition from 11/18/18 at 8:34 PM until 11/19/18 at 9:43 AM. The facility's failure to ensure the Physician was notified of a significant change in a timely manner, conduct an on-going assessment of Resident #1's condition, document findings, and provide care in a timely manner and in accordance with professional standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 11/30/18 and determined to exist on 11/18/18. The facility was notified of the Immediate Jeopardy on 11/30/18. An acceptable Credible Allegation of Compliance (AoC) was received on 12/11/18 alleging the Immediate Jeopardy was removed on 12/03/18. The State Survey Agency (SSA) validated the AoC and determined the Immediate Jeopardy was removed on 12/03/18. The Scope and Severity was lowered to a level D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Management of Acute Change in Resident Status-Recommended Protocol, last revised 01/15/01, revealed when an acute change in status is identified, staff should assess the resident and determine the code status, vital signs, level of consciousness and complete a neuro exam. If signs and symptoms of cardiac or respiratory distress are identified, staff should notify the Physician, obtain an order for [REDACTED]. Record review revealed the facility admitted Resident #1 on 02/04/15 with [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN) #2, on 11/29/18 at 12:10 PM, revealed Resident #1 was not feeling well, had some congestion and a weak cough on 11/16/18 and 11/17/18. LPN #2 stated she was monitoring the resident by asking him/her how he/she was feeling, checking lung sounds and vital signs. However, LPN #2 stated she did not document the assessment findings because there was no change in the resident's condition. She further stated she did not document the vital signs because they were at base line. Record review revealed no documentation of LPN #2's assessment findings on 11/16/18 or 11/17/18. Interview with Staffing Coordinator/LPN #1, on 11/29/18 at 12:00 PM, and on 11/30/18 at 9:38 AM, revealed she worked the floor on 11/17/18 because there was not a nurse to cover the shift. LPN #1 stated it was reported from 11/16/18, night shift, that Resident #1 had a productive cough but the resident was able to clear the phlegm. LPN #1 stated she did not notice the resident coughing during her shift on 11/17/18, nor was there any other noted changes in Resident #1's condition during the shift. She stated Resident #1's Percutaneous Endoscopic Gastrostomy (PEG) tube was flushing well and there were no noted changes in the resident's urine from the base line. LPN #1 stated the Certified Medical Tech (CMT) checked the resident's vital signs and there was nothing note worthy as far as a significant change. LPN #1 further stated there were no reports from the Certified Nurse Aides (CNAs) regarding changes in the resident. Record review revealed there was no documented evidence of assessments of Resident #1 on the 11/17/18 6:00 AM to 6:00 PM shift. Interview with LPN #4, on 11/29/18 at 12:40 PM, revealed on 11/18/18, CNA #3 made her aware the resident was breathing funny at approximately 12:00 PM. LPN #4 stated the resident's O2 saturation level was in the 90's with room air. She stated she placed O2 at two (2) liters per minute (LPM) per nasal cannula on the resident at that time and the O2 saturation level improved a little. LPN #4 stated she asked CNA #3 to check Resident #1's temperature, and it was normal, and the resident denied complaints of pain or discomfort. Further, LPN #4 stated she was in Resident #1's room a few times during the shift, but she did not notice further difficulty. LPN #4 stated she did not recall if she documented the change in the medical record. Record review revealed there was no documented evidence of Resident #1's condition change on 11/18/18 6:00 AM to 6:00 PM shift. Nor was there documented evidence the Physician or the resident's representative were notified of the resident's change. Interview with LPN #3, on 11/29/18 at 12:45 PM, 11/30/18 at 8:35 AM and at 3:56 PM, revealed she worked 6:00 PM to 6:00 AM on 11/18/18. LPN #3 stated at approximately 7:00 PM, while administering the night-time medications, she noted Resident #1's respirations were fast; but the resident was able to speak with her and denied complaints. Further, LPN #3 stated the resident's O2 saturation level was good at 96ish and (his/her) O2 never dropped. LPN #3 stated she notified the on-call Physician at approximately 7:00 PM or 8:00 PM, of the resident's condition and received orders for a chest x-ray and nebulizer treatments. Further interview with LPN #3 revealed she was unable to document in the electronic record due to a fire in the area that caused outages of the computers, phone lines and fax (facsimile) lines. LPN #3 stated she documented a late entry via her cell phone once she got home on 11/19/18. She stated she checked the resident's vital signs, but she did not document them because she did not remember them, once she reached her home. LPN #3 further stated she did not notify the resident's representative because it was late at night, and she did not want to call. Record review revealed a late entry was documented per LPN #3 (phoned on-call Physician of change in respiratory status and ordered a chest x-ray and as needed nebulizer treatments every four (4) hours as needed for congestion and wheezing. Seemed to be some effectiveness. O2 saturation is 96% on two (2) LPM of O2 via nasal cannula. Will continue to monitor and waiting on chest x-ray to be completed). Additionally, LPN #3 documented on 11/19/18 at 5:38 AM (received chest x-ray results and notified Physician on-call and received new order for [MEDICATION NAME] 500 milligrams (mg) every day for seven (7) days. Will continue to monitor for any changes). Interview with Registered Nurse (RN) #1, on 11/29/18 at 4:00 PM, revealed she, as a Unit Manager, expected staff to document anything out of the ordinary or anything abnormal for the resident. Interview with the Assistant Director of Nursing (ADON), on 11/30/18 at 2:00 PM, revealed any time the staff was unable to document in the electronic record, it was expected the staff revert back to paper charting with paper medication administration records (MARs) and treatment administration records (TARs) as well. She further stated she expected any interventions or changes in a resident's condition to be documented in the resident's record. **The facility implemented the following to remove the Immediate Jeopardy on 12/03/18: 1. The facility's Administrative Nursing Team consisting of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Wing one (1) Unit Manager (UM), Wing two (2) Unit Manager (UM), Minimum Data Set (MDS) Coordinator and Staff Development Coordinator (SDC), met on 11/30/18 to determine the root cause of the Immediate Jeopardy. A performance improvement action plan was written and initiated; and a clinical monitoring audit tool for review of progress notes, review of assessments, and review of Physician orders [REDACTED]. 2. Audits of all residents' progress notes for the past thirty (30) days were initiated by the Administrative Nursing Team on 11/30/18 and completed on 12/01/18. As a result of the audit, two (2) responsible parties were notified of change in condition. 3. Daily audits of Nurses' Progress Notes, physician's orders [REDACTED]. Review of the Progress Notes, physician's orders [REDACTED]. After thirty (30) days, the DON and the ADON, will review the weekend Nurse's Notes, assessments and orders on Monday mornings. Any findings of non-compliance through the Progress Notes, assessments and Physician order [REDACTED]./or Social Services Director (SSD). 4. In-services and trainings for all licensed staff were initiated on 11/30/18 and concluded on 12/03/18. In-services and trainings included competent assessment skills including gathering information such as vital signs, lung sounds, skin color and temperature, and any signs of distress; facility Physician and family notification policy - notification is to include changes in condition, and labs / x-ray results to be done in a timely manner and documented timely; use of interact Clinical Pathways for assessment process; professional standards for documentation of resident care and assessment findings; and timely administration of antibiotic medications. In-services and trainings were completed face-to-face and via telephone. Each licensed staff member were provided with written material on all of the in-services and trainings. 5. Competency tests and skill check-offs, for the in-serviced materials, for all licensed staff were completed on 12/06/18. The testing and check-offs will be ongoing weekly for thirty (30) days then monthly for another six (6) months. 6. Newly hired licensed staff will be educated with skill check-offs regarding licensed nurse competency; physical assessment including lung sounds; documentation of change of status - notification of the Physician and responsible party; monitoring residents for O2, checking Physician orders [REDACTED]. 7. The clinical Quality Assurance and Performance Improvement (QAPI) process was initiated on 11/30/18. The QAPI members included: DON, ADON, Medical Director, Wing One (1) and Wing Two (2) UM's, SDC, Director of Social Services, and the MDS Coordinator. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the QAPI meeting notes, dated, 11/30/18, revealed the facility identified the deficient practices as not following up with the Physician with test results, timely administrations of antibiotics, and not notifying the Physician and responsible party in a timely manner and an action plan was initiated. 2. Review of the Clinical Monitoring Audit tool revealed chart audits for each resident was completed by 12/02/18 with focus on progress notes, assessments, and Physician orders. 3. Additionally, audits have been completed daily since 12/02/18 and are on-going. 4. Review of the employee sign-in sheet and through interviews on 12/11/18, at 10:55 AM with RN #1; at 11:10 AM with RN #2; at 11:20 AM with RN #3; at 11:25 AM with RN #4; at 11:35 AM with LPN #6; at 11:45 AM with LPN #7; at 11:55 AM with RN #5; at 12:00 PM with the ADON; at 12:10 PM with LPN #1; at 1:21 PM with LPN #8; at 2:39 PM with LPN #5; at 2:26 PM with RN #6; at 2:31 PM with LPN #9; and at 3:01 PM with LPN, it was determined in-services and trainings with all licensed staff was completed on 12/03/18. Review of the in-service material revealed training was provided on Timely Antibiotic Administration, Physician/Legal Representative Notification, Clinical Nursing Skills including charting format, monitoring residents receiving O2, and physical assessment of chest with lung sounds. 5. Review of the sign-in sheet for competency check-off, dated 12/03/18, revealed all licensed staff were competent in physical assessment, documentation of change in status, notifications of Physician and legal representative, monitoring residents with O2, and new antibiotic orders. Additionally, skills testing for licensed staff was initiated on 12/03/18 and is on-going. 6. Review of the facility's new-hire folder revealed an in-service agenda with topic including licensed nurse competencies for physical assessment including lung sounds, documentation of change of status, notification of the Physician and legal representative; monitoring of residents with O2, and new orders for antibiotic therapy. 7. Interview with the DON, on 12/11/18 at 1:20 PM, revealed the QAPI team would be meeting again on 12/12/18 then weekly for four (4) weeks thereafter.

Based on interview, record review, and facility policy review, it was determined the facility failed to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (1) of six (6) sampled residents (Resident #1). Resident #1 exhibited symptoms of a weak cough, congestion, and complaints of not feeling well on [DATE] and [DATE], night shift. The resident's oxygen (O2) saturation level began dropping on [DATE] at approximately 12:00 PM and O2 was initiated. However, the on-call Physician was not notified of the change in condition until seven (7) to eight (8) hours later. an order for [REDACTED]. Additionally, the facility received the x-ray results at 1:08 AM on [DATE], which revealed left lower lung infiltrate and effusion, but the Physician on-call was not notified of the results until 5:38 AM (four hours later), at which time an order for [REDACTED]. The resident's representative was not notified of the resident's change in condition until [DATE] at 7:00 AM. The facility transferred Resident #1 to the hospital on [DATE] at 8:50 AM. Resident #1 was admitted to the intensive care unit with [DIAGNOSES REDACTED]. He/she expired on [DATE]. The facility's failure to ensure the Physician was notified of a significant change in a timely manner, conduct an on-going assessment of Resident #1's condition, document findings, and provide care in a timely manner and in accordance with professional standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Credible Allegation of Compliance (AoC) was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency (SSA) validated the AoC and determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a level D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Management of Acute Change in Resident Status-Recommended Protocol, last revised [DATE], revealed when an acute change in status is identified, staff should assess the resident and determine the code status, vital signs, level of consciousness and complete a neuro exam. If signs and symptoms of cardiac or respiratory distress are identified, staff should notify the Physician, obtain an order for [REDACTED]. If vital signs are stable and there is no change in the level of consciousness: assess all other signs/symptoms of the change in condition; assure that qualified staff remain with the resident until the physician contact is completed and the resident is determined to be stable; and contact the (physician) to notify of findings and to obtain orders. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable. Further review of the MDS revealed the resident had a feeding tube and a supra-pubic urinary catheter. The resident was Do Not Resuscitate code status. Interview with Licensed Practical Nurse (LPN) #5, on [DATE] at 9:50 AM, revealed she worked day shift [DATE] and there were no noted changes in Resident #1's condition during the shift, and the resident was afebrile. Interview with LPN #1, on [DATE] at 12:00 PM, and on [DATE] at 9:38 AM, revealed she was the scheduler for the facility, but she was needed on the floor on [DATE], day shift and worked 6:00 AM to 6:00 PM. LPN #1 stated she worked the floor because there was not a nurse to cover the shift. LPN #1 stated she was familiar enough with Resident #1 to know if there were medical changes. Further interview with LPN #1 revealed it was reported from [DATE], night shift, that Resident #1 had a productive cough but the resident was able to clear the phlegm. LPN #1 stated she did not notice the resident coughing during her shift on [DATE], day shift, nor was there any other noted changes in Resident #1's condition during the shift. She stated the resident's Percutaneous Endoscopic Gastrostomy (PEG) tube was flushing well and there were no noted changes in the resident's urine from the base line. LPN #1 stated the Certified Medication Technician (CMT) checked the resident's vital signs and there was nothing note worthy as far as a significant change. LPN #1 further stated there were no reports from the CNAs regarding changes in the resident. Interview with LPN #2, on [DATE] at 12:10 PM, revealed Resident #1 was not feeling well, had some congestion and a weak cough on [DATE] and [DATE] night shifts. LPN #2 stated the resident was afebrile. She stated a day shift nurse had made the Physician aware of the cough; however, LPN #2 was unable to identify the day shift nurse. She stated she reported the symptoms to the on-coming nurses, LPN #1 on [DATE] and LPN #4 on [DATE]. LPN #2 stated she was monitoring the resident by asking him/her how he/she was feeling, checking lung sounds and vital signs. LPN #2 stated she did not document the assessment findings or vital signs because there was no change in the resident's condition and the vital signs were at base line. Further record review revealed there was no documented evidence of LPN #2's assessment findings on [DATE] or [DATE] night shifts. Additionally, review of the medical record revealed no documentation regarding the resident's condition or notification of the Physician of Resident #1's weak cough, congestion or not feeling well from [DATE] to [DATE]. Interview with Certified Medication Technician (CMT) #2, on [DATE] at 3:05 PM, revealed she worked as a Certified Nurse Aide (CNA) on [DATE] and [DATE] dayshift or nightshift. She stated she was in Resident #1's room only once on [DATE] because the resident was not on her assignment. She stated she could tell the resident was not feeling well when she went into the room. CMT #2 stated the resident did not complain, but he/she was not his/her normal self. CMT #2 stated she thought the nurse was aware of the resident's condition. Interview with CNA #3, on [DATE] at 3:27 PM, revealed she fed Resident #1 breakfast on [DATE]. CNA #3 stated the resident was shaking really bad while eating and complained of not feeling well. After breakfast at approximately 10:00 AM or 11:00 AM, CNA #3 informed LPN #4 that the resident was pale, shaking and not feeling well. The CNA stated LPN #4 assessed the resident's O2 saturation to be in the low 90's (normal for resident). CNA #3 further stated she checked the resident's temperature and stated it was normal 98 something. The CNA further stated LPN #4 placed O2 on the resident., but she was not aware of any other follow-up from LPN #4. Interview with CNA #1, on [DATE] at 2:50 PM, revealed at approximately noon, 12:00 PM or so, on [DATE], she noted Resident #1 was pale and (his/her) breathing was rapid and was not acting normal. CNA #1 stated she informed LPN #4 and LPN #4 assessed the resident's O2 saturation level to be 93% on room air. The CNA stated she stayed with the resident while LPN #4 retrieved an O2 concentrator and set up the O2 for the resident. CNA #1 stated the O2 helped a little, but not much, and the resident continued to have rapid breathing. Interview with LPN #4, on [DATE] at 12:40 PM, revealed she was in Resident #1's room at approximately 8:00 AM on [DATE] to administer the morning medications. LPN #4 stated the resident was sleeping when she entered the room but woke and talked to her. The LPN stated the resident appeared normal at that time. LPN #4 stated that CNA #3 made her aware of a change in the resident around lunch time, approximately 12:00 PM, that the resident was breathing funny. She stated the resident's O2 saturation level was in the low 90s with room air. LPN #4 placed O2 at two (2) liters per minute (LPM) per nasal cannula on the resident at that time and the O2 saturation level improved a little but she was unable to recall what the O2 level improved to. LPN #4 stated she asked CNA #3 to check the resident's temperature, and it was normal, and the resident denied complaints of pain or discomfort. Further, LPN #4 stated she was in the resident's room a few times during the shift, but she did not notice any further difficulty. Additionally, LPN #4 stated she did not check the physician's orders [REDACTED]. LPN #4 stated she did not recall if she documented the change in the medical record. Record review revealed there was no documented evidence of Resident #1's condition change on [DATE] on the 6:00 AM to 6:00 PM shift. Nor was there documented evidence that the Physician or the resident's representative were notified of the resident's change. Additionally, review of the physician's orders [REDACTED]. Interview with LPN #3, on [DATE] at 12:45 PM, on [DATE] at 8:35 AM, and on [DATE] at 3:56 PM, revealed she worked 6:00 PM to 6:00 AM on [DATE]. LPN #3 stated when she started the shift, it was reported, by LPN #4, that the resident was receiving O2 at two (2) LPM via nasal cannula and that LPN #4 had notified the resident's representative. LPN #3 stated she did not check to see if there was an order for [REDACTED].#3 stated the resident spoke to her and denied complaints. Further, LPN #3 stated the resident's O2 saturation level was good at 96ish and (his/her) O2 never dropped. LPN #3 stated she notified the on-call Physician at approximately 7:00 PM or 8:00 PM, at the beginning of her shift, of the resident's condition and received orders for a chest x-ray and nebulizer treatments. She further stated she administered a nebulizer treatment and it seemed to help. LPN #3 stated she notified the mobile x-ray company for a chest x-ray right after receiving the order. Further, LPN #3 stated when she received the x-ray report, which revealed left lower lung infiltrate and effusion, she notified the on-call Physician and left a message, and at approximately 5:30 AM, the Physician returned the call with orders for [MEDICATION NAME] (an antibiotic). LPN #3 stated she did not administer the ordered antibiotic when she received the order because it was close to the end of her shift, and she did not have time to do so, even though the medication was stored in the facility's Emergency Drug Kit (EDK). Additionally, she stated the on-coming day-shift nurse would be administering the resident's morning medications and could give it then since all medications were administered through the resident's PEG tube. LPN #3 stated she was unable to document in the electronic record due to a fire in the area that caused outages of the computers, phone lines and fax (facsimile) lines. LPN #3 further stated she documented a late entry via her cell phone once she got home on [DATE]. She stated she checked the resident's vital signs, but she did not document them because she did not remember them, once she reached her home. LPN #3 further stated she did not notify the resident's representative because is was late at night, and she did not want to call. LPN #3 stated she reported to the on-coming nurse (LPN #5) regarding the orders for the chest x-ray, nebulizer treatments, O2 administration, chest x-ray results and the order for the antibiotic. Interview with Registered Nurse (RN) #1, on [DATE] at 10:55 AM, revealed the computers were only down for a short period of time on the morning of [DATE]. Further, the phone lines were down for about twenty-four (24) hours starting the morning of [DATE]. RN #1 stated the computers nor phone lines were down on [DATE] or [DATE]. Record review revealed there was no documented assessment of Resident #1 from [DATE] through [DATE] at 8:38 PM when a late entry was documented per LPN #3 which stated (phoned on-call Physician of change in respiratory status and ordered a chest x-ray and as needed nebulizer treatments every four (4) hours as needed for congestion and wheezing. Seemed to be some effectiveness. O2 saturation is 96% on two (2) LPM of O2 via nasal cannula. Will continue to monitor and waiting on chest x-ray to be completed). Additionally, on [DATE] at 5:38 AM, LPN #3 documented (received chest x-ray results and notified Physician on-call and received new order for [MEDICATION NAME] 500 milligrams (mg) every day for seven (7) days. Will continue to monitor for any changes). Review of the mobile x-ray company's Time Stamp documentation for the ordered chest x-ray for Resident #1 revealed the company received the order for chest x-ray, single view, STAT on [DATE] at 12:16 AM, Eastern Standard Time (EST), (11:16 PM), three (3) to four (4) hours after LPN #3 stated she received the order from the Physician. Further review revealed the first result report was faxed to the facility on [DATE] at 2:08 AM, EST, (1:08 AM) and a confirmation call was made to the facility on [DATE] at 2:36 AM, EST, (1:36 AM), four (4) hours prior to the Physician notification of results. Interview with CMT #1, on [DATE] at 2:35 PM, revealed when she first observed Resident #1 on the morning of [DATE], the resident was in dire distress. CMT #1 stated the resident would not look at her, would not talk and kept his/her head down, and his/her breathing was labored. CMT #1 stated the resident was wearing O2 at that time. She further stated she attempted to check the resident's vital signs because the resident was on antibiotics. The resident's temperature was 99.6 degrees F, but CMT #1 did not remember the other vital signs. CMT #1 stated she attempted to obtain a blood pressure using a wrist cuff, but the reading revealed a low blood pressure. The CMT stated she summoned LPN #5 to check the blood pressure because she felt the reading was inaccurate. Once LPN #5 arrived at the bed side, CMT #1 left the resident's room and continued with the medication pass. Interview with CNA #2, on [DATE] at 2:54 PM, revealed on the morning of [DATE], Resident #1's skin was red and clammy and he/she looked like he/she did not feel well. She stated LPN #5 was present and assessed the resident's O2 saturation level at 72%. Interview with LPN #5, on [DATE] at 10:20 AM, and [DATE] at 8:10 AM, revealed she worked [DATE], day shift. LPN #5 stated she received report from LPN #3 at the beginning of the shift that Resident #1's O2 saturation had dropped on [DATE], that a chest x-ray was obtained, nebulizer treatments and an antibiotic were ordered. LPN #5 stated on first observation and assessment of the resident at approximately 7:00 AM, the resident was flushed and had an elevated temperature of 99 degrees Farenheit (F) and the O2 saturation was ,[DATE]% with O2 at two(2) LPM via nasal cannula. Tylenol (for fever) and [MEDICATION NAME] were administered along with other ordered morning medications. LPN #5 stated she then attempted to notify the resident's representative to obtain approval to transport the resident to the emergency room (ER), but had to leave a message as she was unable to reach the representative. LPN #5 stated she wanted to send the resident to the ER, but she was waiting to hear from the family for their wishes. Interview with RN #1, Unit Manager, on [DATE] at 10:55 AM, revealed she was called to Resident #1's bedside per LPN #5. RN #1 assessed the resident with O2 saturation level at 79% and temperature of 99 degrees F. However, RN #1 noted the O2 tubing was unplugged at that time. She reconnected the tubing to the concentrator and the resident's O2 level began to increase. RN #1 stated she was not aware of the resident's status over the weekend of [DATE] and [DATE]. Review of Nurse's Notes, dated [DATE] at 7:00 AM written by LPN #5, revealed (administering routine morning medications, new order received for [MEDICATION NAME] for Pneumonia administered as well as as needed (PRN) Tylenol for fever. Resident has 30 milliliters (ml) of residual at this time, feeding turned off. Resident experiencing some dyspnea at this time, Duo nebulizer treatment administered. Attempt to contact family regarding resident's decline has been unsuccessful so far, will continue to monitor resident and attempt to contact daughters. Resident's blood pressure ,[DATE] (base line ,[DATE]), heart rate 122 (base line 80), respirations labored at 28 (base line 20)). (8:20 AM spoke with resident's daughter at this time, resident has since required increase in O2 as saturation has dropped to mid 80's. Daughter initially wanted to come see resident to make a decision on whether to keep (him/her) in the facility or send (him/her) out. Second nebulizer treatment administered at 8:30 AM as resident's O2 saturation began to drop again. Maintaining 89% on three (3) LPM via tank and nebulizer on. Message received from daughter at 8:27 AM to go ahead and send resident to the ER. Call placed to Ambulance Service to transfer resident to the ER. Upon further assessment LPN (#5) also observed that resident's urine is very dark in color with large amount of sediment in tubing and bag. The Ambulance Service arrived to pick up resident at 8:50 AM to transfer resident). Further record review revealed the last contact with the Physician was on [DATE] at 5:38 AM. There was no documented evidence of an order to send Resident #1 to the ER for evaluation. Review of the Ambulance Service Care Record, dated [DATE] at 9:57 AM, revealed the chief complaint was shortness of air (SOA) and fever with initial and final patient acuity level Emergent. Upon arrival to the facility, ambulance service staff noted patient had swelling and [MEDICAL CONDITION] on (his/her) legs and trunk, staff states that has been (his/her) normal state for some time now. Patient is flushed, red skinned and warm to touch. Patient is breathing ,[DATE] times a minute and is on O2 at three (3) LPM with saturation of 90 % per staff. Patient was transferred to a stretcher and placed on O2 at four (4) LPM. Once the resident was in the transport vehicle he/she was assessed at 9:00 AM with blood pressure of ,[DATE], pulse was 112, respiratory rate was 24, O2 saturation was 92%. At 9:14 AM, resident's blood pressure was ,[DATE], O2 level was 94%. Initial assessment revealed skin was hot, the resident was using accessory muscles to breath and had decreased lung sounds left lower and left upper, and right lower lung fields. Review of the ER) report, dated [DATE], revealed Resident #1 arrived in the ER at 9:34 AM with chief complaint of Difficulty Breathing [MEDICAL CONDITION] with [DIAGNOSES REDACTED]. Vital signs upon arrival at the ER were listed as: temperature 100 degrees, blood pressure ,[DATE], heart rate 114, respiratory rate 36 and O2 Saturation 92%. Resident assessment in the ER revealed Patient vital signs [MEDICAL CONDITION]. Patient [MEDICAL CONDITION]. Febrile. Hypotensive, Tachypneic. Has suprapubic catheter in place. Urine is dark, foul odor, large amount of sediment and mucous in urine. Laboratory findings included White Blood Count (WBC) 20.90 (4XXX,[DATE].80); Urinalysis revealed urine was cloudy, urine pH >=9.0 (4XXX,[DATE].0), Protein=100 (Negative), Bilirubin=Small (Negative), Blood=Moderate (Negative), Urine WBC ,[DATE] (,[DATE]), Red Blood Cells=,[DATE] (,[DATE]), Bacteria= 4+ (Negative); Chemistry results revealed Blood Urea Nitrogen (BUN)=55 (,[DATE]) and Creatinine=1.57 (0XXX,[DATE].00). Resident #1 was admitted to the Intensive Care Unit at 1:56 PM on [DATE] with [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary revealed Resident #1 expired on [DATE]. Cause of death was Septic Shock secondary to [MEDICAL CONDITION]-Susceptible Staphylococcus Aureus (MSSA) bacteremia and pneumonia. Interview with RN #1, on [DATE] at 4:00 PM, revealed she, as a Unit Manager, expected staff to document anything out of the ordinary or anything abnormal for the resident. RN #1 further stated she would expect staff to obtain an order for [REDACTED].#1 would expect the Physician and the resident's responsible party to be notified of any change in condition immediately. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 2:00 PM, revealed any time the staff is unable to document in the electronic record, it is expected the staff reverts back to paper charting with paper medication administration records (MARs) and treatment administration records (TARs) as well. She further stated she expected any interventions or changes in residents' condition to be documented in resident's record. The ADON further stated she expected staff to obtain an order for [REDACTED].#1. The ADON further stated she believed the care provided to Resident #1 was appropriate. However, she stated she was not aware of the time line of the resident's illness and was not aware of the length of time it took for Resident #1 to receive treatment. Interview with the Primary Care Physician/ Medical Director, on [DATE] at 9:42 AM, revealed Resident #1 was sick frequently and the nursing staff was aware and kept a close eye on him/her. The Physician further stated the resident had chronic infection due to osteomeylitis of the coccyx. The Physician stated the resident did well longer than he expected him/her to or thought he/she would have due to comorbidities. However, he stated if the resident had been treated sooner, it is possible (he/she) would have recovered from the acute illness. **The facility implemented the following to remove the Immediate Jeopardy on [DATE]: 1. The facility's Administrative Nursing Team consisting of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Wing one (1) Unit Manager (UM), Wing two (2) Unit Manager (UM), Minimum Data Set (MDS) Coordinator and Staff Development Coordinator (SDC), met on [DATE] to determine the root cause of the Immediate Jeopardy. A performance improvement action plan was written and initiated; and a clinical monitoring audit tool for review of progress notes, review of assessments, and review of Physician orders [REDACTED]. 2. Audits of all residents' progress notes for the past thirty (30) days were initiated by the Administrative Nursing Team on [DATE] and completed on [DATE]. As a result of the audit, two (2) responsible parties were notified of change in condition. 3. Daily audits of Nurses' Progress Notes, physician's orders [REDACTED]. Review of the Progress Notes, physician's orders [REDACTED]. After thirty (30) days, the DON and the ADON, will review the weekend Nurse's Notes, assessments and orders on Monday mornings. Any findings of non-compliance through the Progress Notes, assessments and Physician order [REDACTED]./or Social Services Director (SSD). 4. In-services and trainings for all licensed staff were initiated on [DATE] and concluded on [DATE]. In-services and trainings included competent assessment skills including gathering information such as vital signs, lung sounds, skin color and temperature, and any signs of distress; facility Physician and family notification policy - notification is to include changes in condition, and labs / x-ray results to be done in a timely manner and documented timely; use of interact Clinical Pathways for assessment process; professional standards for documentation of resident care and assessment findings; and timely administration of antibiotic medications. In-services and trainings were completed face-to-face and via telephone. Each licensed staff member were provided with written material on all of the in-services and trainings. 5. Competency tests and skill check-offs, for the in-serviced materials, for all licensed staff were completed on [DATE]. The testing and check-offs will be ongoing weekly for thirty (30) days then monthly for another six (6) months. 6. Newly hired licensed staff will be educated with skill check-offs regarding licensed nurse competency; physical assessment including lung sounds; documentation of change of status - notification of the Physician and responsible party; monitoring residents for O2, checking Physician orders [REDACTED]. 7. The clinical Quality Assurance and Performance Improvement (QAPI) process was initiated on [DATE]. The QAPI members included: DON, ADON, Medical Director, Wing One (1) and Wing Two (2) UM's, SDC, Director of Social Services, and the MDS Coordinator. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the QAPI meeting notes, dated, [DATE], revealed the facility identified the deficient practices as not following up with the Physician with test results, timely administrations of antibiotics, and not notifying the Physician and responsible party in a timely manner and an action plan was initiated. 2. Review of the Clinical Monitoring Audit tool revealed chart audits for each resident was completed by [DATE] with focus on progress notes, assessments, and Physician orders. 3. Additionally, audits have been completed daily since [DATE] and are on-going. 4. Review of the employee sign-in sheet and through interviews on [DATE], at 10:55 AM with RN #1; at 11:10 AM with RN #2; at 11:20 AM with RN #3; at 11:25 AM with RN #4; at 11:35 AM with LPN #6; at 11:45 AM with LPN #7; at 11:55 AM with RN #5; at 12:00 PM with the ADON; at 12:10 PM with LPN #1; at 1:21 PM with LPN #8; at 2:39 PM with LPN #5; at 2:26 PM with RN #6; at 2:31 PM with LPN #9; and at 3:01 PM with LPN, it was determined in-services and trainings with all licensed staff was completed on [DATE]. Review of the in-service material revealed training was provided on Timely Antibiotic Administration, Physician/Legal Representative Notification, Clinical Nursing Skills including charting format, monitoring residents receiving O2, and physical assessment of chest with lung sounds. 5. Review of the sign-in sheet for competency check-off, dated [DATE], revealed all licensed staff were competent in physical assessment, documentation of change in status, notifications of Physician and legal representative, monitoring residents with O2, and new antibiotic orders. Additionally, skills testing for licensed staff was initiated on [DATE] and is on-going. 6. Review of the facility's new-hire folder revealed an in-service agenda with topic including licensed nurse competencies for physical assessment including lung sounds, documentation of change of status, notification of the Physician and legal representative; monitoring of residents with O2, and new orders for antibiotic therapy. 7. Interview with the DON, on [DATE] at 1:20 PM, revealed the QAPI team would be meeting again on [DATE] then weekly for four (4) weeks thereafter.

Based on interview, record review and facility policy review, it was determined the facility failed to immediately consult with the resident's Physician and notify the resident's representative of a change in respiratory status for one (1) of six (6) sampled residents (Resident #1). Resident #1 exhibited symptoms of a weak cough, congestion and complaints of not feeling well on [DATE] and [DATE]. On [DATE] at approximately 12:00 PM, the resident's oxygen saturation (O2 sat) level began to drop, requiring O2. However, the on-call Physician was not notified until 8:34 PM (eight hours later) when a chest x-ray was ordered. The x-ray result was received on [DATE] at 1:08 AM and indicated left lower lung infiltrate and effusion. However, the on-call Physician was not notified until [DATE] at 5:38 AM (four hours later) of the x-ray results. On the morning of [DATE] at 7:00 AM, the resident's O2 saturation level dropped again requiring the O2 to be increased. The facility failed to notify the Physician and the resident's representative was not answering. The facility transferred the resident to the emergency room (ER) at 8:50 AM with no notification to the Physician of the transport. Resident #1 was admitted to the intensive care unit with [DIAGNOSES REDACTED]. He/she expired on [DATE]. The facility's failure to ensure the Physician was notified of a significant change in a timely manner, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Credible Allegation of Compliance (AoC) was received on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. The State Survey Agency (SSA) validated the AoC and determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a level D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Physician/Legal Representative Notification, last revised (MONTH) 2012, revealed it is the policy of the facility to immediately inform the resident; consult with the resident's Physician; and if known, notify the resident's legal representative or an interested family member when: there is a significant change in the resident's physical, mental or psychosocial status (i.e. a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications); there is a need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment); there is a decision to transfer or discharge the resident from the facility specified in 483.12(a). The facility will notify the Physician as indicated above as follows: The charge nurse will make two (2) attempts to notify the attending Physician. If unsuccessful, they will notify the Physician on-call or the Medical Director. The legal representative is to be notified as indicated above. In non-critical situations (those not involving hospitalization or other immediate interventions), the legal representative will be notified immediately unless otherwise indicated on a Notification Request form. All notifications and/or attempted notifications are to be documented in the Nurses' Notes. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable. Further review of the MDS revealed the resident had a feeding tube and a supra-pubic urinary catheter. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 12:10 PM, revealed Resident #1 was not feeling well, had some congestion, a weak cough and was afebrile on [DATE] and [DATE]. She stated a day shift nurse had made the Physician aware of the cough; however, she was unable to identify the day shift nurse. Review of the medical record revealed there was no documented evidence the Physician was made aware of Resident #1's weak cough, congestion or not feeling well on [DATE] and [DATE]. Interviews, on [DATE], with Certified Nurse Aide (CNA) #3 at 3:27 PM and CNA #1 at 2:50 PM, revealed when CNA #3 fed Resident #1 breakfast on [DATE], the resident was shaking really bad while eating and complained of not feeling well. CNA #1 noted at approximately 12:00 noon that Resident #1 was pale and (his/her) breathing was rapid and was not acting normal. The CNAs stated they informed LPN #4 and she assessed the resident's O2 saturation to be 93% and CNA #3 checked the resident's temperature and it was normal at 98 something. CNA #1 stated she stayed with the resident while LPN #4 retrieved an O2 concentrator and set up the O2 for the resident. CNA #1 stated the O2 helped a little, but not much, and the resident continued to have rapid breathing. Interview with LPN #4, on [DATE] at 12:40 PM, revealed CNA #3 made her aware Resident #1 was breathing funny around lunch time, approximately 12:00 PM, on [DATE]. LPN #4 stated the resident's O2 saturation level was in the 90's on room air and she placed O2 at 2 liters per minute (LPM) per nasal cannula on the resident at that time. She stated the resident's O2 saturation level improved a little but she was unable to recall to what percentage it improved. LPN #4 stated she asked CNA #3 to check the resident's temperature, and it was normal, and the resident denied complaints of pain or discomfort. Continued interview revealed LPN #4 was in the resident's room a few times during the shift, but she did not notice further difficulty. LPN #4 stated she did not call the Physician or the resident's representative to notify them of the change in the resident's condition. Review of the Nurses' Notes, dated [DATE], revealed there was no documented evidence of Resident #1's condition change or notification of the Physician or resident's representative on [DATE] from 6:00 AM to 6:00 PM. In addition, review of the physician's orders [REDACTED]. Interview with LPN #3, on [DATE] at 12:45 PM, [DATE] at 8:35 AM and at 3:56 PM, revealed she worked 6:00 PM to 6:00 AM on [DATE]. LPN #3 stated at approximately 7:00 PM, while administering the night-time medications, she noted Resident #1's respirations were fast; however, the resident spoke to her and denied complaints. The LPN stated the resident's O2 saturation level was good at 96ish and (his/her) O2 sat never dropped. LPN #3 stated she notified the on-call Physician at approximately 7:00 PM or 8:00 PM, of the resident's condition and received orders for a chest x-ray and nebulizer treatments. LPN #3 stated she notified the mobile x-ray right after receiving the order and when she received the x-ray report, she notified the on-call Physician and left a message. The LPN stated, at approximately 5:30 AM, the Physician returned the call with orders for [MEDICATION NAME] (an antibiotic). LPN #3 further stated she did not notify the resident's representative because it was late at night, and she did not want to call. Review of a late entry in the Nurse's Notes, dated [DATE] at 8:34 PM, revealed LPN #3 documented she phoned the on-call Physician of a change in respiratory status and he ordered a chest x-ray and nebulizer treatments every four (4) hours as needed for congestion and wheezing. Review of the Nurse's Notes, dated [DATE] at 5:38 AM, revealed LPN #3 documented received chest x-ray results and notified Physician on-call and received new order for [MEDICATION NAME] 500 milligrams (mg) every day for seven (7) days. However, review of the mobile x-ray company's time stamp documentation for the ordered chest x-ray for Resident #1 revealed the company received the order for chest x-ray, single view, STAT on [DATE] at 11:16 PM, three (3) to four (4) hours after LPN #3 stated she received the order for the chest x-ray from the Physician. In addition, further review revealed the first result report was faxed to the facility on [DATE] at 1:08 AM, and a confirmation call was made to the facility on [DATE] at 1:36 AM, four (4) hours prior to the Physician notification of the results. Interview with Certified Medication Technician (CMT) #1, on [DATE] at 2:35 PM, revealed when she first observed Resident #1 on the morning of [DATE], the resident was in dire distress and his/her breathing was labored. CMT #1 stated she attempted to check the resident's vital signs because the resident was on antibiotics; the resident's temperature was 99.6 degrees Fahrenheit (F). CMT #1 stated she attempted to obtain a blood pressure using a wrist cuff, but the reading revealed a low blood pressure. CMT #1 summoned LPN #5 to check the resident's blood pressure because she felt the reading was inaccurate. Interview with LPN #5, on [DATE] at 10:20 AM, and [DATE] at 8:10 AM, revealed she worked [DATE], on the day shift. LPN #5 stated she received report from LPN #3 at the beginning of the shift that Resident #1's O2 saturation had dropped on [DATE], a chest x-ray was obtained, and nebulizer treatments and an antibiotic were ordered. Further interview with LPN #5 revealed, on her first observation and assessment at approximately 7:00 AM, the resident's skin was flushed, temperature was elevated to 99 degrees F, and O2 saturation was ,[DATE] % with O2 at 2 LPM via nasal cannula. LPN #5 stated she attempted to notify the resident's representative to obtain approval to transport the resident to the ER, but she had to leave a message as she was unable to reach the representative. The LPN stated she wanted to send the resident to the ER, but she was waiting to hear from the family for their wishes. Review of a Nurse's Notes, dated [DATE] at 7:00 AM, revealed LPN #5 documented Resident #1 was experiencing some dyspnea at this time with Duo nebulizer treatment administered. Further review revealed Resident #1's blood pressure was ,[DATE] (baseline ,[DATE]), heart rate 122 (baseline 80), and respirations labored at 28 (baseline 20). At 8:20 AM, LPN #5 spoke with the resident's daughter and the resident had since required an increase in O2, as his/her saturation had dropped to the mid 80's. A second nebulizer treatment was administered at 8:30 AM as the resident's O2 saturation began to drop again, maintaining 89% on 3 LPM via tank and the nebulizer on. A return call was received from his/her daughter at 8:27 AM with instructions to send him/her to the ER and a call was placed to the Ambulance Service to transport the resident to the ER. Upon further assessment, LPN #5 also observed the resident's urine was very dark in color with a large amount of sediment in the tubing and bag. The Ambulance Service arrived to pick the resident up at 8:50 AM to transfer him/her. Further record review revealed the last contact with the Physician was on [DATE] at 5:38 AM. There was no documented evidence of Physician notification or an order to send Resident #1 to the ER for evaluation. Review of the ER Report, dated [DATE], revealed Resident #1 arrived in the ER at 9:34 AM with [DIAGNOSES REDACTED]. Resident #1 was admitted to the Intensive Care Unit at 1:56 PM on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary revealed Resident #1 expired on [DATE]. The cause of death was Septic Shock secondary to [MEDICAL CONDITION]-Susceptible Staphylococcus Aureus (MSSA), Bacteremia, and Pneumonia. Interview with Registered Nurse (RN) #1, on [DATE] at 4:00 PM, revealed she, as a Unit Manager, expected the Physician and the resident's responsible party to be notified of any change in condition immediately. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 2:00 PM, revealed she expected staff to notify the Physician and obtain an order for [REDACTED].#1 was appropriate, but stated she was not aware of the timeline of the resident's illness and was not aware of the length of time it took for the resident to receive treatment. Interview with the Primary Care Physician/Medical Director, on [DATE] at 9:42 AM, revealed Resident #1 had a chronic infection due to osteomeylitis of the coccyx. The Physician stated the resident did well longer than he expected him/her to or thought he/she would have due to comorbidities. However, he stated if the resident had been treated sooner, it is possible he/she would have recovered from the acute illness. **The facility implemented the following to remove the Immediate Jeopardy on [DATE]: 1. The facility's Administrative Nursing Team consisting of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Wing one (1) Unit Manager (UM), Wing two (2) Unit Manager (UM), Minimum Data Set (MDS) Coordinator and Staff Development Coordinator (SDC), met on [DATE] to determine the root cause of the Immediate Jeopardy. A performance improvement action plan was written and initiated; and a clinical monitoring audit tool for review of progress notes, review of assessments, and review of Physician orders [REDACTED]. 2. Audits of all residents' progress notes for the past thirty (30) days were initiated by the Administrative Nursing Team on [DATE] and completed on [DATE]. As a result of the audit, two (2) responsible parties were notified of change in condition. 3. Daily audits of Nurses' Progress Notes, physician's orders [REDACTED]. Review of the Progress Notes, physician's orders [REDACTED]. After thirty (30) days, the DON and the ADON, will review the weekend Nurse's Notes, assessments and orders on Monday mornings. Any findings of non-compliance through the Progress Notes, assessments and Physician order [REDACTED]./or Social Services Director (SSD). 4. In-services and trainings for all licensed staff were initiated on [DATE] and concluded on [DATE]. In-services and trainings included competent assessment skills including gathering information such as vital signs, lung sounds, skin color and temperature, and any signs of distress; facility Physician and family notification policy - notification is to include changes in condition, and labs / x-ray results to be done in a timely manner and documented timely; use of interact Clinical Pathways for assessment process; professional standards for documentation of resident care and assessment findings; and timely administration of antibiotic medications. In-services and trainings were completed face-to-face and via telephone. Each licensed staff member were provided with written material on all of the in-services and trainings. 5. Competency tests and skill check-offs, for the in-serviced materials, for all licensed staff were completed on [DATE]. The testing and check-offs will be ongoing weekly for thirty (30) days then monthly for another six (6) months. 6. Newly hired licensed staff will be educated with skill check-offs regarding licensed nurse competency; physical assessment including lung sounds; documentation of change of status - notification of the Physician and responsible party; monitoring residents for O2, checking Physician orders [REDACTED]. 7. The clinical Quality Assurance and Performance Improvement (QAPI) process was initiated on [DATE]. The QAPI members included: DON, ADON, Medical Director, Wing One (1) and Wing Two (2) UM's, SDC, Director of Social Services, and the MDS Coordinator. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the QAPI meeting notes, dated, [DATE], revealed the facility identified the deficient practices as not following up with the Physician with test results, timely administrations of antibiotics, and not notifying the Physician and responsible party in a timely manner and an action plan was initiated. 2. Review of the Clinical Monitoring Audit tool revealed chart audits for each resident was completed by [DATE] with focus on progress notes, assessments, and Physician orders. 3. Additionally, audits have been completed daily since [DATE] and are on-going. 4. Review of the employee sign-in sheet and through interviews on [DATE], at 10:55 AM with RN #1; at 11:10 AM with RN #2; at 11:20 AM with RN #3; at 11:25 AM with RN #4; at 11:35 AM with LPN #6; at 11:45 AM with LPN #7; at 11:55 AM with RN #5; at 12:00 PM with the ADON; at 12:10 PM with LPN #1; at 1:21 PM with LPN #8; at 2:39 PM with LPN #5; at 2:26 PM with RN #6; at 2:31 PM with LPN #9; and at 3:01 PM with LPN, it was determined in-services and trainings with all licensed staff was completed on [DATE]. Review of the in-service material revealed training was provided on Timely Antibiotic Administration, Physician/Legal Representative Notification, Clinical Nursing Skills including charting format, monitoring residents receiving O2, and physical assessment of chest with lung sounds. 5. Review of the sign-in sheet for competency check-off, dated [DATE], revealed all licensed staff were competent in physical assessment, documentation of change in status, notifications of Physician and legal representative, monitoring residents with O2, and new antibiotic orders. Additionally, skills testing for licensed staff was initiated on [DATE] and is on-going. 6. Review of the facility's new-hire folder revealed an in-service agenda with topic including licensed nurse competencies for physical assessment including lung sounds, documentation of change of status, notification of the Physician and legal representative; monitoring of residents with O2, and new orders for antibiotic therapy. 7. Interview with the DON, on [DATE] at 1:20 PM, revealed the QAPI team would be meeting again on [DATE] then weekly for four (4) weeks thereafter.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident receives adequate supervision to prevent accidents for one (1) of six (6) sampled residents (Resident #4). The facility failed to ensure they were providing Resident #4 assistance with toileting needs in the bathroom and not allowing the resident to do so independently after he/she was assessed as needing assistance for safety. In addition, the facility failed to ensure Resident #4's Falls Risk Care Plan was followed and also failed to ensure Resident #4's Quarterly Falls Assessment was completed as required. The resident had a fall resulting in a [MEDICAL CONDITION], with he/she having a left hip surgical repair procedure on 08/30/18. The findings include: Review of the facility's policy Resident Safe Environment, not dated, revealed to evaluate residents for fall risk by utilizing a falls assessment tool (FAST) evaluation form initially and quarterly. The policy further stated to implement interventions outlined in the recommendations for each level of risk identified by the FAST evaluation. Record review revealed the facility admitted Resident #4 on 02/15/18 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 08/19/18, revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of the Fall Risk Assessment, dated 05/21/18, revealed the resident was a high falls risk. Further review of the resident's clinical record revealed there was no evidence a quarterly falls risk assessment had been completed in (MONTH) (YEAR) when it was due in coordination with the Quarterly MDS Assessment, dated 08/19/18. Review of the Comprehensive High Risk for Fall's Care Plan, initiated on 03/02/18, revealed the facility care planned the resident as being high risk for falls related to deconditioning, incontinence, vision/hearing problems, weakness and having a history of falls. Further review of the care plan revealed interventions to complete fall assessment quarterly, and Do not leave alone in bath room, in shower chair or on bedside commode (BSC). Review of a Nurse's Note, dated 08/29/18 at 5:05 PM, revealed Resident #4 was found on the floor next to Resident #4's bed by a State Registered Nurse Aide (SRNA) and the fall was and unwitnessed fall. The resident had two (2) skin tears noted to his/her left arm and was complaining of left hip pain. It further stated the Physician was notified and orders were received to send the resident to the emergency room (ER) to be evaluated and treated. Review of Hospital Records, dated 08/29/18, revealed Resident #4 was admitted to the hospital due to a fall. Further review of the hospital records revealed x-rays were taken and the x-rays showed Resident #4 had a Comminuted Intertrochanteric Fracture Proximal Left Femur with Extension into displacement of the Lesser Trochanter. Review of the MDS Entry Tracking Record, dated 09/04/18, revealed Resident #4 returned to the facility on [DATE] from the hospital. Review of a Pain Assessment, dated 09/11/18, revealed Resident #4 complained of having frequent pain present. Further review of the Pain Assessment revealed Resident #4 was receiving as needed (PRN) pain medication at least daily for pain related to the Fractured Left Hip. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of Hospital Records, dated 09/24/18, revealed Resident #4 received a left hip surgical repair procedure on 08/30/18. Interview with SRNA #2, on 11/30/18 at 12:21 PM, revealed she was working on Resident #4's unit when he/she fell and fractured his/her hip. She stated she remembered Resident #4 had been taking himself/herself to the bathroom and getting up and ambulating a lot on his/her own. She stated she was not aware Resident #4 had a care plan intervention not to be left alone in the bathroom or while on the bedside commode. Interview with SRNA #4, on 11/30/18 at 12:24 PM, revealed she was working when Resident #4 fell and she recalled Resident #4 had been ambulating himself/herself to and from the bathroom and getting around on his/her own by himself/herself. She stated she was not aware of Resident #4 having a care plan intervention to not be left alone in the bathroom or on the bedside commode. Interview with Registered Nurse (RN) #2, on 11/29/18 at 3:13 PM, revealed she was Resident #4's nurse on duty when Resident #4 fell on [DATE] and suffered a [MEDICAL CONDITION]. She stated Resident #4 informed her that he/she was coming back from the bathroom and was getting into his/her bed when he/she fell . She stated she knew Resident #4 had been taking himself/herself to the bathroom due to he/she seemed independent and was able to do for himself/herself. She stated she was not aware of what the care plan interventions for Resident #4's falls risk care plan were, as she did not have time to look at the care plans on all the residents. Interview with the facility's MDS/Care Plan Coordinator #1, on 11/29/18 at 12:33 PM, revealed falls risk assessments were supposed to be done for all residents on a quarterly basis by the MDS Department. She stated somehow Resident #4's Falls Risk Assessment due in (MONTH) (YEAR) was missed and not done. She further stated the falls risk assessments were done quarterly to know if a resident had had a change or decline that would put the resident at further risk for falls. She stated she expected all staff to follow the care plans as the care plans were created as a guide for staff to follow to know how to best take care of the residents in the safest ways. Interview with the Director of Nursing (DON), on 11/29/18 at 3:08 PM, revealed she expected staff to follow the care plans and she expected the falls assessments to be done quarterly for all residents.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident does not develop pressure ulcers or injuries, unless clinically unavoidable, and that the facility provides care and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (1) of six (6) sampled residents (Resident #4). The facility admitted Resident #4 on 02/15/18 with no pressure ulcers and only required limited assistance of one staff for bed mobility and transfers. Resident #4 was hospitalized from [DATE] to 09/04/18 for surgical repair of a left [MEDICAL CONDITION]. When he/she returned to the facility, the resident required extensive assistance of two (2) staff for bed mobility/transfer. However, the facility failed to put interventions in place to address the resident's increased assistance needed for pressure relief due to the resident's increased need of staff assistance in bed mobility/transfer and increased pressure ulcer risk due to the [MEDICAL CONDITION]. On 09/23/18, the resident was identified to have a Deep Tissue Injury (DTI) to his/her right heel that measured 3.2 centimeters (cm) by 1.5 cm. The findings include: Review of the facility's policy Skin Care Management, revised 03/12, revealed the purpose of the policy is to prevent the development of avoidable pressure ulcers. The policy further stated that protocols will be in place for the prevention of pressure ulcers. Record review revealed the facility admitted Resident #4 on 02/15/18 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 08/19/18, revealed the facility assessed Resident #4 required limited assistance of one (1) staff for both bed mobility and transfers. Review of Resident #4's Comprehensive Care Plan for Risk of Pressure Ulcer Development, initiated on 02/28/18, revealed Resident #4 was at risk for pressure ulcer development due to having Diabetes, Impaired Mobility, and Incontinence. Further review of the care plan revealed interventions initiated on 02/28/18, which included a pressure reduction mattress to the bed, a pressure reduction cushion to the wheel chair, and to apply moisturizer to his/her skin daily after his/her bath and do not massage over bony prominences. Review of Hospital Records, dated 08/29/18, revealed Resident #4 was admitted to the hospital due to a fall on 08/29/18 and returned to the facility on [DATE]. Further review of the hospital records revealed x-rays were taken and the x-rays showed Resident #4 had a Comminuted Intertrochanteric Fracture Proximal Left Femur with extension into displacement of the Lesser Trochanter. Review of hospital records for follow up, dated 09/24/18, revealed Resident #4 received a left hip surgical repair procedure on 08/30/18. Review of Resident #4's Significant Change MDS Assessment, dated 09/18/18, revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident was not interviewable. Further review of the MDS Assessment, revealed the facility assessed the resident to be at risk for developing pressure ulcers and required extensive assistance of two (2) staff for bed mobility and total assistance of two (2) staff for transfers which was a decline, as prior to this, the resident had only required limited assistance of one (1) staff for bed mobility/transfers. Review of the Activities of Daily Living Care Area Assessment (CAA) dated 09/27/18 revealed the resident required extensive to total staff assist with ADL's and was toe touch weight bearing status with mechanical lift of two (2) staff for transfers. However, review of the Comprehensive Care Plan for Risk of Pressure Ulcer Development, initiated on 02/28/18, revealed there were no interventions put in place to address the resident's increased assistance needed for pressure relief due to the resident's decline in bed mobility/transfer or, increased pressure ulcer risk due to the [MEDICAL CONDITION]. Review of Resident #4's documented weekly skin assessments, dated 09/08/18, 09/15/18 and 09/22/18, revealed Resident #4 had no pressure ulcers present. Review of a Nurse's Note, dated 09/23/18 at 8:37 PM, revealed staff identified Resident #4 had a DTI to his/her right heel that measured 3.2 centimeters (cm) by 1.5 cm. Further review of the Nurse's Note revealed Resident #4 complained of discomfort to the right heel and pain medication was given. The Physician and family were notified and orders for a treatment were received. The Comprehensive Care Plan for Risk of Pressure Ulcer Development, initiated on 02/28/18, was revised on 09/24/18, a day after staff found the DTI to the resident's right heel and twenty (20) days after he/she returned to the facility from the hospital stay. Observation of his/her right heel, on 11/29/18 at 4:20 PM, revealed a circular unstageable pressure ulcer that had a black, dry necrotic cap present approximately two (2) cm by two (2) cm. Review of Physician Orders, dated 11/29/18, revealed an order to apply skin prep to Resident #4's right heel unstageable pressure ulcer. Interview with the MDS/Care Plan Coordinator #1, on 11/29/18 at 12:33 PM, revealed care plans should be updated with any changes in a resident's condition. She stated it was an ongoing process to review and update the care plans with any resident changes. Interview with Registered Nurse (RN) #1, on 11/29/18 at 3:52 PM, revealed she was the Unit Manager. She stated Resident #4 developed an in-house acquired pressure ulcer that was unstageable to his/her right heel. She stated the pressure ulcer that Resident #4 acquired in-house should have been prevented. Interview with RN #2, on 11/29/18 at 4:30 PM, revealed Resident #4 developed an unstageable pressure ulcer to his/her right heel during his/her stay at the facility. She stated Resident #4's pressure ulcer to his/her right heel was avoidable and should not have developed, especially since it occurred on his/her non-affected lower extremity which was not immobile due to a [MEDICAL CONDITION]. Interview with the Assistant Director of Nursing (ADON), on 11/30/18 at 10:36 AM, revealed she had not seen anything in Resident #4's clinical record that would indicate his/her right heel pressure ulcer was unavoidable. She stated Resident #4 should not have developed a pressure ulcer to his/her right heel while at the facility.

Based on interview, record review and facility policy review, it was determined the facility failed to revise the care plan for one of nine (9) sampled residents after a fall. Resident #9 sustained a fall on 01/04/19 and the facility determined the root cause of the fall was the resident attempting to ambulate to the bathroom without staff supervision and staff not hearing the resident's sensor alarm. However, further review of the care plan revealed there was no intervention put in place to address the resident ambulating without staff assistance or to address staff not being able to hear the alarm. Resident #9 had a subsequent fall on 03/03/19 while ambulating to the bathroom without staff supervision/assistance which resulted in a pelvic fracture and an increase in pain. The findings include: Review of facility policy titled, Development of Care Plan, not dated, revealed the care plan is to be reviewed and revised as per the RAI manual with significant changes, and changes in orders as received by the MDS Coordinator. Record review revealed the facility admitted Resident #9 on 10/08/18 with [DIAGNOSES REDACTED]. Review or the Admission Minimum Data Set (MDS) assessment, dated 10/15/18 revealed the facility assessed Resident #9's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Review of an Event Report, dated 01/04/19; a Health Status Note dated 01/07/19 at 4:00 PM, and a Health Status Note dated 01/07/19 at 4:00 PM; and interviews with Registered Nurse (RN) #2 on 03/26/19 at 9:15 AM, revealed Resident #9 had a fall on 01/04/19 at 6:30 AM when he/she attempted to ambulate to the bathroom without staff supervision and sustained a bruise to left knee and a knot on forehead. Further review of the report and notes revealed the resident's sensor alarm was in place, but it was not heard due to the resident's door being shut per the resident's and family wishes. The resident and resident's family were educated prior to this fall there was an increased risk of the resident falling with the door shut and they voiced understanding. However, review of the Resident #9's Comprehensive Care Plan dated 10/29/18 revealed the care plan was not revised with an intervention to address the resident ambulating without supervision, and staff not being able to hear the bed sensor alarm when the resident attempted to ambulate per facility policy until 01/29/19 when an alarming mat was put in place on the floor on the resident's right side of bed. However, further review of the care plan revealed the facility still failed to revise the care plan to address the resident's need for increased supervision due to the resident attempting to ambulate without assistance per facility policy. Review of Progress Note (Incident Note), dated 03/03/19 at 8:00 PM revealed the nurse heard resident's bed and floor alarms sounding and responded immediately. Resident #9 was found laying on left side in front of bathroom door that was closed. Resident #9 stated he/she hit his/her head on the door when he/she fell and there was no injury observed at this time. Review of Resident #9's hospital records dated 03/03/19 revealed Resident #9 had a non-displaced fracture of pelvis. The resident was admitted for comfort measures and to try to help with pain and given [MEDICATION NAME] and [MEDICATION NAME] for underlying anxiety or restlessness. The resident was discharged back to the facility on [DATE]. Review of Pain Assessment and Weekly Physical assessment dated [DATE] revealed Resident #9 has vocal complaints and facial expressions of severe left hip pain daily with [DIAGNOSES REDACTED].#9 was on scheduled pain medication of PM (evening) [MEDICATION NAME] and [MEDICATION NAME] with PRN [MEDICATION NAME]. Interview on 03/25/19 at 1:50 with RN #2, 03/25/19 at 1:55 PM with Licensed Practical Nurse (LPN) #7, 03/25/19 at 1:58 PM with LPN #8, and 03/25/19 at 2:01 PM with LPN #6, 03/25/19 at 2:10 PM with RN #5 revealed the MDS updates the care plans. Interview on 03/21/19 at 10:45 AM with MDS Coordinator revealed MDS did the majority of updating and reviewing of the care plans. Interview with the Director of Nursing (DON) on 03/21/19 at 3:28 PM, 03/22/19 at 3:05 PM, and 03/26/19 at 11:26 AM and 3:40 PM revealed the root cause of Resident #9's falls was the resident would ambulate by self when he/she needed assistance to ambulate. The DON stated the care plans were updated with the IDT recommended intervention (s) when the falls are reviewed in morning clinical meeting and when the IDT discussed interventions, the care plan was updated at the same time. She stated an IDT review was completed on the 01/04/19 fall on 01/07/19; but it was ongoing and the IDT continued to look at what else could be done. The DON stated the care plan was not updated on 01/07/19 as they had determined the fall occurred because of the family and resident wanting the door closed even after education it put the resident at an increased fall risk. Interview on 03/26/19 at 4:24 PM with the Administrator revealed she did not start at the facility until 01/19/19. The Administrator stated she would have expected the IDT to review and to put interventions in place to address the falls.

Based on interview, record review and facility policy review, it was determined the facility failed to revise the care plan for one of nine (9) sampled residents after a fall. Resident #9 sustained a fall on 01/04/19 and the facility determined the root cause of the fall was the resident attempting to ambulate to the bathroom without staff supervision and staff not hearing the resident's sensor alarm. However, further review of the care plan revealed there was no intervention put in place to address the resident ambulating without staff assistance or to address staff not being able to hear the alarm. Resident #9 had a subsequent fall on 03/03/19 while ambulating to the bathroom without staff supervision/assistance which resulted in a pelvic fracture and an increase in pain. The findings include: Review of facility policy titled, Development of Care Plan, not dated, revealed the care plan is to be reviewed and revised as per the RAI manual with significant changes, and changes in orders as received by the MDS Coordinator. Record review revealed the facility admitted Resident #9 on 10/08/18 with [DIAGNOSES REDACTED]. Review or the Admission Minimum Data Set (MDS) assessment, dated 10/15/18 revealed the facility assessed Resident #9's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Review of an Event Report, dated 01/04/19; a Health Status Note dated 01/07/19 at 4:00 PM, and a Health Status Note dated 01/07/19 at 4:00 PM; and interviews with Registered Nurse (RN) #2 on 03/26/19 at 9:15 AM, revealed Resident #9 had a fall on 01/04/19 at 6:30 AM when he/she attempted to ambulate to the bathroom without staff supervision and sustained a bruise to left knee and a knot on forehead. Further review of the report and notes revealed the resident's sensor alarm was in place, but it was not heard due to the resident's door being shut per the resident's and family wishes. The resident and resident's family were educated prior to this fall there was an increased risk of the resident falling with the door shut and they voiced understanding. However, review of the Resident #9's Comprehensive Care Plan dated 10/29/18 revealed the care plan was not revised with an intervention to address the resident ambulating without supervision, and staff not being able to hear the bed sensor alarm when the resident attempted to ambulate per facility policy until 01/29/19 when an alarming mat was put in place on the floor on the resident's right side of bed. However, further review of the care plan revealed the facility still failed to revise the care plan to address the resident's need for increased supervision due to the resident attempting to ambulate without assistance per facility policy. Review of Progress Note (Incident Note), dated 03/03/19 at 8:00 PM revealed the nurse heard resident's bed and floor alarms sounding and responded immediately. Resident #9 was found laying on left side in front of bathroom door that was closed. Resident #9 stated he/she hit his/her head on the door when he/she fell and there was no injury observed at this time. Review of Resident #9's hospital records dated 03/03/19 revealed Resident #9 had a non-displaced fracture of pelvis. The resident was admitted for comfort measures and to try to help with pain and given [MEDICATION NAME] and [MEDICATION NAME] for underlying anxiety or restlessness. The resident was discharged back to the facility on [DATE]. Review of Pain Assessment and Weekly Physical assessment dated [DATE] revealed Resident #9 has vocal complaints and facial expressions of severe left hip pain daily with [DIAGNOSES REDACTED].#9 was on scheduled pain medication of PM (evening) [MEDICATION NAME] and [MEDICATION NAME] with PRN [MEDICATION NAME]. Interview on 03/25/19 at 1:50 with RN #2, 03/25/19 at 1:55 PM with Licensed Practical Nurse (LPN) #7, 03/25/19 at 1:58 PM with LPN #8, and 03/25/19 at 2:01 PM with LPN #6, 03/25/19 at 2:10 PM with RN #5 revealed the MDS updates the care plans. Interview on 03/21/19 at 10:45 AM with MDS Coordinator revealed MDS did the majority of updating and reviewing of the care plans. Interview with the Director of Nursing (DON) on 03/21/19 at 3:28 PM, 03/22/19 at 3:05 PM, and 03/26/19 at 11:26 AM and 3:40 PM revealed the root cause of Resident #9's falls was the resident would ambulate by self when he/she needed assistance to ambulate. The DON stated the care plans were updated with the IDT recommended intervention (s) when the falls are reviewed in morning clinical meeting and when the IDT discussed interventions, the care plan was updated at the same time. She stated an IDT review was completed on the 01/04/19 fall on 01/07/19; but it was ongoing and the IDT continued to look at what else could be done. The DON stated the care plan was not updated on 01/07/19 as they had determined the fall occurred because of the family and resident wanting the door closed even after education it put the resident at an increased fall risk. Interview on 03/26/19 at 4:24 PM with the Administrator revealed she did not start at the facility until 01/19/19. The Administrator stated she would have expected the IDT to review and to put interventions in place to address the falls.

Based on interview, record review, and facility policy review, it was determined the facility failed to implement and develop a Comprehensive Care Plan for one (1) of six (6) sampled residents (Resident #4). The facility care planned Resident #4 for staff to complete fall assessment quarterly and do not leave alone in bathroom, in shower chair or on bedside commode (BSC). On 08/29/18, Resident #4 had a change from continent of bowel to incontinent of bowel. However, the facility failed to develop a care plan to address the resident's incontinence. In addition, the resident was care planned to receive a complete fall assessment quarterly and to not leave alone in bathroom, in shower chair or on bedside commode (BSC); however, staff failed to complete a quarterly fall risk assessment in (MONTH) (YEAR) (last quarterly assessment) and the resident fell when returning to bed after using the restroom. The resident sustained [REDACTED]. The facility failed to ensure Resident #4's Falls Risk Care Plan interventions were followed; and, failed to develop an Incontinent of Bowel Care Plan when the resident's status changed from continent of bowel to incontinent of bowel. The findings include: Interview with Minimum Data Set (MDS)/Care Plan Coordinator #1, on 11/29/18 at 12:33 PM, revealed the facility did not have a specific Care Plan policy. She stated the facility followed the Resident Assessment Instrument (RAI) Manual and Federal Regulations as guidelines. Record review revealed the facility admitted Resident #4 on 02/15/18 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS Assessment, dated 08/19/18, revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interveiwable. Further review revealed the resident was always continent of bowel. Review of Resident #4's Comprehensive Care Plan for High Risk for Falls, initiated 03/02/18, revealed an intervention to complete fall assessment quarterly and do not leave alone in bathroom, in shower chair or on bedside commode (BSC). However, interview with Registered Nurse (RN) #2, on 11/29/18 at 3:13 PM, revealed Resident #4 informed her that he/she was coming back from the bathroom and was getting into his/her bed when he/she fell . In addition, further record review revealed there was no evidence a quarterly falls risk assessment had been completed since (MONTH) (YEAR) and the next assessment was due; however, had not been completed in coordination with the Quarterly MDS assessment, dated 08/19/18. Review of the Nurse's Note, dated 08/29/18 at 5:05 PM, revealed Resident #4 was found on the floor by a Certified Nurse Aide (CNA). The resident had two (2) skin tears noted to his/her left arm and was complaining of left hip pain. The Physician was notified and orders were received to send him/her to the emergency room (ER) to be evaluated and treated. Review of Hospital Records, dated 08/29/18, revealed Resident #4 was admitted to the hospital due to a fall. Further review of the hospital records, revealed x-rays were taken which showed Resident #4 had a Comminuted Intertrochanteric Fracture Proximal Left Femur with Extension into displacement of the Lesser Trochanter. Further review of Hospital Records, dated 09/24/18, revealed Resident #4 received a left hip surgical repair procedure on 08/30/18. Interview with CNA #2, on 11/30/18 at 12:21 PM, revealed she was working on Resident #4's unit when the resident fell and fractured his/her hip. She stated she remembered Resident #4 had been taking himself/herself to the bathroom a lot and getting up and ambulating on his/her own. She stated she was not aware of Resident #4's care plan intervention to not be left alone in the bathroom or while on the bedside commode. She stated she was aware she was expected to follow the residents' care plans. Interview with CNA #4, on 11/30/18 at 12:24 PM, revealed she was working when Resident #4 fell and she recalled Resident #4 had been ambulating himself/herself to and from the bathroom and getting around on his/her own. She stated she wasn't aware of Resident #4 having a care plan intervention to not be left alone in the bathroom or on the bedside commode. She stated she knew she was supposed to follow the care plans for the residents she takes care of. Further interview with RN #2, on 11/29/18 at 3:13 PM, revealed she was unaware of what the care plan interventions for Resident #4's falls risk care plan were as she does not have time to look at the care plans on all the residents, but knows she was expected to know and follow the care plans. In addition, review of Resident #4's Significant Change MDS Assessment, dated 09/18/18, revealed the facility coded the resident as frequently incontinent of bowel. In addition, review of Resident #4's sixty (60) day MDS assessment, dated 11/01/18, revealed the facility assessed the resident as having a BIMS score of fourteen (14) which indicated the resident's cognition was intact and he/she was interviewable and the resident was always incontinent of bowel. However, further review of the Comprehensive Care Plans for Resident #4, revealed no evidence the facility developed a bowel incontinence care plan for him/her. Interview with facility MDS/Care Plan Coordinator #1, on 11/29/18 at 12:33 PM, revealed she expected all staff to follow the care plans as the care plans were created as a guide for staff to follow to know how to best take care of the residents in the safest way. She stated a bowel incontinence care plan should have been developed for Resident #4 when he/she had a change from continent of bowel to incontinent of bowel. Interview with the Director of Nursing (DON), on 11/29/18 at 3:08 PM, revealed she expected staff to follow the care plans for all residents. She stated she expected a resident who is incontinent of bowel to have a care plan developed for such.

Based on interview and record review, it was determined the facility failed to ensure a resident with bowel incontinence, based on the resident's comprehensive assessment, receives appropriate treatment and services to restore as much normal bowel function as possible for one (1) of six (6) sampled residents (Resident #4). The facility failed to assess Resident #4 for possible interventions to improve the resident's noted decline in bowel continence. The findings include: Interview with Minimum Data Set (MDS) Coordinator #1, on 11/30/18 at 9:48 AM, revealed the facility did not have a specific policy on bowel incontinence management and used the Federal Regulations as guidelines. Record review revealed the facility admitted Resident #4 on 02/15/18 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 08/19/18, revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review revealed the resident was always continent of bowel. Review of the bowel and bladder assessment, dated 08/26/18, revealed Resident #4 was continent of bowel and mentally aware of toileting needs always, with a total score of seventeen (17) which indicated the resident was a good candidate for individualized training. Review of Resident #4's Significant Change MDS Assessment, dated 09/18/18, revealed the facility coded the resident as frequently incontinent of bowel. Review of the 60 Day MDS Assessment, dated 11/01/18, revealed the facility coded the resident as always incontinent of bowel. Review of the bowel and bladder assessment, dated 11/16/18, revealed he/she was incontinent of bowel one (1) to two (2) times a week, and was sometimes aware of toileting needs; with a total score of twelve (12) which indicated Resident #4 was a candidate for timed toileting. Review of Resident #4's Comprehensive Care Plans, dated 02/20/18, 02/23/18, 02/28/18, 03/02/18 and 09/19/18, revealed no documented evidence the facility developed a bowel incontinence care plan for the resident once he/she was identified to have a decline on 09/18/18 and 11/16/18. In addition, further record review revealed no documented evidence the facility attempted any type of program or interventions to improve Resident #4's noted decline in bowel continence. Interview with MDS Coordinator #1, on 11/30/18 at 9:48 AM, revealed the MDS Coordinator does the bowel and bladder assessments for the residents. She stated when they see a change in continence/incontinence they would be expected to fill out the bowel and bladder assessment. The MDS Coordinator stated they take into consideration the score of the assessment and the resident's history and decide if they would attempt anything or if it would be beneficial. Further interview revealed sometimes that may be an actual program, or they just see if the resident would benefit from scheduled toileting. She stated she should have assessed Resident #4 at the time of his/her 60 day MDS Assessment due to his/her BIMS score improving and a decline in incontinence, but she had failed to do so. Interview with the Director of Nursing (DON), on 11/29/18 at 3:08 PM, revealed she expected a resident who was incontinent of bowel to have a care plan developed. She stated she expected residents who have had a change in bowel incontinence to be assessed for appropriate interventions and possible toileting programs.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure there was sufficient nursing staff to provide timeliness in addressing residents' elimination needs and providing basic cares and showers for two (2) of six (6) sampled residents (Residents #4 and #5). The facility failed to ensure sufficient staffing was in place to ensure staff were able to complete residents' basic Activities of Daily Living (ADL) care, hygiene, and or showers in a timely manner. The findings include: Review of the facility's policy titled Staffing Policy, not dated, revealed it is the policy of the facility to ensure that sufficient qualified nursing staff are available on a daily basis to meet the residents' needs for nursing care in a manner and in an environment which promotes each residents' physical, mental and psycho-social well-being thus enhancing their quality of life. 1. Record review revealed the facility admitted Resident #4 on 02/15/18 with [DIAGNOSES REDACTED]. Review of the sixty (60) day Minimum Data Set (MDS) assessment, dated 11/01/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident's cognition was intact and he/she was interviewable. Interview with Resident #4, on 11/29/18 at 8:50 AM, revealed staff did take care of him/her, but they were slow to answer call lights at times, when he/she needed to use the bathroom, because there was not enough staff. Resident #4 stated he/she had missed an appointment recently due to not enough staff to go with him/her for the appointment. Interview with Registered Nurse (RN) #2, on 11/29/18 at 4:30 PM, revealed last Monday, Resident #4 missed a follow-up eye appointment because there was only one (1) State Registered Nurse Aide (SRNA) on the unit. RN #2 stated they did not have enough staff so they could send a staff member to the appointment with Resident #4, so they rescheduled the appointment. 2. Record review revealed the facility admitted Resident #5 on 03/18/17 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 11/08/18, revealed the facility assessed him/her as having a BIMS score of fifteen (15) which indicated the resident's cognition was intact and he/she was interviewable. Interview with Resident #5, on 11/29/18 at 9:05 AM, revealed staffing seemed short a lot, but staff do the best they can. Resident #5 stated he/she always gets his/her care done even if staff can't do it when it's time, they will do it later on in the day or the next day. Interview with SRNA #6, on 11/29/18 at 9:28 AM, revealed the resident's baths and basic ADL (Activities of Daily Living) care was missed at times due to short staffing. She stated the facility had been having a lot of call-ins and it had left the building understaffed at times. She stated when there were call-ins, the staff at the facility were expected to do more than they could. Interview with SRNA #1, on 11/29/19 at 9:36 AM, revealed the facility was short staffed a lot on all shifts and at times the staff couldn't get all the basic ADL care/hygiene, baths, showers done as needed and required. Interview with SRNA #7, on 11/29/18 at 9:55 AM, revealed the facility was short staffed a lot and staff could not provide care for the residents at times because they couldn't get them all done. She stated it seemed that staffing was short on all shifts. Interview with SRNA #2, on 11/29/18 at 10:05 AM, revealed they were short staffed sometimes and when showers were missed or couldn't be done, they tried to do a bed bath or catch up on missed showers the next day. Interview with Licensed Practical Nurse (LPN) #5, on 11/29/18 at 10:13 AM, revealed they had really had some issues with staffing shortages at the facility. She stated there have been SRNAs quitting due to being over worked and not being able to get their tasks done for the residents. LPN #5 stated they were expected to work short. She stated the SRNAs have been put on mandatory overtime due to staffing shortages. Interview with SRNA #8, on 11/29/18 at 10:47 AM, revealed they were short staffed all the time and due to the short staffing the SRNA's have been put on mandatory overtime. Interview with SRNA #5, on 11/29/18 at 12:41 PM, revealed there have been issues with short staffing at the facility. She stated Restorative SRNAs were pulled to work the floor due to staff shortage at times. Interview with SRNA #4, on 11/29/18 at 2:35 PM, revealed there have been days when they were short staffed and some ADL care wasn't get done or things had to be put off onto a different shift. Interview with Registered Nurse (RN) #2, on 11/29/18 at 9:17 AM, revealed they have had some of the residents' showers missed when they were due and had to do them the next day or on Sundays. Interview with the Staffing Coordinator, on 11/30/18 at 11:00 AM, revealed they have had some struggles with staffing. She stated they had implemented a SRNA on call program but it did not work, so recently they implemented a Mandatory Over Time Schedule for SRNAs because they have been short staffed. She stated there were times when she worked the floor as a SRNA due to call-ins or short staffing. The Staffing Coordinator stated they were trying to enforce discipline and repercussions with staff call-ins, as past staff were allowed to call in as much as they wanted with no disciplinary repercussions. Interview with the Assistant Director of Nursing (ADON), on 11/30/18 at 10:36 AM, revealed sometimes the facility did have staffing struggles due to call-ins or staff being sick. She stated she felt like even with call-ins and staffing being short at times, there was enough staff in the building to ensure the residents' basic care was done.

Based on interview, record review, and facility policy review, it was determined the facility failed ensure the medical record of one (1) of three (3) sampled residents was complete (Resident #1). On 07/16/18, Resident #1 was found in the courtyard unresponsive and was sent to the hospital; however, review of Resident #1's medical record revealed there was no documented evidence the event occurred. The findings include: Review of facility policy titled Event Report Investigation, not dated, revealed the Director of Nursing (DON) or designee will audit the nursing notes to verify all necessary event information was included. As each required item is identified in the nursing notes, it is to be checked off. Any areas not identified in the nursing notes, are to be documented immediately. Record review revealed the facility admitted Resident #1 on 12/08/17 with [DIAGNOSES REDACTED]. Interview with Certified Medication Technician (CMT) #4 on 07/24/18 at 9:39 AM revealed she was beginning her medication pass at approximately 5:00 PM and happened to notice Resident #1 in the courtyard, slumped over, and to be asleep. She stated she called Wing #1 to check on the resident to ensure he/she had his/her chest harness in place so not to fall out of the chair, and the resident was discovered to be unresponsive instead of asleep. Interview with Licensed Practical Nurse (LPN) #1 on 07/23/18 at 3:15 PM revealed she was at wing #2 when she was summoned to wing #1 nurses station related to Resident #1. LPN #1 stated the resident ws out in the courtyard and was non-responsive. LPN #1 revealed Resident #1 was a little sweaty, and his/her skin color was flushed/pale. LPN #1 stated the staff assisted the resident into the facility and placed the resident in the closest bed and proceeded to attempt to cool off the resident with cool wet wash clothes. She stated she then called 911 for an ambulance to transport him/her to the emergency room (ER) for evaluation and treatment. However, review of the Nursing Progress Note revealed there was no documentation on the resident being found in the courtyard unresponsive, the resident's condition, or the resident being sent to the hospital. Further interview with LPN #1 revealed she did not chart on the event because Resident #1 was not her resident, and she thought Registered Nurse (RN) #1 would have completed the documentation. Further review of the Nursing Progress Notes revealed on 07/16/18 at 11:01 PM, the nurse phoned the emergency room to check on the resident's status and was informed by the nurse caring for Resident #1 that he/she would be admitted to telemetry with [MEDICAL CONDITIONS] and possible Urinary Track Infection [MEDICAL CONDITION]. Interview with RN #1 on 07/24/18 at 12:15 PM revealed when she got to Resident #1, he/she was no longer unresponsive, and the ambulance had already been called by LPN #1. She stated she was tired and asked the Director of Nursing (DON) if she could chart after she got home and was told she could; however, when she got home she put in the entry but it did not go through and she did not check the Progress Notes the next day to ensure the documention had been received. Interview with the Interim Director of Nursing (DON) on 07/24/18 at 3:20 AM revealed she was the Minimum Data Set (MDS) Coordinator at the time of the event, and the DON, at the time of the event, was no longer working at the facility. She stated she was not aware the event had not been documented in the Nursing Progress Notes but she would have expected it to be charted.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) unsampled resident not in the selected sample of eighteen (18) residents had the right to be treated with dignity and respect (Unsampled Resident #64. The findings include: Review of the facility policy titled, Resident Rights, not dated, revealed the resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. The resident has the right for the facility to treat them with respect, dignity, and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing their individuality. The facility must protect and promote the rights of the resident. Record review revealed the facility admitted Unsampled Resident #49's on 12/04/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/14/18, revealed the facility assessed Resident #49's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Section H; Bowel and Bladder, revealed the facility assessed Resident #49's bowel elimination at a two (2), which indicated he/she was frequently incontinent; and bladder elimination at a one (1), which indicated occasionally incontinent. Observation on 03/21/18 at 12:20 PM, revealed Unsampled Resident #49, turned on the call light after returning from his/her lunch meal. Certified Nurse Aide (CNA) #2 entered the room, turned off the call light, and the resident informed the CNA, he/she needed assistance to the bathroom, CNA #2 stated, I have to finish passing trays, and I will get somebody to help me take you to the toilet. CNA #2 left the room without toileting the resident. Interview with Unsampled Resident #49, on 03/21/18 at 1:30 PM, revealed CNA #2 answered the call light and told him/her you have to wait, people are eating. The resident stated he/she turned on the call light again at 1:20 PM, and was toileted at that time. Resident #49 further stated he/she felt helpless because he/she was not toileted when requested. Resident #49 also stated, that happens all the time, the staff will answer the call light, say they will be back, or it is meal time, and I can't help you right now. Resident #49 revealed he/she feels the urge to toilet but due to staff's delay in assistance, he/she is incontinent at times. Interview with Unsampled Resident #64 (BIMS 15 {13-15:cognition : intact}), on 03/20/18 at 4:22 PM, revealed the resident stated, it takes the staff as long as an hour to answer call lights. Resident #64 is incontinent of bowel and bladder and wears an adult brief but stated when he/she notifies staff of an incontinent episode, there are occasions where he/she has to keep on soiled brief while waiting for a staff member to provide incontinent care. Resident #64 stated, it's embarrassing, I get so frustrated. Interview with Unsampled Resident #39 (BIMS: 14), on 03/20/18 at 4:00 PM, revealed the resident stated, the staff won't answer your call lights, I go to the desk, and there is four (4) or five (5) of them (staff) just standing there, I had pissed all over myself, I was mad. Interview with Unsampled Resident #57 (BIMS: 14), on 03/20/18 at 3:40 PM, revealed the resident is frequently incontinent of urine and occasionally incontinent of bowel. The resident revealed he/she has limited mobility and unable to toilet self but feels the urge to toilet. Unsampled Resident #57 stated, they (staff) take a long time to answer my buzzer, when they (staff) come it's too late. They (staff) make me feel embarrassed, cause I can't take care of myself. I hear them (staff) talking, right here at the desk outside of my door. Interview with Unsampled Resident #68 (BIMS: 10 {8-10 cognition moderately impaired}), on 03/20/18 at 3:04 PM, revealed he/she is always incontinent of bowel and bladder and chooses to wear an adult brief. Interview revealed the resident stated, I have waited longer than an hour sometimes for staff to answer my call light and/or change me. I stay in the bed, and don't get up, I hate when they (staff) tell me to go toilet in my diaper. Interview with CNA #2, on 03/22/18 at 3:45 PM, revealed she responded to Resident #49's call light, on 03/21/18 after lunch, for request to toilet. CNA #2 stated she informed the resident she had to finish passing meal trays and would be back in just a moment. Further interview revealed the CNA did not know what the facility's process was related to toileting the residents during meal time but stated, I typically do not toilet residents during meal time but, I will go back to help the resident when the meal is over. Interview with CNA #4, on 03/22/18 at 4:30 PM, revealed some staff don't like to toilet residents during meal times. CNA #4 stated a resident should not have to wait to be toileted or receive incontinent care. CNA #4 further stated it could be a neglect of dignity issue, CNA's are responsible to toilet residents every two (2) hours or as close to the hour possible. Interview with Registered Nurse (RN) #1, on 03/22/18 at 4:20 PM, revealed she would expect the CNA's to meet the residents' toileting and/or incontinent care needs when requested. Interview with the Director of Nursing (DON), on 03/23/18 at 9:45 AM, revealed she was not aware the residents had concerns related to call lights and toileting needs not being met. The DON stated the staff should always attend to resident care needs at any time in a timely manner. The DON revealed if a resident had to wait or becomes incontinent while waiting to toilet it would be a concern for the resident's dignity.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, related to bleach wipes being left unattended on a medication cart. The findings include: Interview with the Director of Nursing (DON) on 03/23/18 at 10:57 AM , revealed the facility did not have a policy related to storage of bleach wipes. Observations on 03/21/18 at 9:23 AM, 9:35 AM, and 10:03 AM, revealed a container of Micor-Kill Bleach Germicidal Bleach Wipes were left unattended on a medication cart on Wing two (2), with two residents observed nearby. Review of the Safety Data Sheet for the Micro-Kill Bleach Wipes revealed the product should be kept out of reach of children. Interview with Licensed Practical Nurse (LPN) #1 on 03/23/18 at 11:25 AM, revealed she was using the bleach wipes to clean equipment and had left them on the cart with the lid on. She further stated the bleach wipes are stored in the medication room until they are to be used. Further interview with the DON, on 03/23/18 at 10:57 AM, revealed she expected the bleach wipes to be stored in the medication room and not kept out on carts. She further stated the wipes could be harmful to residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of eighteen (18) sampled resident (Resident #46). Resident #46 was care planned to have Oxygen at 4 liters (l); however, observations revealed the oxygen was set at 6 Liters on three (3) days of the survey. The findings include: Review of the facility policy, Development of a Care Plan, not dated, revealed staff are to provide care according to the care plan and any exceptions to the care provided should be reported to the charge nurse. Record review revealed the facility admitted Resident #46 on 01/22/18, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 01/29/18, revealed the facility assessed Resident #46's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of Resident #46's Comprehensive Care Plan for ineffective gas exchange related to [MEDICAL CONDITION] , target date 04/23/18, revealed Resident #46 was to maintain oxygen absorption with interventions to include administering Oxygen as ordered at 4 l/m per N/C. However, observations of Resident #46 on 03/20/18 at 2:50 PM, on 03/21/18 at 9:32 AM, and on 03/22/18 at 9:25 AM, revealed the resident in bed with Oxygen on at 6 l/m per N/C nasal cannula. Interview with Resident #46 on 03/22/18 at 3:21 PM, revealed he/she has never turned up his oxygen and further stated only the nurses turn the oxygen concentrator on and off. Resident #46 denied having any respiratory issues or difficulty breathing. Interview with Certified Nurse Aide (CNA) #1 on 03/22/18 at 9:43 AM, revealed the nurse aides monitor the portable oxygen tanks to ensure they are not empty, however, they do not hook them up or touch the settings on the oxygen concentrators in residents' rooms. She further revealed the nurses know what the oxygen concentrators should be set on. Interview with CNA #2, on 03/22/18 at 10:32 AM, revealed CNA's do not touch the oxygen concentrators, only the nurse's do. She stated she was not sure what Resident #46's oxygen setting was supposed to be on. Interview with Registered Nurse (RN) #1 on 03/22/18 at 10:34 AM, revealed she would expect Resident #46's oxygen to be on the ordered settings. She stated Resident #46 had been out to the emergency room recently and the oxygen setting may have been changed on that date. She further stated she would expect resident care plans to be followed for oxygen settings. Interview with the Director of Nursing (DON) on 03/23/18 at 10:57 AM, revealed she didn't feel as though Resident #46 could deal with any less than six (6) liters of oxygen. She stated they got an order for [REDACTED].