Every finding on record at River City Care Center

Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately documented and complete for each resident, for 1 of 4 residents (Resident #1) reviewed for the accuracy of their medical records. The facility failed to ensure the accuracy and completeness of the resident's clinical record by failing to document controlled substance administration on the MAR after the medication had been signed out on the controlled substance record. This resulted in discrepancies between the residents' MAR and the narcotic accountability records. This failure could place residents at risk of receiving improper care.Record review of Resident #1's face sheet, dated 7/1/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Depression (a mental health condition where a person feels very sad, hopeless), Chronic Pain (is ongoing pain that lasts longer than expected and continues for months or years), and Chronic Obstructive Pulmonary Disease (Is a disease that makes it difficult to breathe because the lungs do not work as well as they should). Record review of Resident #1's BIM'S assessment, completed 4/4/26, revealed a BIM'S score of 15, which indicated intact cognition. Record review of Resident #1's care plan, updated 12/22/2023, revealed an intervention of administer medications as ordered. Record review of Resident #1's monthly physician orders for June 2026 revealed an order for Oxycodone oral tablet 10 mg, to be administered every 6 hours as needed for pain. Record review of Resident #1's controlled substance administration log, undated, revealed that an Oxycodone 10 mg tablet had been signed out on 6/15/2026 at 4:30 AM, 10:30 AM, and 4:30 PM. Record review of Resident #1's MAR administration report for June 2026 revealed no documentation of Oxycodone tablet 10 mg. Interview with Resident #1 on 7/1/2026 at 2:00 PM; stated he was not 100% sure whether he received an Oxycodone tablet, 10 mg, on 6/15/2026 at 4:30 AM, 10:30 AM, and 4:30 PM. Group interview conducted on 7/2/2026 at 11:30 AM with LVN A, LVN B, and LVN C revealed LVN A was the night nurse, LVN B the day nurse, and LVN C the evening nurse on 6/15/2026. Each nurse reported administering a 10 mg Oxycodone tablet as recorded on the controlled substance administration log. They acknowledged that they did not document this administration on MARS due to human error. All nurses recognized that failing to document on the MARS while recording only in the controlled substance log could hinder other staff from verifying medication administration. During, interview on 7/2/2026 at 1:00 PM , the DON confirmed knowing that nursing staff have not recorded controlled substances on the medication administration record after signing them out on the narcotic count record. She admitted this causes incomplete and inaccurate clinical documentation. Her plan to fix this includes retraining licensed nursing staff in proper documentation, checking MARs and narcotic records for accuracy and completeness, and establishing ongoing checks to ensure compliance and prevent recurrence. Record review of the facility's undated documentation policy revealed: The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to fill out the night temperatures for 2 freezers and 1 refrigerator on May 2026 temperature log for 05/27/26.2. The facility failed to store sliced cheese in a sealed container on 05/28/26.3. The facility failed to label a bag of onions and bell peppers with a discard date on 05/28/26.4. The facility failed to ensure there was not a personal beverage in the food preparation area on 05/28/26. These failures could place residents at risk for food borne illness. The findings included: During an observation and interview on 05/28/26 at 08:39 AM revealed there was a missing temperature for 2 freezers and 1 refrigerator on May 2026 temperature log for 05/27/26 night temperature. [NAME] B revealed it was important to have the temperature logs up to date to ensure no food went bad. During an observation and interview on 05/28/26 at 08:42 AM, revealed there was a bag of sliced cheese in the walk-in refrigerator that was not sealed and exposed to air. In the walk-in refrigerator, it was further revealed there was a bag of onions and bell peppers with no discard/use-by date. The Dietary Manager and [NAME] B revealed foods that were stored in the refrigerator should have a discard date and be in a sealed bag to ensure the foods that were used for residents' meals were not old or became hard. The Dietary Manager revealed temperatures needed to be documented to ensure proper food storage. The Dietary Manager revealed all kitchen staff could ensure temperatures were recorded and food was stored properly but he oversaw everything. During an interview and observation on 05/28/26 at 11:34 AM, revealed there was a personal beverage (open clear cup of fluid) in the food preparation area while [NAME] B was prepping 05/28/26 lunch. [NAME] B and the Dietary Manager revealed the personal beverage should not be in the food preparation area to prevent cross contamination and it belonged to Dietary Aide D. During an interview on 05/28/26 at 11:37 AM, Dietary Aide D confirmed that he did have a personal beverage in the food preparation area, but he had just poured it and left the kitchen. He revealed he should not have a personal beverage in the food preparation area because it could cause cross contamination. Record review of the facility's policy Daily Food Temperature Control, dated 2012, reflected . 3. Temperatures are recorded on the Temperature Log form . Record review of the facility's policy Refrigerator/Freezer Temperature Log (Instructions), dated 2012, reflected 1. Dietary Services Manager will be the person responsible for making sure the temperature of the refrigerator/freezer is recorded on a daily basis. 7. Take temperatures at the same time every morning and evening. Record review of the facility's policy Food Storage and Supplies, dated 2012, reflected . 4. Open packages of food are stored in closed containers with covers or in sealed bags. Record Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the FDA Food Code 2022, U.S. Department of H&HS, reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #3) out of 7 residents reviewed for accidents and supervision. The facility failed to ensure Resident #3 did not have [a cleaning solution] at bedside on 05/28/26 and 05/29/26. These failures could place residents at risk for negative adverse effects. Findings included: Record review of Resident #3's admission record, dated 05/26/26, reflected resident was a [AGE] year-old male, admitted [DATE], with diagnoses to include major depressive disorder and generalized anxiety disorder. Record review of Resident #3's quarterly MDS assessment, dated 05/09/26, reflected that resident had a BIMS score of 13 out of 15, indicating intact cognition. Record review of Resident #3's care plan, last care plan review completed 05/14/26, did not reflect that resident could have cleaning supplies/chemical agents in his room for personal use. Observation on 05/28/26 at 08:12 AM revealed Resident #3 had [a cleaning agent] on the side of his bed. During an interview and observation on 05/29/26 at 08:33 AM, LVN A confirmed that Resident #3 had [a cleaning agent] at his bedside. She removed it from his room and revealed he was not allowed to have it in his room. During an interview on 05/29/26 at 08:35 AM, CNA E revealed she had seen [a cleaning agent] in Resident #3's room, but she assumed he was allowed to have it in his room because she was new, because she expected other nursing staff who knew the resident more would take it out of his room because other staff had been providing resident care as well. She further revealed she knew [a cleaning agent] should not be in a resident's room to keep residents safe. During an interview on 05/29/26 at 12:40 PM, the ADM and the DON revealed Resident #3 was okay to have [a cleaning agent] in his room because he was alert and oriented, but in order to protect other residents they were going to put it in his care plan that him and his family bring in cleaning agents despite education, so nursing staff could monitor his room and keep any cleaning agents behind the nurse's station. During an interview on 05/29/26 at 02:10 PM, the DON revealed it was important to not give residents that may not be alert and oriented access to cleaning agents to keep them safe. During an interview on 05/29/26 at 02:18 PM, the ADM revealed that they did not have any residents that wandered into other residents' rooms at this facility. She revealed the facility did not have to worry about a resident going into Resident #3's room so residents remained safe because they could not get the cleaning agent.Policies regarding accidents and hazards, prohibited items/items allowed in the facility (to include chemicals/cleaning supplies) were requested from the ADM on 05/29/26 at 09:27 AM and the ADM did not have these policies.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 7 residents (Residents #2 and #3) reviewed for care plans. The facility failed to update Resident #2's care plan to reflect what type of assistance the resident needed for eating.The facility failed to update Resident #3's care plan that he liked to use [a cleaning agent] to clean his room, but they had to keep this behind the nurse's station for him. This failure could place residents at risk of not having their needs met and not receiving appropriate care.The findings included:Record review of Resident #2's admission record, dated 05/28/26, reflected resident was a [AGE] year-old male, initially admitted [DATE] and re-admitted [DATE], with diagnoses to include burns of various body parts. Record review of Resident #2's quarterly MDS assessment, dated 03/15/26, reflected that resident had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. It further reflected that Resident #2 needed setup or clean-up assistance for eating. Record review of Resident #2's care plan, last care plan review completed 12/07/25, did not reflect resident needed setup or clean-up assistance for eating. Record review of Resident #2's weight history for the last 6 months reflected no significant changes in weight. During an interview on 05/27/2026 at 04:16 PM, CNA C revealed Resident #2 was able to feed himself. During an interview on 05/28/2026 at 04:11 PM, the MDS nurse revealed Resident #2's type of assistance needed for eating was not documented in his care plan. He revealed it was important to know how the resident ate so staff knew how to help Resident #2 with eating. 2. Record review of Resident #3's admission record, dated 05/26/26, reflected resident was a [AGE] year-old male, admitted [DATE], with diagnoses to include major depressive disorder and generalized anxiety disorder. Record review of Resident #3's quarterly MDS assessment, dated 05/09/26, reflected that the resident had a BIMS score of 13 out of 15, indicating intact cognition. Record review of Resident #3's care plan, last care plan review completed 05/14/26, did not reflect that resident could have cleaning supplies/chemical agents in his room for personal use. During an observation on 05/29/26 at 08:33 AM revealed there was [a cleaning agent] on the side of Resident #3's bed. During an interview on 05/29/26 at 08:33AM, LVN A confirmed that Resident #3 had [a cleaning agent] at his bedside. She removed it from his room and revealed he was not allowed to have it in his room. She revealed that they had educated the resident multiple times that he could not have [a cleaning agent] in his room. She revealed she was unsure if it was in his care plan but it could be added. During an interview on 05/29/26 at 08:35 AM, CNA E revealed she had seen [a cleaning agent] in Resident #3's room, but she assumed he was allowed to have it in his room because she was new, because she expected other nursing staff who knew the resident more would take it out of his room because other staff had been providing resident care as well. She revealed it would be helpful if this was documented in his care plan so she knew that she should remove [a cleaning agent] from his room when she saw it. During an interview on 05/29/26 at 12:40 PM, the ADM and the DON revealed Resident #3 was okay to have [a cleaning agent] in his room because he was alert and oriented and liked to clean his room on his own. They revealed in order to protect other residents from possibly coming into his room and taking [a cleaning agent] that they were going to document that resident kept [a cleaning agent] in his room despite educating him not to keep it in his room so nursing staff knew to take it out of his room as needed and keep it behind the nurse's station for when he wanted to use it to clean his room. Policies regarding accidents and hazards, prohibited items/items allowed in the facility (to include chemicals/cleaning supplies) were requested from the ADM on 05/29/26 at 09:27 AM and the ADM did not have these policies. Record review of the facility's policy Comprehensive Care Planning, undated, reflected .The comprehensive care plan will describe the following-The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on observation, interview, and record review the facility failed to ensure each resident received and the facility provided food that accommodates residents' food preferences and food allergies for 2 of 7 residents (Resident #1 and Resident #2) reviewed for food preferences and food allergies.The facility failed to ensure Resident #1 received orange juice per her 05/28/26 breakfast meal tray ticket.The facility failed to ensure that Resident #2's 05/28/26 lunch meal tray ticket reflected that he had a lactose allergy. This failure could place residents at risk for a decline in health status or an allergic reaction due to inadequate or inappropriate nutritional intake, respectively. The finding included:Record review of Resident #1's admission record, dated 05/27/26, reflected resident was an [AGE] year-old female, admitted [DATE], with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities). Record review of Resident #1's quarterly MDS assessment, dated 03/25/26, reflected that resident had a BIMS score of 04 out of 15, indicating severe cognitive impairment. Record review of Resident #1's care plan, undated, reflected a focus of [Resident #1] has nutritional problem dementia, requires frequent redirection, initiated 10/02/25, with intervention Provide and serve diet as ordered, initiated 10/23/25. Record review of Resident #1's weight history for the last 6 months reflected no significant changes in weight. During an interview, observation, and record review of Resident #1's 05/28/26 breakfast tray ticket at 08:18 AM, revealed her tray ticket reflected orange juice. Observation of her breakfast meal revealed apple juice was served instead of orange juice. During an interview, Resident #1 revealed she did like orange juice, but she was okay with the apple juice today and that sometimes she did not receive everything on her tray ticket, but she was able to ask the nursing staff for what she wanted to eat. During an interview on 05/28/26 at 08:26 AM, LVN A revealed Resident #1's 05/28/26 breakfast tray did not include orange juice, but the resident was able to voice if she wanted something else to eat or drink. She revealed nurses oversaw the meal tray tickets matching the meals served and they had to work with the kitchen to get the correct foods that were reflected on the meal tray tickets. She revealed sometimes the kitchen did not serve foods that were on the tray tickets. She revealed it was important to follow tray tickets to follow preferences, dislikes, and allergies. She revealed following residents' diets was important as their diets were based on their health conditions like diabetes. During an interview on 05/28/26 at 08:39 AM, [NAME] B revealed when a tray ticket had orange juice on it, they could put any juice on the resident's tray instead. She revealed she did not know why the tickets did not just have juice instead of orange juice on the residents' tray tickets. She revealed it was important to follow residents' tray tickets so that the residents received what they wanted. During an interview on 05/28/26 at 08:42 AM, the Dietary Manager revealed meal tray tickets should be followed to meet the residents' needs. He revealed the kitchen had orange juice and they should have served residents orange juice if it was on their tray ticket. He further revealed it was every kitchen staff's responsibility to ensure the meals being served matched the meal tray tickets. 2. Record review of Resident #2's admission record, dated 05/28/26, reflected resident was a [AGE] year-old male, initially admitted [DATE] and re-admitted [DATE], with diagnoses to include burns of various body parts. It further reflected that the resident had a lactose allergy. Record review of Resident #2's quarterly MDS assessment, dated 03/15/26, reflected that resident had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Record review of Resident #2's care plan, last care plan review completed 12/07/25, reflected Resident #2 had a lactose allergy Record review of Resident #2's weight history for the last 6 months reflected no significant changes in weight. During an interview and record review on 05/28/26 at 03:28 PM, Resident #2 revealed his lunch meal tray ticket did not state that he had an allergy to lactose as was reflected in his electronic medical record. Resident #2 revealed he was lactose intolerant but still received milk on his meal trays. He revealed he knew to not eat or drink products that had lactose, but it would be helpful if the kitchen did not give him those food products. During an interview on 05/28/26 at 03:35 PM, the Dietary Manager revealed he did not know that Resident #2 was allergic to lactose, but he would get that information from nursing so he could put that on the tray ticket, so the resident did not receive anything they were allergic to. During an interview on 05/28/26 at 03:39 PM, CNA C revealed he was not aware that Resident #2 was allergic to lactose because Resident #2 was served foods that had lactose and it was good to know now. He noticed Resident #2 did not drink lactose products, so it made sense. During an interview on 05/28/2026 at 04:11 PM, the DON revealed they confirmed with Resident #2 that he had a lactose intolerance. She revealed she was unaware of when lactose allergy was reflected in his electronic medical record and it should be on his meal tray tickets. During an interview 05/28/2026 at 04:34 PM, the ADM and DON revealed it was important to follow meal tray tickets to ensure they have the right diet, right texture, and right resident. During an interview on 05/29/26 at 11:56 AM, the RD reviewed Resident #2's electronic medical record remotely and his nutrition related assessments did not reflect Resident #2 having a lactose allergy. She revealed Resident #2's lactose allergy was on his face sheet but she was not aware of when that was there because in his interviews he never mentioned having a lactose allergy. She revealed it may have been a miss on our part and she was unaware of who communicated residents' allergies to the kitchen to put it on their meal tray ticket so that everyone involved in his care knew what foods to serve him and prevent problems due to allergies. During an interview on 05/29/2026 at 01:38 PM, the DON revealed Resident #2's lactose allergy should have been communicated to the dietary department. She revealed nursing staff could do that, and it was important in order for residents to not have reactions with foods. Record review of the facility's policy Food Preference List, dated 2012, reflected . 2. Information should be obtained by interview on all new residents. 3. Tray cards are to be updated at least quarterly and reflect appropriate information from food preferences. Generally, the dislikes are the most relevant on the tray card. Record review of the facility's policy Resident Meal Service and HS Snack, dated, reflected 1. Upon admission and periodically thereafter, the resident and/or family member will be interviewed by the dietary manager or designee to determine individual food preferences, dislikes, and allergies.

Based on interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 8 residents (Resident #12) reviewed for abuse/neglect as evidenced by:The facility failed to ensure Resident #12 was free from abuse when CNA A squirted Resident #12 with a water gun in her mouth while she slept on 5/24/25. The facility failed to ensure Resident #12 was free from abuse when Resident #12 made an allegation of abuse by CNA C. The allegation was reported to the Administrator on 05/31/2025 by CNA C and on 06/19/2025 by HHSC Surveyor L.An Immediate Jeopardy (IJ) was identified on 07/08/2025 at 4:40 p.m. The IJ template was provided to the facility on [DATE] at 5:06 p.m. While the IJ was removed on 07/10/2025 at 4:10 p.m., the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal (POR). This failure could place residents at risk of abuse, injury, and psychosocial harm. Findings included: 1). Record review of Resident #12's admission record, dated 6/18/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12 had diagnoses which included: type 2 diabetes mellitus chronic kidney disease (disease that affects how the body uses blood sugar), seizures (sudden surge of abnormal electrical activity in the brain), COPD (chronic obstructive pulmonary disease is a lung condition caused by damage to the lungs), and dementia (loss of cognitive functioning). Record review of Resident #12's quarterly MDS, dated [DATE], revealed the resident had severely impaired cognition for daily decision-making skills with a BIMS score of 5.Record review of Resident #12's care plan, dated 06/18/2025, reflected Resident #12 had impaired cognitive function/dementia or impaired thought process, BIMS score severe cognitive impairment, and at times resident made statements that were far from reality or are nonsensical, with an initiated date of 01/16/2025, and revised on 06/06/2025. Record review of the facility's investigation report, dated 06/04/2025, stated On the afternoon of 05/28/2025, CNA [B] reported to Administrator's office with ., Business Office Manager/HR informing that resident [#12] stated that on Saturday, 5/23 [sic], CNA [A] had dropped the bed remote on her left arm. She reported that, when she told him not to do that again, he stated that he would do it as many times as he wanted. Later that day while she was taking a nap, [Resident #12] reported that [CNA A] entered her room and woke up her by shooting a water gun in her mouth .Record review of witness statement summaries: [CNA A] stated that he works weekends only. He denied ever dropping a remote on [Resident #12]'s arm or making statements about continuing to do so despite the protest. When asked if he had ever brought a water gun to work, he stated that he had only squirted residents with it in the kitchen area. He denied squirting [Resident #12] or having the water gun in her room.[Resident #33] a resident in the same section of hallway/CNA assignment as the alleged victim, was asked if she knew [CNA A]. She confirmed that he was her CNA .When asked if she had ever seen him with a water gun, she stated that he had brought one into her room recently and squirted her with it while she laid in bed. She reported that she was not bothered by this act but did think it bizarre behavior.[Resident #16] a resident on the same section of hallway/CNA assignment as the alleged victim, acknowledged that he knew [CNA A] as his weekend CNA. He confirmed that [CNA A] had brought a water gun to the facility and squirted him with it while in his room. He did not feel negatively toward this act and asked that [CNA A] not get in no trouble for this behavior . During an interview on 06/18/2025 at 11:44 a.m. Resident #12 stated she was terrified and scared when she awoke in her room to CNA A splashing water into her mouth with a pistol. Resident #12 stated CNA A had dropped a remote on her arm that caused her pain earlier that day and she told him not to do that again. Resident #12 stated CNA A told her he would do it as many times as he wanted. Resident #12 stated she reported the incident to CNA B on 05/28/2025. During an interview on 06/19/2025 at 12:08 p.m. CNA D stated she knew of an outdoor water activity where they threw water balloons but never saw or knew of any activities that involved water guns. CNA D stated no residents ever reported to her being squirted with a water gun. CNA D stated Resident #12 hallucinated before, but they did a UA (urine analysis), and she had a UTI. During an interview on 06/19/2025 at 1:01 p.m. CNA A stated there was an outdoor activity Resident #12 was never involved in and the water gun was left over from the facility activity. He stated he never sprayed any residents with a water gun only other staff in the dining room area. CNA A stated Resident #33 vouched for him that he never sprayed any residents with the water gun. He stated he was suspended pending the investigation around 05/29/2025 and terminated on 06/05/2025. CNA A stated if residents were squirted with a water gun and did not approve of it, it could make them mad and it would bother them. During an interview on 06/19/2025 at 1:24 p.m. Resident #33 stated she used to share a room with Resident #12, but she had since been moved due to her watching the TV loudly. Resident #33 stated Resident #12 had delusions of a man in the window or her family in the room that was not there. Resident #33 stated Resident #12 had a UTI that had caused her delusions and once treated she did not have any more. Resident #33 stated CNA A did squirt them with a water gun before, but she had fun and only wished she had a water gun to squirt him back. During an interview on 06/19/2025 at 3:06 p.m. the Administrator stated Resident #12 told her about the incident during her afternoon rounds . The Administrator stated Resident #12 told her about how the CNA A dropped the remote on her arm and the resident found it to be malicious. The Administrator stated Resident #12 told her about being squirted in the mouth by CNA A. The Administrator stated Resident #12 felt humiliated, embarrassed, and annoyed by CNA A's childish behavior. The Administrator stated Resident #12 had issues with clarity but after she interviewed a few other residents they also stated CNA A had squirted them with a water gun while they were in bed. The Administrator stated CNA A worked weekends only and was suspended during the investigation and later terminated after the investigation was completed. Record review of a facility incident summary for intake #1012723, dated 06/03/2025, revealed the immediate actions taken regarding CNA A and Resident #12 included: Nursing staff performed head to toe assessment on resident. CNA A was contacted and suspended. Trauma informed PRN assessment was completed with the resident. A report was filed with [city] police department. Messaged were left to inform family of alleged incident. RP [name] returned call and was notified on 06/02/2025. The conclusion revealed, The allegation that [CNA A] dropped a bed remote on resident's arm and stated that he would ‘do it as many times as he wanted' despite her protest is UNCONFIRMED. Findings: [CNA A] denies the allegation. There were no eyewitnesses to the alleged incident. No physical injury consistent with the event was documented during the head-to-toe assessment. No corroborating witness statements exist. The document also revealed, The allegation that, later the same day, [CNA A] entered [Resident #12]'s room while she was sleeping and squirted a water gun in her mouth is PARTIALLY CONFIRMED. The use of a water gun on residents was confirmed by multiple witnesses, which lends credibility to [Resident #12]'s claim. However, the specific act of squirting water into her mouth while asleep could not be directly verified. The overall behavior pattern was confirmed, though the specific incident remains UNCONFIRMED. Findings: [CNA A] denies this specific incident but admits to having used a water gun on residents in common areas. Two other residents [#33, #16] independently confirmed that [CNA A] had brought a water gun into their rooms and squirted them with it. While those residents did not find the behavior harmful, they substantiated the pattern of bringing and using a water gun in resident areas. Staff members interviewed had no witnessed the behavior but also did not directly contradict the claims. The Administrator completed the summary. 2) During an interview on 6/18/25 at 11:44 a.m., Resident #12 stated CNA A's family member, CNA C after the incident, delivered a food tray to her room and put it down so hard she thought the food was going to fall off the tray. Resident #12 stated CNA C stated she would not come into the resident's room alone because the resident may tell people she hit her. The resident stated this made her feel guilty and a little afraid because she does not like to argue with people. During an interview on 07/08/2025 at 12:52 p.m., the Administrator stated she did not recall being informed on 06/19/2025 by HHSC Surveyor L that Resident #12 reported to the HHSC Surveyor L that CNA C had put Resident #12's food down so hard she thought the food would fall off the tray, CNA C told Resident #12 she could not take care of Resident #12 alone because Resident #12 may tell people CNA C hit her and Resident #12 reported feeling guilty and afraid after the interaction. The Administrator stated if she had been notified, she would have suspended CNA C and started an investigation into the allegation. During an interview on 07/08/2025 at 1:30 p.m., Resident #12 stated she remembered a female CNA going into her room and stated, she slammed my tray down really hard, and she had an angry look on her face. Resident #12 stated CNA C said, I just cannot be in here I have to have someone else with me because I don't want you to say I hit you. Resident #12 stated it scared her when the incident occurred and stated, she doesn't take care of she and she doesn't like to take care of me. Someone else brings me my meals. Resident #12 stated she told someone about the incident but did not remember who she told. During an interview on 07/08/2025 at 1:50 p.m., CNA C stated she had received training on abuse and neglect and reporting abuse and neglect to the Abuse Prevention Coordinator that CNA C identified as the Administrator. CNA C stated she was notified by RN K on 05/31/2025 that Resident #12 reported to RN K that CNA C was being mean to her. CNA C stated she immediately called the Administrator to report the allegation Resident #12 made against her and the Administrator told CNA C that she could not refuse to provide care to Resident #12. CNA C stated she also called and reported the allegation to the DON. CNA C stated she had the phone call logs to prove that she contacted the Administrator and the DON to report the allegation. CNA C stated she was never interviewed or suspended related to the allegation. During an interview on 07/08/2025 at 2:15 p.m., the Administrator stated she was presented an IJ template on 06/20/2025 and stated she signed the template without reading the information on the template that included the allegation against CNA C. The Administrator stated, after reading the template on 07/08/2025, the Administrator acknowledged that the allegation toward CNA C was on the template and stated she was suspending CNA C on 07/08/2025 and initiated an investigation into the allegation. The Administrator stated she recalled having a conversation with CNA C around the time of the investigation into CNA A but did not recall CNA C reporting to the Administrator that Resident #12 was alleging that CNA C was mean to Resident #12. During an interview on, 07/08/2025 at 2:39 p.m., the DON stated staff had received training on abuse and neglect and all abuse allegations should be reported immediately to the Abuse Prevention Coordinator who was the Administrator. The DON stated she did not recall receiving a call from CNA C regarding an allegation made by Resident #12 on 05/31/2025. The DON stated intimidation was a form of abuse and should have been investigated immediately. During an interview, 07/08/2025 at 2:54 p.m., HHSC Surveyor L stated she met with the Administrator on 06/19/2025 at 3:06 p.m. and notified the Administrator of the allegation Resident #12 was making toward CNA C. HHSC Surveyor L stated she discussed retaliation with the Administrator due to the incident with CNA C occurring after CNA A was suspended and the fact that CNA C and CNA A were in a relationship. Record review of a facility IJ Template, dated 06/19/2025 at 11:06 a.m., revealed, Resident #12 stated CNA A's [family member], CNA C after the incident, delivered a food tray to her room and put it down so hard she thought the food was going to fall off the tray. Resident #12 stated CNA C stated she would not come into the resident's room alone because the resident may tell people she hit her. The resident stated this made her feel guilty and a little afraid because she does not like to argue with people. The template revealed, The Administrator stated CNA A was terminate and CNA C had called in for most of her shifts since the incident and has not worked with the resident. The template revealed, Resident #12 was terrified and scared. She also felt guilty and afraid from CNA C's visit. The template was signed by the Administrator and HHSC Surveyor L on 06/20.2025. Record review of the facility's Abuse/Neglect policy, dated 3/29/18, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . This was determined to be an Immediate Jeopardy on 07/08/2025 at 4:40 p.m. The Administrator was notified of the IJ and provided the IJ Template 07/08/2025 at 5:06 p.m.On 07/08/2025 the facility provided a plan of removal titled: Plan of Removal F600. The plan of removal was accepted on 07/09/2025 at 2:18 p.m. It was documented as follows: Plan of Removal F600Problem: FREE FROM ABUSE AND NEGLECTInterventions:One on One in-service on Abuse Investigation with the Administrator/DON was conducted by the Regional Compliance Nurse on 7/8/2025. This in-service included reviewing and conducting timely investigations for allegations. Staff working with Alleged perpetrators (CNA A and CNA C) have been interviewed on 7/8/2025.The alleged perpetrator, CNA C, was suspended on 7/8/25.Resident safe surveys were completed on 7/8/25.Un-interviewable residents had a head-to-toe assessment completed on 7/8/25.The following in-services were initiated on 7/8/25 and any staff member not present or in-serviced on 7/8/25, will not be allowed to assume their duties until in-services have been completed. Any new employees or agency staff if utilized will receive the following in-services before first shift to be worked.All StaffAbuse/NeglectAbuse/Neglect ReportingWho to Report Abuse/Neglect toInservice included reporting timelines and abuse and neglect coordinator notification. The medical director was notified of the immediate jeopardy situation on 7/8/25 at 4:40 pm. Followed by a text message notification to him on 7/8/2025 notifying him of the active IJ issuance. On 5/28/2025, CNA A was presented with suspension via telephone. On 6/2/25 CNA A was terminated from employment. On 5/29/2025, a police report was filed regarding allegation of abuse from CNA A. Report Case Number: [case number] was taken by [Officer Name]. On 5/29/2025, a trauma informed assessment was completed for Resident #12 which was negative for findings that required follow up interventions. On 7/8/25 a second Trauma Informed Assessment was completed for resident #12.CNA C was interviewed by the Administrator and refused to comment or give a statement on 7/8/25.7/8/25 Staff that worked with perpetrator were interviewed and asked if they had noted any abuse by the alleged perpetrator.ADHOC QAPI discussed with IDT on 7/8/25. MonitoringDON/Admin/Designee will interview 5-10 staff weekly x 6-week situational abuse scenarios had how to address effective 7/8/25.DON/Admin/Designee will interview 5 residents how staff treat them weekly x 6 weeks effective 7/8/25.ADO/Regional Compliance Nurse will monitor weekly x 6 weeks monitoring tools for staff and resident interviews effective 7/8/25.The QA committee will review the findings monthly x 3 months and makes changes as needed. The Administrator will resolve once no further issues have been identified. Effective 7/8/25 The facility's POR verification was as follows: Record review of a facility in-service training attendance record, dated 07/08/2025 revealed it was conducted by RCN and was signed by the Administrator and DON. The topic was abuse and neglect to include timely reporting. Record review revealed 13 staff members were interviewed between 07/08/2025 -07/09/2025 regarding witnessing abuse or neglect by a staff member and all responses were no. Record review revealed 13 staff interviews were conducted, and no additional findings were identified with the staff interviews. Record review of an Employee Disciplinary Report, dated 07/08/2025 listed CNA C as the employee and revealed that CNA C was placed on an investigatory suspension. Record review of facility safe survey questions revealed 27 resident interviews were conducted. Resident # 45, 30, 47 and 46 voiced allegations toward staff members. All other interviews revealed no identified allegations of abuse or neglect. Record review revealed 13 residents had skin assessments completed on 07/08/2025 and 07/09/2025 and no concerns were identified. Record review of a facility in-service, dated 07/08/2025, instructed by the DON, listed the topic of the in-service Abuse and Neglect, and included the Administrator as the Abuse Coordinator and to report any and all abuse to the Administrator. The in-service contained 54 staff signatures. Record review of CNA A's employee disciplinary report revealed CNA A received an investigatory suspension on 05/28/2025. Record review of CNA A's payroll/personnel action form revealed CNA A was terminated from the facility with an effective date of 05/26/2025. Record review of a [city] police report revealed an Officer provided an intake [case number] on 05/29/2025. Type of offense was described as assault. Record review of Resident #12's trauma informed prn assessment, dated 05/29/2025 at 7:52pm revealed resident #12 voiced no trauma concerns. Record review of Resident #12's trauma informed prn assessment, dated 07/08/2025 revealed Resident #12 and Resident #12 ‘s RP identified childhood trauma. Record review of Resident #12 progress note, dated 07/08/2025, by the DON revealed [behavioral health company] and [psychiatry company] were called to follow up on recent allegations, behavioral changes and follow up on Resident #12's trauma informed assessment from 07/08/2025. Record review of a statement by the Administrator, dated 07/08/2025, revealed when CNA C was brought into the office to discuss the allegation against her on 07/08/2025, CNA C got upset and stated it was the Administrator's fault because the resident is making false accusations against staff, CNA C declined to sign the suspension paperwork and left the facility stating I need to get out of here before I say something I regret. Record review of an email from CNA C to the DON, dated 07/08/2025 at 10:18 p.m. revealed CNA C reported an incident with Resident #12 on 05/31/2025 to the DON and the Administrator in which Resident #12 was reporting to staff that CNA C was being mean to her. Record review revealed an Ad Hoc QAPI sign in sheet dated 07/08/2025 and listed 10 names that included the Administrator, DON, Medical Director via phone, Dietary, Activity Director, MDS, Housekeeping, Regional Compliance Nurse, other and BOM/HR. Record review of the facility document revealed a weekly monitoring sheet for staff where it would be tracked for 6 weeks regarding abuse and neglect. The document revealed 3 staff members were interviewed on 07/09/2025 and indicated staff responded correctly to interview questions. Record review of a facility document revealed a weekly monitoring sheet where it would be tracked for 6 weeks which residents were monitored for abuse and neglect. The starting date was 07/09/2025 and listed 2 interviews conducted with no negative response and no incidents reviewed in stand up on 07/09/2025 or identified on facility rounds on 07/09/2025. During an interview with the Administrator on, 07/09/2025 at 3:27 p.m., the Administrator stated she and the DON were in-serviced by the Regional Compliance Nurse on 07/08/2025 regarding reviewing and conducting timely observations. The Administrator stated staff who worked with the alleged perpetrators CNA A and CNA C were interviewed on 07/08/2025 regarding observing or witnessing any abuse or neglect in relation to CNA A and CNA C. No additional allegations were identified or voiced. The Administrator stated the interviews were conducted with 13 employees. The Administrator stated CNA C was suspended on 07/08/2025 pending an investigation into the allegation. The Administrator stated safe surveys were conducted with 27 residents and 3 allegations of abuse were identified and reported to HHSC on 07/08/2025 and 07/09/2025 that included Resident #30, 45, 46 and 47. The identified employees were suspended, and an investigation was initiated. The Administrator said non-interviewable residents received a head-to-toe assessment that was completed on 7/8/25 and no issues or concerns were identified. The Administrator stated staff in-servicing began on 07/08/2025 and included all staff members. The Administrator verified there were 52 staff members, and all staff also received training on the [alert system notification] that was sent by text and email to all staff and included a PDF of the abuse policy. The Administrator stated there were 54 wet signatures on the in-services. The in-services topics included reporting on abuse and neglect, reporting protocols, who to report to and definitions of abuse and neglect. The Administrator stated the Medical Director was notified of the immediate jeopardy on 7/8/2025 at 4:40pm. The Administrator stated CNA A was suspended by telephone on 5/28/2025 and was terminated from employment on 6/2/2025 after the investigation. The Administrator stated a police report was filed on 5/29/2025 regarding an allegation of abuse by CNA A. The Administrator stated a case number was provided, and the resident declined to press charges. The Administrator stated a trauma informed assessment was completed on 5/29/2025 for Resident #12 and was negative for any findings at that time. The Administrator stated a second trauma informed assessment was completed for Resident #12 on 7/8/25 and the findings included mention of childhood trauma and resident was seen by an LPC on 07/08/2025 and 07/09/2025. The Administrator stated she attempted to interview CNA C on 07/08/2025 and CNA C refused to provide a statement. The Administrator stated she received a statement from CNA C on 07/08/2025 at 10:18 p.m. that was emailed to the DON. Staff members who had worked with CNA C were interviewed regarding observations of abuse or neglect and no allegations were identified from staff interviews. An Ad Hoc QAPI meeting was held on 07/08/2025 and staff in attendance included the MD by phone, Administrator, DON, Dietary Manager, Activity Director, Regional Compliance Nurse, Maintenance Director, MDS Coordinator, Housekeeping Supervisor and HR Director. The Administrator stated the Administrator or DON would interview 5-10 staff members weekly for 6 weeks. The interviews would consist of situational abuse scenarios and how to address abuse scenarios. The finding would be brought to the monthly QAPI meeting to review for 3 months. The Administrator stated the Administrator or DON would interview 5 residents weekly for 6 weeks related to staff treatment and the finding would be brought to the monthly QAPI meeting for review for 3 months. The Administrator stated the Regional Compliance Nurse or ADO would monitor the monitoring tools weekly for 6 weeks to ensure compliance. The Administrator stated the QA committee would be reviewing findings from the monitoring tools monthly for 3 months and will make changes to the plan as needed. During interviews on 07/10/2025 from 9:04 a.m. to 1:05 p.m., with 10 employees (2 CNAs , 1 MA, 2 LVNs, 2 housekeeping staff, 1 cook, 1 Dietary Aide, 1 Hospitality Aide) from the day shift (6 AM to 2 PM) and 4 employees (1 CNA, 2 LVNs and 1 RN) from 2pm -10 pm, and 2 employees (1 LVN and 1 CNA) who work double weekend shifts from 6a-10pm and 1 CNA from the night shift (10 PM to 6 AM) revealed staff had received in-service education on Abuse and Neglect, identified the Abuse Coordinator, how and when to contact the Abuse Coordinator. The staff members were able to identify and define types of abuse and neglect. During an interview, 07/10/2025 at 10:11 a.m., the RCN stated the Administrator and DON were reeducated on abuse and neglect on 07/08/2025. The RCN stated the education included the importance of the Administrator and DON ensuring facility staff were reporting abuse to them timely and reviewed the timeline they had to report. The RCN stated the Administrator and DON were told they had 2 hours to report abuse or neglect, and they were to report first and then investigate the allegations. The RCN stated she notified the Medical Director of IJ on 07/08/2025 and stated an Ad Hoc QAPI meeting was held at that time with the Medical Director. The RCN stated RCN and/or the ADO would review the facility monitoring tools weekly and would verify the monitoring tools by interviewing a random sample of residents and staff to validate the interviews are occurring weekly. The RCN and/or ADO would sign the weekly template to validate their review of the tools. During an interview on 07/10/2025 at 10:40 a.m., the Medical Director stated he was notified by the DON and RCN on 07/08/2025 about the IJ and discussed the plan of action and training conducted to address the IJ concerns. During an interview on 07/10/2025 at 11:37 a.m., CNA C stated she was suspended on 07/08/2025. CNA C stated she wrote a statement and sent it by email to the DON and CNA C stated her statement included information on CNA C reporting Resident #12's allegation on 05/31/2025 to the DON and the Administrator on that date. CNA C stated she provided the DON phone records to prove that CNA C called and spoke to the Administrator and DON on 05/31/2025. CNA C stated the phone records revealed CNA C called the Administrator on 05/31/2025 at 11:56 a.m. and there was no answer. The Administrator returned CNA C's call at 1:58 p.m. and the length of the call was 21 minutes. During an interview on 07/10/2025 at 1:55 p.m., the Administrator stated the training she received on 07/08/2025 by RCN included how to conduct investigations of abuse and neglect and the steps that needed to be included when conducting investigations. The Administrator stated 13 residents had head to toe assessments completed and no concerns were identified. The Administrator and DON were informed the Immediate Jeopardy was removed on 07/10/2025 at 4:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food service safety for 1 of 1 facility in that: 1. The facility failed to clean a ceiling vent. 2. The facility failed to clean a side wall panel air vent. 3. The facility failed to date an opened jar on mayonnaise in the refrigerator. 4. The facility failed to date two bags of cookie pieces in the storage room. 5. The facility failed to maintain a dish machine sanitation unit. These failures could place residents at risk for food borne illness. The findings included: Observation on 06/17/2025 from 9:15am until 9:45am with the Food Service Director revealed the following: a. There was a 3x2 foot overhead ceiling vent in the main kitchen area that was covered with dirt and dust particles. b. There was a 3x3 foot side wall ceiling vent next to the dish machine that was covered with dirt and dust particles. c. There was an opened one gallon jar of mayonnaise in the refrigerator that was not dated. d. There were 2 bags of 2 gallon size Oreo piece cookies in the storage room that were not dated. e. The dish machine did not record the sanitizer concentrate level after the dish machine cycle. During an interview on 06/17/25 at 9:50am, the Food Service Director stated the dirty ceiling and side wall vents did not allow a clean kitchen environment to be maintained The Food Service Director stated food items in the refrigerator and storage room had to be labeled for use by dates to be followed. The Food Service Director stated he was unaware of the dish machine sanitizer not working after each wash cycle and it was working properly the day before which was confirmed. The Food Service Director stated the sanitizer unit on the dish machine would be immediately fixed. He stated that the dish machine's use of the sanitizer was necessary for proper cleaning of dishware. During an interview with the Administrator on 6/17/25 at 10:00am stated that the dirty ceiling and side wall vents would be cleaned for a clean kitchen environment. She stated that dating of all food was necessary for the use by dates to be followed. The Administrator stated that the dish machine sanitizer unit would be immediately fixed and a same day repair by the dish machine service vendor was confirmed. During an interview with the Maintenance Director on 6/18/25 at 7:25am stated he had not received a previous work order to clean the ceiling and side vents in the kitchen. Record review of facility policy entitled Cleaning Schedules in the Dietary Services Policy and Procedure Manual dated 2012 stated The Dietary department and all equipment in the dietary department will be cleaned on a regular scheduled basis. Record review of the facility policy entitled Left-Over Foods in the Dietary Services Policy and Procedure Manual dated 2012 stated Left-over foods shall be refrigerated, dated, label and properly covered promptly after meal service.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 3 medication cart (west medication cart and nursing treatment cart) and 1 of 2 medication (west medication storage room) storage rooms reviewed for storage of drugs. 1. The facility failed to ensure the west medication cart did not have loose pills and did not have an insulin vial with no open date. 2. The facility failed to ensure the west hall medication storage room fridge had a permanently affixed narcotic lock box. The box contained vials of liquid lorazepam (controlled benzodiazepine tranquilizer medication used to treat anxiety or seizures). 3. The facility failed to ensure the nurse treatment cart did not store the keys to the cart on the cart. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: 1. Observation and interview on 6/20/25 at 9:35 a.m. revealed the west medication cart had two loose white pills and two loose pink pills in the top drawer. A vial of insulin belonging to Resident #23 did not have an open date on the vial. LVN E stated she was unsure where the pills came from or what they were. LVN E stated any loose pills should be discarded, not administered to residents, and threw them in the sharp's container. LVN E stated the insulin vials should have a open date written on the box and vial in case the box and vial get separated and you do not know when it was opened. During an interview on 6/20/25 at 1:28 p.m. the DON stated there should not be loose pills in the medication storage carts because they do not know what they are, and they should not be used. The DON stated staff were expected to label both the insulin vial and the box with an open date in case they get separated. 2. During an observation on 6/20/25 at 9:58 a.m. the west hall medication storage room contained a refrigerator for resident medications. Inside the fridge was a plastic box with a chain. The chain was connected to the inside of the fridge with a pad lock. The pad lock was not completely closed and the screws that secured the bracket to the fridge were weak, and came loose and unscrewed when the pad lock was manipulated. Resident's liquid lorazepam was in the cold narcotic storage box. During an observation and interview on 6/20/25 at 10:28 a.m. the DON demonstrated the lock was not fully closed or engaged but could not be opened. When the DON manipulated the pad lock one screw came out of the side of the fridge. The DON stated the nurses had the keys to the pad lock inside the fridge. The DON stated she was not sure why it was not fully locked but the way it was you could not turn the lock to open it. The DON stated she thought the box was still permanently affixed inside the fridge. 3. During an observation on 6/20/25 at 1:49 p.m. the nursing treatment cart had a white container on the side of it. LVN F walked up to the cart grabbed the container, opened it, took the keys to the cart out, and unlocked the cart. LVN F stated residents did not know they keys were in the container to open the cart. During an interview on 6/20/25 at 1:53 p.m. the DON stated the key for the nursing treatment cart were not in the line of sight and residents did not know it was there. The DON stated it was acceptable to have the keys in an unlocked container on the cart. Record review of the facility's policy titled Medication Storage in the Facility, dated 2025, stated: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .9. Each States rule vary on securing the classes of controlled substances the facility will adhere to their individual State's rules as it relates, some states require that ALL classes of controlled substances be stored in the lock-box located in the medication cart to adhere to the required double locked/secured storage .13. outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures. are immediately removed from stock, disposed of according to the procedures for medication destruction . Record review of the facility's policy titled Recommended Medication Storage, dated 7/2012, stated Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list and the manufacturer recommendations will supersede this list .INSULINS (Vials, Cartridge, Pens) .

Based on observation, interview, and record review, the facility failed to 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 disease and infection for 1 of 8 residents (Resident #21) reviewed for infection control: The facility failed to ensure Resident #21's indwelling urinary catheter bag was not on the floor. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #21's face sheet dated 6/20/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included sepsis due to streptococcus pneumoniae (life threatening condition that arises when the body's response to infection can cause tissue damage, organ failure, or even death), urinary tract infection (infection of the urinary tract), vesicoureteral-reflux with reflux nephropathy with hydroureter, bilateral (condition where urine flows backwards from the bladder to both ureters (muscular tubes that transport urine from the kidneys to the bladder)), dementia, and Parkinson's disease without dyskinesia (progressive movement disorder of the nervous system). Record review of Resident #21's significant change MDS assessment, dated 6/3/25, revealed the resident cognition was severely impaired for daily decision-making skills, required substantial assistance with bed mobility and transfers and utilized a catheter. Record review of Resident #21's Physician Order, dated 6/20/25, revealed the following: -Ensure foley bag is in privacy bag while in bed or wheelchair every shift, with a start date of 6/1/25, and no end date. -may change foley catheter using 16 fr 10mL bulb if leaking or blockage as needed for foley care, with a start date of 6/1/25, and no end date. Record review of Resident #21's comprehensive care plan revealed a care area, initiated 6/13/25, the resident had a indwelling catheter due to recurrent UTI infection and neurogenic bladder with interventions to Position catheter bag and tubing below the level of the bladder and in a privacy bag, and check tubing for kinks and maintain the drainage bag off the floor. Observation on 6/17/25 at 11:20 a.m. revealed Resident #21 was in bed sleeping and the indwelling urinary catheter draining to gravity on the left side of the bed. The catheter bag was visible from the doorway. The catheter bag was not in a dignity bag and was touching the floor. During an interview on 6/19/25 at 12:05 p.m., CNA D stated catheter bags should be inside a dignity bag and have a basin under them. CNA D stated a dignity bag and basin were added to the resident's catheter bag, but she was unsure who fixed it. CNA D stated the catheter bag needed a dignity bag and or basin so contamination from the floor would not happen or so no one could step on the bag. During an interview on 6/20/25 at 1:25 p.m., the DON stated the indwelling urinary catheter bag should not be touching the floor because there was a potential for infection. The DON stated there was a basin and dignity bag on the catheter at that time and someone probably moved it the other day. Record review of the facility policy titled Catheter Care, dated 2/13/2007, stated General Guidelines .10. 10. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on interview and record review, the facility failed to provide the required 80 square feet per resident in 45 of 46 resident rooms (Rooms #2-5, #7, #9-30, #32, #34, #36-51) reviewed for bedroom measurement . The facility failed to ensure rooms measured the required 80 square feet per resident. This failure could impede the ability of residents living in these rooms to attain their highest practicable well-being. Findings included: During an interview on 6/18/25 at 4:00pm with Life Safety Inspector-G stated that all of the room measurements were taken for the listed rooms. Rooms: #2 (146) 73 square feet with 2 beds in the room #3 (147) 73.5 square feet with 2 beds in the room #4 (147.6) 73.8 square feet with 2 beds in the room #5 (147.1)73.5 square feet with 2 beds in the room #7 (147) 73.5 square feet with 2 beds in the room #9 (146.3) 73.1 square feet with 2 beds in the room #10 (146.3) 73.15 square feet with 2 beds in the room #11 (147.1) 73.5 square feet with 2 beds in the room #12 (147.1) 73.5 square feet with 2 beds in the room #13 (146.9) 73.4 square feet with 2 beds in the room #14 (146) 73 square feet with 2 beds in the room #15 (145.77) 72.82 square feet with 2 beds in the room #16 (145.77) 72.82 square feet with 2 beds in the room #17 (146.27) 73 square feet with 2 beds in the room #18 (145.23) 72.62 square feet with 2 beds in the room #19 (145.23) 72.62 square feet with 2 beds in the room #20 (145.23) 72.62 square feet with 2 beds in the room #21 (145.53) 72.76 square feet with 2 beds in the room #22 (148.403) 74.20 square feet with 2 beds in the room #23 (147.811) 73.91 square feet with 2 beds in the room #24 (148.282) 74.14 square feet with 2 beds in the room #25 (147.465) 73.73 square feet with 2 beds in the room #26 (148.664) 74.33 square feet with 1 bed in the room #27 (147.919) 73.96 square feet with 2 beds in the room #28 (146.937) 73.47 square feet with 2 beds in the room #29 (147.571) 73.79 square feet with 2 beds in the room #30 (152.176) 76.09 square feet with 2 beds in the room #32 (158.190) 79.10 square feet with 2 beds in the room #34 (149.669) 74.83 square feet with 2 beds in the room #36 (148.516) 74.26 square feet with 2 beds in the room #37 (155.894) 77.95 square feet with 2 beds in the room #38 (140.45) 70.23 square feet with 2 beds in the room #39 (147.921) 73.96 square feet with 2 beds in the room #40 (147.244) 73.62 square feet with 2 beds in the room #41 (149.234) 74.62 square feet with 2 beds in the room #42 (157.707) 78.85 square feet with 2 beds in the room #43 (160.834) 80.42 square feet with 2 beds in the room #44 (157.169) 78.58 square feet with 2 beds in the room #45 (157.169) 78.58 square feet with 2 beds in the room #46 (155.038) 77.52 square feet with 2 beds in the room #47 (153.302) 76.65 square feet with 2 beds in the room #48 (153.728) 76.86 square feet with 2 beds in the room #49 (149.055) 74.53 square feet with 2 beds in the room #50 (148.311) 74.311 square feet with 2 beds in the room #51 (159.466) 79.73 square feet with 2 beds in the room Record review of the Provider History Profile which was updated on 4/8/24 revealed an existing room size waiver from the re-certification survey with an exit date of 4/08/24. Interview and record review with the Administrator on 6/19/25 at 4:00pm provided a signed Form 3762-Room Size Waiver request form dated 6/4/25. The Administrator stated that the facility requested the same room size waiver be continued for the next year. The Administrator stated there had been no change in the number or size dimensions of the affected rooms requested for waiver consideration.

Based on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents and hazards, in that: Resident #1 was able to leave the front porch of the facility on 09/09/2024 without staff's knowledge and go to a grocery store 1.7 miles away, then became confused when leaving the grocery store as to where he resided. Resident was found at the homeless shelter where he had previously lived. Resident #1 had a cognitive decline and that although staff were concerned about letting the resident sit out on the front porch, they continued to do so prior to his elopement. An IJ was identified on 02/27/2025. The IJ template was provided to the facility on [DATE] at 2:12 PM. While the IJ was removed on 02/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death. Findings were: Record review of Resident #1's admission record, dated 02/25/2025, reflected a [AGE] year-old resident with an admitted [DATE], and diagnoses of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality), mood disturbance, and anxiety, alcohol abuse, uncomplicated, hypertensive crisis (severely elevated blood pressure), unspecified, unspecified dementia, unspecified, severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential (primary) hypertension (high blood pressure that develops gradually over time and has no clear cause), disorientation, unspecified. Resident #1's Quarterly MDS assessment with a completion date of 09/02/2024 reflected a male with a BIMS of 08, which indicated moderate cognitive impairment, and had exhibited behaviors of wandering type occurred daily. Further review of Resident #1's MDS reflected he required supervision or touch assistance with mobility. Record review of Resident #1's Comprehensive Person-Centered Care Plan, dated 08/21/2024, reflected nothing related to do with wandering or being an elopement risk. Record review of Resident #1's Comprehensive Person-Centered Care Plan, dated 09/09/2024, reflected Focus: Resident has had an actual elopement. The incident: During an interview on 02/25/2025 at 1: 31 PM, the DON stated Resident #1 went out on 09/09/2024 to sit on the front patio the day of the incident with another resident (Resident #1 now resides at a memory care facility. The other resident has been discharged .) and was observed to be gone from the front porch by the receptionist. DON stated the staff looked for Resident #1 everywhere, called the police, called the homeless community where he had been prior informing them, he was missing in case he went there, and when they received a call from the police and the homeless community, he had returned to the homeless community they went and picked up the resident. DON further stated Resident #1 had left the front patio to go to the store and reported he did not know where to go when he came out of the store. During an interview on 02/25/2025 at 2:21 PM LVN P stated he had been working for the facility for about a month. LVN P further stated he had not received training during his orientation on elopements, however then stated he was to notify the administrator, look for the resident and figure out what was going on. LVN P stated to determine if a resident should be out on the front patio would be based on the resident's cognition and if they were an elopement risk. LVN P stated they had a list at the nurses' station with names of residents who were an elopement risk and he had 2 residents on his unit. During an interview on 02/25/2025 at 3:19 PM CNA J stated the facility did not really have elopements too often, stating the receptionist during the day watched the residents when they were outside. CNA J further stated prior to letting residents sit on the front porch they would ask the nurse. He stated if they felt a resident would wander off, they would have to sit with the resident. CNA J stated he believed there was a list of residents at risk of eloping. During an interview on 02/26/2025 at 1:06 PM the corporate nurse revealed all residents were assessed after the incident for elopement risk, elopement risk was to be conducted on admission, quarterly and when incidents occurred. She stated a sign had been placed on the door alerting staff and families to speak with nurse prior to assisting residents outside. Staff had been in-serviced on elopement prevention, elopement response, and elopement codes. The corporate nurse stated the Kardex informed staff of residents who were an elopement risk and there haven't been any issues since this was put in place. During an interview on 02/27/2025 at 5:39 AM CNA Q stated if she was not able to find a resident, she would tell the nurse and look for the resident. She stated they would look everywhere for the resident. CNA Q stated residents who were more focused and not confused were able to go outside to the front, however the courtyard was safer and fenced in. She stated she would ask the nurse prior to assisting and if a resident was more alert, they were able to go out. During an interview on 02/27/2025 at 9:20 AM with the MDS Coordinator revealed the BIMS for Resident #1 changed from an 11 in July 2024 to an 8 in September 2024 and it was not a significant change in cognition. Stating depending on the time of day a person's BIMS could vary on score if done in morning or the afternoon. Stating he (Resident #1) liked to go outside and sit with his pal, and this would occur several times a day. Stated Resident #1 had not been showing signs of wanting to leave. During an interview on 02/27/2025 at 10:01 AM the ADON stated a resident who was an elopement risk would be someone who actually was exit seeking, states they want to leave and attempts. The ADON stated cognitive issues would affect the residents being able to go out on the front porch. The ADON further stated the nurses knew to review the elopement assessment. The ADON stated Resident #1 was smart and intact in the mornings, but in the evenings, he could have some confusion on time, regarding if he had coffee or if he had eaten. During an interview on 02/27/2025 at 10:35 AM LVN A stated the determination on whether a resident was able to go out on the front porch was based on the elopement risk, assessments, and nursing judgement at the time depending on the actions of the resident. LVN A further stated she had access to the residents' assessments and care plans on the computer. During an interview on 02/27/2025 at 10:42 AM interview with DON revealed she did not feel Resident #1 was able to be out on the porch alone. The DON stated he had become friends with another resident who he would sit outside with. The DON described Resident #1 as forgetful and would basically walk back and forth around the facility, she would not have considered his behavior wandering he was just walking. The DON stated the determination on if a resident was able to sit on the front porch would be by looking at the BIMS, looking at the assessments and what was going on in the moment. The DON further stated if the individual was not making sense, she would not recommend them sitting on the front porch. The DON further stated staff were made aware of changes through the UDAs (user defined assessment) under the assessment section of PCC (point click care). The DON stated the BIMS can always change throughout the day depending on when you ask the resident. The DON stated she always encouraged the nurses to check the assessment and listen to the resident/observe the resident before making a decision. During an interview on 02/27/2025 at 10:58 AM with MA B revealed she didn't feel Resident #1 was safe to be out front alone. The MA B stated Resident # 1 would ask to go outside every couple of minutes and staff would redirect him. The MA B stated Resident #1 would talk about before he came to the facility how he went everywhere, and he did not like to be told what to do. MA B stated she knew if an individual was able to go out front through her nurse. She stated the nurse would let them know along with the administrative staff. MA B further stated they had in-services and would talk about this quite often. MA B stated everything went through the charge nurse. During an interview on 02/27/2025 at 11:05 CNA I stated to prevent elopements the staff received updates through a group chat and verbally letting them know if they had a new resident if they were on elopement protocol. CNA I stated the nurses would let them know who was able to sit on the front porch. During an interview on 02/27/2025 at 11:20 AM the Dietary Supervisor stated Resident #1 was always moving around and would move a lot through the facility. The Dietary Supervisor stated he would notify the nurse if someone wanted to go outside, and they would tell him if they could. He further stated the nurse would look at assessments and see who could or could not. During an interview on 02/27/2025 at 11:30 AM with CNA C further stated Resident #1 was not safe to go out on the front porch alone and the nurse would go out on the front porch with him. CNA C stated Resident #1 always had to be redirected and would ask people to let him outside. CNA C stated before opening the doors she would notify the nurse and ask who was allowed to go outside. Record review of the Provider Investigation Report dated 9/12/2024 revealed Resident #1 was last seen at 1:50 p.m. He was found at a local homeless shelter at 3:55 p.m. and returned to the facility at 4:45 p.m. Record review of google maps reflected the local store was 1.7 miles from the facility. Record review of facility in-service training named Elopement Prevention dated 09/09/2025, revealed 63 staff had signed the in-service. Record review of facility in-service training named Emergency Codes, dated 09/09/2025, revealed 62 staff had signed the in-service. Record review of facility in-service training named Elopement Response, dated 09/09/2025 revealed 63 staff had signed the in-service. Record review of facility's employee roster revealed the facility had 63 employees. During an interview on 02/27/2025 at 11:48 AM the Administrator revealed Resident #1 had a different cognitive level at different times of the day without an assessment it would not have been safe for him to be out at that time. The Administrator further stated one of the changes they had made was people were to be assessed prior to being outside unattended. This was determined to be an Immediate Jeopardy (IJ) on 02/27/2025 at 2:12 PM. Administrator was provided with the IJ template on 02/27/2025. The following Plan of Removals was accepted on 02/27/2025 at 7:32 PM. Plan of Removal: River City Care Center 2/27/25 POR-Elopement (Incident Date 9/9/24) Problem: On 9/9/24 at approximately. 1:50 pm resident [resident initials] was seen sitting out front right in the front walkway area, at approximately. 2:05 pm the receptionist noticed that resident [resident initials] was no longer sitting there. Interventions: On 2/27/25 100% of residents in facility assessed for any active exit seeking behaviors or any active wandering behaviors by DON or designee, none noted. On 2/27/25 Elopement assessments completed for 100% of residents in facility, By DON or Designee- Any resident at risk for elopement has interventions in place to include risk for elopement on residents Kardex and care plan. On 2/27/25 100 % of resident current BIMS assessments reviewed to determine Cognitive status by MDS nurse. On 2/27/25 Medical Director [Directors Name] Notified of Immediate Jeopardy Situation on by RCN. On 2/27/25 ADHOC QA completed with IDT team on Regarding Immediate Jeopardy Situation. Inservice's: in services initiated on 2/27/25 with an anticipated completion date of 2/27/25, staff will receive in servicing either in person or via phone by DON or Designee. If staff is in serviced via phone, they will sign in-services prior to their next working shift. No staff will be allowed to work until they receive the in-services- (Includes any agency staff or new hires) - Elopement policy - Elopement prevention - How to identify a resident at risk for Elopement in PCC Via POC task (Non licensed nursing staff) - How to identify a resident bims score in pcc via POC task, BIMS Assessment score ( 0-7 Severe cognitive impairment or 8-12 Moderate cognitive impairment) Will utilize the back courtyard to sit outside upon their request or staff supervision. - (Non-Licensed nursing staff) - All other non-licensed staff will inquire with licensed nurses for questions regarding resident bims score. - How to Identify a resident at risk for Elopement in PCC Via Elopement assessment, POC task and Care plan (Licensed Nurses) - How to identify resident BIMS assessment score located in special instructions tab in residents' chart in pcc. (Licensed Nurse) - All non-licensed staff to notify licensed nurses prior to letting any resident go outside of facility. (Non-licensed staff) - - Resident who have been identified as cognitively impaired via BIMS Assessment score (0-7 Severe cognitive impairment or 8-12 Moderate cognitive impairment) Will utilize the back courtyard to sit outside upon their request or staff supervision. - Inservice completed with DON/ADON and MDS nurse regarding entering BIMS score in special instruction tab in pcc by RCN on. - BIMS assessment score will be located in the special instructions tab in each patient's chart. (licensed nurses.) *** Facility patio/ back courtyard is located on facility premises within a secure gate not considered leaving facility property*** Monitoring: All monitoring will be maintained on a monitoring log. Monitoring will begin on 2/27/25. DON and or Designee will review all elopement assessments weekly to ensure any residents at risk for elopement have proper interventions in place. (Includes new admissions) x 4 weeks and periodically thereafter to ensure compliance. DON and or Designee will review all residents BIMS assessments to ensure residents identified with cognitive impairment have interventions in place (Special instructions in place in pcc) weekly x 4 weeks and periodically thereafter to ensure compliance (Includes new admissions) DON or Designee will be responsible to update special instructions tab in pcc if a change in BIMS score is identified, weekly x 4 weeks and periodically thereafter to ensure compliance. DON/Designee will notify staff if any BIMS score change is noted upon review of assessments and on an as needed basis via communication board in pcc. DON/Designee will ask 4 non licensed nursing staff situational questions related to elopement (How to identify a resident at risk for elopement in pcc, what to do if a resident elopes) x 4 weeks and periodically thereafter to ensure compliance. DON/Designee will ask 4 licensed nurses situational questions regarding elopement and cognition (How to identify a resident at risk for elopement in pcc, how to identify a resident with a cognitive deficit in pcc) x 4 weeks and periodically thereafter to ensure compliance. DON/Designee will Monitor once a day 3xs a week to ensure there is no evidence of facility staff or visitors allowing residents to go outside without notifying nurse x 4 weeks and periodically thereafter to ensure compliance. All findings will be reviewed in monthly QA and changes will be made to the plan if needed. Verification: Interview with the Corporate Nurse Liaison on 02/28/2025 at 9:00 AM revealed the facility started in-services on 02/27/2025. Corporate Nurse Liaison stated all staff had been in-serviced in person and via phone. She stated staff who were in-serviced via phone were to sign the in-services prior to starting their shifts. Observations of the facility front porch and courtyard on 02/28/2025 at 11:30 AM, 2:00 PM and 6:00 PM revealed no one sitting on the front porch or in the courtyard of the facility. Interview with MA D on 02/28/2025 at 10:21 AM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. MA D was able to demonstrate an understanding of the in-service materials. Interview with LVN E on 02/28/2025 at 11:04 AM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, and DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC. LVN E was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping Supervisor on 02/28/2025 at 1:25 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, Elopement Prevention, and all other non-licensed staff will inquire with licensed nurse for questions regarding resident BIMS score. The Housekeeping Supervisor was able to demonstrate an understanding of the in-service materials. Interview with Housekeeper F on 02/28/2025 at 1:30 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, Elopement Prevention, and all other non-licensed staff will inquire with licensed nurse for questions regarding resident BIMS score. Housekeeper F was able to demonstrate an understanding of the in-service materials. Interview with Laundry G on 02/28/2025 at 1:35 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, Elopement Prevention, and all other non-licensed staff will inquire with licensed nurse for questions regarding resident BIMS score. Laundry G was able to demonstrate an understanding of the in-service materials. Interview with DA H on 02/28/2025 at 1:40 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, Elopement Prevention, and all other non-licensed staff will inquire with licensed nurse for questions regarding resident BIMS score. DA H was able to demonstrate an understanding of the in-service materials. Interview with LVN A on 02/28/2025 at 1:55 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, and DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC. LVN A was able to demonstrate an understanding of the in-service materials. Interview with CNA I on 02/28/2025 at 2:00 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA I was able to demonstrate an understanding of the in-service materials. Interview with MA B on 02/28/2025 at 2:05 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. MA B was able to demonstrate an understanding of the in-service materials. Interview with Medical Records on 02/28/2025 at 2:10 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. Medical Records was able to demonstrate an understanding of the in-service materials. Interview with MDS Coordinator on 02/28/2025 at 2:20 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC and the DON/ADON and or MDS nurse will be responsible for entering BIMS score in special instruction tab in PCC. The MDS coordinator was able to demonstrate an understanding of the in-service materials. Interview with CNA J on 02/28/2025 at 2:30 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA J was able to demonstrate an understanding of the in-service materials. Interview with LVN K on 02/28/2025 at 3:00 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, and DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC. LVN K was able to demonstrate an understanding of the in-service materials. Interview with CNA L on 02/28/2025 at 3:15 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA L was able to demonstrate an understanding of the in-service materials. Interview with CNA M on 02/28/2025 at 3:36 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA M was able to demonstrate an understanding of the in-service materials. Interview with CNA N on 02/28/2025 at 3:49 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA N was able to demonstrate an understanding of the in-service materials. Interview with the DON on 02/28/2025 at 4:00 PM revealed the monitoring logs had been started on 02/27/2025, all residents had been reassessed for elopement, BIMS and care plans had been updated. The DON further stated the Medical Director had been notified of the current IJ. She stated PCC and POC had been updated on all residents with special instructions along with the task had been updated. Interview with LVN O on 02/28/2025 at 4:30 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, and DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC. LVN O was able to demonstrate an understanding of the in-service materials. Record review of all residents' Elopement Risk assessments on 02/28/2025 revealed the facility completed the re-assessments of all residents on 02/27/2025. Record review of all residents' Special Instructions in PCC on 02/28/2025 revealed the facility had updated the Special Instructions with BIMS and Elopement Risk of all residents on 02/27/2025. Record review of all residents' BIMS Assessments in PCC on 02/28/2025 revealed the facility had completed re-assessments of all residents' BIMS on 02/27/2025. Record review of in-service training on Staff to notify licensed nurses prior to letting any resident go outside of facility, dated 02/27/2025, on 02/28/2025 revealed 40 of 56 staff had signed the in-service training and 16 staff members had been notified by phone. Record review of in-service training on Resident who have been identified as cognitively impaired via BIMS Assessment score (0-7 Severe cognitive impairment or 8-12 Moderate cognitive impairment) Will utilize the back courtyard to sit outside upon their request or staff supervision, dated 02/27/2025, on 02/28/2025 revealed 40 of 56 staff had signed the in-service training and 16 staff members had been notified by phone. Record review of in-service training on Elopement Policy dated 02/27/2025, on 02/28/2025 revealed 40 of 56 staff had signed the in-service training and 16 staff members had been notified by phone. Record review of in-service training on How to identify a resident at risk for Elopement in PCC via POC task (non-licensed nursing staff), dated 02/27/2025, on 02/28/2025 revealed 11 of 17 non-licensed nursing staff had signed the in-service training and 6 staff members had been notified by phone. Record review of in-service training on How to identify a resident at risk for Elopement in PCC via Elopement assessment, POC task and Care plan (Licensed Nurses), dated 02/27/2025, on 02/28/2025 revealed 11 of 17 licensed nurses had signed the in-service training and 6 staff members had been notified by phone. Record review of in-service training on Elopement Prevention, dated 02/27/2025, on 02/28/2025 revealed 40 of 56 staff had signed the in-service training and 16 staff members had been notified by phone. Record review of in-service training on BIMS assessment score will be located in the special instructions tab in each patients chart (licensed nurses), dated 02/27/2025, on 02/28/2025 revealed 11 of 17 licensed nurses had signed the in-service training and 6 staff members had been notified by phone. Record review of in-service training on How to identify a resident BIMS assessment core located in special instructions tab in residents' chart in PCC. (Licensed Nurses), dated 02/27/2025, on 02/28/2025 revealed 11 of 17 licensed nurses had signed the in-service training and 6 staff members had been notified by phone. Record review of in-service training on DON/ADON and or MDS nurse will be responsible for entering BIMS score in special instruction tab in PCC, dated 02/27/2025, on 02/28/2025 revealed 3 of 3 had signed the in-service training. Record review of in-service training on All other non-licensed staff will inquire with licensed nurses for questions regarding residents BIMS score, dated 02/27/2025, on 02/28/2025 revealed 19 of 26 other non-licensed staff had signed the in-service training and 7 staff members had been notified by phone. Record review of in [TRUNCATED]

45857 Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to ensure food was properly labeled. 2. The facility failed to ensure expired food products were discarded. 3. The facility failed to ensure food with freezer burn was discarded. 4. The facility failed to ensure a bag of spaghetti was not spilled on the shelf and a container of sugar was closed. 5. The facility failed to ensure staff did not keep personal drinks on the food prep tables. 6. The facility failed to ensure staff did not lick their fingers while placing dietary cards on resident food trays. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During an observation on [DATE] at 9:01 a.m. in the walk in fridge/freezer a pound of strawberries were observed with no date, one bag of leafy greens contained no date or label, a plastic bag of mixed frozen vegetables had ice buildup on it, was open and were not able to read an expiration date, and a bag of croissant dough had no date on it and had ice buildup on it. An open box with a date of [DATE] contained 1 container of hummus with expiration date of [DATE]. In the dry food storage, a bag of spaghetti was open and spilled onto the shelf and an open bag of sugar was seen on the shelf. During an observation and interview on [DATE] at 9:01 a.m. the DM stated the strawberries belonged to a staff member, they were not supposed to be in there, and he would throw them out. The DM stated the bag of leafy greens belonged to the activities director and it should have been sealed in a bag, dated, and he would throw it out. The DM stated the bag of mixed vegetables had ice on it and he could not identify a date. The DM stated if they could not see a date then it had to be thrown out. The DM stated opened items were kept for 6 days and then discarded. The DM stated the bag of croissant dough did not have a date that could be read, had ice on it, and should be thrown out. The DM stated the box of hummus was placed in the fridge by the activities director and they should not keep expired items. The DM stated spaghetti was the alternative meal for the day and picked up the open package of spaghetti and threw it out. During an observation on [DATE] at 9:58 a.m. a container of sugar was open. During an interview on [DATE] at 9:58 a.m. Dietary Aide N stated the sugar container should be covered and then covered the sugar container. During an observation on [DATE] at 10:39 a.m. a cart in the kitchen next to the food prep table had a green metal cup with a straw. There was a green sanitizer bucket next to the cup and two oven mitts on top of the cart. During an observation on [DATE] at 10:58 a.m. Dietary Aide L placed dietary preference sheets on the resident food tray. Dietary Aide L licked her finger then grabbed a sheet and placed it on the tray. This surveyor asked Dietary Aide L if she was licking her fingers. Dietary L stated she was and continued to place the papers on the tray. Temporary Dietary Manager O asked Dietary Aide L to go wash her hands. During an interview on [DATE] at 10:58 a.m. Dietary Aide L stated she should not have licked her fingers when she placed the dietary preference sheets on the resident food trays because it was not sanitary, and residents could get sick. During an interview on [DATE] at 11:38 a.m. Cook K stated the green cup was hers and she removed it from the kitchen because it was not supposed to be in the kitchen. During an interview on [DATE] at 12:25 p.m. the Activity Director stated she had a current food handlers' certificate. The Activity Director stated the DM instructed her to place any of the food items she used for residents together in a bag and put a date on it. The Activity Director stated the leafy greens and hummus were not items she had used for residents. The Activity Director stated dietary staff were responsible for the kitchen. Record review of the facility's policy, titled Dietary Food Service Personnel Policy and Procedures, dated 2012, stated The next pages of information are designed for dietary employees to acquaint you with the rules and personnel procedures of this department. It is important that these be followed at all times in order to . maintain the efficiency of the department and make this a pleasant place for you and others to work. The resident is the reason that we are here and our job in the residents' care plan is to serve attractive, appetizing, nourishing, and high-quality food to help keep them healthy .Sanitation and Food Handling .3. Wash your hands (with soap and hot water) before starting work, after coughing, or sneezing .touching something that is not clean and then handling food can cause food poisoning .8. Work surfaces must be kept as neat and clean as possible during preparation and service .11. All unused food must be securely covered. All items are to be dated and labeled as to their content. Store items in their original container unless instructed to do otherwise .

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 3 of 6 residents (Resident #22, #40, and #39) reviewed for resident rights, in that: 1. LVN A did not knock on Resident #22's door prior to entering his room. 2. CNA R stood while she fed Resident #40 at dinner time. 3. LVN A stood while she fed two unidentified residents at dinner time. 4. RN E did not knock on Resident #39's door prior to entering her room. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity and self-worth. The findings included: 1. Record review of Resident #22's face sheet, dated 5/4/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis (hemiplegia is defined as paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and disorders of visual pathways due to vascular disorders (slow/progressive disease of narrowing/blockage of blood vessels). Record review of Resident #22's most recent quarterly MDS assessment, dated 4/19/24 revealed the resident was moderately cognitively impaired for daily decision-making skills. Observation on 4/30/24 at 3:40 p.m., during initial tour, revealed Resident #22 sitting up in bed. As Resident #22 was being interviewed by the State Surveyor, LVN A entered Resident #22's room without knocking on the door. LVN A, after realizing the State Surveyor was in the room, excused herself and left the room. During an interview on 4/30/24 at 3:40 p.m., Resident #22 was asked if staff usually entered his room without knocking and Resident #22 replied, yes, they do it all the time and I hate it. During an interview on 4/30/24 at 4:05 p.m., LVN A confirmed she had not knocked on Resident #22's door before entering his room and further stated, I had been in there several times and Resident #22 was expecting me. That was my third time going in there. I do knock on the door just to let you know. 2. Record review of Resident #40's face sheet, dated 5/3/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people) Bell's Palsy (weakness in the muscles on one half of the face), protein-calorie malnutrition, dysphagia (difficulty swallowing) and cognitive communication deficit. Record review of Resident #40's most recent quarterly MDS assessment, dated 2/12/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #40's comprehensive care plan, with revision date 3/5/24 revealed the resident had an ADL self-care performance deficit with interventions that included the resident required staff participation to eat. During an observation and interview on 4/30/24 at 5:18 p.m., CNA R was observed standing while feeding Resident #40. CNA R stated she was standing while feeding Resident #40 because there were no available chairs to sit on. CNA R further stated she could not leave Resident #40's side because she had already started feeding him. CNA R revealed she should not have been standing while feeding Resident #40 because she needed to be at his eye level. 3. Observation and interview on 5/1/24 at 5:02 p.m., revealed LVN A was standing while feeding two unidentified residents during dinner time. LVN A stated she could not find a chair to sit on and was supposed to be sitting down while feeding the residents for the resident's comfort. 4. Record review of Resident #39's face sheet, dated 5/3/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), dysphasia (difficulty swallowing), and lack of coordination. Record review of Resident #39's most recent quarterly MDS assessment, dated 4/3/24 revealed the resident was severely cognitively impaired for daily decision-making skills. Observation on 5/3/24 at 8:48 a.m., revealed RN F, during the medication pass, entered Resident #39's room to administer medications without knocking. During an interview on 5/3/24 at 9:13 a.m., RN F stated she had announced herself to Resident #39 but realized she had not knocked on the door before entering the room. RN F stated, it's a big deal because you are going into somebody else's space and their space needs to be respected. During an interview on 5/1/24 at 5:31 p.m. the Administrator responded they shouldn't be doing that regarding staff standing while feeding the residents. During an interview on 5/2/24 at 5:55 p.m., the DON revealed it was her expectation for staff to knock and announce themselves before entering a resident's room because you don't know what the resident is doing and that is their room. It's their right to privacy. The DON further revealed, staff should be sitting when feeding the residents because it's a dignity thing. Record review of the facility policy and procedure titled, Resident Rights, revision date 11/28/16 revealed in part, .The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States .The resident has the right to be informed of, and participate in, his or her treatment .The resident has a right to be treated with respect and dignity .

45857 Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 8 of 13 residents (Resident #14, #19, #21, #23, #31, #34, #35, and #41) reviewed for comprehensive care plans in that: The facility failed to update a plan of care to address Resident #14, #19, #21, #23, #31, #34, #35, and #41 for enhanced barrier precautions. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: a. Record review of Resident #14's face sheet, dated 05/01/2024, revealed a [AGE] year old female with an original admitted [DATE] and a readmitted [DATE] with diagnoses including acute kidney failure (kidneys suddenly become unable to filter waste products from your blood) and neuromuscular dysfunction of bladder (problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination). Record review of Resident #14's most recent quarterly MDS assessment, dated 4/21/24 revealed the resident was moderately cognitively impaired for daily decision-making skills and indicated she had an indwelling urinary catheter. Record review of Resident #14's order summary report, dated 5/01/24 revealed the following: - Ensure foley bag is in privacy bag while in bed or w/c every shift, with an order date of 1/19/24, and no end date. - Urinary Catheter 16F/10cc to gravity drainage every shift, with an order date of 2/01/24 and no end date. - provide catheter care every shift, with order date 1/19/24 and no end date. Record review of Resident #14's comprehensive care plan, with revision date 04/30/24 revealed the resident had an Indwelling Catheter: due to neuromuscular dysfunction of bladder with interventions to position catheter bag and tubing below the level of the bladder and in a privacy bag, change the catheter as ordered, and check tubing for kinks and maintain the drainage bag off the floor. The care plan did not mention the resident was on enhanced barrier precautions. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #14 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 5/01/24 at 11:16 a.m. revealed Resident #14 was in her bedroom and the indwelling urinary catheter was draining via gravity on the left side of the bed and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. No PPE storage with gowns was noted in or around the room. b. Record review of Resident #19's face sheet, dated 4/30/24 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart disease and chronic kidney disease stage 3 (kidneys are damaged and can't filter blood the way they should) Record review of Resident #19's most recent quarterly MDS assessment, dated 2/28/24 revealed the resident was severely cognitively impaired for daily decision-making skills and had an indwelling urinary catheter. Record review of Resident #19's order summary report, dated 4/30/24 revealed the following: - may change foley (indwelling urinary) catheter as needed for leakage sediment buildup or blockage with order date 8/12/23 and no end date. - ensure supra pubic catheter is in privacy bag while in bed or wheelchair every shift with order date 9/22/22 and no end date. - provide catheter care every shift, with order date 9/22/22 and no end date. Record review of Resident #19's comprehensive care plan, with revision date 11/30/22 revealed the resident had a supra pubic catheter related to obstructive and reflux uropathy with interventions that included to change the catheter as ordered, check tubing for kinks and maintain the drainage bag off the floor. The care plan did not mention the resident was on enhanced barrier precautions. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #19 had been identified requiring Enhanced Barrier Precautions. Observation on 4/30/24 at 11:38 a.m. revealed Resident #19 in his bedroom and the indwelling urinary catheter was draining via gravity on the left side of the bed, and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. Observation on 5/1/24 at 9:19 a.m. revealed Resident #19 in his bedroom and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. c. Record review of Resident #21's face sheet, dated 05/01/2024, revealed a [AGE] year old female with an original admitted [DATE] and a readmitted [DATE] with diagnoses including chronic kidney disease stage 3 (kidneys are damaged and can't filter blood the way they should), dementia, and urinary tract infection. Record review of Resident #21's most recent quarterly MDS assessment, dated 4/19/24 revealed the resident was severely cognitively impaired for daily decision-making skills and indicated she had an indwelling urinary catheter. Record review of Resident #21's order summary report, dated 4/30/24 revealed the following: - Ensure foley bag is in privacy bag while in bed or w/c every shift, with an order date of 2/1/23, and no end date. - Urinary Catheter 16F/10ml to gravity drainage every shift for fc, with an order date of 2/1/23 and no end date. - provide catheter care every shift, with order date 2/1/23 and no end date. Record review of Resident #21's comprehensive care plan, with revision date 4/20/24 revealed the resident had an Indwelling Catheter: wound management, with interventions to position the catheter bag and tubing below the level of the bladder and in a privacy bag, change the catheter as ordered, and check tubing for kinks, and maintain the drainage bag off the floor. The care plan did not mention the resident was on enhanced barrier precautions. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #21 had been identified requiring Enhanced Barrier Precautions related to having a wound and indwelling catheter. Observation on 5/01/24 at 11:24 a.m. revealed Resident #21 was in her bedroom and the indwelling urinary catheter was draining via gravity on the right side of the bed, in a dignity bag, touching the floor, and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. No PPE storage with gowns was noted in or around the room. d. Record review of Resident #23's face sheet, dated 5/02/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving and gastrostomy status (insertion is the placement of a feeding tube through the skin and the stomach wall). Record review of Resident #23's most recent quarterly MDS assessment, dated 4/16/24 revealed the resident was severely cognitively impaired for daily decision-making skills and had a feeding tube. Record review of Resident #23's order summary report, dated 5/2/24 revealed the following: - Enteral Feed Order every shift Cleanse g-tube site- Monitor for any signs and symptoms of infection including redness, warmth, or drainage. If noted notify MD, with an order date of 12/28/22, and no end date. Record review of Resident #23's comprehensive care plan, with revision date 4/20/24 revealed the resident required tube feeding related to swallowing problems, with interventions to provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection. The care plan did not mention the resident was on enhanced barrier precautions. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #23 had been identified requiring Enhanced Barrier Precautions related to having a feeding tube. Observation on 4/30/24 at 11:35 a.m. revealed Resident #23 was in his bedroom and a feeding tube syringe was on his bedside table. An unidentified nurse confirmed Resident #23 had a g tube. There were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions and no PPE gowns noted in the room or nearby. e. Record review of Resident #31's face sheet, dated 5/2/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included retention of urine and senile degeneration of brain. Record review of Resident #31's most recent quarterly MDS assessment, dated 4/17/24 revealed the resident was severely cognitively impaired for daily decision-making skills and had an indwelling urinary catheter. Record review of Resident #31's order summary report, dated 5/2/24 revealed the following: - may change foley (indwelling urinary) catheter as needed for leakage sediment buildup or blockage with order date 8/12/23 and no end date. - provide catheter care every shift, with order date 6/10/22 and no end date. Record review of Resident #31's comprehensive care plan, with revision date 4/12/24 revealed the resident had bladder incontinence and had an indwelling urinary catheter with interventions that included to position the catheter bag and tubing below the level of the bladder and in a privacy bag and to provide incontinent care frequently and apply moisture barrier cream after each episode. The care plan did not mention the resident was on enhanced barrier precautions. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #31 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 4/30/24 at 11:43 a.m. revealed Resident #31 in her room with the indwelling urinary catheter on the left side of the bed draining to gravity and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. Observation on 5/1/24 at 9:19 a.m. revealed Resident #31 in her bedroom and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. During an observation and interview on 5/2/24 at 12:54 p.m., revealed Resident #31 in the bed with the indwelling urinary catheter on the left side of the bed. CNA B was in Resident #31's room to provide catheter care but Resident #31 refused care. CNA B then stated, she would empty Resident #31's indwelling urinary catheter bag. CNA B washed her hands, put on a pair of gloves and emptied Resident #31's indwelling urinary catheter bag of urine and emptied the contents into the toilet. CNA B did not wear a gown per enhanced barrier precautions. During a follow-up interview on 5/2/24 at 1:09 p.m., CNA B revealed she believed enhanced barrier precautions applied to residents who received barrier cream. CNA B believed those residents identified on enhanced barrier precautions were identified on the POC (Point of Care) used by the CNA staff. CNA B stated, enhanced barrier precautions were to do with barrier cream and not anything to do with PPE (personal protective equipment). CNA B further revealed, whenever a resident had an open wound and also during wound care, then we would be wearing a gown and shield with the gloves. CNA B revealed for a resident on isolation due to an infection, there would be a yellow isolation sign on the resident's door with precautions and a cart set up with PPE on the outside of the room. f. Record review of Resident #34's face sheet, dated 4/30/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included neuromuscular dysfunction of bladder, and acute respiratory failure with hypoxia (develops when the lungs can't get enough oxygen into the blood). Record review of Resident #34's most recent quarterly MDS assessment, dated 4/20/24 revealed the resident was moderately cognitively impaired for daily decision-making skills, had an indwelling urinary catheter and had a feeding tube. Record review of Resident #34's order summary report, dated 4/30/24 revealed the following: - enteral feed order every shift check residual before medications and feedings; return contents after each check. Hold feeding if residual greater than 100 ml's, with order dated 9/8/22 and no end date. - enteral feed order every shift cleanse g-tube site and change dressing, with order date 11/24/23 and no end date. - Change foley (indwelling urinary catheter) as needed or for leakage, sediment, clogged with order date 4/30/24 and no end date. - Change foley catheter every month every night shift starting on the 10th and ending on the 10th every month for peri care with order date 3/1/23 and no end date. -Clean peg tube site with normal saline, pat dry, apply clean/dry split gauze every night shift with order date 11/24/23 and no end date. Record review of Resident #34's comprehensive care plan, with revision date 2/5/24 revealed the resident had an indwelling urinary catheter with interventions to change the catheter as ordered, check tubing for kinks and maintain the drainage bag off the floor. Further review of Resident #34's comprehensive care plan revealed the resident required enteral feedings with interventions to check for tube placement and gastric contents/residual volume per facility protocol and the comprehensive care plan did not include interventions for enhanced barrier precautions. The care plan did not mention the resident was on enhanced barrier precautions. Observation on 4/30/24 at 11:42 a.m. revealed Resident #34 in her bedroom and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #34 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 5/1/24 at 9:19 a.m. revealed Resident #34 in her bedroom and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. Observation on 5/2/24 at 8:39 a.m., LVN C washed her hands, then took a paper towel to dry her hands, and then used the same paper towel to turn off the water faucet. LVN C then provided medications to Resident #34 via a feeding tube but did not wear a gown per enhanced barrier precautions. During an interview on 5/2/24 at 8:55 a.m., LVN C stated, she should have grabbed another paper towel to turn off the faucet because it could be considered cross contamination. LVN C further stated, whatever residue was left on my hand from drying it could be on the faucet. g. Record review of Resident #35's most recent MDS assessment, dated 4/16/24 revealed a recent admitted [DATE], diagnoses of diabetes and asthma. The MDS revealed the resident's cognition was intact and he had an indwelling catheter. Record review of Resident #35's order summary report, dated 5/2/24 revealed the following: - Urinary Catheter 20F/30cc to gravity drainage every shift for Neurogenic bladder, with an order date of 9/22/23, and no end date. - provide catheter care every shift, with order date 9/23/23 and no end date. Record review of Resident #35's comprehensive care plan, with revision date 4/20/24 revealed the resident had obstructive uropathy (excess urine accumulation in kidney(s) that causes swelling of kidneys) Catheter:20F/30cc and with interventions that included to Position catheter bag and tubing below the level of the bladder and in a privacy bag, change catheter as ordered, check tubing for kinks and maintain the drainage bag off the floor. The care plan did not mention the resident was on enhanced barrier precautions. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #35 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 4/30/24 at 11:41 a.m. revealed Resident #35 in the hallway outside of his room while Staff H cleaned his room. Resident #35 was sitting in his wheelchair and his catheter was hanging on the bottom of his chair touching the floor. The catheter bag was a solid color purple on one side and clear on the other side and urine was visible from that side. There were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. RN F and CNA G assisted resident with his catheter that was touching the floor. The staff did not have on gowns. h. Record review of Resident #41's face sheet dated 5/02/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included gastrostomy status (insertion is the placement of a feeding tube through the skin and the stomach wall). Record review of Resident #41's admission MDS assessment, dated 4/15/24 revealed the resident was severely cognitively impaired for daily decision-making skills and had a feeding tube. Record review of Resident #41's MAR dated 5/2/24 revealed an order for enteral feed order every night shift cleanse g-tube site and was marked as completed last on 5/1/24. Record review of Resident #41's comprehensive care plan, with revision date 4/30/24 revealed the resident required tube feeding related to swallowing problems, with interventions clean insertion site daily as ordered, monitoring for s/s infection or breakdown. The care plan did not mention the resident was on enhanced barrier precautions. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #41 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 4/30/24 at 10:37 a.m. revealed Resident #41 was in his bedroom and a feeding tube syringe was on his bedside table. There were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions and no PPE gowns noted in the room or nearby. During an interview on 5/2/24 at 1:43 p.m., the DON revealed the facility had received a provider letter from corporate on enhanced barrier precautions, recently. The DON stated the nurse managers were responsible for updating the care plans and the DON was responsible for checking they were added to the care plans. The DON stated she thought she checked the care plans to see if enhanced barrier precautions were added to the residents' plan of care. The DON further revealed, residents were at risk for infection if staff were not following the enhanced barrier precautions. During an interview on 5/2/24 at 2:17 p.m., the ADON revealed residents on enhanced barrier precautions should have it care planned because it was part of their plan of care. The ADON stated she was a nurse manager but was not tasked with adding the enhanced barrier precautions to the care plans. Record review of the facility training document titled Enhanced Barrier Precaution, dated 3/27/24 revealed in part, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities . The facility will utilize postings outside the room and [electronic medical record program] to communicate to staff if a resident requires EBP.

Based on observation, interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents for 1 of 5 residents (Resident #11) reviewed for medication administration, in that: The facility failed to ensure Resident #11 was administered Methadone (an opioid prescribed for pain) as ordered by the physician. This deficient practice could place residents at risk of not receiving the intended therapeutic effect of medications and could result in diminished health and well-being. The findings included: Record review of Resident #11's face sheet, dated 5/3/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), blindness in one eye and anxiety disorder (a normal reaction to stress in an intense, excessive, and persistent worry and fear about everyday situations). Record review of Resident #11's most recent quarterly MDS assessment, dated 2/16/24 revealed the resident was cognitively intact for daily decision-making skills, was treated with opioids and required medication for pain management. Record review of Resident #11's comprehensive care plan, revision date 5/1/24 revealed the resident had a potential for uncontrolled pain with interventions that included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain and to monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Further review of comprehensive care plan revealed Resident #11 was on pain medication therapy with intervention to administer medications as ordered. Record review of Resident #11's Order Summary Report, dated 5/3/24 revealed the following: - when alert, monitor for pain every shift using a scale of 0-10, if anything greater than 0 is noted, indicate in the space provided, provide relief and document in progress notes every shift, with order date 4/3/23 and no end date - Methadone 10 mg oral tablet, give 1 tablet by mouth two times a day for pain, with order date 4/3/23 and no end date Record review of Resident #11's Methadone narcotic log for April 2024 revealed the resident had a 60-day supply of Methadone, beginning 4/1/24, to be administered twice a day. Further review of Resident #11's Methadone narcotic log revealed the resident received the last dose of Methadone on 4/30/24 at 7:00 a.m. Record review of Resident #11's Medication Administration Record (MAR) for April 2024 revealed Med Aide Q documented the code 9 on the Methadone scheduled evening dose for 4/30/24 which indicated Other/See Nurse Notes. Record review of the nursing progress note, dated 4/30/24 and authored by Med Aide Q revealed, in response to the MAR code 9 revealed the following: Administered, Med Aide Q Record review of Resident #11's MAR for May 2024 revealed the morning dose for Methadone scheduled on 5/1/24 was blank. Record review of Resident #11's MAR for May 2024 revealed Med Aide Q documented the code 9 on the Methadone scheduled evening dose for 5/1/24 which indicated Other/See Nurse Notes. Record review of the nurse's progress note dated 5/1/24 at 2:57 p.m. and authored by Med Aide Q revealed the following: Methadone HCl Oral Tablet 10 MG, Give 1 tablet by mouth two times a day for Pain. See Nurse's Notes Med Aide Q During an interview on 4/30/24 at 10:48 a.m., Resident #11 revealed he was having issues with the facility obtaining Methadone prescribed for pain and was told the facility ran out of the medication on the morning of 4/30/24. Resident #11 stated an unidentified nurse had been telling me for 3 days that it (Methadone) needed to be filled. During a follow-up interview on 5/1/24 at 3:14 p.m., Resident #11 stated he did not receive the scheduled morning dose of Methadone. During an interview on 5/1/24 at 3:31 p.m., Med Aide Q revealed she had administered Resident #11 an evening dose of Methadone on 4/30/24 and an evening dose of Methadone on 5/1/24. Med Aide Q stated, the nursing progress notes she had written indicated she gave Resident #11 his scheduled Methadone. Med Aide Q revealed the last dose of Methadone received by Resident #11 was the evening dose scheduled on 5/1/24. Med Aide Q further revealed Resident #11's Methadone was out and should be coming in tonight. Med Aide Q revealed the DON and the ADON had been notified Resident #11's Methadone medication had run out. Med Aide Q stated, not sure what would happen to Resident #11 if he were not taking it (Methadone), I know it's only scheduled one time daily with me, don't know what it's for. During an interview on 5/1/24 at 4:02 p.m., the DON revealed the NP had been notified about Resident #11 running out of Methadone and was waiting for the MD to sign for the prescription. The DON stated she had talked to the NP and had been told the prescription would be signed by the MD and the Methadone should arrive later in the day. The DON stated if the Resident #11 did not receive the Methadone as scheduled, the resident could suffer withdrawals. During a follow-up interview on 5/2/24 at 6:00 p.m., the DON stated the documentation on the narcotic log should match the documentation on the nursing progress notes. The DON revealed she needed to look more into the situation to determine any discrepancy and only stated, the narcotic log should match the MAR. Record review of the facility policy and procedure titled, Medication Administration Procedures, dated 2003 revealed in part, .All medications are administered by licensed medical or nursing personnel .If a dose of regularly scheduled medication is withheld .the nurse is to initial and circle the front of the medication administration record in the space provided for that dosage administration and an explanatory note is to be entered in the nursing notes .Defining the schedules for administering medications to .Maximize the effectiveness (optimal therapeutic effect) of the medication .The 10 rights of medication should always be adhered to .Right documentation .Any deviation from specified and recommended procedures in dispensing or administering medications to the resident requires documented approval .and shall be in concurrence with current statutes and regulations .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 10 of 13 residents (Resident #14, #19, #18, #21, #22, #23, #31, #34, #35, and #41) reviewed for infection control, in that: 1. The facility failed to utilize enhanced barrier precautions for Resident #14, #19, #21, #23, #31, #34, #35, and #41. 2. LVN A failed to utilize appropriate hand hygiene and infection control principles. LVN A did not perform hand hygiene between glove changes and obtained an accu check (a test used to obtain a rapid assessment of blood glucose concentration results; finger stick blood sampling) on Resident #22 without properly sanitizing the site. 3. LVN C failed to utilize appropriate hand hygiene and infection control principles. LVN C washed her hands and used the same paper towel to dry her hands and to turn off the water faucet. 4. Med Aide D failed to utilize appropriate hand hygiene and infection control principles. Med Aide D washed her hands and used the same paper towel to dry her hands and to turn off the water faucet. These deficient practices could place residents at risk of infection for transmission of communicable diseases and a decline in health. The findings included: 1. a. Record review of Resident #14's face sheet, dated 05/01/2024, revealed a [AGE] year-old female with an original admitted [DATE] and a readmitted [DATE] with diagnosis including acute kidney failure (kidneys suddenly become unable to filter waste products from your blood ) and neuromuscular dysfunction of bladder (problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination). Record review of Resident #14's most recent quarterly MDS assessment, dated 4/21/24 revealed the resident was moderately cognitively impaired for daily decision-making skills and indicated she had an indwelling urinary catheter. Record review of Resident #14's order summary report, dated 5/01/24 revealed the following: - Ensure foley bag is in privacy bag while in bed or w/c every shift, with an order date of 1/19/24, and no end date. - Urinary Catheter 16F/10cc to gravity drainage every shift, with an order date of 2/01/24 and no end date. - provide catheter care every shift, with order date 1/19/24 and no end date. Record review of Resident #14's comprehensive care plan, with revision date 04/30/24 revealed the resident had Indwelling Catheter: due to neuromuscular dysfunction of bladder with interventions to position catheter bag and tubing below the level of the bladder and in a privacy bag, change the catheter as ordered, and check tubing for kinks and maintain the drainage bag off the floor. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #14 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 5/01/24 at 11:16 a.m. revealed Resident #14 was in her bedroom and the indwelling urinary catheter was draining via gravity on the left side of the bed and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. No PPE storage with gowns was noted in or around the room. b. Record review of Resident #19's face sheet, dated 4/30/24 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart disease and chronic kidney disease stage 3 (kidneys are damaged and can't filter blood the way they should) Record review of Resident #19's most recent quarterly MDS assessment, dated 2/28/24 revealed the resident was severely cognitively impaired for daily decision-making skills and had an indwelling urinary catheter. Record review of Resident #19's order summary report, dated 4/30/24 revealed the following: - may change foley (indwelling urinary) catheter as needed for leakage sediment buildup or blockage with order date 8/12/23 and no end date. - ensure supra pubic catheter is in privacy bag while in bed or wheelchair every shift with order date 9/22/22 and no end date. - provide catheter care every shift, with order date 9/22/22 and no end date. Record review of Resident #19's comprehensive care plan, with revision date 11/30/22 revealed the resident had a supra pubic catheter related to obstructive and reflux uropathy with interventions that included to change the catheter as ordered, check tubing for [NAME] and maintain the drainage bag off the floor. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #19 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 4/30/24 at 11:38 a.m. revealed Resident #19 in his bedroom and the indwelling urinary catheter was draining via gravity on the left side of the bed and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. Observation on 5/1/24 at 9:19 a.m. revealed Resident #19 in his bedroom and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. c. Record review of Resident #21's face sheet, dated 05/01/2024, revealed an [AGE] year old female with an original admitted [DATE] and a readmitted [DATE] with diagnosis including chronic kidney disease stage 3 (kidneys are damaged and can't filter blood the way they should), dementia, and urinary tract infection. Record review of Resident #21's most recent quarterly MDS assessment, dated 4/19/24 revealed the resident was severely cognitively impaired for daily decision-making skills and indicated she had an indwelling urinary catheter. Record review of Resident #21's order summary report, dated 4/30/24 revealed the following: - Ensure foley bag is in privacy bag while in bed or w/c every shift, with an order date of 2/1/23, and no end date. - Urinary Catheter 16F/10ml to gravity drainage every shift for fc, with an order date of 2/1/23 and no end date. - provide catheter care every shift, with order date 2/1/23 and no end date. Record review of Resident #21's comprehensive care plan, with revision date 4/20/24 revealed the resident had Indwelling Catheter: wound management, with interventions to position catheter bag and tubing below the level of the bladder and in a privacy bag, change the catheter as ordered, and check tubing for kinks and maintain the drainage bag off the floor. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #21 had been identified requiring Enhanced Barrier Precautions related to having wounds and an indwelling catheter. Observation on 5/01/24 at 11:24 a.m. revealed Resident #21 was in her bedroom and the indwelling urinary catheter was draining via gravity on the right side of the bed, in a dignity bag, touching the floor, and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. No PPE storage with gowns was noted in or around the room. d. Record review of Resident #23's face sheet, dated 5/02/24 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving and gastrostomy status (insertion is the placement of a feeding tube through the skin and the stomach wall). Record review of Resident #23's most recent quarterly MDS assessment, dated 4/16/24 revealed the resident was severely cognitively impaired for daily decision-making skills and had a feeding tube. Record review of Resident #23's order summary report, dated 5/2/24 revealed the following: - Enteral Feed Order every shift Cleanse g-tube site- Monitor for any s/s of infection including redness, warmth, or drainage. If noted notify MD, with an order date of 12/28/22, and no end date. Record review of Resident #23's comprehensive care plan, with revision date 4/20/24 revealed the resident required tube feeding related to swallowing problems, with interventions Provide local care to G-Tube site as ordered and monitor for s/sx of infection. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #23 had been identified requiring Enhanced Barrier Precautions related to having a feeding tube. Observation on 4/30/24 at 11:35 a.m. revealed Resident #23 was in his bedroom and a feeding tube syringe was on his bedside table. An unidentified nurse confirmed Resident #23 had a g tube. There were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions and no PPE gowns noted in the room or nearby. e. Record review of Resident #31's face sheet, dated 5/2/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included retention of urine and senile degeneration of brain. Record review of Resident #31's most recent quarterly MDS assessment, dated 4/17/24 revealed the resident was severely cognitively impaired for daily decision-making skills and had an indwelling urinary catheter. Record review of Resident #31's order summary report, dated 5/2/24 revealed the following: - may change foley (indwelling urinary) catheter as needed for leakage sediment buildup or blockage with order date 8/12/23 and no end date. - provide catheter care every shift, with order date 6/10/22 and no end date. Record review of Resident #31's comprehensive care plan, with revision date 4/12/24 revealed the resident had bladder incontinence and had an indwelling urinary catheter with interventions that included to position catheter bag and tubing below the level of the bladder and in a privacy bag and to provide incontinent care frequently and apply moisture barrier cram after each episode. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #31 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 4/30/24 at 11:43 a.m. revealed Resident #31 in her room with the indwelling urinary catheter on the left side of the bed draining to gravity and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. Observation on 5/1/24 at 9:19 a.m. revealed Resident #31 in her bedroom and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. During an observation and interview on 5/2/24 at 12:54 p.m., revealed Resident #31 in the bed with the indwelling urinary catheter on the left side of the bed. CNA B was in Resident #31's room to provide catheter care but Resident #31 refused care. CNA B then stated, she would empty Resident #31's indwelling urinary catheter bag. CNA B washed her hands, put on a pair of gloves and emptied Resident #31's indwelling urinary catheter bag of urine and emptied the contents into the toilet. CNA B did not wear a gown per enhanced barrier precautions. During a follow-up interview on 5/2/24 at 1:09 p.m., CNA B revealed the believed enhanced barrier precautions applied to residents who received barrier cream. CNA B believed those residents identified on enhanced barrier precautions were identified on the POC (Point of Care) used by the CNA staff. CNA B stated, enhanced barrier precautions were to do with barrier cream and not anything to do with PPE (personal protective equipment). CNA B further revealed, whenever a resident had an open wound and also during wound care, then we would be wearing a gown and shield with the gloves. CNA B revealed for a resident on isolation due to an infection, there would be a yellow isolation sign on the resident's door with precautions and a cart set up with PPE on the outside of the room. f. Record review of Resident #34's face sheet, dated 4/30/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included neuromuscular dysfunction of bladder, and acute respiratory failure with hypoxia (develops when the lungs can't get enough oxygen into the blood). Record review of Resident #34's most recent quarterly MDS assessment, dated 4/20/24 revealed the resident was moderately cognitively impaired for daily decision-making skills, had an indwelling urinary catheter and had a feeding tube. Record review of Resident #34's order summary report, dated 4/30/24 revealed the following: - enteral feed order every shift check residual before medications and feedings; return contents after each check. Hold feeding if residual greater than 100 ml's, with order dated 9/8/22 and no end date. - enteral feed order every shift cleanse g-tube site and change dressing, with order date 11/24/23 and no end date. - Change foley (indwelling urinary catheter) as needed or for leakage, sediment, clogged with order date 4/30/24 and no end date. -Change foley catheter every month every night shift starting on the 10th and ending on the 10th every month for peri care with order date 3/1/23 and no end date. -Clean peg tube site with normal saline, pat dry, apply clean/dry split gauze every night shift with order date 11/24/23 and no end date. Record review of Resident #34's comprehensive care plan, with revision date 2/5/24 revealed the resident had an indwelling urinary catheter with interventions to change the catheter as ordered, check tubing for kinds and maintain the drainage bag off the floor. Further review of Resident #34's comprehensive care plan revealed the resident required enteral feedings with interventions to check for tube placement and gastric contents/residual volume per facility protocol and the comprehensive care plan did not include interventions for enhanced barrier precautions. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #34 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 4/30/24 at 11:42 a.m. revealed Resident #34 in her bedroom and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. Observation on 5/1/24 at 9:19 a.m. revealed Resident #34 in her bedroom and there were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. Observation on 5/2/24 at 8:39 a.m., LVN C washed her hands, then took a paper towel to dry her hands, and then used the same paper towel to turn off the water faucet. LVN C then provided medications to Resident #34 via a feeding tube but did not wear a gown per enhanced barrier precautions. During an interview on 5/2/24 at 8:55 a.m., LVN C stated, she should have grabbed another paper towel to turn off the faucet because it could be considered cross contamination. LVN C further stated, whatever residue was left on my hand from drying it could be on the faucet. g. Record review of Resident #35's most recent MDS assessment, dated 4/16/24 revealed a recent admitted [DATE], diagnoses of diabetes and asthma. The MDS revealed the resident's cognition was intact and he had an indwelling catheter. Record review of Resident #35's order summary report, dated 5/2/24 revealed the following: - Urinary Catheter 20F/30cc to gravity drainage every shift for Neurogenic bladder, with an order date of 9/22/23, and no end date. - provide catheter care every shift, with order date 9/23/23 and no end date. Record review of Resident #35's comprehensive care plan, with revision date 4/20/24 revealed the resident had obstructive uropathy (excess urine accumulation in kidney(s) that causes swelling of kidneys) Catheter:20F/30cc and with interventions that included to the resident has 20F/30cce. Position catheter bag and tubing below the level of the bladder and in a privacy bag, change catheter as ordered, check tubing for kinks and maintain the drainage bag off the floor. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #35 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 4/30/24 at 11:41 a.m. Resident #35 in the hallway outside his room while staff H cleaned his room. Resident #35 was sitting in his wheelchair and his catheter was hanging on the bottom of his chair touching the floor. The catheter bag was a solid color purple on one side and clear on the other side and urine was visible from that side. There were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions. RN F and CNA G assisted resident with his catheter that was touching the floor. The staff did not have on gowns. h. Record review of Resident #41's face sheet, dated 5/02/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included gastrostomy status (insertion is the placement of a feeding tube through the skin and the stomach wall). Record review of Resident #41's admission MDS assessment, dated 4/15/24 revealed the resident was severely cognitively impaired for daily decision-making skills and had a feeding tube. Record review of Resident #41's MAR dated 5/2/24 revealed an order for enteral feed order every night shift cleanse g-tube site and was marked as completed last on 5/1/24. Record review of Resident #41's comprehensive care plan, with revision date 4/30/24 revealed the resident required tube feeding related to swallowing problems, with interventions clean insertion site daily as ordered, monitoring for s/s infection or breakdown. Record review of the facility document titled, Enhanced Barrier Precautions, undated, revealed Resident #41 had been identified requiring Enhanced Barrier Precautions related to having an indwelling catheter. Observation on 4/30/24 at 10:37 a.m. revealed Resident #41 was in his bedroom and a feeding tube syringe was on his bedside table. There were no enhanced barrier precaution signs or any indication the resident was on enhanced barrier precautions and no PPE gowns noted in the room or nearby. During an interview on 5/2/24 at 1:17 p.m. CNA G stated no residents were on enhanced precautions and were on standard precautions only. CNA G stated he only needed to wear gloves during care with all residents. CNA G stated he had recently started and was trained over contact precautions and droplet precautions but had never heard of enhanced barrier precautions and did not know what enhanced barrier precautions was. During an interview on 5/2/24 at 1:21 p.m. LVN A stated no residents (resident # 14, #21, #23, #35, and #41) under her care required staff to wear a gown for care. LVN A stated PPE gowns were available for use if needed on the other side of the building at a different nurse's station, but they did not need them. LVN A stated she started 2 weeks prior and did not know what enhanced barrier precautions were and had received not training on enhanced barrier precautions. During an interview on 5/2/24 at 1:43 p.m., the DON revealed the facility had received a provider letter from corporate on enhanced barrier precautions, recently. The DON stated she and the ADON were responsible for in-service training, but the enhanced barrier precautions training was done by the facility computer training program. The DON stated she had a list of those residents who were supposed to be on enhanced barrier precautions and was in the process of implementing by adding signage and PPE supplies for each resident bedroom identified. The DON stated, I don't know why it wasn't done, I'm responsible, but we're working on it. The DON further revealed, residents were at risk for infection if staff were not following the enhanced barrier precautions. During an interview on 5/2/24 at 2:17 p.m., the ADON revealed enhanced barrier precautions training was provided to the staff on the facility computer training program. The ADON further revealed she was responsible for ensuring new staff were in-serviced for following enhanced barrier precautions. The ADON revealed the enhanced barrier precautions was in place for infection control purposes. 2. Record review of Resident #22's face sheet, dated 5/3/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), muscle wasting, lack of coordination and adult failure to thrive. Record review of Resident #22's most recent quarterly MDS assessment, dated 4/19/24 revealed the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #22's Order Summary Report, dated 5/3/24 revealed the following: - Triamcinolone Acetonide External Ointment 0.1%, apply to left arm and left thigh topically two times a day for rash, with order date 3/12/24 and no end date - Voltaren External Gel 1%, apply to right knee topically two times a day for pain - May apply barrier cream as needed, with order date 10/28/21 and no end date Record review of Resident #22's comprehensive care plan revealed the resident had diabetes with interventions that included to monitor for signs and symptoms of infection to any open areas. Observation on 4/30/24 at 3:48 p.m., revealed Resident #22 on the bed and LVN A entered the room to obtain an accu check. LVN A put on a pair of gloves, did not utilize proper hand hygiene, and then obtained a sample of blood from Resident #22's finger without properly sanitizing the area. LVN A then removed her gloves, did not utilize proper hand hygiene and put on a pair of gloves and applied topical medication to resident #22's left forearm and thigh. LVN A then removed her gloves, did not utilize proper hand hygiene, put on a pair of gloves, and applied topical medication to Resident #22's back. During an interview on 4/30/24 at 3:48 p.m., Resident #22 stated, LVN A did not use an alcohol wipe to clean his finger before obtaining an accu check and further stated, most of the nurses used an alcohol wipe, but LVN A did not. During an interview on 4/30/24 at 4:05 p.m., LVN A stated she had not used an alcohol wipe to sanitize Resident #22's finger before obtaining the accu check and further stated, I was afraid you were going to catch that. LVN A revealed, the area used for the accu check needed to be sanitized prior to prevent infection. LVN A confirmed she had not washed or sanitized her hands before and after glove changes and had read somewhere that it was not necessary, only to change gloves because I am going to different parts of the body. LVN A revealed she was not sure what the facility policy was on hand hygiene between glove changes. During an interview on 5/2/24 at 5:42 p.m., the DON revealed it was her expectation, when obtaining an accu check from the resident, staff must sanitize the area first with an alcohol wipe before the area is punctured with a needle. The DON stated, if the area was not cleaned before punctured with a needle the area could become infected. The DON further revealed, hand hygiene should be utilized before and after glove changes to prevent cross contamination and was considered an infection control issue resulting in the resident getting an infection. 3. Record review of Resident #34's face sheet, dated 4/30/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included neuromuscular dysfunction of bladder, and acute respiratory failure with hypoxia (develops when the lungs can't get enough oxygen into the blood). Record review of Resident #34's most recent quarterly MDS assessment, dated 4/20/24 revealed the resident was moderately cognitively impaired for daily decision-making skills, had an indwelling urinary catheter and had a feeding tube. Record review of Resident #34's order summary report, dated 4/30/24 revealed the following: - enteral feed order every shift check residual before medications and feedings; return contents after each check. Hold feeding if residual greater than 100 ml's, with order dated 9/8/22 and no end date. - enteral feed order every shift cleanse g-tube site and change dressing, with order date 11/24/23 and no end date. -Clean peg tube site with normal saline, pat dry, apply clean/dry split gauze every night shift with order date 11/24/23 and no end date. Record review of Resident #34's comprehensive care plan, with revision date 2/5/24 revealed the resident required enteral feedings with interventions to check for tube placement and gastric contents/residual volume per facility protocol. Observation on 5/2/24 at 8:39 a.m., during the medication pass revealed LVN C washed her hands, then took a paper towel to dry her hands, and then used the same paper towel to turn off the water faucet. LVN C then provided medications to Resident #34 via a feeding tube. During an interview on 5/2/24 at 8:55 a.m., LVN C stated, she should have grabbed another paper towel to turn off the faucet because it could be considered cross contamination. LVN C further stated, whatever residue was left on my hand from drying it could be on the faucet. 4. Record review of Resident #18's face sheet, dated 5/3/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), personal history of infectious and parasitic diseases and morbid obesity. Record review of Resident #18's most recent quarterly MDS assessment, dated 4/10/24 revealed the resident was cognitively intact for daily decision-making skills. Observation on 5/2/24 at 7:23 a.m., during the medication pass revealed Med Aide D washed her hands, then took a paper towel to dry her hands, and then used the same paper towel to turn off the water faucet. Med Aide D then provided medications to Resident #18. During an interview on 5/2/24 at 7:50 a.m., Med Aide D revealed she had used a paper towel to dry her hands and then used the same paper towel to turn off the water faucet. Med Aide D revealed, using the same paper towel to dry her hands and to turn off the water faucet was considered cross contamination and could result in spreading germs. Med Aide D then stated, we were taught that when we finished drying our hands with the towel, I could use the same towel to turn off the faucet. During an interview on 5/2/24 at 5:42 p.m., the DON revealed it was her expectation for staff to toss out the paper towel after drying their hands and get a new towel to turn off the faucet because it was considered going from a clean area to a dirty area. The DON stated, there's always a potential for something, like cross contamination or infection. Record review of the facility training document titled Enhanced Barrier Precaution, dated 3/27/24 revealed in part, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing .A single set of PPE cannot be used for more than 1 patient .EBP are indicated for residents with any of the following Wounds and/or indwelling medical devices even if the resident is not known to be infected .Wounds generally include chronic wounds .pressure ulcers .Indwelling medical device examples include central lines, urinary catheters, feeding tubes .The facility will ensure PPE and alcohol-based hand rub are readily accessible to staff prior to entry to their room .Donning PPE for residents on EBP based on activity provided/Assistance while in resident room .perform wound care; any skin opening requiring a dressing .device care or use: central line, urinary catheter, feeding tube .The facility will utilize postings outside the room .and to communicate to staff if a resident requires EBP . Record review of the facility policy and procedure titled, Hand Hygiene, undated, revealed in part, .You may use alcohol-based hand cleaner or soap/water for the following .before and after performing any invasive procedure (e.g. fingerstick blood sampling) .after removing gloves . 45857

Based on observation, interview and record review the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #39) reviewed for enteral feeding tubes in that: 1. RN F did not ensure Resident #39's head of bed was elevated to at least 30 degrees. These failures could place residents at risk for complications of enteral feeding. The findings included: Record review of Resident #39's face sheet, dated 5/3/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) following cerebrovascular disease (disorders in which an area of the brain is affected by bleeding of the brain), gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach) and protein-calorie malnutrition. Record review of Resident #39's most recent quarterly MDS assessment, dated 4/3/24 revealed the resident was severely cognitively impaired for daily decision-making skills and had a feeding tube. Record review of Resident #39's comprehensive care plan, with revision date 12/22/23 revealed the resident had gastroesophageal reflux with interventions that included to avoid lying down for at least 1 hour after eating, and to keep the head of bed elevated and give medications as ordered. Record review of Resident #39's order summary report, dated 5/3/24 revealed the following: - enteral feed order, every night shift change syringe every 24 hours with order date 11/27/23 and no end date - enteral feed order, every shift, flush tube with 30 ml water before and after medication and feedings, with order date 11/27/23 and no end date - enteral feed order, every shift head of bed up at least 30 degrees during administration of enter formula or water, with order date 11/27/23 and no end date - Carvedilol 25 mg, give 1 tablet via g-tube (feeding tube) two times a day related to hypertension, with order date 12/13/23 and no end date -Isosource 1.5, 250 ml via g-tube five times per day per family request, with order date 1/22/24 and no end date - Aspirin 81 mg, give 1 tablet via g-tube every day shift related to hypertension, with order date 11/27/23 and no end date - Atorvastatin Calcium tablet 40 mg, give 1 tablet every day shift via g-tube related to cerebral infarction, with order date 11/27/23 and no end date - Glipizide 5 mg tablet via g-tube every day shift related to type 1 diabetes, with order date 11/27/23 and no end date - Lisinopril 20 mg, give 1 tablet via g-tube two times a day, with order date 1/4/24 and no end date - Lactulose 10 mg/15 ml, give 30 milliliters by mouth one time a day for constipation, with order date 1/15/24 and no end date Observation on 5/3/24 at 9:01 a.m. revealed RN F administered medications to Resident #39 via the feeding tube but did not elevate the resident's head of the bed to 30 degrees. Resident #39 was observed laying flat on the bed and two pillows were observed on either side of the resident's head. During an interview on 5/3/24 at 9:13 a.m., RN F revealed Resident #39's head of the bed might not have been elevated to 30 degrees and if not, the resident could regurgitate. During a follow up interview on 5/3/24 at 12:34 p.m., the DON revealed it was her expectation for the nursing staff to ensure the head of the bed was elevated when providing feedings or medications to a resident who had a feeding tube to prevent aspiration.

Based on observation, interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #146) reviewed for advanced directives, in that: The facility failed to ensure Resident #146's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and signed by a witness, 2nd physician, and or notary public which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings included: Record review of Resident #146's face sheet, dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (serious condition in which your lungs cannot release enough oxygen into your blood or remove carbon dioxide effectively), acute kidney failure with tubular necrosis (a condition that causes the lack of oxygen and blood flow to the kidneys, damaging them. Tube-shaped structures in the kidneys, called tubules, filter out waste products and fluid. These structures are damaged in acute tubular necrosis), and cardiomyopathy (disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body). Further review of Resident #146's face sheet revealed the resident was identified as DNR status. Record review of Resident #146's admission MDS assessment, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #146's comprehensive care plan, updated [DATE] revealed the resident was DNR status with interventions which included in absence of b/p, pulse, and respiration, CPR will not be initiated. Record review of Resident #146's Order Summary Report, dated [DATE] revealed the following: - DNR (Do Not Resuscitate), with order date [DATE] and no end date. Record review of Resident #146's OOH DNR, dated [DATE] revealed it was signed by the nearest living relative on [DATE] and by the physician on [DATE]. The areas for two witnesses, a notary, or 2nd physician were all blank. During an interview on [DATE] at 4:13 p.m. the DON confirmed they had deleted the DNR document from the electronic medical record so they could fix it. The DON stated they were waiting for hospice to fix the DNR. The DON stated at the facility it was still considered valid but if they called the city, they would perform CPR and that would not be honoring the resident's wishes. Record review of the facility policy titled DNR, undated, stated There are 2 ways we can obtain a DNR order: 1. The Out of Hospital DNR used on the Texas form. This version is universally accepted for all medical personnel in all settings 2. Physician's order for DNR. This can only be honored by your facility. I have attached the policy for DNR that covers both of these in detail. Below is a summary of requirements of a standalone physician order for DNR: (this does not apply to Out of Hospital DNR. That process remains unchanged). It can no longer just be a standalone physician order. There are certain components that must, be met. We need to have it documented in the clinical record: That the resident or resident representative is requesting the DNR. Where we contacted the physician with that request. The physician's response to the request. Use the [electronic medical record program] UDA Request for DNR in order to have all the components. This is active in [electronic medical record program] now. Scan completed Request for DNR forms into the residents document tab of PCC. The order: The DNR order takes effect at the time the order is issued. It does not need to be signed in order to be valid .This link will take you directly to the regulation. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.166.htm#166.201 I have attached the OOH DNR form and Frequently Asked Questions. These only apply to the OOH DNR .The stand alone physician order DNR should be a temporary solution for a residents wishes while the OOH DNR is obtained.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 3 residents reviewed for PASRR (Residents #16). The facility failed to ensure Residents #16 had an accurate PASRR Level 1 Screenings indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #16's face sheet, dated 5/1/24 indicated Resident #16 was an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included bipolar disorder (A serious mental illness characterized by extreme mood swings) and age related cognitive decline. Record review of Resident #16's quarterly MDS assessment, dated 2/5/24, indicated Resident #16's cognition was intact for daily decision making and had a diagnosis of bipolar disorder. Record review of Resident #16's a physician's order dated 5/1/2021 indicated Resident #16 took Depakote daily for bipolar disorder. Record review of Resident #16's PASRR Level 1 Screening completed on 1/16/23 indicated in section C0100 there was no evidence of this individual having mental illness. During an interview on 5/3/24 at 1:11 p.m. the DON stated Resident #16's bipolar diagnosis was added a few days after his PASRR level 1 was completed. The DON stated they should have resubmitted a new level 1 when the diagnosis was added. The DON stated they should have done this because the resident could miss out on PASRR services.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 residents (Resident #21 and Resident #35) reviewed for indwelling urinary catheter care, in that: 1. The facility failed to ensure Resident #21's and Resident #35's indwelling urinary catheter drainage bags were not touching the floor and were in a dignity bag. This failure could place residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections. The findings included: Record review of Resident #21's face sheet, dated 05/01/2024, revealed a [AGE] year-old female with an original admitted [DATE] and a readmitted [DATE] with diagnoses including chronic kidney disease stage 3 (kidneys are damaged and can't filter blood the way they should), dementia, and urinary tract infection. Record review of Resident #21's most recent quarterly MDS assessment, dated 4/19/24 revealed the resident was severely cognitively impaired for daily decision-making skills and indicated she had an indwelling urinary catheter. Record review of Resident #21's comprehensive care plan, with revision date 4/20/24 revealed the resident had Indwelling Catheter: wound management, with interventions to position the catheter bag and tubing below the level of the bladder and in a privacy bag, change the catheter as ordered, and check tubing for kinks and maintain the drainage bag off the floor. Record review of Resident #21's order summary report, dated 4/30/24 revealed the following: - Ensure foley bag was in privacy bag while in bed or w/c every shift, with an order date of 2/1/23, and no end date. - Urinary Catheter 16F/10ml to gravity drainage every shift for fc, with an order date of 2/1/23 and no end date. - provide catheter care every shift, with order date 2/1/23 and no end date. Observation on 5/01/24 at 11:24 a.m. revealed Resident #21 was in her bedroom and the indwelling urinary catheter was draining via gravity on the right side of the bed, in a dignity bag, touching the floor. Record review of Resident #35's most recent MDS assessment, dated 4/16/24 revealed a recent admitted [DATE], diagnoses of diabetes and asthma. The MDS revealed the resident's cognition was intact and he had an indwelling catheter. Record review of Resident #35's comprehensive care plan, with revision date 4/20/24 revealed the resident had obstructive uropathy (excess urine accumulation in kidney(s) that causes swelling of kidneys) Catheter:20F/30cc and with interventions that included position catheter bag and tubing below the level of the bladder and in a privacy bag, change catheter as ordered, check tubing for kinks and maintain the drainage bag off the floor. Record review of Resident #35's order summary report, dated 5/2/24 revealed the following: - Urinary Catheter 20F/30cc to gravity drainage every shift for Neurogenic bladder, with an order date of 9/22/23, and no end date. - provide catheter care every shift, with order date 9/23/23 and no end date. - Ensure foley bag is in privacy bag while in bed or w/c every shift, with a start date of 9/22/23 and no end date. Observation on 4/30/24 at 11:41 a.m. revealed Resident #35 in the hallway outside his room while staff H cleaned his room. Resident #35 was sitting in his wheelchair and his catheter was hanging on the bottom of his chair touching the floor. The catheter bag was a solid color purple on one side and clear on the other side and urine was visible from the clear side. During an interview on 4/30/24 at 11:47 a.m. RN F stated CNA G transferred Resident #35 to his wheelchair that day and hung his catheter on his wheelchair. RN F stated the catheter bag should not be touching the floor because it could become contaminated. RN F then called CNA G into the room to help her adjust the catheter so it would not touch the floor. During an interview on 5/1/24 at 11:26 a.m. CNA G stated Resident #21's catheter bag was touching the floor. CNA G stated he had a basin to use to keep the catheter and dignity bag from touching the floor, but he did not use it. CNA G stated resident's catheters should not be touching the floor because they could get damaged. During an interview on 5/2/23 at 6:13 p.m. the DON stated the catheter bags they have were covered on one side. The DON stated it provided privacy while the resident was in bed but not full privacy when the resident was out of bed. The DON stated the catheters should still be placed in a dignity bag for privacy and the catheters should not be touching the floor because it could tear or rip open. The DON stated they had basins they could use to put under the catheters to keep them from touching the floor. Record review of the facility's policy titled Catheter Care, dated 2/13/07, stated General Guide lines .keep tubing off floor .10. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 1 residents (Residents #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1 received laboratory services in accordance with professional standards of practice. 2. The facility failed to ensure Resident #1 was accurately assessed, treated, or documented with a split meatus on his penis, after his admission with a skin injury to his genitalia. An Immediate Jeopardy (IJ) situation was identified on 9/18/2022. While the IJ was removed on 9/22/2022, the facility remained out of compliance at a scope of a pattern of actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for harm by delayed interventions from physicians, nurse practitioners, and specialists and at risk for developing unaddressed infections. The findings include: 1. A record review of Resident #1's Annual MDS dated [DATE], and signed by the DON, revealed Resident #1 was admitted to the facility from the community on 7/21/2021. Resident #1 was assessed on 8/3/2021 with adequate vision and hearing with severe mental cognition impairment, BIMS score of 08. Resident #1 required Extensive Assistance - Total Assistance with all his activities of daily life. Resident #1 was non-ambulatory and utilized a wheelchair for mobility. Resident #1 was not able to void independently and had a urinary catheter. Resident #1 was assessed with no skin breakdown, scars, or skin anomalies. A record review of Resident #1's admission record, dated 9/17/2022, revealed an admitted [DATE] and a discharge date of [DATE], with diagnoses which included obstructive and reflux uropathy (a condition in which the flow of urine is blocked), hemiparesis and hemiplegia following cerebral infarction (paralysis of partial or total body function on one side of the body, one?sided weakness), chronic kidney disease (conditions that damage your kidneys and decrease their ability to keep you healthy by filtering wastes from your blood). A record review of Resident #1's care plan, dated 9/17/2022, revealed, [Resident #1] has an indwelling catheter . [Resident #1] will show no signs or symptoms of urinary infection through the review date . change the catheter as ordered . monitor/record/report to MD for signs and symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. A record review of Resident #1's physician's orders, dated 9/17/2022, revealed the following orders, change Foley catheter as needed for clogged, dislodged, or leaking . flush Foley catheter with 60 ml normal saline every shift for Patency . monitor Foley catheter every shift for leakage, blockage, settlement build up, or low output every shift . monitor output every shift related to obstructive and reflux your uropathy . provide catheter care every shift. A record review of Resident #1's progress notes revealed a SBAR note by RN A, dated Monday 9/12/2022 at 6:25 PM, which documented RN A contacted the Nurse Practitioner (NP) on behalf of Resident #1 and reported a suspected urinary tract infection, the resident has a catheter .foul smelling urine .unable to flush Foley as ordered; purulent foul smelling discharge on brief .Describe any ordered medications/treatments initiated and their results .UA/CS: Foley changed .name of MD or NP notified, (NP) .new orders collect UA C&S. (UA, urinalysis with a culture and sensitivity, ordered to find which bacteria is causing the infection and the best medicine to treat it. A 2-part test). A record review of Resident #1's physicians orders did not reveal any orders for the UA with C&S. A record review of the facility's laboratory contractor's website, online que log, revealed an order, entered by the DON, for a urinary analysis with a culture and sensitivity, ordered Monday 9/13/2022 at 7:32 AM and was collected on Thursday 9/15/2022 at 9:00 PM. A record review of the facility's September 2022, handwritten, nurses' 24-hour report, dated 9/12/2022 revealed RN A documented, 2-10 PM, [Resident #1], reinsert FC 16 FR, Foley not flushing, UA CS (checkbox). A record review of the facility's September 2022, handwritten, nurses' 24-hour report, dated 9/13/2022 revealed LVN D documented, 10 PM-6 AM, [Resident #1], new Foley, pending UA to be collected (checkbox). LVN J documented, 6 AM- 2 PM, [Resident #1], UA needs to be P/U, (checkbox). RN A documented, 2 PM- 10 PM, Resident #1, u/a needs to be picked up. A record review of the facility's September 2022, handwritten, nurses' 24-hour report, dated 9/14/2022 revealed RN A documented, 2 PM - 10 PM, [Resident #1], urine in fridge. A record review of the facility's September 2022, handwritten, nurses' 24-hour report, dated 9/15/2022 revealed LVN D documented, 10 P- 6 AM, [Resident #1], urine in fridge, stable. LVN J documented, 6 AM - 2 PM, [Resident #1], pending ua p/u, (checkbox). RN A documented, 2 PM-10 PM, [Resident #1], urine picked up this afternoon. A record review of the facility's September 2022, handwritten, nurses' 24-hour report, dated 9/16/2022 revealed LVN D documented, 10 PM - 6 AM, [Resident #1], pending u/a results, (checkbox). LVN E documented, 6 AM -2 PM, [Resident #1], SENT OUT, RESPIRATORY DISTRESS, HOSPITAL. A record review of Resident #1's progress notes revealed a note by LVN E, dated 9/16/2022, 6:38 AM, CMA notified this nurse that [Resident #1] did not look like himself. Upon assessment, (Resident) is pale, taking short rapid breaths, O2 stats are 39%, fingernails are blue. Placed on oxygen at 5L and called EMS notifying them (Resident) is in respiratory distress. (Respiratory distress is life threatening, normal oxygen saturation is above 92% with room air). Record review of Resident #1's admitting hospital records, dated 9/16 to 9/22/2022, revealed Resident #1 was admitted on [DATE] with a diagnosis of sepsis (the body's extreme response to an infection. It is a life-threatening medical emergency), respiratory failure, urinary tract infection and intubated and placed on a ventilator (a medical procedure that involves inserting a flexible plastic tube down a person's throat. A ventilator is used in critical care when a patient cannot breathe on their own). Further review revealed a physician note on 9/16/2022 at 9:50 AM, Diagnosis, Assessment & Plan .assessment: .severe sepsis (the infection causing sepsis, starts before a patient goes to the hospital in nearly 87% of cases), acute hypoxemic respiratory failure (Respiratory failure develops when the lungs can't get enough oxygen into the blood), acute encephalopathy (a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by infectious agent (bacteria), community acquired pneumonia (an infection of the lungs that can cause mild to severe illness), urinary tract infection . A record review of Resident #1's urinalysis report, collected at the facility on 9/15/2022, revealed few bacteria. A record review of Resident #1's urinalysis report, collected at the hospital on 9/16/2022, revealed, many bacteria, (a 1 day increase). During an interview on 9/16/2022 at 5:23 PM, Hospital RN B stated Resident #1 was transferred from the facility to the hospital. RN B stated she was Resident #1's case manager and was responsible for his care in the Surgical Intensive Care Unit (SICU). RN B stated Resident #1 was diagnosed with pneumonia, a urinary tract infection, and a split meatus on his penis. RN B stated Resident #1 presented with purulent drainage to his penis at the urinary catheter and had reported to the urologist she could not flush the catheter and was awaiting consult from the physician. During an interview on 9/17/2022 at 11:08 AM LVN E stated she was newly hired (August 2022), was routinely scheduled weekends from 6 AM to 2 PM. LVN E stated she worked 9/16/2022 from 6 AM to 2 PM when her CMA alerted her to Resident #1's poor condition. LVN E stated she assessed him immediately, and recognized Resident #1 was experiencing respiratory distress and called 911 to which EMS soon transported Resident #1 to the hospital. During an interview on 9/17/2022 at 1:48 PM, Resident #1's Representative (RP) stated LVN J called her, on Tuesday (9/13/2022) to report Resident #1's urinary catheter looked infected and had a smell. RP stated she never heard back from the facility until LVN E called her on Friday to report Resident #1 was hospitalized . RP stated she was given a report at the hospital that Resident #1 was diagnosed with a urinary tract infection, which had spread, and Resident #1 was on a ventilator related to pneumonia. RP stated RN B stated Resident #1 had an infected split to his penis. RP stated she asked RN B could that have made him sick? RN B answered yes, we need to make you aware of that. RP stated, I was upset, I called the facility and spoke with (the DON) . The RP stated she was stern and complained. The RP stated the DON stated she was not aware of any skin breakdown, and the DON stated this was the first I have heard of it. During an interview on 9/17/2022 at 4:00 PM, the DON stated the facility laboratory services contractor routinely picked up lab specimens twice a week on Sundays and Thursdays. The DON stated labs ordered with a routine status would be picked up on Sundays and Thursdays and if a prescriber needed results sooner the lab would be ordered STAT (Immediately). The DON stated all nurses were aware of the pickup days. During an interview on 9/17/2022 at 5:25 PM, RN A stated she was newly hired (August 2022) and was the 2 PM to 10 PM Monday through Friday Nurse. RN A stated she received report on 9/12/2022 from the 6 AM to 2 PM nurse, LVN J, that Resident #1's urinary catheter could not be flushed (an injection of normal saline into the catheter to backwash the sediment which builds up and clogs the catheter). RN A stated she assessed Resident #1 with purulent drainage at the insertion point of the Foley catheter into the penis. RN A stated she alerted the on-call NP and gave an SBAR and received orders for a urinalysis with culture and sensitivity with a routine status for collection. RN a stated she had [AGE] years RN experience and routine status for collection was a standard practice and called for the sample to be collected the next business day, in this case 9/13/2022. RN A stated she discovered the urine she collected was placed in the facility's specimen fridge on Monday night (9/12/2022), was still there on Thursday 9/15/2022 when she came to work, It should have gone out Tuesday (9/13/2022). RN A stated she called the DON and reported the new order for a routine urinalysis so she could enter the order into the facility's laboratory contractor's website. RN A stated she did not have access to the website and thus could not enter the order. RN A stated she documented the incident on the hand-written 24-hour nurse to nurse report and gave report to the oncoming 10 PM to 6 AM LVN D. RN A stated she forgot to document the order into Resident #1's medical record and stated, I'm sorry that's me, I should have. RN A stated she believed the handwritten nurses' 24-hour report was reviewed by leadership during their morning leadership meetings. RN A stated she was aware Resident #1 experienced respiratory failure and was sent to the hospital. During an interview on 9/17/2022 at 6:20 PM, the NP stated on 9/12/2022 around early evening, RN A provided an SBAR for Resident #1 and NP gave orders for Resident #1 to receive a urinalysis with a culture and sensitivity for a suspected urinary infection. The NP stated he was responsible for a few skilled nursing facilities and could not recall all the specific details for each specific facility's laboratory collection days. The NP stated the standard of practice was for labs to be collected the next business day when ordered routine and stat orders were to be collected and sent to the laboratory immediately. The NP stated the order for Resident #1 was routine and the expectation was for the order to be collected and sent to the lab the next business day. The NP stated when RN A provided her report, she did not alert him to the twice a week lab pick-up schedule. The NP stated the lab pick up of the urine specimen, days later, was too late for Resident #1, (the lab report would not be recent enough to give an accurate current condition for the Resident). The NP stated had he been given an accurate SBAR he may have altered his order to include a STAT lab, and thus may have provided a better outcome for Resident #1. 2. A record review of Resident #1's admission MDS, dated [DATE], revealed no skin breakdown and no skin abnormalities or scars. Record reviews of Resident #1's skin assessments did not reveal any skin break down, skin tears, and/or any abnormal skin specific to Resident #1's penis. During an interview on 9/17/2022 at 4:40 PM, CNA G and CNA H stated they worked the past year with Resident #1 and during that time his penis had been split small split upon the tip maybe 1/2 inch CNA G and CNA H stated they worked with Resident #1 this week and he had a sensitive penis / catheter area, they stated, we are careful and gentle with his cath care. CNA G and CNA H stated they reported the split on Resident #1's penis to their nurses, LVN J and RN A. CNA G stated its commonly known. During an interview on 9/17/2022 at 4:00 PM, the DON stated she received several complaints from Resident #1's RP yesterday (9/16/2022) after Resident #1 was admitted to the hospital. Resident #1's RP stated she received reports from the hospital that Resident #1 had pressure ulcers to his sacrum and his penis. The DON stated she assessed Resident #1 on weekly skin assessments and was not aware of any skin breakdown for Resident #1. During an interview on 9/17/2022 at 5:25 PM, RN A stated Resident #1 had a fissure, (a narrow opening or crack of considerable length and depth usually occurring from some breaking or parting), at his penile meatus (the opening on the penis glans). RN A stated she had not documented the fissure because it was not new but old. During an interview on 9/17/2022 at 6:20 PM, the NP stated he was not aware of any skin tear, breakdown to Resident #1's penile meatus. The NP stated the skin damage may have been a result of long-term urinary use via traction from the catheter. The NP stated if he received a report or read a skin assessment in Resident #1's medical records he and/or the Medical Director could have intervened to stop any further damage and provide interventions to mitigate the damage such as, requesting a urologist specialist consult, requesting a supra pubic catheter, enhanced monitoring of the anchoring system for the urinary catheter. During an interview on 9/19/2022 at 3:39 PM, LVN J stated Resident #1 did have a small split to his penis at the meatus where the Foley catheter was in place. LVN J stated he was admitted with the split. LVN J stated the DON assessed Resident #1 when he was admitted . LVN J stated she was not aware the split was not documented. LVN J stated the DON performed weekly skin assessments for Resident #1. LVN J stated she had not documented any skin breakdown for Resident #1's penis since it was not new. A record review of the facility's Skin Assessment policy, dated 8/15/2016, revealed, It is the policy of this facility to establish a method whereby nursing can assess a residence skin integrity to allow appropriate intervention be initiated in a timely manner. Procedure: all new admits and residents returning from a hospital stay will have a head-to-toe skin assessment completed if the facility treatment nurse is available, he or she should complete the assessment within four hours of the resident's arrival at the facility. the charge nurse will then notify the treatment nurse of any skin problems noted. complete the appropriate attachments assessments. the DON along with the treatment nurse and other team members or review for the follow up assessment and recommendations. any alterations in skin integrity will be treated according to physician orders. notify Don and responsible family member. documentation will then be entered into the residence chart . all residents should have a skin assessment on a weekly basis completed in PCC . A record review of the facility's Change in a Resident's Condition or Status policy , dated 8/6/2022, revealed, our facility promptly notifies the Resident, his or her attending physician, and the resident representative of changes in the residence medical, mental condition and or status . the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the residence physical condition . prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . This was determined to be an Immediate Jeopardy (IJ) on 09/19/2022 at 2:22 PM. The administrator was notified. The Administrator was provided with the IJ template on 9/19/2022. The following Plan of Removal was accepted on 9/20/2022 at 4:00 PM. 9/19/22 [Facility] Plan of Removal Quality of Care Interventions: o In servicing for licensed nurses beginning on 9/19/22 by the DON, ADON, and/or regional nurse regarding the following: (if not present on 9/19/22, Inservice will occur prior to assuming their duties of their next shift) o Lab timing - routine and non-stat orders will be picked up on Sundays and Thursdays of each week. If stat order from a physician or nurse practitioner, notify the lab for stat pick up. o Providing all resident assessment data regarding a resident change of condition to the physician or nurse practitioner so that a determination can be made regarding the timing of a lab related service. o If a lab is ordered by the physician or nurse practitioner, clarify the timing of the lab. Either stat or routine Sunday/Thursday pick up. o If for any reason there is a delay in obtaining a lab, notify the ordering practitioner. o While awaiting a lab, if the resident has additional changes, then the physician or nurse practitioner should be notified immediately. o To notify the physician or nurse practitioner of any resident change of condition, including any trauma to skin related to urinary catheter use. o Reporting lab results to the ordering practitioner in a timely manner. o All lab orders for a resident must be entered into the resident's medical record in the order tab of PCC. o How to order lab- Routine labs are to be ordered on the trident website, requisition printed and placed in lab book. STAT labs are to be ordered on the trident website, called in to Trident and confirmation number is required, requestion is then printed and placed in lab binder. o DON/ADON will be responsible for reviewing/Verifying that lab orders were created, and documented o Admin will print and review pcc 24 hour report with clinical team at least 5 times a week x 6 weeks and periodically thereafter in daily stand up meeting to ensure DON/ADON are reviewing the documented condition of each resident who had a lab ordered. o Nurse Aides will document any skin changes in pcc point of care via the skin change task and notify Charge nurse. o On 9/19/22, a notice was placed at each nurse's station communicating the labs time frames and who to notify if there is a delay in lab service. o In servicing for nurse aides beginning on 9/19/22 by the DON, ADON, and/or regional nurse regarding reporting skin changes to the nurse immediately and to document any skin changes in PCC point of Care via the Skin Changes task, this includes potential trauma related to indwelling catheter use. (If not present on 9/19/22, Inservice will occur prior to assuming their duties of their next shift) o On 9/19/22 the DON, ADON and/or regional nurse assessed all residents with an indwelling catheter for potential trauma caused by the catheter, signs of UTI, and to ensure the care plan regarding urinary catheter use was up to date. o An Ad hoc QAPI meeting was held on 9/19/22 regarding this plan of action. o The medical director was notified of this plan on 9/19/22 Monitoring: o The DON and/or ADON will monitor the following at least 5 times per week for at least 6 weeks then periodically thereafter: o Resident orders to ensure that the timing was appropriate (routine pick up or stat) for all lab orders and to ensure the lab was completed timely according to the order. This will be performed by reviewing the 24-hour report in PCC, and then reviewing the documented condition of each resident who had a lab ordered. o Review the 24-hour report and documentation to ensure any lab order was entered into PCC correctly and ensure that the lab was ordered via the lab service portal. o Review the 24-hour report to ensure negative resident changes of condition were reported to the physician in a timely manner. Nursing staff will utilize the 24-hour in pcc. The 24-hour report in PCC is based on documentation entered into PCC in the past 24 hours. o Lab results were reported to the physician or nurse practitioner in a timely manner. o Will review any skin changes documented in PCC by the nurse aides and ensure practitioner notification was completed and any ordered treatments were initiated. o The DON and/or ADON will ask at least 4 nurses per week for 6 weeks and then periodically thereafter to ensure compliance. o the timing parameters for the current lab service, i.e., non-stat vs stat o what they would do if there is a delay in obtaining a lab specimen by the lab. o What they would do if there is a resident change while awaiting the lab service to obtain a specimen. o At least 1 time per week, the DON and/or ADON will review all weekly skin assessments for residents who have an indwelling catheter to ensure the resident does not have any trauma related to catheter use, Monitoring will be weekly x 6 weeks and periodically thereafter to ensure compliance. Monitoring The DON and/or ADON will monitor the following at least 5 times per week: Date____________ Date____________ Date____________ Date____________ Date____________ The timing of all lab orders were appropriate to the residents' condition? Yes or No If No, describe corrective action on the back of this form. All lab orders were entered into PCC correctly and entered into the lab service portal as well. Yes or No If No, describe corrective action on the back of this form. All negative resident changes were communicated to the MD or NP? Yes or No If No, describe corrective action on the back of this form. Lab results were reported to the physician or nurse practitioner in a timely manner. Yes or No If No, describe corrective action on the back of this form. The DON and/or ADON will ask at least 4 nurses per week: o the timing parameters for the current lab service, i.e., non-stat vs stat o what they would do if there is a delay in obtaining a lab specimen by the lab. o What they would do if there is a resident change while awaiting the lab service to obtain a specimen. Did they answer all the questions correctly? Date____________ Date____________ Date____________ Date____________ Date____________ Yes or No If No, describe corrective action on the back of this form. At least 1 time per week, the DON and/or ADON will review all weekly skin assessments for residents who have an indwelling catheter to ensure the resident does not have any trauma related to catheter use. Any resident with trauma related to catheter use? Yes or No, if yes explain on the back of this form. Monitoring of the facility's Plan of Removal included the following: During plan of removal monitoring on 9/21/2022 and 9/22/2022, eight of the facility's eight nursing staff were interviewed and revealed all eight received detailed re-enforced training on 9/19/2022 and 9/20/2022 prior to their next scheduled work shift to include providing a detailed Situation Background Assessment Recommendation/Report (SBAR) to include training on utilizing / accessing the laboratory's website for entering lab requests, to include, scheduled pick-up days and all pertinent data to the prescriber to facilitate an accurate order. If labs are ordered, the nurse was to clarify the timing, stat/routine, and when the lab was expected to be picked up and when the prescriber may receive a result report. If a lab was delayed or the Resident had a change of condition notify the prescriber. Notify the prescriber of skin injuries, to include urinary catheter areas, and report lab results in a timely manner. During an interview on 9/21/2022 at 12:13 PM in response to the Immediate Jeopardy DON stated, .there was no harm. Anyone can always improve their processes. I do not know why this ended up in an IJ. We were going on doctors' orders and reported to NP. In regard to the breakdown in providing pertinent data to prescribers and documenting orders in residents medical records, DON stated, all nurses have gone to school, it is not job specific, nurses need to be held accountable for putting labs in computer. In regard to monitoring staff and residents well being / health statuses, the DON stated the residents are reviewed daily at the leadership morning meetings which are augmented by the electronic 24-hour report which included data from each Resident's medical record to include new orders and changes in health status. DON stated the meetings are recorded via minutes, this surveyor requested the minutes for record review and were not provided. During an interview on 9/21/2022 at 12:54 PM Administrator stated there was room for improvement specific for nursing services, the Administrator stated he did not believe the events arose to the level of an immediate jeopardy and were transcription errors, we can improve our communications everywhere .(there is) room for improvement with follow up. I do not feel like this was neglect .(for neglect) the facility would have failed to care for the Resident. In this situation it was provided it just was not documented in the proper location .no actual harm. Staff performance is monitored via personal observations of staff and residents to include families of residents, electronic reports generated from Resident medical record data, and daily leadership meetings, I trust my staff to round and make sure they are doing what is right, otherwise I wouldn't work here. During an interview on 9/21/2022 at 2:51 PM RN A stated she was in-serviced on the scheduled pick-up times for routine labs to be Sundays and Thursdays every week. RN A stated she was in-serviced on 9/19/2022 at around 4:00 PM in a group setting with other nurses. Record review of the facility's in-service records dated 9/19/2022 4:30 PM revealed RN A was in attendance an received re-enforced training on lab timing r/t scheduled routine pick days on Sundays and Thursdays, training on detailed SBAR's for prescribers, training on clarifying stat/routine status for labs ordered, notifying prescribers of any delays in labs ordered and/or changes in condition of residents who were ordered labs, notifications for prescribers any Resident skin breakdown/injuries regarding urinary catheters, Lab orders must be documented/entered as orders in the residents' medical record. During a joint interview on 9/21/2022 at 4:02 PM the DON and ADON stated they received re-enforced training from the corporate regional nurse on 9/19/2022 at 7:40 PM which included they were responsible for reviewing/verifying lab orders were created /documented. The DON stated she would utilize the 24-report generated by resident's medical records and ensure she or the ADON would review all residents for accurate, timely, and appropriate lab orders. The ADON concurred. A record review of the facility's re-enforced training record dated 9/19/2022 at 7:40 PM revealed the DON and ADON in attendance with the facility corporate regional nurse and received training for which the DON and ADON was responsible for reviewing / verifying lab orders were created and documented. During a joint interview on 9/21/2022 at 4:02 PM the DON and ADON stated as leaders they would monitor compliance with the re-enforced training by utilizing the 24-hour report generated by the resident's medical record at least 5 times a week for 6 weeks by the daily leadership morning meetings specifically for residents who received lab orders. The ADON concurred. A record review of the facility's 24-hour report, dated 9/20/2022, revealed a printed copy of the facility's 24-hour report generated from the residents' medical records to include new orders, changes of conditions, and lab orders and draws. During an interview on 9/22/2022 at 3:00 PM, the Administrator stated the report was printed from the residents' electronic medical records and included at a minimum, new orders, changes of condition, and lab orders and/or results to which he and the interdisciplinary team review during the daily leadership morning meeting. The Administrator stated he reviewed the report and after the meeting signed the report. Observation on 9/21//2022 at 9:00 Am revealed posted signage stating, Name of Lab comes on Sundays and Thursdays **if delay notify MD/NP ** Notify DON / ADON ASAP!! During plan of removal monitoring on 9/21/2022 and 9/22/2022, 14 of the facility's 14 nurse aide staff were interviewed and revealed all 14 received detailed re-enforced training on 9/19/2022 and 9/20/2022 prior to their next scheduled work shift to include documenting any skin injuries/breakdown in the resident's medical record and to follow up with the nurse to ensure all information was documented and residents were assessed by the nurse. During plan of removal monitoring 14 of the facility's 14 nursing staff training records were reviewed and revealed all 14 received detailed re-enforced training on 9/19/2022 and 9/20/2022 prior to their next scheduled work shift to include training on CNA's: any Resident change of conditions, skin changes must be reported to the nurse immediately, this includes potential trauma related to indwelling catheter use .Nurse aides will document any skin changes in PCC point click care via the skin change task and notify the charge nurse. During an interview on 9/21/2022 at 3:43 PM, CNA G stated she received re-enforced training on 9/19/2022 at 4:30 PM from the facility's DON and ADON for documenting in the resident's medical record under the skin assessment tab any changes or injuries for residents especially if they had a urinary catheter and to follow up with the nurse to ensure the nurse assessed the resident. A record review of the facility's re-enforced training record, dated 9/19/2022 at 4:30 PM, revealed CNA G was in attendance and received re-enforced training for CNA's: any Resident change of conditions, skin changes must be reported to the nurse immediately, this includes potential trauma related to indwelling catheter use .Nurse aides will document any skin changes in PCC point click care via the skin change task and notify the charge nurse. During a joint interview on 9/21/2022 at 4:02 PM, the DON and ADON stated all residents who had urinary indwelling catheters were reviewed and assessed for safe and appropriate use of urinary catheters and all assessments were unremarkable and all urinary catheters wer [TRUNCATED]

Based on interviews and record reviews, the facility failed implement written policies and procedures that ensure residents were free from neglect for 8 of 30 residents (Residents #1, #2, #3, #9, #27, #28, #29, and #30) whose care was reviewed for neglect, in that: 1. The facility failed to ensure processes were developed and implemented to ensure staff communicated with physician when Residents (#1, #2 and #3) had a change of condition. a. LVN K and LVN L did not call the physician or nurse practitioner when Resident #1 had a change in condition and was placed on 6 liters - of oxygen via non-rebreather mask for an oxygen saturation of 80% on room air. b. LVN M did not notify physician or the nurse practitioner when Resident #2's blood pressure dropped to ,[DATE] mmHg and pulse 59 beat per minutes on [DATE] during 6 AM - 2 PM Shift. c. LVN L did not notify the physician or the nurse practitioner when Resident #2 had blood pressure of ,[DATE] mmHg and pulse 56 beat per minutes on [DATE] during 2 PM - 10 PM shift and ,[DATE] mmHg and 54 beat per minutes on [DATE] during 10 PM - 6 AM shift. d. RN J did not notify physician after Resident #3's had a low blood sugar on [DATE]. 2. The facility failed to implement a process to ensure staff completed a COVID Assessment resulting in Resident #1, #2, and #3 not being assessed for COVID 19 sign and symptoms every shift. a. Resident #1 did not have COVID assessment on [DATE] during 6AM - 2 PM shift and 2 PM - 10 PM Shift. b. Resident #2 did not have COVID assessment on [DATE] during 2PM - 10 PM shift and on [DATE] and [DATE] during 6 AM - 2 PM shift and 2 PM - 10 PM shift. c. Resident #3 did not have COVID assessment on [DATE] during 6 AM - 2 PM shift and 2 PM - 10 PM shift. 3. The facility failed to have a structure to ensure staff wear proper PPE when they care for Residents (#9, #27, #28, #29, and #30) in the positive COVID unit. a. RN B did not wear eye protection when she performed blood sugar checks for COVID positive Residents. b. Housekeeper A came out of a COVID positive residents' rooms went with a surgical mask instead of a N95 mask. c. Housekeeper A walked out of the back door at end of hall and walked back in with a surgical mask instead of N95 mask. d. CNA C did not wear gloves when delivering meal tray to Resident #29 and did not sanitize or wash her hands after delivering meal tray. e. CNA D did not wear gloves and did not sanitize or wash her hands after touching the light switch and delivery of a meal tray to Resident #9. f. RN E did not wear a face shield or goggles when she entered to Resident #30's room to deliver a meal tray. g. LVN K did not wear a face shield or googles when she performed swab test for Resident #27 and Resident #28. h. Medication Aide O entered positive COVID unit without PPE and did not put on PPE until she entered the medication room inside the COVIVD positive unit. These deficient practices could affect COVID positive Residents who had change of condition were not being assessed and identified, could place them at risk of infection from transmission of communicable disease and could result in worsening health status, hospitalization , and death. These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE]. The immediacy was lifted on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all COVID Residents. The findings were: Record review of the facility's policy titled Abuse/Neglect dated [DATE] revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . 7. Neglect: is the failure of the facility, its employees or service provider to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1a. Record review of Resident #1's admission record dated [DATE] revealed an admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's order summary report dated [DATE] revealed an order of [MEDICATION NAME] tablet 325 MG give 2 tablets by mouth every 6 hours as needed for elevated temperature; moderate pain. Start date: [DATE]. Record review of Resident #1's Treatment Administration Record schedule for ,[DATE] dated [DATE] - [DATE] revealed [MEDICATION NAME] tablet 325 mg give 2 tablets by mouth every 6 hours as needed for elevated temperature; moderate pain was documented as administering to Resident #1 at 7:39 PM. Record review of Resident #1's documentation on oxygen saturation dated [DATE] revealed oxygen saturation at 1:41 AM was 97 % room air, at 9:09 AM was 95% room air, at 6:23 PM 94% room air, at 8:36 PM was 93% high flow oxygen, at 8:46 PM was 97% high flow oxygen. Record review of Resident #1's progress noted dated [DATE] at 8:49 PM written by LVN K revealed Resident presented with a 100.4 fever, this nurse and other nurse helped resident, this nurse gave him tylenol 650mg by mouth, and other nurse gave tylenol suppository to help bring down the fever, also placed resident on oxygen 6L via non-rebreather mask. Rechecked temperature of patient and it was 99.5, resident O2 sat was at 97% on 6L via non-rebreather, resident appeared stable and resting. This nurse and other nurse left room for ,[DATE] minutes to attend to other resident's needs, did not call family prior because patient appeared stable. This nurse and other nurse went to check again on the patient and patient was gasping for air and not responding to stimuli, verbal or physical. Other nurse immediately started CPR on resident, CNA went to grab crash cart and brought it to the patient's room. This nurse put AED pads on resident, turned on AED, AED said no shockable rhythm noted, other nurse continued CPR, this nurse came and called emergency responders, emergency responders came and relieved nurse of CPR duties, this nurse came to nurses' station and called responsible party of situation. Resident is currently on stretcher with EMS, providing emergency care, will monitor resident. Record review of Resident #1's SBAR - 8hr. - V2 with effective date [DATE] 20:35 revealed date and time MD or NP notified was on [DATE] at 8:30 PM Record review of EMS Patient Care Report dated [DATE] revealed EMS was notified on [DATE] at 8:20 PM. Review EMS's assessment at 8:36 PM revealed breathing absent, pulse carotid absent; mental status: unresponsive. Interview on [DATE] at 4:14 PM with LVN K she confirmed LVN L was making round shortly after dinner and saw Resident #1 was gasping for air. LVN K stated she checked Resident #1's vital signs which revealed oxygen saturation was at 80% on room air, and temperature 100.4 F. LVN K confirmed she administered Tylenol by mouth and suppository and administered 6 liters of oxygen via non-rebreather for Resident #1. LVN K stated she rechecked Resident #1's temperature and oxygen saturation which revealed 99.5 F and 97% on 6 liters of oxygen via non-rebreather mask. LVN K confirmed Resident #1 appear resting and stable, so LVN K and LVN L left Resident #1 room and went check other residents for 5 - 10 minutes. LVN K confirmed when LVN K and LVN returned and checked on Resident #1, they noticed Resident #1 was gasping for air, and Resident #1 did not respond to verbal command and sternal rub. LVN K confirmed LVN L initiated CPR, and LVN K brought crash cart. Interview on [DATE] at 4:28 PM with LVN K confirmed she initiated SBAR after calling 911, and then she notified the nurse practitioner and family. Interview on [DATE] at 5:00 PM with LVN L confirmed LVN K asked LVN L to check on Resident #1 toward the end of shift. LVN L confirmed she found out Resident #1 had elevated temperatures approximately 102-degree Fahrenheit and oxygen saturation was low at 88% on room air. LVN L confirmed she administered Tylenol 650 suppository and administered 6 liters of oxygen via non-rebreather mask. LVN L confirmed she sat with Resident #1 for 20 minutes. Then, she checked Resident #1's temperature and oxygen saturation again revealed temperature was at 99-degree Fahrenheit and oxygen saturation was 98% on 6 liters of oxygen via non-rebreather mask. LVN L stated she went out to change her PPE because her PPE was torn, and LVN K stayed with Resident #1. LVN L further confirmed she then left the unit for break and did not know if LVN K remained to stay with Resident #1 or not. LVN L stated after she went on break for about 20 minutes, and while she was talking with the receptionist, LVN K asked LVN L to come back the unit and told LVN L that I think he passed away. LVN L said she put on PPE and rushed Resident #1's room. LVN L stated she checked Resident #1 revealed no pulse and no breathing, and then she started CPR. LVN L stated Maintenance brought the crash cart, LVN K called EMS. Then, EMS came and took over the CPR. EMS tried to resuscitate Resident #1 for 45 minutes. LVN L stated LVN K had nurse practitioner and family on the phone. Interview on [DATE] at 4:50 PM with the DON confirmed according to the SBAR note the nurse had notified the doctor when she noticed Resident #1's elevated temperature and got order from the physician for Tylenol 650 mg by mouth and suppository. Interview on [DATE] at 4:55 PM with DON stated it was ok for the nurse to step out Resident #1's room after stabilizing Resident #1. Interview on [DATE] at approximately 8:49 AM with Nurse Practitioner R confirmed the nurse should have notified the physician or the nurse practitioner after stabilizing Resident #1 with Tylenol and oxygen. Nurse Practitioner R confirmed if Resident #1 was on room air or was on oxygen via nasal canula and later Resident #1 need to be on 6 liters of oxygen via non-rebreather mask, then Resident #1 had a change in condition. Nurse Practitioner R stated he did not know about Resident #1 was on 6 litters of oxygen via non-rebreather mask. Nurse Practitioner R stated the nurse at the facility communicated with him after Resident #1 expired. b. Record review of Resident #2's face sheet date [DATE] revealed an admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Order Summary Report dated [DATE] revealed order of [MEDICATION NAME] tablet 2.5 mg give 1 tablet by mouth one time a day for hypertension, [MEDICATION NAME] capsule 0.4 mg (tamsulosin HCl) give 1 capsule by mouth at bed time for enlarged prostate, [MEDICATION NAME] tablet 20 mg ([MEDICATION NAME]) give 1 tablet by mouth one time a day for blood thinner, Tylenol tablet 325 mg ([MEDICATION NAME]) give 2 tablets by mouth every 6 hours as needed for pain. Record review of Resident #2's Blood Pressure Summary dated [DATE] revealed Resident#2 had systolic blood pressure (the first number - indicated how much pressure of blood is exerting against artery walls when heart beat) from [DATE] to [DATE] was equal or greater than 90 mmHg. Record review of Resident #2's pulse summary dated [DATE] revealed Resident #2 had heart rate (pulse) from [DATE] to [DATE] was greater than 60 beat per minutes. Record review of Resident #2's vital signs was documented by LVN M on [DATE] at 9:45 AM revealed blood pressure was ,[DATE] mmHg and pulse was 59 beat per minute. Record review of Resident #2 Medication Administration Record [REDACTED]#2 on [DATE] for the morning dose. Further review revealed [MEDICATION NAME] tablet 20 mg give 1 tablet by mouth one time a day for blood thinner was documented as administered to Resident #2 on [DATE] for the morning dose. Interview on [DATE] at 11:05 AM with LVN M confirmed she documented on [DATE] at 9:45 AM bp ,[DATE] mmHg and pulse 59 beat per minute. LVN M confirmed she took Resident #2's vital signs, write them down, and moved on to another resident. LVN M confirmed she did not recheck Resident #2's blood pressure and pulse because there was nothing significant going on with Resident #2. LVN M confirmed blood pressure and pulse did not give her any alarm concern because Resident #2 just woke up and responded, therefore, LVN M did not check his blood pressure again and did not notify the physician or nurse practitioner. c. Record review of Resident #2's vital sign documented by LVN L on [DATE] at 10:01 PM revealed blood pressure was ,[DATE] mmHg and pulse was 56 beat per minute. Further review Resident #2's vital sign documented by LVN L on [DATE] at 5:41 AM revealed blood pressure was ,[DATE] mmHg and pulse was 54 beat per minute. Interview on [DATE] at 5:22 PM with LVN L confirmed she documented Resident #2's blood pressure [DATE] at 10:01 PM was ,[DATE] mmHg and blood pressure on [DATE] at 5:41 AM was ,[DATE] mmHg. LVN further confirmed on [DATE] at 5:24 PM she believed Resident #2's blood pressure - ,[DATE] mmHg and ,[DATE] mmHg was his baseline and his response was normal, so LVN L did not notify the physician or nurse practitioner. Interview on [DATE] at 3:34 PM with LVN L confirmed Resident #2's blood pressure of ,[DATE] mmHg and pulse was 56 beat per minutes and blood pressure ,[DATE] mmHg and pulse was 54, she did not check the blood pressure and the pulse again, did not review resident trending blood pressure and pulse, and she did not notify the physician or nurse practitioner because she was being told by LVN K that Resident #2's blood pressure and heart rate run low. Interview on [DATE] at 5:38 PM with the DON confirmed Resident #2's blood pressure look lower on [DATE] at 9:45 AM was ,[DATE] mmHg, [DATE] at 10:01 PM was ,[DATE] mmHg, and [DATE] at 5:41 AM was ,[DATE] mmHg. Interview on [DATE] at 5:42 PM with the DON confirmed Resident #2's pulse look lower on [DATE] at 9:45 AM was 59 beat per minute, [DATE] at 10:01 PM was 56 beat per minute, and [DATE] at 5:41 AM was 54 beat per minute. Interview on [DATE] at 5:52 PM with the DON confirmed the nurse should have called the physician or nurse practitioner on Resident #2's low blood pressure and pulse. d. Record review of Resident #3's admission record dated [DATE] with admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's order summary order dated [DATE] revealed orders of Accucheck blood sugar three times per day for [MEDICAL TREATMENT]/sliding scale, monitor vital sign every shift report any abnormal result to MD, insulin [MEDICATION NAME] solution 100 unit/mL inject 8 unit subcutaneously one time a day for diabetes. Further review revealed there was order created on [DATE] and ended [DATE] read [MEDICATION NAME] Hypokit Solution Reconstituted 1 MG inject 1 mg subcutaneously one time only for Resident blood sugar at 43 during last round for 1 day. Record review of Resident #3's progress note documented by RN J dated [DATE] at 5:08 AM revealed Resident more effort to arouse on second rounds. Vital sign taken. Resident on [MEDICAL TREATMENT] blood sugar taken to be @ 43mg/dl. [MEDICATION NAME] given. Sugar dissolved in H2O rubbed around in her gums. 30 minutes later resident more easily follows commands. Pending blood sugar value post [MEDICATION NAME] 1mg administration and added sugar to resident's gums. Further review Resident #3's progress note dated [DATE] at 5:56 AM revealed Resident able to follow commands more readily. Able to stick out tongue when giving carbohydrate source. Able to move arms on command to wipe face. B/S currently 60mg/dl 1hr post Glugacon 1mg. Interview on [DATE] at 10:40 AM RN J confirmed while he was documenting at nursing station and an aide informed him that Resident #3 was acting differently. He went to Resident #3's room and assessed her. RN J said Resident #3 was slow to answer the question, Resident #3 know her name, but did not know where she was at. RN J stated he checked her blood sugar and found out it was low, then he gave her [MEDICATION NAME] and supplemental carbohydrate because she was able to take thing by mouth. RN J confirmed the whole facility had standing order for [MEDICATION NAME] and carbohydrate supplemental if resident had low blood sugar and change level of consciousness, he stated, because you don't have time to call the provider. RN J confirmed after giving Resident #3 was given [MEDICATION NAME] and carbohydrate supplemental, she was able to response and answer question appropriately and back to her baseline. Interview on [DATE] at 10:43 AM with RN J confirmed he did not notify the physician or nurse practitioner regarding Resident #3's low blood sugar and needed [MEDICATION NAME] injection. RN J further confirmed he did not document on SBAR report, but he confirmed he document on progress note because of standing order. Interview on [DATE] at 6:11 PM with the DON confirmed the RN J should have notified the physician or nurse practitioner, and RN J should have done the SBAR because Resident #3 had change of condition due to low blood sugar. Interview on [DATE] at 6:16 PM with RN F - Regional Compliance Nurse and the DON confirmed they did not see the SBAR for the incident of Resident #3's low blood sugar on [DATE]. Interview on [DATE] at 8:59 AM with NP R confirmed for resident had low blood sugar the nurse should have used clinical judgment to assess the patient whether the patient was alert, coherent, or having [MEDICAL CONDITION] or respiratory status was stable or not. If resident need oxygen, diaphoretic, non-response, and elevated heart rate the patient can treat with [MEDICATION NAME] and watch them come out of hypoglycemic safely and the vital sign was stable. The nurse should report to the physician about resident's low blood sugar, and there would be a review of medication why patient blood sugar went so low, was it the compliance issue or diet issue, how many times happened before or resident acutely ill. If patient went to situation of blood sugar was low and being corrected with [MEDICATION NAME], once the patient stable the nurse should have check resident blood sugar every hour or at least couple hours to make sure resident eating and go back to check blood sugar as routine schedule. Interview on [DATE] at 9:03 AM NP R confirmed resident #3 had change of condition because she had symptomatic of low blood sugar and need [MEDICATION NAME], therefore, the nurse should have notified the NP or physician and complete SBAR report. Interview on [DATE] at 10:06 AM with the Medical Director confirmed depend on resident condition, if patient conscious, the nurse should administer orange juice or glucose tablet. The Medical Director further confirmed the nurse could administer [MEDICATION NAME] if there was an order was available. The Medical Director stated usually after the nurse stabilized resident with [MEDICATION NAME], the nurse should check blood sugar every 2 hours and if the blood sugar was back to normal they should check resident blood sugar on their regular schedule such as AC&HS - before meal and at bed time or every 6 hours. 2a. Record review of Resident #1's Assessments revealed the last assessment before [DATE] (6 AM - 2 PM shift) was COVID assessment dated [DATE] at 3:58 PM and the next assessment after [DATE] (2 PM -10 PM shift) was COVID assessment dated [DATE] at 00:58 AM. Further review revealed there was no COVID Assessment on [DATE] during 6 AM - 2 PM shift and 2 PM - 10 PM shift. Interview on [DATE] at 9:21 AM with LVN I confirmed there was no COVID assessment for Resident #1 on [DATE] during 6 AM -2 PM and 2 PM -10 PM. she stated it was busy during day shift, but night shift had more time to do assessment. Interview on [DATE] at 5:27 PM with the DON confirmed she did not see the COVID Assessment for Resident #1 on [DATE] during 6AM - 2 PM shift and 2PM - 10 PM. She further confirmed she only saw other assessments documented in progress note and vital sign during 6AM - 2PM shift and 2PM - 10 PM shift. b. Record review of Resident #2's Assessments dated on [DATE] revealed Weekly Nursing summary dated [DATE] at 5:54 PM and COVID assessment dated [DATE] at 1:52 PM. Further review revealed there was no documentation on COVID Assessment on [DATE] during 2 PM - 10 PM shift. Interview on [DATE] at 3:24 PM with LVN K confirmed she worked on [DATE] during 2 PM - 10 PM shift on East Wing. LVN K further confirmed there was no COVID assessment for Resident #2 on her shift on [DATE]. LVN K explained she had 5 admissions on that day and another nurse who worked with her on that day should have done COVID assessment for Resident #2. Record review of Resident #2's Assessments revealed the last assessment before [DATE] (6AM - 2PM shift) was COVID assessment dated [DATE] at 1:52 PM and the next assessment after [DATE] (2 PM - 10 PM shift) was COVID assessment dated [DATE] at 4:22 AM. Further review revealed there was no documentation on [DATE] and [DATE] during 6 AM - 2 PM and 2 PM - 10 PM shift. Interview on [DATE] at 7:57 PM with RN H confirmed she did not have time do COVID assessment for Resident #2 on [DATE] and [DATE] during her shift 6AM - 2PM. RN H further confirmed she expected LVN I came in during 2 PM -10 PM shift to help her to complete the COVID Assessment. Interview on [DATE] at 9:16 AM with LVN I confirmed there was no COVID assessment for Resident #2 on [DATE] and [DATE] during 6 AM - 2 PM and 2 PM-10 because it was busy during the morning shift, so night shift had more time to do assessment. c. Record review of Resident #3's electronic chart on Assessments revealed Resident #3 did not have COVID assessment on [DATE] during 6 AM - 2 PM shift and 2 PM - 10 PM shift. Record review of Resident #3's Assessment revealed there was no COVID Assessment on [DATE] during 6 AM - 2 PM shift and 2 PM - 10 PM shift. Further review revealed the assessment before [DATE] (6 AM - 2 PM shift) was Skilled Nurses Notes dated [DATE] at 01:35 AM, and the assessment after [DATE] (2 PM - 10 PM shift) was Skilled Nurse Notes dated [DATE] at 04:27 AM. Interview on [DATE] at 4:35 PM with the DON confirmed there was no COVID Assessment for Resident #3 on [DATE] during 6 AM - 2 PM and 2 PM - 10 PM shift. Interview on [DATE] at 4:38 PM with the DON confirmed the license nurse could complete COVID Assessment, Respiratory Screen, or Skilled Nurse Note to consider as assessed Resident with COVID every 12 hours. The DON further confirmed when any resident admitted to the facility, the computer would automatically generate assessment to complete every 12 hours. The DON confirmed the facility updated to assess COVID resident every 8 hours. Interview on [DATE] at 4:43 PM with the DON confirmed vital sign should be done every shift. Interview on [DATE] at 4:44 PM with the DON confirmed she monitored documentation for assessment and vital sign. The DON said if there was documentation missing, she would talk to the nurse. The DON further confirmed the licensed nurses received orientation up on hire and ongoing in-service training on what they are supposed to document on their assessment and vital sign. The DON confirmed weekly monitoring and now daily monitoring even on weekend on chart auditing on major change of condition, vital sign, and assessments. Interview on [DATE] at 4:48 PM the DON confirmed if the license nurse noticed a change of condition, he or she should stabilize the resident first, and call physician to let them know what going with resident. The DON said if the physician had new order for resident, the nurse should initiate the new order, and the nurse need to documentation the communication with doctor and family. Interview on [DATE] at 4:53 PM the DON confirmed there was ongoing in-service with license staff on Resident's change of condition by going over scenarios and getting feedback from staff. Interview on [DATE] at 4:55 PM with the DON confirmed run report see who had change of condition, anything change in weekend and follow up with individual resident to find out why they transfer out. The DON further confirmed if there was no documentation, she would follow up with the nurse. Interview on [DATE] at 6:55 PM with the Administrator confirmed he had been rounding on the residents and they stated they were comfortable. Administrator sated they have more than an adequate supply of eye protection (face shields, goggles) available for staff. He further stated staff should be wearing eye protection when providing direct contact care. Administrator stated he was surprised they have not had positive staff in the building as he thought some of the infection control issues were due to staff becoming complacent. He sated he thought staff were being in-serviced on COVID and infection control process by agency. Interview on [DATE] at 10:03 AM with Medical Director confirmed he managed patients at the facility. He confirmed he utilized tele-monitoring to see resident at the facility. The nurse assessed the patient and if there was any issue would reported to the nurse practitioner. Then, the nurse practitioner and the doctor would have conversation online about the patient's situation. The Medical Director confirmed the facility had their own protocol on the assessment and frequency of assessing COVID residents. When the resident had change of condition the nurse should notify the nurse practitioner, then the nurse practitioner provide any necessary order and then the nurse practitioner communicated with the medical director and make change in resident plan of care as needed. Record review of COVID 19 plan dated [DATE] revealed .Resident Screening . Resident will be screened during their stay according to the following: at least daily for the following symptoms: fever, new or worse cough, new or worse shortness of breath, chills, repeated shaking with chills, new muscle pain or aches, headache, sore throat, new loss of taste or smell, new or worse dizziness, nausea/vomiting/diarrhea. If any of the above symptoms are assessed, the resident will be placed on contact/droplet precaution until further evaluation for COVID 19 . This facility will also review CDC guidance for Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019. Record review of Responding to Coronavirus (COVID-19) in Nursing Homes Responding to COVID-19 dated [DATE] revealed Resident with new-onset suspected or confirmed COVID-19: Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections. Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms. retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding on [DATE]. Record review of Notifying the Physician of Change in Status dated [DATE] revealed the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for medicate medical attention. This facility utilizes the INTERAC tool, Change in Condition - When to Notify the MD/NP/PA to review resident condition and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition require immediate notification of the physician and non-immediate/report on next work day notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in resident's clinical record . 6. The nurse will monitor and reassess the resident's status and response to interventions. Physician should develop a working [DIAGNOSES REDACTED]. 7. The nurse ill document all attempts to contact the physician, all attempt to notify the family and or legal representative, the physician's response, the physician orders [REDACTED]. 3. a. Observation on [DATE] at 5:00 PM revealed RN B walked in residents' rooms to conduct blood glucose without wearing a face shield or goggles. During an interview on [DATE] at 5:08 PM with RN B confirmed she did not wear face shield or goggle because the facility had a limited supply of eye protection available. Interview on [DATE] at 6:55 PM with the Administrator he confirmed the facility had more than an adequate supply of eye protection (face shields, goggles) available for staff. He further stated staff should be wearing eye protection when providing direct contact care. The Administrator stated he was surprised they have not had positive staff in the building as he thought some of the infection control issues were due to staff becoming complacent. The Administrator stated he thought nursing agency staff were being in-serviced on COVID and infection control process by agency. b. Observation on [DATE] at 5:10 PM revealed Housekeeper A came out of a COVID positive residents' room with a surgical mask on instead of a N95 mask. c. Observation on [DATE] at 5:10 PM revealed Housekeeper A walked out of the back door at end of hall and walked back in with just a surgical mask. Interview on [DATE] at 5:12 PM with RN B confirmed Housekeeper A was wearing surgical mask while he was working in the positive COVID Residents' rooms. RN B further confirmed Housekeeper A should have worn N95 mask while working in COVID positive unit. d. Record review of Resident #29's admission record dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on [DATE] at 5:42 PM revealed CNA C did not wear gloves when she placed meal tray on a bedside table of Resident #29. Further observation revealed CNA C did not sanitize or wash her hands after exiting Resident #29's room. CNA C continue getting another meal tray at the nursing station to deliver to another resident. During an interview on [DATE] at 5:45 PM with CNA C she did not wear gloves when she took the tray into Resident #29's room. She also confirmed she did not wash or sanitize her hands after delivering the tray to Resident #29's room. CNA C further stated she had not had in-service training on caring for COVID positive residents. e. Record review of Resident #9's admission record date [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on [DATE] at 5:42 PM revealed CNA D did not wear gloves when she delivered meal tray to Resident #9's room. Further observation revealed CNA D turned the light switch on in Resident #9's room and placed the meal tray on a bedside table with her bare hands. Without sanitizing or washing her hands, CNA D continued to pass out a meal tray to another resident. In(TRUNCATED)

Based on interviews and record reviews the facility failed to immediately consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 4 of 6 residents (Resident #1, #2, #3, and #4) reviewed for change of status, in that: 1. LVN K and LVN L did not call the physician or nurse practitioner when Resident #1 had a change in condition and was placed on 6 liters - of oxygen via non-rebreather mask for an oxygen saturation of 80% on room air. 2. a. Resident #2 presented with a decline in health and charge nurse RN H and LVN I did not report the finding to the physician, their supervisor, or family resulting in resident #2 sent to hospital via 911 emergency services. b. LVN M did not notify physician or the nurse practitioner when Resident #2 had blood pressure dropped to ,[DATE] mmHg and pulse 59 beat per minutes on [DATE] during 6 AM - 2 PM Shift. c. LVN L did not notify the physician or the nurse practitioner when Resident #2 had blood pressure dropped to ,[DATE] mmHg and pulse 56 beat per minutes on [DATE] during 2 PM - 10 PM shift and ,[DATE] mmHg and 54 beat per minutes on [DATE] during 10 PM - 6 AM shift. 3. RN J did not notify physician after Resident #3 had low blood sugar on [DATE]. 4. Resident #4 presented with a decline in health and the charge nurse RN H did not report the finding to the physician, her supervisor, or family thereby denying supervisors and medical prctioners the opportunity to intervene for the resident. This deficient practice caused residents harm and placed residents at risk for harm by not providing the physician the opportunity for interventions and resident families for opportunities to advocate for the residents. These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place to ensure residents were being assessed for a change in condition and physician was being notified. The findings were: 1. Record review of Resident #1's admission record dated [DATE] revealed an admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's order summary report dated [DATE] revealed an order of [MEDICATION NAME] tablet 325 MG give 2 tablets by mouth every 6 hours as needed for elevated temperature; moderate pain. Start date: [DATE]. Record review of Resident #1's Treatment Administration Record schedule for ,[DATE] dated [DATE] - [DATE] revealed [MEDICATION NAME] tablet 325 mg give 2 tablets by mouth every 6 hours as needed for elevated temperature; moderate pain was documented as administering to Resident #1 at 7:39 PM. Record review of Resident #1's documentation on oxygen saturation dated [DATE] revealed oxygen saturation at 1:41 AM was 97 % room air, at 9:09 AM was 95% room air, at 6:23 PM 94% room air, at 8:36 PM was 93% high flow oxygen, at 8:46 PM was 97% high flow oxygen. Record review of Resident #1's progress noted dated [DATE] at 8:49 PM written by LVN K revealed Resident presented with a 100.4 fever, this nurse and other nurse helped resident, this nurse gave him Tylenol 650mg by mouth, and other nurse gave Tylenol suppository to help bring down the fever, also placed resident on oxygen 6Liters via non-rebreather mask. Rechecked temperature of patient and it was 99.5, resident o2 sat was at 97% on 6Liters via non-rebreather, resident appeared stable and resting. This nurse and other nurse left room for ,[DATE] minutes to attend to other resident's needs, did not call family prior because patient appeared stable. This nurse and other nurse went to check again on the patient and patient was gasping for air and not responding to stimuli, verbal or physical. Other nurse immediately started CPR on resident, CNA went to grab crash cart and brought it to the patient's room. This nurse put AED pads on resident, turned on AED, AED said no shockable rhythm noted, other nurse continued CPR, this nurse came and called emergency responders, emergency responders came and relieved nurse of CPR duties, this nurse came to nurse's station and called responsible party of situation. Resident is currently on stretcher with EMS, providing emergency care, will monitor resident. Record review of Resident #1's the SBAR - 8hr. - V2 with effective date [DATE] 20:35 revealed date and time MD or NP notified was on [DATE] at 8:30 PM. Record review of EMS Patient Care Report dated [DATE] revealed EMS was notified on [DATE] at 8:20 PM. Review EMS's assessment at 8:36 PM revealed breathing absent, pulse carotid absent; mental status: unresponsive. Interview on [DATE] at 4:14 PM with LVN K she confirmed LVN L was making round shortly after dinner and saw Resident #1 was gasping for air. LVN K stated she checked Resident #1's vital signs which revealed oxygen saturation was at 80% on room air, and temperature 100.4 F. LVN K confirmed she administered Tylenol by mouth and suppository and administered 6 liters of oxygen via non-rebreather for Resident #1. LVN K stated she rechecked Resident #1's temperature and oxygen saturation which revealed 99.5 F and 97% on 6 liters of oxygen via non-rebreather mask. LVN K confirmed Resident #1 appear resting and stable, so LVN K and LVN L left Resident #1 room and went check other residents for 5 - 10 minutes. LVN K confirmed when LVN K and LVN returned and checked on Resident #1, they noticed Resident #1 was gasping for air, and Resident #1 did not respond to verbal command and sternal rub. LVN K confirmed LVN L initiated CPR, and LVN K brought crash cart. Interview on [DATE] at 4:28 PM with LVN K confirmed she initiated SBAR after calling 911, and then she notified the nurse practitioner and family. Interview on [DATE] at 5:00 PM with LVN L confirmed LVN K asked LVN L to check on Resident #1 toward the end of shift. LVN L confirmed she found out Resident #1 had elevated temperatures approximately 102-degree Fahrenheit and oxygen saturation was low at 88% on room air. LVN L confirmed she administered Tylenol 650 suppository and administered 6 liters of oxygen via non-rebreather mask. LVN L confirmed she sat with Resident #1 for 20 minutes. Then, she checked Resident #1's temperature and oxygen saturation again revealed temperature was at 99-degree Fahrenheit and oxygen saturation was 98% on 6 liters of oxygen via non-rebreather mask. LVN L stated she went out to change her PPE because her PPE was torn, and LVN K stayed with Resident #1. LVN L further confirmed she then left the unit for break and did not know if LVN K remained to stay with Resident #1 or not. LVN L stated after she went on break for about 20 minutes, and while she was talking with the receptionist, LVN K asked LVN L to come back the unit and told LVN L that I think he passed away. LVN L said she put on PPE and rushed Resident #1's room. LVN L stated she checked Resident #1 revealed no pulse and no breathing, and then she started CPR. LVN L stated Maintenance brought the crash cart, LVN K called EMS. Then, EMS came and took over the CPR. EMS tried to resuscitate Resident #1 for 45 minutes. LVN L stated LVN K had nurse practitioner and family on the phone. Interview on [DATE] at 4:50 PM with the DON confirmed according to the SBAR note revealed the nurse had notified the doctor when she noticed the resident elevated temperature and got order from the physician for Tylenol 650 mg by mouth and suppository. Interview on [DATE] at 4:55 PM with DON confirmed it was ok for the nurse to step out Resident #1's room after stabilizing Resident #1. Interview on [DATE] at approximately 8:49 AM with Nurse Practitioner R confirmed the nurse should have been notified the physician or the nurse practitioner after stabilizing Resident #1 with Tylenol and oxygen. Nurse Practitioner R confirmed if Resident #1 was on room air or was on oxygen via nasal canula and later Resident #1 need to be on 6 liters of oxygen via non-rebreather mask, then Resident #1 had change of condition. The Nurse Practitioner R confirmed he did not know about the situation of Resident #1 was on 6 liters of oxygen via non-rebreather mask. Nurse Practitioner R further confirmed the nurse at the facility communicated with him after Resident #1 expired. 2. a. Record review of Resident #2's admission record revealed an admission date of [DATE] with a discharge date of [DATE] and [DIAGNOSES REDACTED]. Record review of Resident #2's nursing progress notes revealed a nurse note dated [DATE] at 8:20 AM, Authored by RN H stated, Pt continues with grimacing and increased irritability; difficult to redirect and provide care/assessment. Noted febrile. Record review of Resident #2's nursing progress notes revealed a nurse note dated [DATE] at 8:22 AM, Authored by RN H stated, Increased agitation/hallucinating attempting to get out of bed. Record review of Resident #2's nursing progress notes revealed a nurse note dated [DATE] at 7:33 AM, Authored by RN H stated, grimacing. Record review of Resident #2's nursing progress notes revealed a nurse note dated [DATE] at 7:34 AM, Authored by RN H stated, pt febrile 101.7 axillary. Record review of Resident #2's nursing progress notes revealed a nurse note dated [DATE] at 9:48 authored by LVN I stated, refused, spitting meds out. Record review of Resident #2's nursing progress notes revealed a nurse note Authored by LVN N, dated [DATE] at 10:24 AM stated, Resident #2 was transferred to a Hospital on [DATE] 11:00 AM related to Altered mental status. This is intended to serve as notice of an emergency transfer. Interview on [DATE] at 2:14 PM with RN H confirmed she worked on [DATE] and [DATE] from 6:00 AM to 10:00 PM, on each day and was the charge nurse responsible for resident #2. She confirmed Resident #2 was refusing some medications and fluids, refusing wound care, presenting with mental confusion and aggression on [DATE] and [DATE]. RN H confirmed the air condition in the facility was not cooling the facility well and was very uncomfortable for resident #2 on [DATE] and [DATE]. RN H confirmed she attempted to perform nursing interventions by offering Resident #2 anti-psychotics and pain relievers as needed. RN H confirmed she did not report to the physician or document any nursing interventions related to Resident #2's medication and meal / fluid intake refusals, fever occurrences, and the residents increasing altered mental status and aggression. RN H confirmed she moved resident #2 and his roommate Resident #4 from room [ROOM NUMBER] to room [ROOM NUMBER] on [DATE], related to room [ROOM NUMBER] was cooler than room [ROOM NUMBER]; RN H confirmed she did not report any findings to the physician or family. Interview on [DATE] at 11:24 AM with LVN I confirmed she was the LVN responsible for Resident #2 on [DATE] and [DATE] from 2:00 PM to 6:00 am. She confirmed Resident #2 was refusing medications and care on both days. LVN I confirmed she reported the refusals to her supervisor RN H. LVN I confirmed she did not report the findings to the physician or the family. Interview on [DATE] at 3:30 PM with the facility's DON confirmed she had no report from RN H or LVN I related to Resident #2's medication refusals, wound care refusals, and meal and fluids refusals on [DATE] and [DATE]. Interview on [DATE] at 2:08 PM with the facility's APRN FNP R confirmed he had no report from anyone at the facility related to Resident #2's refusals of wound care, meals, fluids, or room change on [DATE] and [DATE]. b. Record review of Resident #2's Order Summary Report dated [DATE] revealed order of [MEDICATION NAME] tablet 2.5 mg give 1 tablet by mouth one time a day for hypertension, [MEDICATION NAME] capsule 0.4 mg (tamsulosin HCl) give 1 capsule by mouth at bed time for enlarged prostate, [MEDICATION NAME] tablet 20 mg ([MEDICATION NAME]) give 1 tablet by mouth one time a day for blood thinner, Tylenol tablet 325 mg ([MEDICATION NAME]) give 2 tablets by mouth every 6 hours as needed for pain. Record review of Resident #2's Blood Pressure Summary dated [DATE] revealed Resident#2 had systolic blood pressure (the first number - indicated how much pressure of blood is exerting against artery walls when heart beat) from [DATE] to [DATE] was equal or greater than 90 mmHg. Record review of Resident #2's pulse summary dated [DATE] revealed Resident #2 had heart rate (pulse) from [DATE] to [DATE] was greater than 60 beat per minutes. Record review of Resident #2's vital sign was documented by LVN M on [DATE] at 9:45 AM revealed blood pressure was ,[DATE] mmHg and pulse was 59 beat per minute. Record review of Resident #2 Medication Administration Record [REDACTED]#2 on [DATE] for the morning dose. Further review revealed [MEDICATION NAME] tablet 20 mg give 1 tablet by mouth one time a day for blood thinner was documented as administered to Resident #2 on [DATE] for the morning dose. Interview on [DATE] at 11:05 AM with LVN M confirmed she documented on [DATE] at 9:45 AM blood pressure ,[DATE] mmHg and pulse 59 beat per minute. LVN M confirmed she took Resident #2's vital signs, wrote them down, and moved on to another resident. LVN M confirmed she did not recheck Resident #2's blood pressure and pulse because there was no significant going on with Resident #2. LVN M confirmed blood pressure and pulse did not give her any alarm concern because Resident #2 just woke up and responded, therefore, LVN M did not check his blood pressure again and did not notify the physician or nurse practitioner. c. Record review of Resident #2's vital sign documented by LVN L on [DATE] at 10:01 PM revealed blood pressure was ,[DATE] mmHg and pulse was 56 beat per minute. Further review Resident #2's vital signs documented by LVN L on [DATE] at 5:41 AM revealed blood pressure was ,[DATE] mmHg and pulse was 54 beat per minute. Interview on [DATE] at 5:22 PM with LVN L confirmed she documented Resident #2's blood pressure [DATE] at 10:01 PM was ,[DATE] mmHg and blood pressure on [DATE] at 5:41 AM was ,[DATE] mmHg. LVN further confirmed on [DATE] at 5:24 PM she believed Resident #2's blood pressure - ,[DATE] mmHg and ,[DATE] mmHg was his baseline and his response was normal, so LVN L did not notify the physician or nurse practitioner. Interview on [DATE] at 3:34 PM with LVN L confirmed Resident #2's blood pressure of ,[DATE] mmHg and pulse was 56 beat per minutes and blood pressure ,[DATE] mmHg and pulse was 54, she did not check the blood pressure and the pulse again, did not review resident's trending of blood pressure and pulse, and she did not notify the physician or nurse practitioner because she was being told by LVN K that Resident #2's blood pressure and heart rate run low. Interview on [DATE] at 5:38 PM with the DON confirmed Resident #2's blood pressure look lower on [DATE] at 9:45 AM was ,[DATE] mmHg, [DATE] at 10:01 PM was ,[DATE] mmHg, and [DATE] at 5:41 AM was ,[DATE] mmHg. Interview on [DATE] at 5:42 PM with the DON confirmed Resident #2's pulse look lower on [DATE] at 9:45 AM was 59 beat per minute, [DATE] at 10:01 PM was 56 beat per minute, and [DATE] at 5:41 AM was 54 beat per minute. Interview on [DATE] at 5:52 PM with the DON confirmed the nurse should have called the physician or nurse practitioner on Resident #2's low blood pressure and pulse. 3. Record review of Resident #3's admission record dated [DATE] with admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's order summary order dated [DATE] revealed orders of Accucheck blood sugar three times per day for [MEDICAL TREATMENT]/sliding scale, monitor vital sign every shift report any abnormal result to MD, insulin [MEDICATION NAME] solution 100 unit/mL inject 8 unit subcutaneously one time a day for diabetes. Further review revealed there was order created on [DATE] and ended [DATE] read [MEDICATION NAME] Hypokit Solution Reconstituted 1 MG inject 1 mg subcutaneously one time only for Resident blood sugar at 43 during last round for 1 day. Record review of Resident #3's progress note documented by RN J dated [DATE] at 5:08 AM revealed Resident more effort to arouse on second rounds. Vital sign taken. Resident on [MEDICAL TREATMENT] blood sugar taken to be @ 43mg/dl. [MEDICATION NAME] given. Sugar dissolved in H2O rubbed around in her gums. 30 minutes later resident more easily follows commands. Pending blood sugar value post [MEDICATION NAME] 1mg administration and added sugar to resident's gums. Further review Resident #3's progress note dated [DATE] at 5:56 AM revealed Resident able to follow commands more readily. Able to stick out tongue when giving carbohydrate source. Able to move arms on command to wipe face. B/S currently 60mg/dl 1hr post Glugacon 1mg. Interview on [DATE] at 10:40 AM RN J confirmed while he was documenting at nursing station and an aide informed him that Resident #3 was acting differently. He went to Resident #3's room and assessed her. RN J said Resident #3 was slow to answer the question, Resident #3 know her name, but did not know where she was at. RN J stated he checked her blood sugar and found out it was low, then he gave her [MEDICATION NAME] and supplemental carbohydrate because she was able to take thing by mouth. RN J confirmed the whole facility had standing order for [MEDICATION NAME] and carbohydrate supplemental if resident had low blood sugar and change level of consciousness, he stated, because you don't have time to call the provider. RN J confirmed after giving Resident #3 was given [MEDICATION NAME] and carbohydrate supplemental, she was able to response and answer question appropriately and back to her baseline. Interview on [DATE] at 10:43 AM with RN J confirmed he did not notify the physician or nurse practitioner regarding Resident #3's low blood sugar and needed [MEDICATION NAME] injection. RN J further confirmed he did not document on SBAR report, but he confirmed he document on progress note because of standing order. Interview on [DATE] at 6:11 PM with the DON confirmed the RN J should have notified the physician or nurse practitioner, and RN J should have done the SBAR because Resident #3 had change of condition due to low blood sugar. Interview on [DATE] at 6:16 PM with RN F - Regional Compliance Nurse and the DON confirmed they did not see the SBAR for the incident of Resident #3's low blood sugar on [DATE]. Interview on [DATE] at 8:59 AM with NP R confirmed for resident had low blood sugar the nurse should have used clinical judgment to assess the patient whether the patient was alert, coherent, or having [MEDICAL CONDITION] or respiratory status was stable or not. If resident need oxygen, diaphoretic, non-response, and elevated heart rate the patient can treat with [MEDICATION NAME] and watch them come out of hypoglycemic safely and the vital sign was stable. The nurse should report to the physician about resident's low blood sugar, and there would be a review of medication why patient blood sugar went so low, was it the compliance issue or diet issue, how many times happened before or resident acutely ill. If patient went to situation of blood sugar was low and being corrected with [MEDICATION NAME], once the patient stable the nurse should have check resident blood sugar every hour or at least couple hours to make sure resident eating and go back to check blood sugar as routine schedule. Interview on [DATE] at 9:03 AM NP R confirmed resident #3 had change of condition because she had symptomatic of low blood sugar and need [MEDICATION NAME], therefore, the nurse should have notified the NP or physician and complete SBAR report. Interview on [DATE] at 10:06 AM with the Medical Director confirmed depend on resident condition, if patient conscious, the nurse should administer orange juice or glucose tablet. The Medical Director further confirmed the nurse could administer [MEDICATION NAME] if there was an order was available. The Medical Director stated usually after the nurse stabilized resident with [MEDICATION NAME], the nurse should check blood sugar every 2 hours and if the blood sugar was back to normal they should check resident blood sugar on their regular schedule such as AC&HS - before meal and at bed time or every 6 hours. 4. Record review of Resident #4's admission record revealed an admitted [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's progress notes revealed no nursing documentation on [DATE] through [DATE]. Record review of Resident #4's progress notes revealed a nursing note on [DATE] at 6:00 PM, authored by RN H stating Pt in respiratory distress/ unresponsive. 911 called and transferred to downtown (wrote name of hospital). (family) notified. Interview on [DATE] at 2:14 PM with RN H confirmed she worked on [DATE] and [DATE] from 6:00 AM to 10:00 PM, on each day and was the charge nurse responsible for resident #4. She confirmed Resident #4 refused some medications and fluids as well as presented with mental confusion and developed a fever on [DATE] and [DATE]. RN H confirmed the air conditioning in the facility was not cooling the facility well and was very uncomfortable for resident #4 on [DATE] and [DATE]. RN H confirmed she did not report to the physician or document any nursing interventions related to Resident #4's medication and meal / fluid intake refusals or Resident #4's fever. RN H confirmed she did not report to the resident's family or her supervisor. RN H confirmed she attempted to perform nursing interventions and offered Resident #4 water and applyed wet towels to his person. RN H confirmed she moved Resident #4 and his roommate Resident #2 on [DATE] to another room that was not as warm. RN H confirmed she did not report the room change or the rationale for the room change to her supervisor, the physician or family, when asked why she did not report her findings to anyone, she did not provide a rationale. Interview on [DATE] at 3:30 PM with the facility's DON confirmed she had no report from RN H related to Resident #4's medication, meal and fluids refusals on [DATE] and [DATE], or room change on [DATE]. Interview on [DATE] at 11:30 AM with Resident #4's family representative confirmed the family did not receive any status update from the facility prior to the report of Resident #4 being sent out via 911 to the hospital on [DATE]. Interview on [DATE] at 2:08 PM with the facility's NP R confirmed he had no report from anyone at the facility related to Resident #4's refusals of medications, meals, fluids, or room change on [DATE] and [DATE]. Record review of the facility's Notifying the Physician of Change of Status, dated [DATE], revealed bullet #1 the nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time and date of call to physician, and interventions that were implemented in the resident's clinical record.; and bullet #2 stating .the nurse is responsible .for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. The Administrator was notified on IJ on [DATE] at 10:42 PM and was given a copy of the IJ templated and a Plan of Removal was requested. The Plan of Removal accepted on [DATE] at 11:50 AM. On [DATE] at 5:47 PM Plan of Removal received from the DON. The facility's Plan of Removal included the following steps to be taken by the facility: ALLEGED ALLEGATIONS: Documentation / Neglect: Staff facility failed to assess residents' vital signs and signs and symptoms of COVID residents. Interventions: The following in-services were initiated by the DON, ADON and regional nurse on [DATE]: Any staff member not present or in-serviced on [DATE], will not be allowed to assume their duties until in-serviced. Licensed Nurses will be In Service on the following: In- Service on Documentation in PCC In-Service on COVID Assessment q shift - completing COVID Assessment Q shift In Service on obtaining Vital Signs - Inservice on Obtaining Vital Signs each shift and as needed. Inservice on Change of Condition which includes a specific change and Physician/NP notification, and any interventions or orders. In service on Abuse/Neglect The medical director was notified of the immediate jeopardy situation on 11:39pm Monitoring The DON / designee will monitor scheduled assessments 7 days a week to ensure all assessments were completed. The DON/designee will ask 10 nurses randomly on various shifts per week for 6 weeks What they would do and document if a resident had a change of condition. The DON/designee will review the 24-hour report 7 days a week to ensure COVID assessments are done each shift and vital signs are taken as ordered. The QA committee will review findings and makes changes as needed. The surveyor verification of the Plan of Removal on [DATE] was as follows: Interview on [DATE] at 2:22 PM with LVN W confirmed he received in-service/training on completing COVID assessments every shift, checked resident vital sign every 4 hour, call physician and document on Resident change of change of condition under SBAR form because COVID patient changed drastically. LVN W further confirmed resident change of condition could be resident become confused, decrease in urine output, or vital sign was out of range. Interview on [DATE] at 3:53 PM with agency staff - LVN Z and EMT AA confirmed they received training on all the documentation on PCC such as SBAR and incident report. LVN Z and EMT AA confirmed COVID assessment need to complete every shift and vital sign every 4 hour for COVID residents. LVN Z and EMT AA also confirmed receiving training on abuse and neglect. Interview on [DATE] at 4:50 PM with RN BB confirmed he received training on documentation in PCC regarding completing COVID assessment, document vital sign, and documentation on notify physician when resident had change of condition. RN BB further confirmed received training on abuse and neglect. Interview on [DATE] at 4:57 PM with RN B confirmed she received training on documentation of COVID Assessment, vital sign, notifying physician and document on resident's change of condition. Interview on [DATE] at 5:11 PM with LVN CC confirmed she received training during mandatory meeting about documentation. LVN CC confirmed documentation on COVID assessment, vital signs. LVN CC confirmed she need to inform the physician when resident had any change such as vital sign off baseline and residents not their normal self. LVN CC confirmed she need to document on intervention, notifying physician and imitated SBAR form. LVN CC confirmed she received training on abuse and neglect. Interview on [DATE] at 7:21 PM with LVN I confirmed she received in-service training on documentation on PCC such as SBAR form for resident change of condition, vital sign and COVID assessment. Record review of the facility in-service training attendance roster titled Completing COVID Assessment - Nurse will complete COVID Assessment on Resident Q shift. Each shift will obtain new set up vital signs and assess resident and complete COVID assessment dated [DATE] revealed 14 of 14 Licensed staff signed the in-service roster; 7 of 7 licensed agency nurses signed the in-service roster Record review of facility in-service training attendance roster titled Notifying the physician of change in status dated [DATE] revealed 14 of 14 Licensed staff signed the in-service roster; 7 of 7 licensed agency nurses signed the in-service roster. Verified on [DATE] revealed DON documented monitor schedule assessment in PCC from [DATE] - [DATE] Verified on [DATE]/2020 revealed DON asked 3 LVN on ,[DATE]; 2 LVNs on ,[DATE]; 1 LVN on ,[DATE]; and 3 LVNs on ,[DATE] on change of condition. Verified on [DATE] revealed DON monitored 24-hour report from [DATE] - [DATE] On [DATE] at 4:41 PM, the Area Director of Operations, Regional Compliance Nurse - RN F, Assistant Administrator, Director of Nursing, and LVN G - Assistant Director of Nursing were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as a pattern due to residents on-going need for assessments for signs and symptoms of COVID-19.

Based on interviews and record reviews, the facility failed to ensure residents were free from neglect for 8 of 30 residents (Residents #1, #2, #3, #9, #27, #28, #29, and #30) whose care was reviewed for neglect, in that: 1. The facility failed to ensure processes were developed and implemented to ensure staff communicated with physician when Residents (#1, #2 and #3) had a change of condition. a. LVN K and LVN L did not call the physician or nurse practitioner when Resident #1 had a change in condition and was placed on 6 liters - of oxygen via non-rebreather mask for an oxygen saturation of 80% on room air. b. LVN M did not notify physician or the nurse practitioner when Resident #2's blood pressure dropped to ,[DATE] mmHg and pulse 59 beat per minutes on [DATE] during 6 AM - 2 PM Shift. c. LVN L did not notify the physician or the nurse practitioner when Resident #2 had blood pressure of ,[DATE] mmHg and pulse 56 beat per minutes on [DATE] during 2 PM - 10 PM shift and ,[DATE] mmHg and 54 beat per minutes on [DATE] during 10 PM - 6 AM shift. d. RN J did not notify physician after Resident #3's had a low blood sugar on [DATE]. 2. The facility failed to implement a process to ensure staff completed a COVID Assessment resulting in Resident #1, #2, and #3 not being assessed for COVID 19 sign and symptoms every shift. a. Resident #1 did not have COVID assessment on [DATE] during 6AM - 2 PM shift and 2 PM - 10 PM Shift. b. Resident #2 did not have COVID assessment on [DATE] during 2PM - 10 PM shift and on [DATE] and [DATE] during 6 AM - 2 PM shift and 2 PM - 10 PM shift. c. Resident #3 did not have COVID assessment on [DATE] during 6 AM - 2 PM shift and 2 PM - 10 PM shift. 3. The facility failed to have a structure to ensure staff wear proper PPE when they worked in the positive COVID unit. a. RN B did not wear eye protection when she performed blood sugar checks for COVID positive Residents. b. Housekeeper A came out of a COVID positive residents' rooms went with a surgical mask instead of a N95 mask. c. Housekeeper A walked out of the back door at end of hall and walked back in with a surgical mask instead of N95 mask. d. CNA C did not wear gloves when delivering meal tray to Resident #29 and did not sanitize or wash her hands after delivering meal tray. e. CNA D did not wear gloves and did not sanitize or wash her hands after touching the light switch and delivery of a meal tray to Resident #9. f. RN E did not wear a face shield or goggles when she entered to Resident #30's room to deliver a meal tray. g. LVN K did not wear a face shield or googles when she performed swab test for Resident #27 and Resident #28. h. Medication Aide O entered positive COVID unit without PPE and did not put on PPE until she entered the medication room inside the COVIVD positive unit. These deficient practices could affect COVID positive Residents who had change of condition were not being assessed and identified, could place them at risk of infection from transmission of communicable disease and could result in worsening health status, hospitalization , and death. These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE]. The immediacy was lifted on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all COVID Residents. The findings were: 1a. Record review of Resident #1's admission record dated [DATE] revealed an admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's order summary report dated [DATE] revealed an order of [MEDICATION NAME] tablet 325 MG give 2 tablets by mouth every 6 hours as needed for elevated temperature; moderate pain. Start date: [DATE]. Record review of Resident #1's Treatment Administration Record schedule for ,[DATE] dated [DATE] - [DATE] revealed [MEDICATION NAME] tablet 325 mg give 2 tablets by mouth every 6 hours as needed for elevated temperature; moderate pain was documented as administering to Resident #1 at 7:39 PM. Record review of Resident #1's documentation on oxygen saturation dated [DATE] revealed oxygen saturation at 1:41 AM was 97 % room air, at 9:09 AM was 95% room air, at 6:23 PM 94% room air, at 8:36 PM was 93% high flow oxygen, at 8:46 PM was 97% high flow oxygen. Record review of Resident #1's progress noted dated [DATE] at 8:49 PM written by LVN K revealed Resident presented with a 100.4 fever, this nurse and other nurse helped resident, this nurse gave him tylenol 650mg by mouth, and other nurse gave tylenol suppository to help bring down the fever, also placed resident on oxygen 6L via non-rebreather mask. Rechecked temperature of patient and it was 99.5, resident O2 sat was at 97% on 6L via non-rebreather, resident appeared stable and resting. This nurse and other nurse left room for ,[DATE] minutes to attend to other resident's needs, did not call family prior because patient appeared stable. This nurse and other nurse went to check again on the patient and patient was gasping for air and not responding to stimuli, verbal or physical. Other nurse immediately started CPR on resident, CNA went to grab crash cart and brought it to the patient's room. This nurse put AED pads on resident, turned on AED, AED said no shockable rhythm noted, other nurse continued CPR, this nurse came and called emergency responders, emergency responders came and relieved nurse of CPR duties, this nurse came to nurses' station and called responsible party of situation. Resident is currently on stretcher with EMS, providing emergency care, will monitor resident. Record review of Resident #1's SBAR - 8hr. - V2 with effective date [DATE] 20:35 revealed date and time MD or NP notified was on [DATE] at 8:30 PM Record review of EMS Patient Care Report dated [DATE] revealed EMS was notified on [DATE] at 8:20 PM. Review EMS's assessment at 8:36 PM revealed breathing absent, pulse carotid absent; mental status: unresponsive. Interview on [DATE] at 4:14 PM with LVN K she confirmed LVN L was making round shortly after dinner and saw Resident #1 was gasping for air. LVN K stated she checked Resident #1's vital signs which revealed oxygen saturation was at 80% on room air, and temperature 100.4 F. LVN K confirmed she administered Tylenol by mouth and suppository and administered 6 liters of oxygen via non-rebreather for Resident #1. LVN K stated she rechecked Resident #1's temperature and oxygen saturation which revealed 99.5 F and 97% on 6 liters of oxygen via non-rebreather mask. LVN K confirmed Resident #1 appear resting and stable, so LVN K and LVN L left Resident #1 room and went check other residents for 5 - 10 minutes. LVN K confirmed when LVN K and LVN returned and checked on Resident #1, they noticed Resident #1 was gasping for air, and Resident #1 did not respond to verbal command and sternal rub. LVN K confirmed LVN L initiated CPR, and LVN K brought crash cart. Interview on [DATE] at 4:28 PM with LVN K confirmed she initiated SBAR after calling 911, and then she notified the nurse practitioner and family. Interview on [DATE] at 5:00 PM with LVN L confirmed LVN K asked LVN L to check on Resident #1 toward the end of shift. LVN L confirmed she found out Resident #1 had elevated temperatures approximately 102-degree Fahrenheit and oxygen saturation was low at 88% on room air. LVN L confirmed she administered Tylenol 650 suppository and administered 6 liters of oxygen via non-rebreather mask. LVN L confirmed she sat with Resident #1 for 20 minutes. Then, she checked Resident #1's temperature and oxygen saturation again revealed temperature was at 99-degree Fahrenheit and oxygen saturation was 98% on 6 liters of oxygen via non-rebreather mask. LVN L stated she went out to change her PPE because her PPE was torn, and LVN K stayed with Resident #1. LVN L further confirmed she then left the unit for break and did not know if LVN K remained to stay with Resident #1 or not. LVN L stated after she went on break for about 20 minutes, and while she was talking with the receptionist, LVN K asked LVN L to come back the unit and told LVN L that I think he passed away. LVN L said she put on PPE and rushed Resident #1's room. LVN L stated she checked Resident #1 revealed no pulse and no breathing, and then she started CPR. LVN L stated Maintenance brought the crash cart, LVN K called EMS. Then, EMS came and took over the CPR. EMS tried to resuscitate Resident #1 for 45 minutes. LVN L stated LVN K had nurse practitioner and family on the phone. Interview on [DATE] at 4:50 PM with the DON confirmed according to the SBAR note the nurse had notified the doctor when she noticed Resident #1's elevated temperature and got order from the physician for Tylenol 650 mg by mouth and suppository. Interview on [DATE] at 4:55 PM with DON stated it was ok for the nurse to step out Resident #1's room after stabilizing Resident #1. Interview on [DATE] at approximately 8:49 AM with Nurse Practitioner R confirmed the nurse should have notified the physician or the nurse practitioner after stabilizing Resident #1 with Tylenol and oxygen. Nurse Practitioner R confirmed if Resident #1 was on room air or was on oxygen via nasal canula and later Resident #1 need to be on 6 liters of oxygen via non-rebreather mask, then Resident #1 had a change in condition. Nurse Practitioner R stated he did not know about Resident #1 was on 6 litters of oxygen via non-rebreather mask. Nurse Practitioner R stated the nurse at the facility communicated with him after Resident #1 expired. b. Record review of Resident #2's face sheet date [DATE] revealed an admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Order Summary Report dated [DATE] revealed order of [MEDICATION NAME] tablet 2.5 mg give 1 tablet by mouth one time a day for hypertension, [MEDICATION NAME] capsule 0.4 mg (tamsulosin HCl) give 1 capsule by mouth at bed time for enlarged prostate, [MEDICATION NAME] tablet 20 mg ([MEDICATION NAME]) give 1 tablet by mouth one time a day for blood thinner, Tylenol tablet 325 mg ([MEDICATION NAME]) give 2 tablets by mouth every 6 hours as needed for pain. Record review of Resident #2's Blood Pressure Summary dated [DATE] revealed Resident#2 had systolic blood pressure (the first number - indicated how much pressure of blood is exerting against artery walls when heart beat) from [DATE] to [DATE] was equal or greater than 90 mmHg. Record review of Resident #2's pulse summary dated [DATE] revealed Resident #2 had heart rate (pulse) from [DATE] to [DATE] was greater than 60 beat per minutes. Record review of Resident #2's vital signs was documented by LVN M on [DATE] at 9:45 AM revealed blood pressure was ,[DATE] mmHg and pulse was 59 beat per minute. Record review of Resident #2 Medication Administration Record [REDACTED]#2 on [DATE] for the morning dose. Further review revealed [MEDICATION NAME] tablet 20 mg give 1 tablet by mouth one time a day for blood thinner was documented as administered to Resident #2 on [DATE] for the morning dose. Interview on [DATE] at 11:05 AM with LVN M confirmed she documented on [DATE] at 9:45 AM bp ,[DATE] mmHg and pulse 59 beat per minute. LVN M confirmed she took Resident #2's vital signs, write them down, and moved on to another resident. LVN M confirmed she did not recheck Resident #2's blood pressure and pulse because there was nothing significant going on with Resident #2. LVN M confirmed blood pressure and pulse did not give her any alarm concern because Resident #2 just woke up and responded, therefore, LVN M did not check his blood pressure again and did not notify the physician or nurse practitioner. c. Record review of Resident #2's vital sign documented by LVN L on [DATE] at 10:01 PM revealed blood pressure was ,[DATE] mmHg and pulse was 56 beat per minute. Further review Resident #2's vital signs documented by LVN L on [DATE] at 5:41 AM revealed blood pressure was ,[DATE] mmHg and pulse was 54 beat per minute. Interview on [DATE] at 5:22 PM with LVN L confirmed she documented Resident #2's blood pressure [DATE] at 10:01 PM was ,[DATE] mmHg and blood pressure on [DATE] at 5:41 AM was ,[DATE] mmHg. LVN further confirmed on [DATE] at 5:24 PM she believed Resident #2's blood pressure - ,[DATE] mmHg and ,[DATE] mmHg was his baseline and his response was normal, so LVN L did not notify the physician or nurse practitioner. Interview on [DATE] at 3:34 PM with LVN L confirmed Resident #2's blood pressure of ,[DATE] mmHg and pulse was 56 beat per minutes and blood pressure ,[DATE] mmHg and pulse was 54, she did not check the blood pressure and the pulse again, did not review resident trending blood pressure and pulse, and she did not notify the physician or nurse practitioner because she was being told by LVN K that Resident #2's blood pressure and heart rate run low. Interview on [DATE] at 5:38 PM with the DON confirmed Resident #2's blood pressure look lower on [DATE] at 9:45 AM was ,[DATE] mmHg, [DATE] at 10:01 PM was ,[DATE] mmHg, and [DATE] at 5:41 AM was ,[DATE] mmHg. Interview on [DATE] at 5:42 PM with the DON confirmed Resident #2's pulse look lower on [DATE] at 9:45 AM was 59 beat per minute, [DATE] at 10:01 PM was 56 beat per minute, and [DATE] at 5:41 AM was 54 beat per minute. Interview on [DATE] at 5:52 PM with the DON confirmed the nurse should have called the physician or nurse practitioner on Resident #2's low blood pressure and pulse. d. Record review of Resident #3's admission record dated [DATE] with admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's order summary order dated [DATE] revealed orders of Accucheck blood sugar three times per day for [MEDICAL TREATMENT]/sliding scale, monitor vital sign every shift report any abnormal result to MD, insulin [MEDICATION NAME] solution 100 unit/mL inject 8 unit subcutaneously one time a day for diabetes. Further review revealed there was order created on [DATE] and ended [DATE] read [MEDICATION NAME] Hypokit Solution Reconstituted 1 MG inject 1 mg subcutaneously one time only for Resident blood sugar at 43 during last round for 1 day. Record review of Resident #3's progress note documented by RN J dated [DATE] at 5:08 AM revealed Resident more effort to arouse on second rounds. Vital sign taken. Resident on [MEDICAL TREATMENT] blood sugar taken to be @ 43mg/dl. [MEDICATION NAME] given. Sugar dissolved in H2O rubbed around in her gums. 30 minutes later resident more easily follows commands. Pending blood sugar value post [MEDICATION NAME] 1mg administration and added sugar to resident's gums. Further review Resident #3's progress note dated [DATE] at 5:56 AM revealed Resident able to follow commands more readily. Able to stick out tongue when giving carbohydrate source. Able to move arms on command to wipe face. B/S currently 60mg/dl 1hr post Glugacon 1mg. Interview on [DATE] at 10:40 AM RN J confirmed while he was documenting at nursing station and an aide informed him that Resident #3 was acting differently. He went to Resident #3's room and assessed her. RN J said Resident #3 was slow to answer the question, Resident #3 know her name, but did not know where she was at. RN J stated he checked her blood sugar and found out it was low, then he gave her [MEDICATION NAME] and supplemental carbohydrate because she was able to take thing by mouth. RN J confirmed the whole facility had standing order for [MEDICATION NAME] and carbohydrate supplemental if resident had low blood sugar and change level of consciousness, he stated, because you don't have time to call the provider. RN J confirmed after giving Resident #3 was given [MEDICATION NAME] and carbohydrate supplemental, she was able to response and answer question appropriately and back to her baseline. Interview on [DATE] at 10:43 AM with RN J confirmed he did not notify the physician or nurse practitioner regarding Resident #3's low blood sugar and needed [MEDICATION NAME] injection. RN J further confirmed he did not document on SBAR report, but he confirmed he document on progress note because of standing order. Interview on [DATE] at 6:11 PM with the DON confirmed the RN J should have notified the physician or nurse practitioner, and RN J should have done the SBAR because Resident #3 had change of condition due to low blood sugar. Interview on [DATE] at 6:16 PM with RN F - Regional Compliance Nurse and the DON confirmed they did not see the SBAR for the incident of Resident #3's low blood sugar on [DATE]. Interview on [DATE] at 8:59 AM with NP R confirmed for resident had low blood sugar the nurse should have used clinical judgment to assess the patient whether the patient was alert, coherent, or having [MEDICAL CONDITION] or respiratory status was stable or not. If resident need oxygen, diaphoretic, non-response, and elevated heart rate the patient can treat with [MEDICATION NAME] and watch them come out of hypoglycemic safely and the vital sign was stable. The nurse should report to the physician about resident's low blood sugar, and there would be a review of medication why patient blood sugar went so low, was it the compliance issue or diet issue, how many times happened before or resident acutely ill. If patient went to situation of blood sugar was low and being corrected with [MEDICATION NAME], once the patient stable the nurse should have check resident blood sugar every hour or at least couple hours to make sure resident eating and go back to check blood sugar as routine schedule. Interview on [DATE] at 9:03 AM NP R confirmed resident #3 had change of condition because she had symptomatic of low blood sugar and need [MEDICATION NAME], therefore, the nurse should have notified the NP or physician and complete SBAR report. Interview on [DATE] at 10:06 AM with the Medical Director confirmed depend on resident condition, if patient conscious, the nurse should administer orange juice or glucose tablet. The Medical Director further confirmed the nurse could administer [MEDICATION NAME] if there was an order was available. The Medical Director stated usually after the nurse stabilized resident with [MEDICATION NAME], the nurse should check blood sugar every 2 hours and if the blood sugar was back to normal they should check resident blood sugar on their regular schedule such as AC&HS - before meal and at bed time or every 6 hours. 2a. Record review of Resident #1's Assessments revealed the last assessment before [DATE] (6 AM - 2 PM shift) was COVID assessment dated [DATE] at 3:58 PM and the next assessment after [DATE] (2 PM -10 PM shift) was COVID assessment dated [DATE] at 00:58 AM. Further review revealed there was no COVID Assessment on [DATE] during 6 AM - 2 PM shift and 2 PM - 10 PM shift. Interview on [DATE] at 9:21 AM with LVN I confirmed there was no COVID assessment for Resident #1 on [DATE] during 6 AM -2 PM and 2 PM -10 PM. she stated it was busy during day shift, but night shift had more time to do assessment. Interview on [DATE] at 5:27 PM with the DON confirmed she did not see the COVID Assessment for Resident #1 on [DATE] during 6AM - 2 PM shift and 2PM - 10 PM. She further confirmed she only saw other assessments documented in progress note and vital sign during 6AM - 2PM shift and 2PM - 10 PM shift. b. Record review of Resident #2's Assessments dated on [DATE] revealed Weekly Nursing summary dated [DATE] at 5:54 PM and COVID assessment dated [DATE] at 1:52 PM. Further review revealed there was no documentation on COVID Assessment on [DATE] during 2 PM - 10 PM shift. Interview on [DATE] at 3:24 PM with LVN K confirmed she worked on [DATE] during 2 PM - 10 PM shift on East Wing. LVN K further confirmed there was no COVID assessment for Resident #2 on her shift on [DATE]. LVN K explained she had 5 admissions on that day and another nurse who worked with her on that day should have done COVID assessment for Resident #2. Record review of Resident #2's Assessments revealed the last assessment before [DATE] (6AM - 2PM shift) was COVID assessment dated [DATE] at 1:52 PM and the next assessment after [DATE] (2 PM - 10 PM shift) was COVID assessment dated [DATE] at 4:22 AM. Further review revealed there was no documentation on [DATE] and [DATE] during 6 AM - 2 PM and 2 PM - 10 PM shift. Interview on [DATE] at 7:57 PM with RN H confirmed she did not have time do COVID assessment for Resident #2 on [DATE] and [DATE] during her shift 6AM - 2PM. RN H further confirmed she expected LVN I came in during 2 PM -10 PM shift to help her to complete the COVID Assessment. Interview on [DATE] at 9:16 AM with LVN I confirmed there was no COVID assessment for Resident #2 on [DATE] and [DATE] during 6 AM - 2 PM and 2 PM-10 because it was busy during the morning shift, so night shift had more time to do assessment. c. Record review of Resident #3's Assessments revealed there was no COVID Assessment on [DATE] during 6 AM - 2 PM shift and 2 PM - 10 PM shift. Further review revealed the assessment before [DATE] (6 AM - 2 PM shift) was Skilled Nurses Notes dated [DATE] at 01:35 AM, and the assessment after [DATE] (2 PM - 10 PM shift) was Skilled Nurse Notes dated [DATE] at 04:27 AM. Interview on [DATE] at 4:35 PM with the DON confirmed there was no COVID Assessment for Resident #3 on [DATE] during 6 AM - 2 PM and 2 PM - 10 PM shift. Interview on [DATE] at 4:38 PM with the DON confirmed the license nurse could complete COVID Assessment, Respiratory Screen, or Skilled Nurse Note to consider as assessed Resident with COVID every 12 hours. The DON further confirmed when any resident admitted to the facility, the computer would automatically generate assessment to complete every 12 hours. The DON confirmed the facility updated to assess COVID resident every 8 hours. Interview on [DATE] at 4:43 PM with the DON confirmed vital sign should be done every shift. Interview on [DATE] at 4:44 PM with the DON confirmed she monitored documentation for assessment and vital signs. The DON said if there was documentation missing, she would talk to the nurse. The DON further confirmed the licensed nurses received orientation up on hire and ongoing in-service training on what they are supposed to document on their assessment and vital sign. The DON confirmed weekly monitoring and now daily monitoring even on weekend on chart auditing on major change of condition, vital sign, and assessments. Interview on [DATE] at 4:48 PM the DON confirmed if the license nurse noticed a change of condition, he or she should stabilize the resident first, and call physician to let them know what going with resident. The DON said if the physician had new order for resident, the nurse should initiate the new order, and the nurse need to documentation the communication with doctor and family. Interview on [DATE] at 4:53 PM the DON confirmed there was ongoing in-service with license staff on Resident's change of condition by going over scenarios and getting feedback from staff. Interview on [DATE] at 4:55 PM with the DON confirmed run report see who had change of condition, anything change in weekend and follow up with individual resident to find out why they transfer out. The DON further confirmed if there was no documentation, she would follow up with the nurse. Interview on [DATE] at 6:55 PM with the Administrator confirmed he had been rounding on the residents and they stated they were comfortable. Administrator sated they have more than an adequate supply of eye protection (face shields, goggles) available for staff. He further stated staff should be wearing eye protection when providing direct contact care. Administrator stated he was surprised they have not had positive staff in the building as he thought some of the infection control issues were due to staff becoming complacent. He sated he thought staff were being in-serviced on COVID and infection control process by agency. Interview on [DATE] at 10:03 AM with Medical Director confirmed he managed patient at the facility. He confirmed he utilized tele-monitoring to see resident at the facility. The nurse assessed the patient and if there was any issue would reported to the nurse practitioner. Then, the nurse practitioner and the doctor would have conversation online about the patient's situation. The Medical Director confirmed the facility had their own protocol on the assessment and frequency of assessing COVID residents. When the resident had change of condition the nurse should notify the nurse practitioner, then the nurse practitioner provide any necessary order and then the nurse practitioner communicated with the medical director and make change in resident plan of care as needed. Record review of the facility's policy titled Abuse/Neglect dated [DATE] revealed the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . 7. Neglect: is the failure of the facility, its employees or service provider to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of COVID 19 plan dated [DATE] revealed .Resident Screening . Resident will be screened during their stay according to the following: at least daily for the following symptoms: fever, new or worse cough, new or worse shortness of breath, chills, repeated shaking with chills, new muscle pain or aches, headache, sore throat, new loss of taste or smell, new or worse dizziness, nausea/vomiting/diarrhea. If any of the above symptoms are assessed, the resident will be placed on contact/droplet precaution until further evaluation for COVID 19 . This facility will also review CDC guidance for Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019. Record review of Responding to Coronavirus (COVID-19) in Nursing Homes Responding to COVID-19 dated [DATE] revealed Resident with new-onset suspected or confirmed COVID-19: Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections. Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms. retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding on [DATE]. Record review of Notifying the Physician of Change in Status dated [DATE] revealed the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for medicate medical attention. This facility utilizes the INTERAC tool, Change in Condition - When to Notify the MD/NP/PA to review resident condition and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition require immediate notification of the physician and non-immediate/report on next work day notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in resident's clinical record . 6. The nurse will monitor and reassess the resident's status and response to interventions. Physician should develop a working [DIAGNOSES REDACTED]. 7. The nurse ill document all attempts to contact the physician, all attempt to notify the family and or legal representative, the physician's response, the physician orders [REDACTED]. 3. a. Observation on [DATE] at 5:00 PM revealed RN B walked in residents' rooms to conduct blood glucose without wearing a face shield or goggles. During an interview on [DATE] at 5:08 PM with RN B confirmed she did not wear face shield or goggle because the facility had a limited supply of eye protection available. Interview on [DATE] at 6:55 PM with the Administrator he confirmed the facility had more than an adequate supply of eye protection (face shields, goggles) available for staff. He further stated staff should be wearing eye protection when providing direct contact care. The Administrator stated he was surprised they have not had positive staff in the building as he thought some of the infection control issues were due to staff becoming complacent. The Administrator stated he thought nursing agency staff were being in-serviced on COVID and infection control process by agency. b. Observation on [DATE] at 5:10 PM revealed Housekeeper A came out of a COVID positive residents' room with a surgical mask on instead of a N95 mask. c. Observation on [DATE] at 5:10 PM revealed Housekeeper A walked out of the back door at end of hall and walked back in with just a surgical mask. Interview on [DATE] at 5:12 PM with RN B confirmed Housekeeper A was wearing surgical mask while he was working in the positive COVID Residents' rooms. RN B further confirmed Housekeeper A should have worn N95 mask while working in COVID positive unit. d. Record review of Resident #29's admission record dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on [DATE] at 5:42 PM revealed CNA C did not wear gloves when she placed meal tray on a bedside table of Resident #29. Further observation revealed CNA C did not sanitize or wash her hands after exiting Resident #29's room. CNA C continue getting another meal tray at the nursing station to deliver to another resident. During an interview on [DATE] at 5:45 PM with CNA C she did not wear gloves when she took the tray into Resident #29's room. She also confirmed she did not wash or sanitize her hands after delivering the tray to Resident #29's room. CNA C further stated she had not had in-service training on caring for COVID positive residents. e. Record review of Resident #9's admission record date [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on [DATE] at 5:42 PM revealed CNA D did not wear gloves when she delivered meal tray to Resident #9's room. Further observation revealed CNA D turned the light switch on in Resident #9's room and placed the meal tray on a bedside table with her bare hands. Without sanitizing or washing her hands, CNA D continued to pass out a meal tray to another resident. Interview on [DATE] at 5:47 PM with CNA D confirmed she turned the light switch on and placed the meal tray on bedside table for Resident #9 without wearing gloves. CNA D further confirmed she did not sanitize or wash her hands after exiting Resident #9's room. <b(TRUNCATED)

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment for 5 of 30 Residents (Resident #9, #27, #28, #29 and #30) reviewed for COVID-19, 3 of 30 Residents (Resident #1, #2, and #3) reviewed for COVID 19 Assessment, and 7 of 77 employees (RN B, Housekeeper A, CNA C, CNA D, RN E, LVN K, MA O) reviewed for proper PPE, in that: 1. RN B did not wear eye protection when she performed blood sugar checks for COVID positive Residents. 2a. Housekeeper A came out of a COVID positive residents' rooms went with a surgical mask instead of a N95 mask. b. Housekeeper A walked out of the back door at end of hall and walked back in with a surgical mask instead of N95 mask. 3. Housekeeper A walked out of the hot zone positive COVID hall with PPE to the warm zone and returned to the hot zone with same PPE on. 4. Staff did not wear proper PPE while working in the COVID positive unit. a. CNA C did not wear gloves when delivering meal tray to Resident #29 and did not sanitize or wash her hands after delivering meal tray. b. CNA D did not wear gloves and did not sanitize or wash her hands after touching the light switch and delivery of a meal tray to Resident #9. c. RN E did not wear a face shield or goggles when she entered to Resident #30's room to deliver a meal tray. d. LVN K did not wear a face shield or googles when she performed swab test for Resident #27 and Resident #28. e. Medication Aide O entered positive COVID unit without PPE and did not put on PPE until she entered the medication room inside the COVIVD positive unit. 5. LVN K allowed surveyor to enter the facility without screening for COVID-19 and checking surveyor's temperature. 6. a. Resident #1 did not have COVID assessment on 7/4/2020 during 6AM - 2 PM shift and 2 PM - 10 PM Shift. b. Resident #2 did not have COVID assessment on 7/3/2020 during 2PM - 10 PM shift and on 7/4/2020 and 7/5/2020 during 6 AM - 2 PM shift and 2 PM - 10 PM shift. c. Resident #3 did not have COVID assessment on 7/5/2020 during 6 AM - 2 PM shift and 2 PM - 10 PM shift. These deficient practices affected residents at the facility and place them at risk of infection from transmission of communicable diseases and could result in a decline in health and/or death. These failures resulted in identification of Immediate Jeopardy (IJ) on 07/12/2020 at 10:42 PM. While the IJ was removed 7/21/2020, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place to ensure residents were being monitored and assessed for signs and symptoms of COVID-19. The findings were: 1. Observation on 7/12/20 at 5:00 PM revealed RN B walked in residents' rooms to conduct blood glucose without wearing a face shield or goggles. During an interview on 7/12/20 at 5:08 PM with RN B confirmed she did not wear face shield or goggle because the facility had a limited supply of eye protection available. Interview on 7/12/2020 at 6:55 PM with the Administrator he confirmed the facility had more than an adequate supply of eye protection (face shields, goggles) available for staff. He further stated staff should be wearing eye protection when providing direct contact care. The Administrator stated he was surprised they have not had positive staff in the building as he thought some of the infection control issues were due to staff becoming complacent. The Administrator stated he thought nursing agency staff were being in-serviced on COVID and infection control process by agency. 2a. Observation on 7/12/20 at 5:10 PM revealed Housekeeper A came out of a COVID positive residents' room with a surgical mask on instead of a N95 mask. 2b. Observation on 7/12/20 at 5:10 PM revealed Housekeeper A walked out of the back door at end of hall and walked back in with just a surgical mask. Interview on 7/12/20 at 5:12 PM with RN B confirmed Housekeeper A was wearing surgical mask while he was working in the positive COVID Residents' rooms. RN B further confirmed Housekeeper A should have worn N95 mask while working in COVID positive unit. 3. Observation 7/12/20 at 5:15 PM revealed Housekeeper A walked out of the hot zone positive COVID hall with PPE to the warm zone and returned with same PPE on. Interview on 7/12/2020 at 5:15 PM with RN B confirmed housekeeper A went from hot zone to warm zone with the same PPE. 4. a. Record review of Resident #29's admission record dated 08/06/2020 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on 7/12/20 at 5:42 PM revealed CNA C did not wear gloves when she placed meal tray on a bedside table of Resident #29. Further observation revealed CNA C did not sanitize or wash her hands after exiting Resident #29's room. CNA C continue getting another meal tray at the nursing station to deliver to another resident. During an interview on 7/12/20 at 5:45 PM with CNA C she did not wear gloves when she took the tray into Resident #29's room. She also confirmed she did not wash or sanitize her hands after delivering the tray to Resident #29's room. CNA C further stated she had not had in-service training on caring for COVID positive residents. b. Record review of Resident #9's admission record date 08/06/2020 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on 7/12/20 at 5:42 PM revealed CNA D did not wear gloves when she delivered meal tray to Resident #9's room. Further observation revealed CNA D turned the light switch on in Resident #9's room and placed the meal tray on a bedside table with her bare hands. Without sanitizing or washing her hands, CNA D continued to pass out a meal tray to another resident. Interview on 7/12/20 at 5:47 PM with CNA D confirmed she turned the light switch on and placed the meal tray on bedside table for Resident #9 without wearing gloves. CNA D further confirmed she did not sanitize or wash her hands after exiting Resident #9's room. c. Record review of Resident #30's admission record date 08/06/2020 revealed an admitted on 07/03/2020 with [DIAGNOSES REDACTED]. Observation on 7/12/2020 at 5:45 PM revealed RN E brought a meal tray into Resident #30's room and assisted Resident #30 to sit up. Further observation revealed RN E did not wear face shield or googles. RN E wore regular eyeglasses. Interview on 7/12/2020 at 5:59 PM RN E confirmed she did not wear goggles or face shield because it was her first day of work, and she did not know where to get the face shield or goggles. d. Record review of Resident #27's admission record dated 08/06/2020 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #28's admission record dated 08/06/2020 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on 7/13/2020 at 3:23 PM revealed LVN K entered Resident #27's room with a test tube. Further observation revealed LVN K did not wear face shield or goggles. During an interview on 7/13/2020 at 3:26 PM with LVN K she confirmed she performed a COVID test for Resident #27 and did not wear face shield or goggle when she performed COVID test. LVN K stated she had hyperventilation - sustained abnormal increase in breathing when she wore a face shield or goggles. Observation on 7/13/2020 at 3:30 PM revealed LVN K exited Resident #28's room with a test tube without wearing face shield or goggles. Interview on 7/13/2020 at 3:30 PM with LVN K confirmed she just finished with COVID test for Resident #28. LVN K further confirmed she did not wear face shield or goggle when she performed the COVID for Resident #28. During an interview on 7/13/2020 at 3:37 PM with LVN DD - ADON confirmed LVN K should have worn either goggle s or face shield when she provided direct patient care. Interview on 7/23/2020 at 9:56 AM with the DON and RN E - Regional Compliance Nurse confirmed there was no staff brought to their attention about having attention that had hyperventilation or health issues when they wore face shields or goggles. The DON and Regional Compliance nurse further confirmed if any staff had medical issue s with wearing full PPE while working with COVID positive residents, the facility would transfer the staff member to a sister facility that did not have COVID positive residents and did not require full PPE. e. Observation on 7/18/2020 at 2:04 PM revealed Medication Aide - MA O entered the COVID positive unit without wearing PPE. Further observation revealed MA O put on a gown, N95 mask, gloves, and face shield in the medication room of the COVID positive unit. Interview on 7/18/2020 at 2:41 PM with MA O confirmed she put on PPE in the medication room after entering the unit because she left her goggles and N95 mask in the medication room when she went on break. Record review of the facility's policy titled PPE Use When Positive COVID Residents are in the Facility, undated, revealed COVID positive or Suspected Positive: Staff working in this area must wear gown, gloves, N95 if available, if not surgical mask, face shield or eye protection when working with COVID positive/suspect patient. If working with more than one COVID positive patient only need to change gloves and perform hand hygiene in between patients. 5. Observation on 7/17/2020 at 4:13 AM revealed LVN K opened the door for surveyor to enter the facility, and then LVN K went straight to the positive COVID unit without screening surveyor for COVID 19 and checking surveyor 's temperature. Surveyor was waiting at the front desk and in the dining area until 4:19 AM, but there was no staff came back to screen surveyor for COVID 19 and check surveyor's temperature. During an interview on 7/17/2020 at 4:57 AM with LVN K she confirmed she let the surveyor enter the facility without screening her for COVID 19 and checking her temperature. LVN K further confirmed the facility did not have receptionist during the night shift. LVN K also stated there were only 2 nurses for both units and she had to return immediately to her unit because there was a new admission who was on hospice and not doing too well. Interview on 7/23/2020 at 9:58 AM with the DON confirmed any facility staff that opened the door for a visitor to enter the facility should screen for COVID symptoms and check temperature. Record review of the facility's COVID 19 Plan dated 5/29/2020 revealed Signing in/screen of visitors, and any others who do not work in the facility will be required to sign in/be screened at the nurses' station or other area near the entrance and attest that they do not meet the criteria for entry. Information on the log includes, visitor temperature, name of visitor, resident visiting, date and time, visitor phone number and the city/state where they reside. 6. a. Record review of Resident #1's admission record dated 7/12/2020 revealed an admitted on 7/2/2020 and readmitted on 7/8/2020 with [DIAGNOSES REDACTED]. Record review of Resident #1's Assessments revealed the last assessment before 7/4/2020 (6 AM - 2 PM shift) was COVID assessment dated [DATE] at 3:58 PM and the next assessment after 7/4/2020 (2 PM -10 PM shift) was COVID assessment dated [DATE] at 00:58 AM. Further review revealed there was no COVID Assessment on 7/4/2020 during 6 AM - 2 PM shift and 2 PM - 10 PM shift. Interview on 7/15/2020 at 9:21 AM with LVN I confirmed there was no COVID assessment for Resident #1 on 7/4/2020 during 6 AM -2 PM and 2 PM -10 PM. she stated it was busy during day shift, but night shift had more time to do assessment. Interview on 7/21/2020 at 5:27 PM with the DON confirmed she did not see the COVID Assessment for Resident #1 on 7/4/2020 during 6AM - 2 PM shift and 2PM - 10 PM. She further confirmed she only saw other assessments documented in progress note and vital sign during 6AM - 2PM shift and 2PM - 10 PM shift. b. Record review of Resident #2's face sheet date 07/12/2020 revealed an admitted on 6/23/2020 with [DIAGNOSES REDACTED]. Record review of Resident #2's Assessments dated on 7/3/2020 revealed Weekly Nursing summary dated 7/3/2020 at 5:54 PM and COVID assessment dated [DATE] at 1:52 PM. Further review revealed there was no documentation on COVID Assessment on 7/3/2020 during 2 PM - 10 PM shift. Interview on 7/14/2020 at 3:24 PM with LVN K confirmed she worked on 7/3/2020 during 2 PM - 10 PM shift on East Wing. LVN K further confirmed there was no COVID assessment for Resident #2 on her shift on 7/3/2020. LVN K explained she had 5 admissions on that day and another nurse who worked with her on that day should have done COVID assessment for Resident #2. Record review of Resident #2's Assessments revealed the last assessment before 7/4/2020 (6AM - 2PM shift) was COVID assessment dated [DATE] at 1:52 PM and the next assessment after 7/5/2020 (2 PM - 10 PM shift) was COVID assessment dated [DATE] at 4:22 AM. Further review revealed there was no documentation on 7/4/2020 and 7/5/2020 during 6 AM - 2 PM and 2 PM - 10 PM shift. Interview on 7/14/2020 at 7:57 PM with RN H confirmed she did not have time do COVID assessment for Resident #2 on 7/4/2020 and 7/5/2020 during her shift 6AM - 2PM. RN H further confirmed she expected LVN I came in during 2 PM -10 PM shift to help her to complete the COVID Assessment. Interview on 7/15/2020 at 9:16 AM with LVN I confirmed there was no COVID assessment for Resident #2 on 7/4/2020 and 7/5/2020 during 6 AM - 2 PM and 2 PM-10 because it was busy during the morning shift, so night shift had more time to do assessment. c. Record review of Resident #3's admission record dated 7/12/2020 with admitted on 7/2/2020 with [DIAGNOSES REDACTED]. Record review of Resident #3's Assessment revealed there was no COVID Assessment on 7/5/2020 during 6 AM - 2 PM shift and 2 PM - 10 PM shift. Further review revealed the assessment before 7/5/2020 (6 AM - 2 PM shift) was Skilled Nurses Notes dated 7/5/2020 at 01:35 AM, and the assessment after 7/5/2020 (2 PM - 10 PM shift) was Skilled Nurse Notes dated 7/6/2020 at 04:27 AM. Interview on 7/23/2020 at 4:35 PM with the DON confirmed there was no COVID Assessment for Resident #3 on 7/5/2020 during 6 AM - 2 PM and 2 PM - 10 PM shift. Interview on 7/23/2020 at 4:38 PM with the DON confirmed the license nurse could complete COVID Assessment, Respiratory Screen, or Skilled Nurse Note to consider as assessed Resident with COVID every 12 hours. The DON further confirmed when any resident admitted to the facility, the computer would automatically generate assessment to complete every 12 hours. The DON confirmed the facility updated to assess COVID resident every 8 hours. Interview on 7/23/2020 at 4:43 PM with the DON confirmed vital sign should be done every shift. Interview on 7/23/2020 at 4:44 PM with the DON confirmed she monitored documentation for assessment and vital sign. The DON said if there was documentation missing, she would talk to the nurse. The DON further confirmed the licensed nurse was received orientation up on hire and ongoing in-service on what they supposed to document on their assessment and vital sign. The DON confirmed weekly monitoring and now daily monitoring even on weekend on chart auditing on major change of condition, vital sign, and assessments. Interview on 7/23/2020 at 4:48 PM with the DON confirmed if the license nurse noticed a change of condition, he or she should stabilize the resident first, and call physician to let them know what going with resident. The DON said if the physician had new order for resident, the nurse should initiate the new order, and the nurse need to documentation the communication with doctor and family. Interview on 7/23/2020 at 4:53 PM the DON confirmed there was ongoing in-service with license staff on Resident's change of condition by going over scenarios and getting feedback from staff. Interview on 7/23/2020 at 4:55 PM with the DON confirmed run report see who had change of condition, anything change in weekend and follow up with individual resident to find out why they transfer out. the DON further confirmed if there was no documentation, she would follow up with the nurse. Interview on 7/12/20 at 6:55 PM with the Administrator confirmed he had been rounding on the residents and they stated they were comfortable. Administrator sated they have more than an adequate supply of eye protection (face shields, goggles) available for staff. He further stated staff should be wearing eye protection when providing direct contact care. Administrator stated he was surprised they have not had positive staff in the building as he thought some of the infection control issues were due to staff becoming complacent. He sated he thought staff were being in-serviced on COVID and infection control process by agency. Interview on 7/24/2020 at 10:03 AM with Medical Director confirmed he managed patient at the facility. He confirmed he utilized tele-monitoring to see resident at the facility. The nurse assessed the patient and if there was any issue would reported to the nurse practitioner. Then, the nurse practitioner and the doctor would have conversation online about the patient's situation. The Medical Director confirmed the facility had their own protocol on the assessment and frequency of assessing COVID residents. When the resident had change of condition the nurse should notify the nurse practitioner, then the nurse practitioner provide any necessary order and then the nurse practitioner communicated with the medical director and make change in resident plan of care as needed. Record review of COVID 19 plan dated 5/29/2020 revealed .Resident Screening . Resident will be screened during their stay according to the following: at least daily for the following symptoms: fever, new or worse cough, new or worse shortness of breath, chills, repeated shaking with chills, new muscle pain or aches, headache, sore throat, new loss of taste or smell, new or worse dizziness, nausea/vomiting/diarrhea. If any of the above symptoms are assessed, the resident will be placed on contact/droplet precaution until further evaluation for COVID 19 . This facility will also review CDC guidance for Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019. Record review of Responding to Coronavirus (COVID-19) in Nursing Homes Responding to COVID-19 dated 4/30/2020 revealed Resident with new-onset suspected or confirmed COVID-19: Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections. Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms. retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding on 7/28/2020. The Administrator was notified on IJ on 7/12/2020 at 10:42 PM and was given a copy of the IJ templated and a Plan of Removal was requested. The Plan of Removal accepted on 7/17/2020 at 11:50 AM. On 07/13/2020 at 5:47 PM Plan of Removal received from the DON. The facility's Plan of Removal included the following steps to be taken by the facility: ALLEGED ALLEGATION: Infection Control: Staff did not use proper handwashing. Staff did not complete proper DONNING/DOFFING when leaving the specific unit. Staff did not wear correct PPE such as goggles and face shield Interventions: The following in-services were initiated by the DON, ADON and regional nurse on 7/12/20: Any staff member not present or in-serviced on 7/12/20, will not be allowed to assume their duties until in-serviced. Staff will be (in-serviced) on the following: DONNING/DOFFING - Staff will be (re-in-serviced) on donning and doffing sequencing All Agency staff will be orientated to the facility and (in-serviced) on proper Donning/Doffing and handwashing. The medical director was notified of the immediate jeopardy situation on 11:39pm (7/12/2020) Monitoring: The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts including weekends. The DON / designee will observe handwashing techniques randomly on 10 staff members weekly on various shifts including weekends The QA committee will review findings and makes changes as needed. ALLEGED ALLEGATIONS: Documentation / Neglect: Staff facility failed to assess residents' vital signs and signs and symptoms of COVID residents. Interventions: The following in-services were initiated by the DON, ADON and regional nurse on 7/12/20: Any staff member not present or in-serviced on 7/12/20, will not be allowed to assume their duties until in-serviced. Licensed Nurses will be In Service on the following: In- Service on Documentation in PCC In-Service on COVID Assessment q shift - completing COVID Assessment Q shift In Service on obtaining Vital Signs - Inservice on Obtaining Vital Signs each shift and as needed. Inservice on Change of Condition which includes a specific change and Physician/NP notification, and any interventions or orders. In service on Abuse/Neglect The medical director was notified of the immediate jeopardy situation on 11:39pm (on 7/12/2020) Monitoring The DON / designee will monitor scheduled assessments 7 days a week to ensure all assessments were completed. The Don/designee will ask 10 nurses randomly on various shifts per week for 6 weeks What they would do and document if a resident had a change of condition. The DON / designee will review the 24-hour report 7 days a week to ensure COVID assessments are done each shift and vital signs are taken as ordered. The QA committee will review findings and makes changes as needed. The surveyor verification of the Plan of Removal on 7/18/2020 was as follows: Interview on 7/18/2020 at 2:22 PM with LVN W confirmed he got in-service/training on completing COVID assessments every shift, checked resident vital sign every 4 hour, call physician and document on Resident change of change of condition under SBAR form because COVID patient changed drastically. LVN W further confirmed resident change of condition could be resident become confused, decrease in urine output, or vital sign was out of range. LVN W confirmed he received and understood in-service/training on infection control such as PPE requirements in COVID unit, don-doff PPE, and hand washing. LVN W stated PPE included gown, gloves, N95, and face shield needed to put on before entering the COVID unit. LVN W confirmed PPE needed to be removed before exiting the COVID unit. Interview on 7/18/2020 at 3:53 PM with agency staff - LVN Z and EMT AA confirmed they received and understood the training on infection control such as donning PPE before entering COVID unit and doffing PPE before exiting COVID, and hand washing. LVN Z and EMT AA confirmed COVID assessment need to complete every shift and vital sign every 4 hour for COVID residents. LVN Z and EMT AA also confirmed receiving training on abuse and neglect. Observation on 7/18/2020 at 4:36 PM revealed RN BB washed hands before checking resident #25's blood sugar and before exiting the resident#25's room. Interview on 7/18/2020 at 4:50 PM with RN BB confirmed he received training on infection control donning on and donning off PPE while working in COVID unit. RN BB confirmed he got training on documentation in PCC regarding completing COVID assessment, document vital sign, and documentation on notify physician when resident had change of condition. RN BB further confirmed received training on abuse and neglect. Interview on 7/18/2020 at 4:57 PM with RN B confirmed she received and understood training on PPE requirement while working in COVID and sequence of don/doff PPE. RN B also confirmed she received training on documentation of COVID Assessment, vital sign, notifying physician and document on resident's change of condition Interview on 7/18/2020 at 5:11 PM with LVN CC confirmed she received training on hand washing, need to put on N95, face shield, gown, and gloves when working in COVID unit. LVN CC confirmed the need to put on PPE before entering COVID unit and taking PPE off before exiting COVID unit. LVN CC confirmed she received training during mandatory meeting about documentation. LVN CC confirmed documentation on COVID assessment, vital signs. LVN CC confirmed she need to inform the physician when resident had any change such as vital sign off baseline and residents not their normal self. LVN CC confirmed she need to document on intervention, notifying physician and imitated SBAR form. LVN CC confirmed she received training on abuse and neglect. Observation on 7/18/2020 at 5:31 PM revealed LVN Z took off gown, gloves, and face shield. Further observation LVN Z washed her hands before exiting the COVID unit on West Wing. Interview on 7/18/2020 at 7:21 PM with LVN I confirmed she received in-service training on how to don - doff PPE. LVN I also confirmed she received in-service training on documentation on PCC such as SBAR form for resident change of condition, vital sign and COVID assessment. Observation on 7/18/2020 at 7:27 PM revealed LVN I already wore N95 mask. LVN I put on gown, gloves, and face shield before entering the COVID unit on East Wing. Interview on 7/19/2020 at 12:46 PM with Maintenance Assistant EE confirmed she received and understood training on Infection Control regarding PPE which included N95, gown, face shield/goggles and gloves before entering COVID unit and to take took off all PPE before exiting COVID unit. Interview on 7/19/2020 at 1:54 PM with housekeeper A - 2 pm - 10 pm shift receiving and understanding the training on infection control such as PEE to work in the COVID unit include gown, gloves, mask, face shield, and boot. Housekeeping A confirmed he need to put on PPE before entering the COVID unit. Housekeeping A confirmed took off gown, gloves, and face shield before exiting the COVID unit. Interview on 7/19/2020 at 2:06 PM with CNA FF - agency staff - confirmed receiving infection control in-service on 7/17/2020. She further confirmed she understood the infection control in-service included gloves use, hand washing, and procedure of removing PPE and putting on PPE. Interview on 7/19/2020 at 2:12 PM with Housekeeper GG - confirmed getting on infection control on 7/17/2020. Housekeeper GG confirmed PPE requirements for working in COVID unit including gloves, N95, face shield, and gown. Housekeeper GG confirmed the in-service was also about don and doff PPE and sanitize between gloves changes. Record review of the facility in-service training attendance roster titled Completing COVID Assessment - Nurse will complete COVID Assessment on Resident Q shift. Each shift will obtain new set up vital signs and assess resident and complete COVID assessment dated [DATE] revealed 14 of 14 Licensed staff signed the in-service roster; 7 of 7 licensed agency nurses signed the in-service roster Record review of facility in-service training attendance roster titled Notifying the physician of change in status dated 7/13/2020 revealed 14 of 14 Licensed staff signed the in-service roster; 7 of 7 licensed agency nurses signed the in-service roster. Record review of the facility in-service training attendance Roster titled infection control overview dated 7/13/2020 revealed 40 of 66 staff signed the in-service roster; 13 of 13 agency staff signed the in-service roster; and 6 of 6 therapy signed the in-service roster. Record review of the facility in-service training attendance Roster titled with Proper PPE use on the COVID unit dated 7/13/2020 revealed 42 of 66 staff signed the in-service roster; 11 of 13 agency staff signed the in-service roster; 2 of 6 therapy staff signed the in-service roster. Record review of the facility in-service training attendance roster titled Infection control - handwashing dated 7/13/20 revealed 29 of 66 staff signed the in-service roster, 6 of 6 therapy staff signed the in-service roster. 1 of13 agency staff signed the in-service roster. Record review on PPE Monitoring - Random PPE Donning/Doffing Review revealed DON checked 3 staff on 7/13; 2 staff on 7/14; 2 staff on 7/15; 1 staff on 7/16; 2 staff on 7/17; 3 staff on 7/18; 3 staff on 7/19; 3 staff on 7/20. Record review on Handwashing Monitoring revealed DON check on staff each day from 7/17/2020 to 7/20/2020 On 4/21/2020 at 4:41 PM, the Area Director of Operations, Regional Compliance Nurse - RN F, Assistant Administrator, Director of Nursing, and LVN G - Assistant Director of Nursing were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as a pattern due to residents on-going need for assessments for signs and symptoms of COVID-19.

Based on observation, interview, and record review, the facility failed to implement the facility's written policies and procedures that prohibited abuse for 1 of 1 (Resident #35) residents reviewed for abuse, in that: The facility failed to protect Resident #35 from abuse after she had been hit by Resident #7 on two different incidents. These failures affected one resident and placed other residents at risk of abuse, harm, pain, mental anguish and or emotional distress. Findings included: Review of facility Nursing Policy and Procedure Manual 2003., Abuse/Neglect., Revised on: 05/09/17 revealed: Resident should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of [REDACTED]. C. Prevention: the facility will provide the resident, families, and staff an environment free from abuse and neglect. G. Protection: The facility will take necessary measures to protect residents and employees from harm during and following abuse, neglect, exploitation, mistreatment of [REDACTED]. Resident to Resident: The above policy will apply to potential resident-to-resident abuse. Provider letter 17-18 will be reviewed to determine if resident-to-resident abuse occurred. Review of Resident #7 clinical chart revealed Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed Resident #7 BIMS Score of 9, indicating moderate cognitive impairment. Behavioral Symptoms included: Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). Did any of the identified symptom(s): A. Put other's at significant risk for physical injury? Was marked 1. Yes. Review of Resident #7 Care Plan revealed: Date initiated: 01/11/19. Focus: The resident has history of demonstrating physical behaviors, will engage in verbal and physical altercations when confronted by other residents. 06/14/19, 06/17/19 - Physical behaviors, Physical Behaviors on 07/17/19 no injuries. Goal: The resident will demonstrate effective coping skills through the review date. Interventions: Analyze of key times, places, circumstances, triggers, and what de-escalate behavior and document; Assess and address for contributing sensory deficits; Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, Communication provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately; Monitor/document/report to MD of danger to self and others. Notify the charge nurse of any physically abusive behaviors. Psychiatric/Psychogeriatric consult as indicated. Review of Resident #7 Event Behavior Note, Effective Date: 06/14/19, revealed: This resident hit roommate and was verbally abusive. Behavior/Altercation: Physical and Verbal. Review of Resident #7 Event Behavior Note, Effective Date: 06/15/19, revealed: No Resident to Resident behaviors during shift resident continues to provoke a confrontation with other residents then wants Tylenol #3 right now. Review of Resident #7 Event Behavior Note, Effective Date: 06/17/19, revealed: Resident struck another in the face. Behavior/Altercation: Physical and Resident to Resident. Review of Resident #7 Behavior Note, Effective Date: 07/14/2019, revealed: Enjoying the verbal aggression towards other residents and especially the staff of verbal derogatory language as exemplified by the jovial laughter she loudly expresses afterward. Review of Resident #7 Event Behavior Note, Effective Date: 07/17/19, revealed: Resident was described as hitting/attacking roommate during day shift on 07/17/19. No injuries occurred, however, this resident was moved to another room. Review of Resident #35 clinical chart revealed Resident was admitted to facility on 03/22/2005 with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed Resident #35, No BIMS score was recorded for resident. Memory problem was recorded for resident having Short-term memory and long-term memory. Resident Makes self understood. Vision: Severely Impaired, no vision or sees only light, colors, shapes; eyes do not appear to follow objects. Review of Resident #35 Care Plan revealed: Date Initiated:01/11/19, Focus: The resident has impaired cognitive function/dementia or impaired thought process. Goal: The resident will develop skills to cope with cognitive decline and maintain safety by the review date. Interventions: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking. Reduce any distractions-turn off tv, radio, close door. The resident understands consistent, simple, directive sentences. Date initiated: 01/11/19, Focus: The resident has impaired visual function. Goal: The resident will maintain optimal quality of life within limitation imposed by visual function through the review date. Interventions: Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss. Date initiated: 02/04/19, Focus: The resident has communication problem R/T Alzheimer's and [MEDICAL CONDITION]. Goal: The resident will be able to make basic needs known by answering yes or no questions daily through the review date. Interventions: Anticipate and meet needs. Ensure a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Use effective strategies: tone of voice, short direct phrases, speak slowly, speak in a calm, distinct manner, time to communicate. Date initiated: 02/04/19, Focus: Resident has a risk of verbal and physical aggression related to random yelling outburst, throwing items when resident feels threatened from who she claims to be in adamant objects or transfer self to floor during hallucinations related to [MEDICAL CONDITION]. Interventions: Anticipate behaviors and redirect when verbal aggression arises. Assess for triggers. Refer to social services for emotional support. Date Initiated: 01/11/19, Focus: The resident has an ADL Self Care Performance Deficit. Goal: Thee resident will maintain or improve current level of function through the review date. Interventions: Bathing requires staff x2 for assistance. Bed Mobility: requires staff x1 for assistance. Dressing: requires staff x1 for assistance. Eating: supervision as needed. The resident requires a lift for all transfers. Toilet use: requires staff x1 for assistance. Review of Resident #35 Nurse Practitioner Progress Note, Dated: 07/12/19, Revealed: Psychiatric consult/care requested by Facility and PCP. Staff report that her and her roommate yell at each all the time. Resident states that her roommate hit her in the head this morning. Her roommate admits to it because of what she had said to her. Staff notified. She is dependent for most ADL's able to feed herself. Recommendations: Gets upset easily, Does provoke her roommate at times by saying things that are inappropriate. Currently on Sentraline. Will continue to monitor. Review of Resident #35 Behavior Note, Effective Date: 07/17/19, revealed: yelling and cursing at another resident, other resident hit resident on head. Behavior/Altercation: Verbal. Interventions: roommate was moved. Review of Resident #35 Progress Nurses Note, Effective Date: 06/13/19. Revealed: Resident was hit on forehead by roommate, no injury noted, will continue to monitor. During observations on 07/16/19 at 10:07 a.m. Resident #7 was observed yelling when coming out of her room to the hallway using derogatory and foul language when addressing facility staff. During hall observations on 07/17/19 at 11:10 a.m. Screaming and crying was heard coming from Resident #7 and Resident #35 room. Staff ran to enter the room and Resident #7 was wheeled out of the room by staff. Surveyor entered the room with LVN M. During Observation and Interview on 07/17/19 at 11:15 a.m. Resident #35 was observed lying in bed with her face covered with a sheet. Resident #35 was observed frantically crying and when asked why she was crying she stated, She hit me, she hit me in the forehead with the radio. LVN M was present and followed to assess resident for injuries. During interview with LVN M on 07/17/19 at 11:20 a.m. LVN M stated she assessed Resident #35 for injuries and stated Resident #35 was complaining of pain on the forehead where Resident #7 hit her. LVN M said no injuries were noted during assessment. LVN M stated she had never seen Resident #35 so upset and crying with emotion like she was. LVN M stated she was going to find a new room to move Resident #7. When asked if Resident #7 had history of hitting Resident #35 or other residents, she stated she was not aware of any other previous physical altercations, but Residents had history of yelling at each other, mainly Resident #7 yelling at Resident #35. During interview with Resident #7 on 07/17/19 at 11:30 a.m. Resident #7 stated she hit her roommate because her roommate called her a dog. When asked what she hit Resident #35 with, she stated she hit her with her fist. Resident #7 stated she had been asking the facility about moving her roommate because they don't get along. Resident #7 stated the facility had done nothing about it. Resident #7 stated, I'm going to hurt her if they don't get her out of the room, it was my room first. When Resident #7 was asked who she talked to about wanting her roommate moved, Resident #7 stated she talked to the social worker. During interview with facility Social Worker on 07/17/19 at 12:01 p.m. Social Worker stated, 2-3 weeks ago I offered Resident #7 to move to another room and she declined moving. I left it at that because Resident #7 declined moving and she has not brought it to my attention since then. During interview with DON on 07/17/19 at 12:02 p.m. DON stated Resident #7 had not requested a room change nor had requested her roommate be moved. When questioned if Resident #7 had previous altercations with other residents, DON stated Resident #7 had a physical altercation once with another resident in the dining room, but it was not recent, and she would have to look for that incident. DON stated per facility policy the Resident requesting for roommate to be moved will have to be the resident that has to move. DON stated Resident #7 will have to be moved to another room because she is the one requesting the roommate to be moved. During interview with LVN J on 07/18/19 at 2:53 p.m. LVN J stated Resident #7 hit Resident #35 once on 06/14/19 and the incident was reported to the DON. LVN J stated at the time of that incident Resident #7 was asked why she hit Resident #35 and Resident #7 stated, I hit her because she screams and yells. During interview with DON on 07/18/19 at 3:50 p.m. regarding resident to resident altercations process. DON stated when there is a resident to resident altercation like in the case of Resident #7 and Resident #35 the facility does not move residents because moving them can cause more distress to the residents. DON stated since the incident that happened on 06/14/19 was the first resident to resident altercation between Resident #7 and #35, residents were not moved. When asked what interventions where put in place to ensure the safety of Resident #35, DON stated after the incident on 06/14/19, Resident #7 was put on 15-minute checks for 72 hours. During interview on 07/18/19 at 4:31 p.m. with LVN J. LVN J revealed she worked at the facility since (MONTH) and usually worked the 2-10 shift. LVN J stated she worked with both residents #7 and #35. When asked about the incident documented by her on 06/14/19, LVN J stated Resident #7 was cursing out loud and she could hear from the hallway. She then went into the room and Resident #7 was already in the hallway. LVN J stated Resident #35 was asked what happened and Resident #35 reported Resident #7 cursed at her and hit her. LVN J stated she followed to assess Resident #35 and no injuries were noted. LVN J stated Resident #35 is not able to see Resident #7 coming at her due to her impaired vision. LVN J stated Resident #35 does not have history of having aggressive behaviors towards other residents nor staff. LVN J stated, Resident #35 is very passive. During interview with Centric Physicians Nurse Practitioner on 07/19/19 at 10:52 a.m. Nurse Practitioner stated she provided psychological services to Resident #35 last week, on 07/12/19. Nurse Practitioner stated she walked into the room and found Resident #7 and #35 yelling at each other and Resident #35 was stating Resident #7 hit her. Nurse Practitioner stated Resident #7 admitted to hitting Resident #35. Nurse Practitioner stated Mediation Aide K was out on the hall and intervened. Nurse Practitioner stated Resident #7 was removed from the room by facility staff. Nurse Practitioner stated she did not report the incident to DON because she assumed facility staff would report it. During interview on 07/19/19 at 11:02 a.m. with Medication Aide K. Medication Aide K revealed she worked at the facility since (MONTH) (YEAR). Medication Aide K stated she assisted with medication pass to both Resident #7 and #35. When asked if she remembered the incident from 07/12/19 about Resident #7 hitting Resident #35, Medication Aide K stated she did remember. Medication Aide K stated she remembered she was passing by and Centric Nurse Practitioner addressed her and made her aware Resident #7 hit Resident #35. Medication Aide K stated CNA L was out on the hall and he assisted in removing and redirecting Resident #7. Medication Aide K stated, Resident #7 was used to yelling and cursing at staff and other residents, she always yells at Resident #35. During phone interview on 07/19/19 at 11:57 a.m. with CNA [MI] CNA L stated he usually worked the East wing but the day of the incident on 07/12/19 he was assigned to the West wing. He stated Mediation Aide K addressed him and made him aware Resident #7 hit Resident #35. CNA L stated he went into resident's room and redirected Resident #7. CNA L stated Resident #7 told him I hit her because she made me mad. CNA L stated he reported the incident to nurse in charge that day. During interview on 07/19/19 at 12:17 p.m. with LVN M, she stated she did not know about the incident that happened on 7/12/19, she stated staff members did not report the incident to her. During interview on 07/19/19 at 1:50 p.m. with DON regarding incident that was documented by Centrics Nurse Practitioner on 07/12/19. DON stated staff did not report the incident to her. She stated, that would have been the second incident of Resident #7 hitting Resident #35 and they would have considered moving Resident #7 or put other interventions in place. When asked if staff should have had to report the incident to her DON stated, yes they should have reported it.

Based on interviews, observations, and record reviews the facility failed to ensure residents were free from abuse for 1 of 1 resident (Resident #35) whose care was reviewed for abuse, in that: The facility failed to protect Resident #35 from abuse after she had been hit by Resident #7 on two different incidents. These failures affected one resident and placed other residents at risk of abuse, harm, pain, mental anguish and or emotional distress. Findings included: Review of Resident #7 clinical chart revealed Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed Resident #7 BIMS Score of 9, indicating moderate cognitive impairment. Behavioral Symptoms included: Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). Did any of the identified symptom(s): A. Put other's at significant risk for physical injury? Was marked 1. Yes. Review of Resident #7 Care Plan revealed: Date initiated: 01/11/19. Focus: The resident has history of demonstrating physical behaviors, will engage in verbal and physical altercations when confronted by other residents. 06/14/19, 06/17/19 - Physical behaviors, Physical Behaviors on 07/17/19 no injuries. Goal: The resident will demonstrate effective coping skills through the review date. Interventions: Analyze of key times, places, circumstances, triggers, and what de-escalate behavior and document; Assess and address for contributing sensory deficits; Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, Communication provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately; Monitor/document/report to MD of danger to self and others. Notify the charge nurse of any physically abusive behaviors. Psychiatric/Psychogeriatric consult as indicated. Review of Resident #7 Event Behavior Note, Effective Date: 06/14/19, revealed: This resident hit roommate and was verbally abusive. Behavior/Altercation: Physical and Verbal. Review of Resident #7 Event Behavior Note, Effective Date: 06/15/19, revealed: No Resident to Resident behaviors during shift resident continues to provoke a confrontation with other residents then wants Tylenol #3 right now. Review of Resident #7 Event Behavior Note, Effective Date: 06/17/19, revealed: Resident struck another in the face. Behavior/Altercation: Physical and Resident to Resident. Review of Resident #7 Behavior Note, Effective Date: 07/14/2019, revealed: Enjoying the verbal aggression towards other residents and especially the staff of verbal derogatory language as exemplified by the jovial laughter she loudly expresses afterward. Review of Resident #7 Event Behavior Note, Effective Date: 07/17/19, revealed: Resident was described as hitting/attacking roommate during day shift on 07/17/19. No injuries occurred, however, this resident was moved to another room. Review of Resident #35 clinical chart revealed Resident was admitted to facility on 03/22/2005 with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed Resident #35, No BIMS score was recorded for resident. Memory problem was recorded for resident having Short-term memory and long-term memory. Resident Makes self understood. Vision: Severely Impaired, no vision or sees only light, colors, shapes; eyes do not appear to follow objects. Review of Resident #35 Care Plan revealed: Date Initiated:01/11/19, Focus: The resident has impaired cognitive function/dementia or impaired thought process. Goal: The resident will develop skills to cope with cognitive decline and maintain safety by the review date. Interventions: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking. Reduce any distractions-turn off tv, radio, close door. The resident understands consistent, simple, directive sentences. Date initiated: 01/11/19, Focus: The resident has impaired visual function. Goal: The resident will maintain optimal quality of life within limitation imposed by visual function through the review date. Interventions: Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss. Date initiated: 02/04/19, Focus: The resident has communication problem R/T Alzheimer's and [MEDICAL CONDITION]. Goal: The resident will be able to make basic needs known by answering yes or no questions daily through the review date. Interventions: Anticipate and meet needs. Ensure a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Use effective strategies: tone of voice, short direct phrases, speak slowly, speak in a calm, distinct manner, time to communicate. Date initiated: 02/04/19, Focus: Resident has a risk of verbal and physical aggression related to random yelling outburst, throwing items when resident feels threatened from who she claims to be in adamant objects or transfer self to floor during hallucinations related to [MEDICAL CONDITION]. Interventions: Anticipate behaviors and redirect when verbal aggression arises. Assess for triggers. Refer to social services for emotional support. Date Initiated: 01/11/19, Focus: The resident has an ADL Self Care Performance Deficit. Goal: Thee resident will maintain or improve current level of function through the review date. Interventions: Bathing requires staff x2 for assistance. Bed Mobility: requires staff x1 for assistance. Dressing: requires staff x1 for assistance. Eating: supervision as needed. The resident requires a lift for all transfers. Toilet use: requires staff x1 for assistance. Review of Resident #35 Nurse Practitioner Progress Note, Dated: 07/12/19, Revealed: Psychiatric consult/care requested by Facility and PCP. Staff report that her and her roommate yell at each all the time. Resident states that her roommate hit her in the head this morning. Her roommate admits to it because of what she had said to her. Staff notified. She is dependent for most ADL's able to feed herself. Recommendations: Gets upset easily, Does provoke her roommate at times by saying things that are inappropriate. Currently on Sentraline. Will continue to monitor. Review of Resident #35 Behavior Note, Effective Date: 07/17/19, revealed: yelling and cursing at another resident, other resident hit resident on head. Behavior/Altercation: Verbal. Interventions: roommate was moved. Review of Resident #35 Progress Nurses Note, Effective Date: 06/13/19. Revealed: Resident was hit on forehead by roommate, no injury noted, will continue to monitor. During observations on 07/16/19 at 10:07 a.m. Resident #7 was observed yelling when coming out of her room to the hallway using derogatory and foul language when addressing facility staff. During hall observations on 07/17/19 at 11:10 a.m. Screaming and crying was heard coming from Resident #7 and Resident #35 room. Staff ran to enter the room and Resident #7 was wheeled out of the room by staff. Surveyor entered the room with LVN M. During Observation and Interview on 07/17/19 at 11:15 a.m. Resident #35 was observed lying in bed with her face covered with a sheet. Resident #35 was observed frantically crying and when asked why she was crying she stated, She hit me, she hit me in the forehead with the radio. LVN M was present and followed to assess resident for injuries. During interview with LVN M on 07/17/19 at 11:20 a.m. LVN M stated she assessed Resident #35 for injuries and stated Resident #35 was complaining of pain on the forehead where Resident #7 hit her. LVN M said no injuries were noted during assessment. LVN M stated she had never seen Resident #35 so upset and crying with emotion like she was. LVN M stated she was going to find a new room to move Resident #7. When asked if Resident #7 had history of hitting Resident #35 or other residents, she stated she was not aware of any other previous physical altercations, but Residents had history of yelling at each other, mainly Resident #7 yelling at Resident #35. During interview with Resident #7 on 07/17/19 at 11:30 a.m. Resident #7 stated she hit her roommate because her roommate called her a dog. When asked what she hit Resident #35 with, she stated she hit her with her fist. Resident #7 stated she had been asking the facility about moving her roommate because they don't get along. Resident #7 stated the facility had done nothing about it. Resident #7 stated, I'm going to hurt her if they don't get her out of the room, it was my room first. When Resident #7 was asked who she talked to about wanting her roommate moved, Resident #7 stated she talked to the social worker. During interview with facility Social Worker on 07/17/19 at 12:01 p.m. Social Worker stated, 2-3 weeks ago I offered Resident #7 to move to another room and she declined moving. I left it at that because Resident #7 declined moving and she has not brought it to my attention since then. During interview with DON on 07/17/19 at 12:02 p.m. DON stated Resident #7 had not requested a room change nor had requested her roommate be moved. When questioned if Resident #7 had previous altercations with other residents, DON stated Resident #7 had a physical altercation once with another resident in the dining room, but it was not recent, and she would have to look for that incident. DON stated per facility policy the Resident requesting for roommate to be moved will have to be the resident that has to move. DON stated Resident #7 will have to be moved to another room because she is the one requesting the roommate to be moved. During interview with LVN J on 07/18/19 at 2:53 p.m. LVN J stated Resident #7 hit Resident #35 once on 06/14/19 and the incident was reported to the DON. LVN J stated at the time of that incident Resident #7 was asked why she hit Resident #35 and Resident #7 stated, I hit her because she screams and yells. During interview with DON on 07/18/19 at 3:50 p.m. regarding resident to resident altercations process. DON stated when there is a resident to resident altercation like in the case of Resident #7 and Resident #35 the facility does not move residents because moving them can cause more distress to the residents. DON stated since the incident that happened on 06/14/19 was the first resident to resident altercation between Resident #7 and #35, residents were not moved. When asked what interventions where put in place to ensure the safety of Resident #35, DON stated after the incident on 06/14/19, Resident #7 was put on 15-minute checks for 72 hours. During interview on 07/18/19 at 4:31 p.m. with LVN J. LVN J revealed she worked at the facility since (MONTH) and usually worked the 2-10 shift. LVN J stated she worked with both residents #7 and #35. When asked about the incident documented by her on 06/14/19, LVN J stated Resident #7 was cursing out loud and she could hear from the hallway. She then went into the room and Resident #7 was already in the hallway. LVN J stated Resident #35 was asked what happened and Resident #35 reported Resident #7 cursed at her and hit her. LVN J stated she followed to assess Resident #35 and no injuries were noted. LVN J stated Resident #35 is not able to see Resident #7 coming at her due to her impaired vision. LVN J stated Resident #35 does not have history of having aggressive behaviors towards other residents nor staff. LVN J stated, Resident #35 is very passive. During interview with Centric Physicians Nurse Practitioner on 07/19/19 at 10:52 a.m. Nurse Practitioner stated she provided psychological services to Resident #35 last week, on 07/12/19. Nurse Practitioner stated she walked into the room and found Resident #7 and #35 yelling at each other and Resident #35 was stating Resident #7 hit her. Nurse Practitioner stated Resident #7 admitted to hitting Resident #35. Nurse Practitioner stated Mediation Aide K was out on the hall and intervened. Nurse Practitioner stated Resident #7 was removed from the room by facility staff. Nurse Practitioner stated she did not report the incident to DON because she assumed facility staff would report it. During interview on 07/19/19 at 11:02 a.m. with Medication Aide K. Medication Aide K revealed she worked at the facility since (MONTH) (YEAR). Medication Aide K stated she assisted with medication pass to both Resident #7 and #35. When asked if she remembered the incident from 07/12/19 about Resident #7 hitting Resident #35, Medication Aide K stated she did remember. Medication Aide K stated she remembered she was passing by and Centric Nurse Practitioner addressed her and made her aware Resident #7 hit Resident #35. Medication Aide K stated CNA L was out on the hall and he assisted in removing and redirecting Resident #7. Medication Aide K stated, Resident #7 was used to yelling and cursing at staff and other residents, she always yells at Resident #35. During phone interview on 07/19/19 at 11:57 a.m. with CNA [MI] CNA L stated he usually worked the East wing but the day of the incident on 07/12/19 he was assigned to the West wing. He stated Mediation Aide K addressed him and made him aware Resident #7 hit Resident #35. CNA L stated he went into resident's room and redirected Resident #7. CNA L stated Resident #7 told him I hit her because she made me mad. CNA L stated he reported the incident to nurse in charge that day. During interview on 07/19/19 at 12:17 p.m. with LVN M, she stated she did not know about the incident that happened on 7/12/19, she stated staff members did not report the incident to her. During interview on 07/19/19 at 1:50 p.m. with DON regarding incident that was documented by Centrics Nurse Practitioner on 07/12/19. DON stated staff did not report the incident to her. She stated, that would have been the second incident of Resident #7 hitting Resident #35 and they would have considered moving Resident #7 or put other interventions in place. When asked if staff should have had to report the incident to her DON stated, yes they should have reported it. Review of facility Nursing Policy and Procedure Manual 2003., Abuse/Neglect., Revised on: 05/09/17 revealed: Resident should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of [REDACTED]. C. Prevention: the facility will provide the resident, families, and staff an environment free from abuse and neglect. G. Protection: The facility will take necessary measures to protect residents and employees from harm during and following abuse, neglect, exploitation, mistreatment of [REDACTED]. Resident to Resident: The above policy will apply to potential resident-to-resident abuse. Provider letter 17-18 will be reviewed to determine if resident-to-resident abuse occurred.

Based on interview and record review the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 1 Residents (#7) whose records were reviewed for behavioral health services. Facility did not ensure Resident #7 continued to receive the necessary Behavioral Health Services to address Resident #7's verbally and physically aggressive behaviors. This failure affected one resident and could place residents with behavioral healthcare needs at risk for their mental and psychosocial needs not being met. The findings were: Review of Resident #7 clinical chart revealed Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Annual MDS dated [DATE] revealed resident BIMS Score of 9, indicating moderate cognitive impairment. Behavioral Symptoms included: Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). Did any of the identified symptom(s): A. Put other's at significant risk for physical injury? Was marked 1.Yes. Review of Resident #7 Care Plan revealed: Date initiated: 01/11/19, Focus: The resident requires [MEDICAL CONDITION] medications, [MEDICATION NAME], Respiredal for [DIAGNOSES REDACTED]. Goal: The resident will remain free of drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive /behavioral impairment through review date. Date initiated: 04/17/19, Focus: The resident uses anti-anxiety medications Clonazempam r/t Anxiety disorder. Goal: The resident will be free from adverse reactions related to anti-anxiety therapy through the review date. Interventions: Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. Monitor/record occurrence of for target behavior symptoms inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. The resident is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia. Date initiated: 01/01/19, Focus: The resident requires antidepressant medication [MEDICATION NAME] for off label use [DIAGNOSES REDACTED]. Interventions: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Monitor/document/report to MD ORN ongoing signs and symptoms of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, attention seeking. Date initiated: 01/11/19, Focus: The resident has an ADL Self Care Performance Deficit. Goal: The resident will maintain current level of function in bed mobility, transfers, eating, dressing, through the review date. Interventions: Assist with personal hygiene as required. Bathing: requires staff x1 for assistance, Bed mobility: requires staff x1 for assistance, Dressing requires staff x1 for assistance, Eating: supervision needed, The resident uses a wheelchair, Toilet use: requires x1 for assistance Date initiated: 01/11/19. Focus: The resident has history of demonstrating physical behaviors, will engage in verbal and physical altercations when confronted by other residents. 06/14/19, 06/17/19 - Physical behaviors, Physical Behaviors on 07/17/19 no injuries. Goal: The resident will demonstrate effective coping skills through the review date. Interventions: Analyze of key times, places, circumstances, triggers, and what de-escalate behavior and document; Assess and address for contributing sensory deficits; Assess and anticipate resident's needs: food, thirst, tolieting needs, comfort level, body positioning, pain, Communication provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately; Monitor/document/report to MD of danger to self and others. Notify the charge nurse of any physically abusive behaviors. Psychiatric/Psychogeriatric consult as indicated. Review of Medication Administration Record [REDACTED]. [MEDICATION NAME] ER Tablet Extended Release 24 Hour 250 MG, 1 tablet by mouth 2 times a day related to [MEDICAL CONDITION] Disorder. Respiredal Tablet 1 MG, 1 tablet by mouth 2 times a day related to [MEDICAL CONDITION]. [MEDICATION NAME] Tablet Delayed Release, 1 tablet by mouth 3 times a day related to Major [MEDICAL CONDITION]. [MEDICATION NAME] Tablet 100MG, 1 tablet by mouth at bedtime related to [MEDICAL CONDITION]. Review of Resident #7 Event Behavior Note, Effective Date: 06/14/19, revealed: This resident hit roommate and was verbally abusive. Behavior/Altercation: Physical and Verbal. Review of Resident #7 Event Behavior Note, Effective Date: 06/15/19, revealed: No Resident to Resident behaviors during shift resident continues to provoke a confrontation with other residents then wants Tylenol #3 right now. Review of Resident #7 Event Behavior Note, Effective Date: 06/17/19, revealed: Resident struck another in the face. Behavior/Altercation: Physical and Resident to Resident. Review of Resident #7 Behavior Note, Effective Date: 07/14/2019, revealed: Enjoying the verbal aggression towards other residents and especially the staff of verbal derogatory language as exemplified by the jovial laughter she loudly expresses afterward. Review of Resident #7 Event Behavior Note, Effective Date: 07/17/19, revealed: Resident was described as hitting/attacking roommate during day shift on 07/17/19. No injuries occurred, however, this resident was moved to another room. Review of Mental and Behavioral health visit noted, dated 04/15/19, revealed: Primary Care Provider sought consults to identify greater needs for intervention. Pt was recognized with [MEDICAL CONDITION] and cognitive losses. Interventions will assist with symptoms reduction and relief through affirming exchanges. Behavioral Health Treatment Plan, Revealed: Target Signs of Depression with Supportive, Cognitive, and Behavioral therapy techniques, Long-Term (4-6 months). Goals: Achieve and maintain baseline, Stabilization. Progress toward Goal: Moderate. Target Signs of Anxiety/[MEDICAL CONDITION] with Supportive, Cognitive, and Behavioral Therapy techniques, Long-Term (4-6 months). Goals: Achieve and maintain baseline, Stabilization. Progress toward goal: Moderate. Treatment continuation: If treatment is terminated now, is continuation, exacerbation or return of symptoms likely: Yes. Review of Physician order [REDACTED]. During interview with Centric Physicians Nurse Practitioner on 07/19/19 at 10:52 a.m. Nurse Practitioner stated she was at the facility to evaluate and assess Resident #7. Nurse Practitioner stated she was contacted by the facility on 07/18/19 about Resident #7 needing to an evaluation. Nurse Practitioner stated Centric Physicians took over Behavioral Care in (MONTH) 2019 and she was in the process of seeing all residents but had not got to evaluate Resident #7. Nurse Practitioner stated she witnessed Resident #7 and Resident #35 having a verbal altercation last week when she was at the facility providing services to Resident #35. Nurse Practitioner stated based on her assessment and evaluation she was making some changes to Resident #7 medications. Review of Physician Prescriber Order dated 07/19/19 revealed the following recommendations: D/C [MEDICATION NAME] 125mg by mouth three times a day, Start [MEDICATION NAME] 250mg by mouth twice a day, start [MEDICATION NAME] 50mg ½ tab by mouth daily x 4 days, then increase to 1 tab by mouth thereafter. During interview on 07/19/19 at 12:17 p.m. with LVN M, when asked if Resident #7 was receiving Behavioral Health Services LVN M stated, yes, Resident #7 has always been seen by Psychological services. When LVN M went to locate previous Behavioral Health notes for Resident #7 she was not able to locate any documentation from Centric Physicians. LVN M stated Resident #7 had consented to be followed by Centric Behavioral Health Group back in May. LVN M stated Resident #7 was receiving Psychological services up until the facility switched to Centric Physicians Group, she said she assumed resident was being followed by Centric Behavioral Health Nurse Practitioner and stated, I don't know why she was not followed on earlier. During interview on 07/19/19 at 1:50 p.m. with DON she stated Resident #7 was referred to Psychological services on 06/22/19.

Based on interviews, observations, and record reviews, the facility failed to ensure residents were free from neglect for 2 of 21 residents (Residents #1 and #2) whose care was reviewed for neglect, in that: The facility's structure to prevent neglect were not implemented when: 1. The facility failed to document or implement interventions for Resident # 1, who they were aware had a history of [REDACTED]. Resident # 1 choked on [DATE] and again on [DATE] and subsequently died . 2.(a) Facility staff did not follow process related to CPR administration when staff did not check resident # 1's pulse or respiration prior to administering CPR. (b) Contrary to facility process, staff administered CPR prior to verifying Resident # 1's DNR status. 3. Resident #2 was supposed to receive a low concentrated sweet diet but was receiving a no added salt diet without any orders. These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of choking, all residents were assessed for DNR status and the staff were in-serviced on assessing residents in emergency situations and ensuring all residents had a therapeutic diet. These deficient practices could affect residents in the facility who are at risk of choking, all residents who are a full code resulting in unnecessary treatment, all residents who are a DNR resulting in their wishes not being honored, and residents requiring a therapeutic diet, and place them at-risk for harm or inadequate nutrition. The findings were: 1. Record review of Resident #1's face sheet revealed an admission date of [DATE], with a readmission date of [DATE], with diagnoses that included: Dysphagia, Cerebral Infarction, [MEDICAL CONDITION] Obstruction, and Gastrostomy. Observation on [DATE] at 11:45 AM revealed fire department and EMS were outside the facility, EMS was seen entering the building and leaving, Resident #1 had already expired. Further observation revealed Resident #1 was laying on the floor in his room, face blue. Record review of Resident #1's consolidated physician orders [REDACTED]. Record review of Resident #1's nursing progress note, dated [DATE] at 1:45 PM written by RN F, revealed: resident propelled self to nurses station and was saying 'hey' over and over again, resident was sweating and somewhat pale and attempting to cough, noted to have a roll of saltine crackers on his lap, oxygen saturation 48, resident was turning blue and [MEDICATION NAME] initiated and was successful, non-rebreather oxygen applied 15 liters Resident # 1 was suctioned orally and watery residual crackers removed from mouth/throat. Resident # 1 got his color back and became more alert. EMS called and transported Resident # 1 to hospital. Further review of Resident #1's progress note revealed DON and physician were made aware, and that interventions were already in place for Resident #1 to eat in the dining room for all meals until roommate finishes his food because resident does not follow redirections to not eat roommates' food. During an interview with Hospitality Aide C on [DATE] at 1:14 PM, Hospitality Aide C revealed she passed out snacks. Hospitality Aide C confirmed Residents #4 and #1 were roommates and were both on pureed diets with thickened liquids (record review of roommates diet revealed he was on mechanical soft nectar thicken liquid). Hospitality Aide C stated she had not given Resident #1 a sandwich, and further stated the resident had behaviors of taking food that did not belong to him. Hospitality Aide C further revealed two weekends ago he came in from smoke break with a pack of saltine crackers he took for another resident. She further revealed she took the crackers from him and notified the RN. Record review of Resident #1's nursing progress note, dated [DATE] at 5:35 PM by RN F, revealed the resident returned from the hospital with no new orders. Further review of the resident's nursing progress notes revealed there were no other progress notes since the date of the resident's incident on [DATE]. Record review of Resident # 1's Quarterly MDS dated [DATE] revealed Resident # 1 did not have any behavioral issues and required extensive one person assist for meals. Further review of MDS revealed Resident # 1 received 51% or more of total calories through parental or tube feeding and was on a mechanically altered therapeutic diet. Record review of Resident #1's care plan, revised on [DATE], revealed the resident's care plan the resident had a swallowing problem related to dysphagia. All staff to be informed of resident's special dietary and safety needs. Check mouth after meals for pocketed food and debris. Instruct resident to eat in an upright position, to eat slowly, thoroughly. Further review of Resident's #1's care plan revealed the resident required one person assist with eating, and had a swallowing problem related to Dysphagia; all staff were to be informed of resident's dietary and safety needs. Record review of facility's incident reports for (MONTH) 2019 revealed an incident report was not completed for Resident #1's choking incident on [DATE]. There was no documentation of an assessment or interventions after Resident # 1's choking episode. Record review of Resident #1's speech therapy encounters revealed Resident #1 was receiving speech services on [DATE] for cognitive-linguistic therapy to facilitate improved orientation to immediate environment. and on [DATE] to improve safety during oral intake. Requires max cueing. Record review of Director of Rehab's facility witness statement dated [DATE] revealed Resident # 1 was in the therapy gym at 9:00 AM, after therapy Resident stayed in therapy room watching television. At approximately 10:55 AM he left for smoke break. He returned and left upset because channel had been changed. Approximately ,[DATE] minutes later code blue was called. Upon arrival on scene was notified he passed away. Resident was known to go to to other residents rooms and trash cans to find food. He was non-compliant with his diet restrictions. During an interview with the MDS Coordinator on [DATE] at 11:50 AM, the MDS Coordinator stated Resident # 1 was choking and MDS Coordinator was able to get a piece of bologna sandwich out of the resident's mouth. The MDS Coordinator confirmed Resident #1 was on a pureed diet. During an interview with the Dietary Manager on [DATE] at 1:04 PM, the Dietary Manager stated the facility offered bologna sandwiches to the residents for snacks on the morning of [DATE]. The Dietary Manager confirmed Resident #1 was on a pureed diet, and revealed that when the dietary staff delivered the snacks to the nurses' station, the nurse accepting the snacks had to sign off as receiving them for. The Dietary Manager further revealed Resident #1 had a history of [REDACTED]. During an interview with the MDS Coordinator on [DATE] at 8:25 AM, the MDS Coordinator confirmed there were no interventions placed after Resident #1 returned from the hospital from choking on [DATE]. The MDS Coordinator stated that to her knowledge there were not any records of Resident #1's non-compliance with his diet being monitored by facility staff. During an interview with the Administrator on [DATE] at 9:45 AM, the Administrator stated that he had not been informed by facility staff of Resident #1's previous choking incident on [DATE] until yesterday, [DATE]. The Administrator stated that had he been made aware of the resident's incident on [DATE] he would have reported the incident, and further stated, communication in this building was non-existent. The Administrator further stated that following Resident #1's previous incident the first thing he would have done would have been to review the resident's care plan to see if interventions were in place. Further interview with the Administrator revealed they have not had a QA meeting and that they began to complete 24 hour reports two weeks after he started His primary focus since staring in (MONTH) (YEAR) had been on cosmetics of the building and care of residents. The Administrator further revealed they were having difficulties transitioning from one corporation to the current corporations as a lot of the staff had to be termed due to not meting the current corporations standards. He further stated they were having difficulty obtaining employee training records. During an interview with the DON on [DATE] at 10:20 AM, the DON revealed facility staff called her on [DATE] and notified her of Resident #1's choking episode and that the resident had been sent to the hospital. The DON confirmed she had not notified the Administrator of Resident #1's incident, and had chosen not to do so because the resident had returned to the facility with no issues. During an interview with NP E on [DATE] at 12:04 PM, NP E revealed that he had never had any issues with Resident #1. NP E stated the resident did not talk much due to his [MEDICAL CONDITION], and further stated the resident did not have any aggressive behaviors; however, the resident was on hospice services for end-stage Dementia. NP E confirmed there was no documentation of Resident #1 being non-compliant with diet. NP E further revealed he was not informed by staff of Resident # 1 non-compliance with diet. NP E stated that if he had been informed the resident had had a choking episode he would have requested for speech therapy to evaluate the resident. Record review of facility's policy on Abuse/Neglect, revised [DATE], revealed: the facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of [REDACTED]. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will identify and investigate any events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. Record review of facility's policy on Event Reporting: Completion of dated 2003 revealed the facility will complete an Event form on variances that occur within the facility. All events that require treatment beyond immediate first aide must be reported immediately to the Administrator and/or DON. The investigation should be completed by the DON/Administrator or designee. The investigation report documents a thorough investigation of the events which including persons, equipment, and materials that were involved. Care plan any required interventions to help prevent further occurrence of the event. 2 a. Record review of LVN B's facility witness statement dated [DATE] revealed LVN B was called by CNA D and RA G. They were standing in the hallway in front of Resident #1's room while Resident #1 was sitting in his wheelchair cyanotic, drooling and appeared to have been choking. LVN B then began chest thrust maneuver and instructed aides to call a code blue. At 11:38 AM Resident #1 was then moved to the bed, and LVN I performed a mouth sweep between chest thrust. Other nurses began suctioning and CPR was started at 11:42 AM; at 11:44 AM the resident was then moved to the floor and CPR was continued. At 11:45 AM an AED was applied to the resident. At 11:48 AM resident # 1 was pronounced dead. Record review of LVN H's facility witness statement dated [DATE] revealed that at 11:42 AM LVN H entered Resident #1's room. Suctioning was started and bread and bologna were removed. Chest thrust maneuver started. At 11:43 AM LVN H started CPR; at 11:44 AM Resident #1 was moved to floor where CPR was continued by RN J At 11:45 AM an AED was applied to the resident and analyzed, resumed compression with ambu bag; at 11:46 AM, LVN I continued chest compressions. At 11:47 AM the MDS Coordinator continued chest compressions with ambu bag. At 11:48 AM RN J called time of death. Record review of LVN I's facility witness statement dated [DATE] revealed when LVN I entered Resident #1's room, LVN B was performing the [MEDICATION NAME] maneuver on the resident. LVN I performed two mouth sweeps that were unsuccessful. Resident #1 was blue; EMS was called and staff started CPR. Initial round of compressions were started by RN J, MDS Coordinator took over breaths given by LVN H. At this point they were told to cease CPR due to resident being a DNR. At this point EMS was on seen. (witness statement does not say who instructed them to stop CPR) Record review of Resident #1's SBAR completed by LVN A dated [DATE] at 1:44 PM revealed vital signs were: [DATE] at 2:00 PM blood pressure ,[DATE] [DATE] at 2:46 PM pulse 71 [DATE] at 2:49 PM respirations 18 [DATE] at 2:51 PM temperature 97.1 oral [DATE] at 2:51 PM oxygen saturation was 97% on room air Further review of SBAR revealed the resident's treatment for [REDACTED]. During an interview with the MDS Coordinator on [DATE] at 8:25 AM, the MDS Coordinator confirmed she did not recall anyone performing any vital signs (blood pressure, pulse, respirations) or saying anything about it before initiating CPR on Resident #1 during the incident on [DATE]. During an interview with LVN B on [DATE] at 9:45 AM, LVN B confirmed she did not recall Resident #1's vitals or pulse being taken prior to starting CPR during the incident on [DATE]. Record review of the Basic Life Support Healthcare Provider Adult [MEDICAL CONDITION] Algorithm - (YEAR) update provided by the facility revealed: victim is unresponsive - look for no breathing or only gasping and check for pulse (simultaneously); if no normal breathing and has pulse - provide rescue breathing; if no breathing or only gasping and no pulse - initiate CPR. Record review of facility's policy on [MEDICATION NAME] Maneuver, revised (MONTH) 2007, revealed: . after the abdominal thrust, the rescuer repeats the process of lifting the chin, moving the tongue, feeling for and possibly removing the object. If the airway is not clear, the rescuer repeats the abdominal thrust as long as necessary. If the foreign object is removed but the victim is not breathing, the rescuer starts ventilation at a rate of two breaths every five seconds. If there is no pulse, CPR will be initiated. b. Record review of Resident #1's CPR timeline, dated [DATE] provided by facility, revealed that on [DATE] at: 11:41 AM A Code Blue was called (meaning there was an emergency situation, such as a resident in cardiopulmonary arrest, choking, or anytime assistance is needed, requiring a team of providers to rush to a specific location and begin immediate resuscitative efforts); EMS was also called. At 11:42 AM suctioning was started At 11:43 AM chest compressions started and staff went to check the resident's code status At 11:44 AM chest compressions continued with the resident moved to the floor and ambu bag was placed At 11:45 AM CPR continued. Further review revealed that an AED was applied to the resident and no shock was advised At 11:46 AM chest compressions continued while staff was still checking the resident's code status. Further review revealed that at 11:47 AM Resident #1's code status was verified and CPR was stopped. Record review of Resident #1's care plan, revised [DATE], revealed Resident #1 had an order for [REDACTED]. During an interview with the DON and the Regional Nurse on [DATE] at 10:20 AM, the DON and the Regional Nurse confirmed residents' advanced directive status should be delegated and verified immediately when a code arises. During an interview with LVN B and LVN K on [DATE] at 9:53 AM, LVN B and LVN K confirmed residents' code status needed to be verified immediately during an emergency situation. Record review of facility's policy on Do Not Resuscitate orders, revised [DATE], revealed: all validly executed physician orders [REDACTED]. The facility will copy the original DNR form and place a copy in the resident's medical record. The original will be placed in a protective cover in the resident's medical records. The resident's record will have a red sheet of paper as the first page of the record with the words, DNR in black letters located on that sheet of paper. 3. Record review of Resident #2 revealed an admission date of [DATE] (no diagnoses information). Observation on [DATE] at 9:00 AM revealed Resident # 2 did not have a diet tray. Further observation revealed hall trays had already been distributed. During an interview with Resident #2 on [DATE] at 9:00 AM, Resident #2 stated she had refused breakfast because she did not want to go to dining room. Record review of Resident #2's consolidated physician orders [REDACTED]. Record review of Resident #2's consolidated physician orders [REDACTED]. Further review of orders revealed Resident #2 was on Humalog sliding scale, Atorvastatin for cholesterol at bedtime, [MEDICATION NAME] three times a day, and Nifidepine once a day for Hypertension. Record review of Resident #2's care plan dated [DATE] revealed the resident's care plan addressed the resident's Hypertension and Diabetes Mellitus. Further review of the resident's care plan revealed Resident has a diet order other than regular and was at risk for unplanned weight loss or gain (specify diet); however, the resident's specific type of diet was not specified. Record review of the facility's diet roster, dated [DATE], revealed Resident #2 was not listed on the diet roster. Record review of the facility's Diet Card notebook revealed there was not a communication diet slip for Resident #2. Record review on [DATE] at 12:04 PM of Resident #2's electronic consolidated physician orders [REDACTED].>During an interview with the DON and Regional Nurse on [DATE] at 2:33 PM, the DON and Regional Nurse confirmed Resident #2 did not have any medication or diet orders in the resident's electronic record. The DON and Regional Nurse further confirmed the consolidated physician orders [REDACTED]. During an interview with the DON and the Regional Nurse on [DATE] at 3:30 PM, the DON and the Regional Nurse confirmed the diet roster, dated [DATE], was the most current and updated diet roster and did not list a diet order for Resident #2. During an interview with Hydration Aide A on [DATE] at 9:10 AM, Hydration Aide A revealed Resident #2 had refused her breakfast tray. Hydration Aide A revealed she knew Resident #2 had been receiving a No Added Salt diet from when she handed out diet trays. During an interview with Dietary Cook L on [DATE] at 10:42 AM, Dietary Cook L stated the Dietary Manager prints out the residents' meal tickets and leaves them ready for the dietary staff. Dietary Cook L stated the dietary staff served the residents' diets based on their meal tickets, and further stated the nursing staff handed a the dietary staff communication slips notifying them of any new orders for residents. Dietary Cook L further stated she could not recall Resident # 2's diet they just follow the meal tickets. During an interview with the Dietary Manager on [DATE] at 10:46 AM, the Dietary Manager stated she kept the dietary communication slips in her office in a blue notebook titled, Diet Card Notebook. The Dietary Manager stated the dietary staff obtained the residents' diet orders from nursing on a dietary communication form. The Dietary Manager further stated that sometimes if the dietary communication slips are handed to the dietary staff in the kitchen they get thrown away. The Administrator was notified of the an IJ on [DATE] at 2:00 PM and a Plan of Removal was requested. The Plan of Removal included the following: Plan of Removal - [DATE] Potential Problem - Staff did not take vital signs in the intervals during a course of CPR for a resident and initiated CPR for a resident with a Do Not Resuscitate order. Interventions - An audit was completed on [DATE] to ensure all residents with a DNR have the order entered into Point Click Care. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. DON/ADON will update DNR binder monthly to ensure accuracy. All licensed nurses were in-serviced by the DON, ADON or Regional Nurse beginning on [DATE] regarding the following: (60% of all staff were in-serviced [DATE] with a completion date [DATE]. Staff will be in-service prior to returning to job duties). Verifying a resident's code status. Locations the code status for a resident can be located. They are as follows: Residents' chart Electronic records - After selecting the resident, look directly below their name on the left side of the screen. Point of Care - After selecting the resident, look directly below their name on the left side of the screen. EMAR - After selecting the resident, look directly below their name on the left side of the screen. In all the locations noted above, if no code status is listed or Full Code; CPR should initiated. If DNR, CPR is not to be started. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. Vital signs during CPR - If a resident is Full Code and is suspected of to be in cardiac and/or respiratory distress, the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. During the course of CPR, about every 2 minutes the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. When documenting an episode of CPR, ensure to include the approximate time the presence of pulse or respirations were checked. BLS Healthcare Provider Adult [MEDICAL CONDITION] Algorithm (see attached) regarding the proper algorithm for CPR for an adult by a healthcare provider according to the (YEAR) guidelines set by the American Heart Association. A copy of this algorithm will placed on the emergency cart on [DATE]. Abuse and Neglect according to facility policy - see attached policy The regional nurse who is a certified CPR instructor will provide in-servicing related to the above topics to the DON and ADONs and all Nursing staff prior to returning to job duties (60% of Nursing were In-Service [DATE]). Any newly hired staff will be provided training to the above topics upon hire by the DON and/or ADON. The Medical Director was notified of this plan on [DATE]. Monitoring The DON and or ADON will ask at least 8 nurses per week how to determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. ADONs will check DNR binders at least 3 times a week x 4 weeks to ensure that all DNRs are accurate and updated, followed by weekly checks from there on after. The binders will be updated immediately upon any code status order change. The DON and/or ADONs will monitor any CPR related documentation to ensure compliance with documentation related to CPR including presence of pulse and respirations The DON and/or ADONs will ensure that at least 1 CPR certified nurse is present 24 hours per day. The Regional Nurse at least weekly will verify that the above monitoring by facility staff is in compliance as stated. Findings will be shared with the QAA committee and changes made as required. Ask at least 8 nurses per week how they would determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. Date_____________________ Name of Nurse___________________ Did the nurse answer each question correctly? Yes or No; If No explain corrective action below. Plan of Removal - Failure to have accurate diet roster and training. Failure to Intervene and update care plan. Staff training and Knowledge of diet. Interventions to prevent reoccurrence. All residents identified with diet orders were reviewed and verified to determine diet accuracy by [DATE]. All residents that have behaviors related to noncompliance with their diet texture and have the potential to choke were identified by the DON and regional nurse on [DATE]. Any residents identified with a behavior to be non-compliant with the diet texture had a task added to their point of care that states, Resident has a history of hoarding and/or stealing food that is not compliant with their diet order which makes them at risk for choking. If observed, attempt to remove the food and notify your supervisor immediately. Certified Nurse Aide staff will be able to acknowledge this every shift. Any residents identified with a behavior to be non-compliant with the diet texture had an entry added to their treatment administration record (TAR) to communicate to the licensed nurse the potential problem. The nurse will initial this entry every shift. Any residents identified with a behavior to be non-compliant with the diet had their care plan reviewed and if needed updated on [DATE] by the DON, ADON, Regional Nurse, or MDS nurse to reflect interventions to attempt prevent the resident from choking related to their behavior. On [DATE] binders were placed on the East and West hydration carts that included all residents' diet orders for easy review by nursing staff if they have a question to what diet a resident has. Nursing Staff were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the Diet Binder placed on each hydration cart on East and West Hall, the task added to the point of care and the entry to the TAR. Any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties. Licenses nurses were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the following: (any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties). If a diet order is obtained by the Charge Nurse, the following protocol will be followed: - The charge nurse will verify the diet orders and enter orders into electronic records. - The Charge Nurse will complete a Dietary Notification form and give to dietary. - The Charge Nurse will review diet orders at each meal service. - DON/ADON will update dietary binder monthly. - Any new diet orders will be followed as directed by the physician. All staff were in-serviced by the DON, ADON, or Regional Nurse regarding the facility's policy on abuse and neglect. See attached policy. This in-service began on [DATE] and any staff not in-serviced on [DATE], will be in-serviced prior to assuming their duties. Any new staff hired will be trained regarding the above in-services by the DON and/or ADON The DON, ADON, and MDS case managers were in-serviced regarding completion of residents care plan not reflecting resident current status by the regional nurse on [DATE]. The DON and Administrator were in-serviced by the regional nurse regarding reporting abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. The DON and Administrator will in-service staff on reporting abuse, neglect or any other reportable incident prior to staff returning to job duties. Completion date [DATE]. Monitoring The DON and or designee will monitor on a daily basis to ensure any new or readmitted resident has a diet order. The DON and/or ADON will complete a random diet order review on 15 residents per week for 4 weeks by comparing the electronic records orders to the resident dietary tray card for accuracy. The DON and/or designee will ask 10 staff members per week for 4 weeks, if they know how to obtain the residents diet. During the weekly care plan meeting the MDS Case Manager and the DON or Designee will ensure that the residents' Care Plans match the resident's current status. The DON, ADON, or MDS nurse will update a residents diet care as needed for any new diet orders, intervention, or non-compliance The Regional Nurse at least weekly will verify that the above monitoring by facility staff is in compliance as stated. The Regional Nurse and/or area director of operations will monitor incidents/events at least weekly to ensure compliance with reporting guidelines. Findings will be reviewed by the QAA committee and changes made to the plan as needed. All of the above monitoring will be documented on a facility formulated monitoring form. Plan of Removal DNR [DATE] Interventions to prevent reoccurrence. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. Code status can also be verified in the electronic records as well as residents chart, point of care kiosk and EMAR. Staff will be in serviced that in the event of a rapid response charge nurse will designate one person to verify code status. 60% of staff are expected to be in-service by [DATE] with a completion date of [DATE]. Monitoring ADONs will check DNR binders 3 times a week x 4 weeks to ensure that all DNRs are accurate and updated, followed by weekly checks from there on after. Verification of the Plan of Removal was as follows: a. Observation on [DATE] at 1:20 PM revealed snacks were on west wing nurses' station countertop. Further observation revealed a female resident was reaching for the yogurt and asked me if she could have it. LVN M was sitting at nurses' station documenting on a computer, and the ADON standing behind the desk. During an interview with the ADON and LVN M on [DATE] at 1:20 PM, at the same time as the observation, the ADON confirmed the snack tray was supposed to be placed behind the nurses' station out of resident's reach. LVN M and the ADON further confirmed that neither one had signed for snacks and were not aware who did or when they were delivered. Record review of in-service training revealed staff were in-serviced immediately on procedures for snacks. Interviews with 3 CNAs and 4 LVNs revealed they were aware of ensuring snacks are placed behind nurses' station out of reach of residents. b. Facility identified a list of residents at risk fo

Based on interviews, observations, and record reviews, the facility failed to develop and implement written policies and procedures to ensure residents were free from neglect for 2 of 21 residents (Residents #1 and #2) whose care was reviewed for neglect, in that: The facility did not prohibit or prevent resident rights to be free from neglect when: 1. Resident # 1 choked to death after the facility did not investigate a previous choking incident or provide interventions to prevent future incidents. 2.(a) The facility staff did not assess Resident # 1 for pulse or respiration prior to administering CPR. (b) Facility staff performed CPR on Resident # 1 even though Resident # 1's status was DNR. 3. Resident #2 was supposed to receive a low concentrated sweet diet but was receiving a no added salt diet without any orders. These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of choking, all residents were assessed for DNR status and the staff were in-serviced on assessing residents in emergency situations and ensuring all residents had a therapeutic diet. These deficient practices could affect residents in the facility who are at risk of choking, all residents who are a full code resulting in unnecessary treatment, all residents who are a DNR resulting in their wishes not being honored, and residents requiring a therapeutic diet, and place them at-risk for harm or inadequate nutrition. The findings were: Record review of facility's policy on Abuse/Neglect, revised [DATE], revealed: the facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of [REDACTED]. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will identify and investigate any events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. Record review of facility's policy on Event Reporting: Completion of dated 2003 revealed the facility will complete an Event form on variances that occur within the facility. All events that require treatment beyond immediate first aide must be reported immediately to the Administrator and/or DON. The investigation should be completed by the DON/Administrator or designee. The investigation report documents a thorough investigation of the events which including persons, equipment, and materials that were involved. Care plan any required interventions to help prevent further occurrence of the event. 1. The facility failed to document or implement interventions for Resident # 1, who they were aware had a history of [REDACTED]. Resident # 1 choked on [DATE] and again on [DATE] and subsequently died . 2.(a) Facility staff did not follow process related to CPR administration when staff did not check resident # 1's pulse or respiration prior to administering CPR. (b) Contrary to facility process, staff administered CPR prior to verifying Resident # 1's DNR status. 3. Resident #2 was supposed to receive a low concentrated sweet diet but was receiving a no added salt diet without any orders. These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of choking, all residents were assessed for DNR status and the staff were in-serviced on assessing residents in emergency situations and ensuring all residents had a therapeutic diet. These deficient practices could affect residents in the facility who are at risk of choking, all residents who are a full code resulting in unnecessary treatment, all residents who are a DNR resulting in their wishes not being honored, and residents requiring a therapeutic diet, and place them at-risk for harm or inadequate nutrition. The findings were: 1. Record review of Resident #1's face sheet revealed an admission date of [DATE], with a readmission date of [DATE], with diagnoses that included: Dysphagia, Cerebral Infarction, [MEDICAL CONDITION] Obstruction, and Gastrostomy. Observation on [DATE] at 11:45 AM revealed fire department and EMS were outside the facility, EMS was seen entering the building and leaving, Resident #1 had already expired. Further observation revealed Resident #1 was laying on the floor in his room, face blue. Record review of Resident #1's consolidated physician orders [REDACTED]. Record review of Resident #1's nursing progress note, dated [DATE] at 1:45 PM written by RN F, revealed: resident propelled self to nurses station and was saying 'hey' over and over again, resident was sweating and somewhat pale and attempting to cough, noted to have a roll of saltine crackers on his lap, oxygen saturation 48, resident was turning blue and [MEDICATION NAME] initiated and was successful, non-rebreather oxygen applied 15 liters Resident # 1 was suctioned orally and watery residual crackers removed from mouth/throat. Resident # 1 got his color back and became more alert. EMS called and transported Resident # 1 to hospital. Further review of Resident #1's progress note revealed DON and physician were made aware, and that interventions were already in place for Resident #1 to eat in the dining room for all meals until roommate finishes his food because resident does not follow redirections to not eat roommates' food. During an interview with Hospitality Aide C on [DATE] at 1:14 PM, Hospitality Aide C revealed she passed out snacks. Hospitality Aide C confirmed Residents #4 and #1 were roommates and were both on pureed diets with thickened liquids (record review of roommates diet revealed he was on mechanical soft nectar thicken liquid). Hospitality Aide C stated she had not given Resident #1 a sandwich, and further stated the resident had behaviors of taking food that did not belong to him. Hospitality Aide C further revealed two weekends ago he came in from smoke break with a pack of saltine crackers he took for another resident. She further revealed she took the crackers from him and notified the RN. Record review of Resident #1's nursing progress note, dated [DATE] at 5:35 PM by RN F, revealed the resident returned from the hospital with no new orders. Further review of the resident's nursing progress notes revealed there were no other progress notes since the date of the resident's incident on [DATE]. Record review of Resident # 1's Quarterly MDS dated [DATE] revealed Resident # 1 did not have any behavioral issues and required extensive one person assist for meals. Further review of MDS revealed Resident # 1 received 51% or more of total calories through parental or tube feeding and was on a mechanically altered therapeutic diet. Record review of Resident #1's care plan, revised on [DATE], revealed the resident's care plan the resident had a swallowing problem related to dysphagia. All staff to be informed of resident's special dietary and safety needs. Check mouth after meals for pocketed food and debris. Instruct resident to eat in an upright positing, to eat slowly, thoroughly. Further review of Resident's #1's care plan revealed the resident required one person assist with eating, and had a swallowing problem related to Dysphagia; all staff were to be informed of resident's dietary and safety needs. Record review of facility's incident reports for (MONTH) 2019 revealed an incident report was not completed for Resident #1's choking incident on [DATE]. There was no documentation of an assessment or interventions after Resident # 1's choking episode. Record review of Resident #1's speech therapy encounters revealed Resident #1 was receiving speech services on [DATE] for cognitive-linguistic therapy to facilitate improved orientation to immediate environment. and on [DATE] to improve safety during oral intake. Requires max cueing. Record review of Director of Rehab's facility witness statement dated [DATE] revealed Resident # 1 was in the therapy gym at 9:00 AM, after therapy Resident stayed in therapy room watching television. At approximately 10:55 AM he left for smoke break. He returned and left upset because channel had been changed. Approximately ,[DATE] minutes later code blue was called. Upon arrival on scene was notified he passed away. Resident was known to go to to other residents rooms and trash cans to find food. He was non-compliant with his diet restrictions. During an interview with the MDS Coordinator on [DATE] at 11:50 AM, the MDS Coordinator stated Resident # 1 was choking and MDS Coordinator was able to get a piece of bologna sandwich out of the resident's mouth. The MDS Coordinator confirmed Resident #1 was on a pureed diet. During an interview with the Dietary Manager on [DATE] at 1:04 PM, the Dietary Manager stated the facility offered bologna sandwiches to the residents for snacks on the morning of [DATE]. The Dietary Manager confirmed Resident #1 was on a pureed diet, and revealed that when the dietary staff delivered the snacks to the nurses' station, the nurse accepting the snacks had to sign off as receiving them for. The Dietary Manager further revealed Resident #1 had a history of [REDACTED]. During an interview with the MDS Coordinator on [DATE] at 8:25 AM, the MDS Coordinator confirmed there were no interventions placed after Resident #1 returned from the hospital from choking on [DATE]. The MDS Coordinator stated that to her knowledge there were not any records of Resident #1's non-compliance with his diet being monitored by facility staff. During an interview with the Administrator on [DATE] at 9:45 AM, the Administrator stated that he had not been informed by facility staff of Resident #1's previous choking incident on [DATE] until yesterday, [DATE]. The Administrator stated that had he been made aware of the resident's incident on [DATE] he would have reported the incident, and further stated, communication in this building was non-existent. The Administrator further stated that following Resident #1's previous incident the first thing he would have done would have been to review the resident's care plan to see if interventions were in place. Further interview with the Administrator revealed they have not had a QA meeting and that they began to complete 24 hour reports two weeks after he started His primary focus since staring in (MONTH) (YEAR) had been on cosmetics of the building and care of residents. The Administrator further revealed they were having difficulties transitioning from one corporation to the current corporations as a lot of the staff had to be termed due to not meting the current corporations standards. He further stated they were having difficulty obtaining employee training records. During an interview with the DON on [DATE] at 10:20 AM, the DON revealed facility staff called her on [DATE] and notified her of Resident #1's choking episode and that the resident had been sent to the hospital. The DON confirmed she had not notified the Administrator of Resident #1's incident, and had chosen not to do so because the resident had returned to the facility with no issues. During an interview with NP E on [DATE] at 12:04 PM, NP E revealed that he had never had any issues with Resident #1. NP E stated the resident did not talk much due to his [MEDICAL CONDITION], and further stated the resident did not have any aggressive behaviors; however, the resident was on hospice services for end-stage Dementia. NP E confirmed there was no documentation of Resident #1 being non-compliant with diet. NP E further revealed he was not informed by staff of Resident # 1 non-compliance with diet. NP E stated that if he had been informed the resident had had a choking episode he would have requested for speech therapy to evaluate the resident. Record review of facility's policy on Abuse/Neglect, revised [DATE], revealed: the facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of [REDACTED]. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will identify and investigate any events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. Record review of facility's policy on Event Reporting: Completion of dated 2003 revealed the facility will complete an Event form on variances that occur within the facility. All events that require treatment beyond immediate first aide must be reported immediately to the Administrator and/or DON. The investigation should be completed by the DON/Administrator or designee. The investigation report documents a thorough investigation of the events which including persons, equipment, and materials that were involved. Care plan any required interventions to help prevent further occurrence of the event. 2 a. Record review of LVN B's facility witness statement dated [DATE] revealed LVN B was called by CNA D and RA G. They were standing in the hallway in front of Resident #1's room while Resident #1 was sitting in his wheelchair cyanotic, drooling and appeared to have been choking. LVN B then began chest thrust maneuver and instructed aides to call a code blue. At 11:38 AM Resident #1 was then moved to the bed, and LVN I performed a mouth sweep between chest thrust. Other nurses began suctioning and CPR was started at 11:42 AM; at 11:44 AM the resident was then moved to the floor and CPR was continued. At 11:45 AM an AED was applied to the resident. At 11:48 AM resident # 1 was pronounced dead. Record review of LVN H's facility witness statement dated [DATE] revealed that at 11:42 AM LVN H entered Resident #1's room. Suctioning was started and bread and bologna were removed. Chest thrust maneuver started. At 11:43 AM LVN H started CPR; at 11:44 AM Resident #1 was moved to floor where CPR was continued by RN J At 11:45 AM an AED was applied to the resident and analyzed, resumed compression with ambu bag; at 11:46 AM, LVN I continued chest compressions. At 11:47 AM the MDS Coordinator continued chest compressions with ambu bag. At 11:48 AM RN J called time of death. Record review of LVN I's facility witness statement dated [DATE] revealed when LVN I entered Resident #1's room, LVN B was performing the [MEDICATION NAME] maneuver on the resident. LVN I performed two mouth sweeps that were unsuccessful. Resident #1 was blue; EMS was called and staff started CPR. Initial round of compressions were started by RN J, MDS Coordinator took over breaths given by LVN H. At this point they were told to cease CPR due to resident being a DNR. At this point EMS was on seen. (witness statement does not say who instructed them to stop CPR) Record review of Resident #1's SBAR completed by LVN A dated [DATE] at 1:44 PM revealed vital signs were: [DATE] at 2:00 PM blood pressure ,[DATE] [DATE] at 2:46 PM pulse 71 [DATE] at 2:49 PM respirations 18 [DATE] at 2:51 PM temperature 97.1 oral [DATE] at 2:51 PM oxygen saturation was 97% on room air Further review of SBAR revealed the resident's treatment for [REDACTED]. During an interview with the MDS Coordinator on [DATE] at 8:25 AM, the MDS Coordinator confirmed she did not recall anyone performing any vital signs (blood pressure, pulse, respirations) or saying anything about it before initiating CPR on Resident #1 during the incident on [DATE]. During an interview with LVN B on [DATE] at 9:45 AM, LVN B confirmed she did not recall Resident #1's vitals or pulse being taken prior to starting CPR during the incident on [DATE]. Record review of the Basic Life Support Healthcare Provider Adult [MEDICAL CONDITION] Algorithm - (YEAR) update provided by the facility revealed: victim is unresponsive - look for no breathing or only gasping and check for pulse (simultaneously); if no normal breathing and has pulse - provide rescue breathing; if no breathing or only gasping and no pulse - initiate CPR. Record review of facility's policy on [MEDICATION NAME] Maneuver, revised (MONTH) 2007, revealed: . after the abdominal thrust, the rescuer repeats the process of lifting the chin, moving the tongue, feeling for and possibly removing the object. If the airway is not clear, the rescuer repeats the abdominal thrust as long as necessary. If the foreign object is removed but the victim is not breathing, the rescuer starts ventilation at a rate of two breaths every five seconds. If there is no pulse, CPR will be initiated. b. Record review of Resident #1's CPR timeline, dated [DATE] provided by facility, revealed that on [DATE] at: 11:41 AM A Code Blue was called (meaning there was an emergency situation, such as a resident in cardiopulmonary arrest, choking, or anytime assistance is needed, requiring a team of providers to rush to a specific location and begin immediate resuscitative efforts); EMS was also called. At 11:42 AM suctioning was started At 11:43 AM chest compressions started and staff went to check the resident's code status At 11:44 AM chest compressions continued with the resident moved to the floor and ambu bag was placed At 11:45 AM CPR continued. Further review revealed that an AED was applied to the resident and no shock was advised At 11:46 AM chest compressions continued while staff was still checking the resident's code status. Further review revealed that at 11:47 AM Resident #1's code status was verified and CPR was stopped. Record review of Resident #1's care plan, revised [DATE], revealed Resident #1 had an order for [REDACTED]. During an interview with the DON and the Regional Nurse on [DATE] at 10:20 AM, the DON and the Regional Nurse confirmed residents' advanced directive status should be delegated and verified immediately when a code arises. During an interview with LVN B and LVN K on [DATE] at 9:53 AM, LVN B and LVN K confirmed residents' code status needed to be verified immediately during an emergency situation. Record review of facility's policy on Do Not Resuscitate orders, revised [DATE], revealed: all validly executed physician orders [REDACTED]. The facility will copy the original DNR form and place a copy in the resident's medical record. The original will be placed in a protective cover in the resident's medical records. The resident's record will have a red sheet of paper as the first page of the record with the words, DNR in black letters located on that sheet of paper. 3. Record review of Resident #2 revealed an admission date of [DATE] (no diagnoses information). Observation on [DATE] at 9:00 AM revealed Resident # 2 did not have a diet tray. Further observation revealed hall trays had already been distributed. During an interview with Resident #2 on [DATE] at 9:00 AM, Resident #2 stated she had refused breakfast because she did not want to go to dining room. Record review of Resident #2's consolidated physician orders [REDACTED]. Record review of Resident #2's consolidated physician orders [REDACTED]. Further review of orders revealed Resident #2 was on Humalog sliding scale, Atorvastatin for cholesterol at bedtime, [MEDICATION NAME] three times a day, and Nifidepine once a day for Hypertension. Record review of Resident #2's care plan dated [DATE] revealed the resident's care plan addressed the resident's Hypertension and Diabetes Mellitus. Further review of the resident's care plan revealed Resident has a diet order other than regular and was at risk for unplanned weight loss or gain (specify diet); however, the resident's specific type of diet was not specified. Record review of the facility's diet roster, dated [DATE], revealed Resident #2 was not listed on the diet roster. Record review of the facility's Diet Card notebook revealed there was not a communication diet slip for Resident #2. Record review on [DATE] at 12:04 PM of Resident #2's electronic consolidated physician orders [REDACTED].>During an interview with the DON and Regional Nurse on [DATE] at 2:33 PM, the DON and Regional Nurse confirmed Resident #2 did not have any medication or diet orders in the resident's electronic record. The DON and Regional Nurse further confirmed the consolidated physician orders [REDACTED]. During an interview with the DON and the Regional Nurse on [DATE] at 3:30 PM, the DON and the Regional Nurse confirmed the diet roster, dated [DATE], was the most current and updated diet roster and did not list a diet order for Resident #2. During an interview with Hydration Aide A on [DATE] at 9:10 AM, Hydration Aide A revealed Resident #2 had refused her breakfast tray. Hydration Aide A revealed she knew Resident #2 had been receiving a No Added Salt diet from when she handed out diet trays. During an interview with Dietary Cook L on [DATE] at 10:42 AM, Dietary Cook L stated the Dietary Manager prints out the residents' meal tickets and leaves them ready for the dietary staff. Dietary Cook L stated the dietary staff served the residents' diets based on their meal tickets, and further stated the nursing staff handed a the dietary staff communication slips notifying them of any new orders for residents. Dietary Cook L further stated she could not recall Resident # 2's diet they just follow the meal tickets. During an interview with the Dietary Manager on [DATE] at 10:46 AM, the Dietary Manager stated she kept the dietary communication slips in her office in a blue notebook titled, Diet Card Notebook. The Dietary Manager stated the dietary staff obtained the residents' diet orders from nursing on a dietary communication form. The Dietary Manager further stated that sometimes if the dietary communication slips are handed to the dietary staff in the kitchen they get thrown away. The Administrator was notified of the immediate jeopardy IJ on [DATE] at 2:00 PM and a Plan of Removal was requested. The Plan of Removal included the following: Plan of Removal - [DATE] Potential Problem - Staff did not take vital signs in the intervals during a course of CPR for a resident and initiated CPR for a resident with a Do Not Resuscitate order. Interventions - An audit was completed on [DATE] to ensure all residents with a DNR have the order entered into Point Click Care. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. DON/ADON will update DNR binder monthly to ensure accuracy. All licensed nurses were in-serviced by the DON, ADON or Regional Nurse beginning on [DATE] regarding the following: (60% of all staff were in-serviced [DATE] with a completion date [DATE]. Staff will be in-service prior to returning to job duties). Verifying a resident's code status. Locations the code status for a resident can be located. They are as follows: Residents' chart Electronic records - After selecting the resident, look directly below their name on the left side of the screen. Point of Care - After selecting the resident, look directly below their name on the left side of the screen. EMAR - After selecting the resident, look directly below their name on the left side of the screen. In all the locations noted above, if no code status is listed or Full Code; CPR should initiated. If DNR, CPR is not to be started. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. Vital signs during CPR - If a resident is Full Code and is suspected of to be in cardiac and/or respiratory distress, the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. During the course of CPR, about every 2 minutes the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. When documenting an episode of CPR, ensure to include the approximate time the presence of pulse or respirations were checked. BLS Healthcare Provider Adult [MEDICAL CONDITION] Algorithm (see attached) regarding the proper algorithm for CPR for an adult by a healthcare provider according to the (YEAR) guidelines set by the American Heart Association. A copy of this algorithm will placed on the emergency cart on [DATE]. Abuse and Neglect according to facility policy - see attached policy The regional nurse who is a certified CPR instructor will provide in-servicing related to the above topics to the DON and ADONs and all Nursing staff prior to returning to job duties (60% of Nursing were In-Service [DATE]). Any newly hired staff will be provided training to the above topics upon hire by the DON and/or ADON. The Medical Director was notified of this plan on [DATE]. Monitoring The DON and or ADON will ask at least 8 nurses per week how to determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. ADONs will check DNR binders at least 3 times a week x 4 weeks to ensure that all DNRs are accurate and updated, followed by weekly checks from there on after. The binders will be updated immediately upon any code status order change. The DON and/or ADONs will monitor any CPR related documentation to ensure compliance with documentation related to CPR including presence of pulse and respirations The DON and/or ADONs will ensure that at least 1 CPR certified nurse is present 24 hours per day. The Regional Nurse at least weekly will verify that the above monitoring by facility staff is in compliance as stated. Findings will be shared with the QAA committee and changes made as required. Ask at least 8 nurses per week how they would determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. Date_____________________ Name of Nurse___________________ Did the nurse answer each question correctly? Yes or No; If No explain corrective action below. Plan of Removal - Failure to have accurate diet roster and training. Failure to Intervene and update care plan. Staff training and Knowledge of diet. Interventions to prevent reoccurrence. All residents identified with diet orders were reviewed and verified to determine diet accuracy by [DATE]. All residents that have behaviors related to noncompliance with their diet texture and have the potential to choke were identified by the DON and regional nurse on [DATE]. Any residents identified with a behavior to be non-compliant with the diet texture had a task added to their point of care that states, Resident has a history of hoarding and/or stealing food that is not compliant with their diet order which makes them at risk for choking. If observed, attempt to remove the food and notify your supervisor immediately. Certified Nurse Aide staff will be able to acknowledge this every shift. Any residents identified with a behavior to be non-compliant with the diet texture had an entry added to their treatment administration record (TAR) to communicate to the licensed nurse the potential problem. The nurse will initial this entry every shift. Any residents identified with a behavior to be non-compliant with the diet had their care plan reviewed and if needed updated on [DATE] by the DON, ADON, Regional Nurse, or MDS nurse to reflect interventions to attempt prevent the resident from choking related to their behavior. On [DATE] binders were placed on the East and West hydration carts that included all residents' diet orders for easy review by nursing staff if they have a question to what diet a resident has. Nursing Staff were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the Diet Binder placed on each hydration cart on East and West Hall, the task added to the point of care and the entry to the TAR. Any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties. Licenses nurses were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the following: (any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties). If a diet order is obtained by the Charge Nurse, the following protocol will be followed: - The charge nurse will verify the diet orders and enter orders into electronic records. - The Charge Nurse will complete a Dietary Notification form and give to dietary. - The Charge Nurse will review diet orders at each meal service. - DON/ADON will update dietary binder monthly. - Any new diet orders will be followed as directed by the physician. All staff were in-serviced by the DON, ADON, or Regional Nurse regarding the facility's policy on abuse and neglect. See attached policy. This in-service began on [DATE] and any staff not in-serviced on [DATE], will be in-serviced prior to assuming their duties. Any new staff hired will be trained regarding the above in-services by the DON and/or ADON The DON, ADON, and MDS case managers were in-serviced regarding completion of residents care plan not reflecting resident current status by the regional nurse on [DATE]. The DON and Administrator were in-serviced by the regional nurse regarding reporting abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. The DON and Administrator will in-service staff on reporting abuse, neglect or any other reportable incident prior to staff returning to job duties. Completion date [DATE]. Monitoring The DON and or designee will monitor on a daily basis to ensure any new o

Based on interviews, observations and record reviews, the facility failed to ensure the services provided by the facility, as outlined by the comprehensive care plan meets professional standards of quality for 1 of 21 residents (Resident #1) reviewed for services, in that: 1 (a).Facility staff did not follow process related to CPR administration when staff did not check resident # 1's pulse or respiration prior to administering CPR. (b) Contrary to facility process LVNs B, H, I and RN J performed CPR on Resident #1, when he was a DNR. These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until all residents were assessed for DNR status. This deficient practice could affect residents in the facility who are a DNR, and place them at-risk in their wishes not being honored. The findings were: Record review of Resident #1's face sheet revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Observation on [DATE] at 11:45 AM revealed fire department and EMS were outside the facility, EMS was seen entering the building and leaving, Resident #1 had already expired. Further observation revealed Resident #1 was laying on the floor in his room, face blue. EMS left police department remained Resident # 1 being sent to medical examiners. Record review of Resident #1's consolidated physician orders [REDACTED]. Record review of LVN B's facility witness statement dated [DATE] revealed LVN B was called by CNA D and RA G. They were standing in the hallway in front of Resident #1's room while Resident #1 was sitting in his wheelchair cyanotic, drooling and appeared to have been choking. LVN B then began chest thrust maneuver and instructed aides to call a code blue. At 11:38 AM Resident #1 was then moved to the bed, and LVN I performed a mouth sweep between chest thrust. Other nurses began suctioning and CPR was started at 11:42 AM; at 11:44 AM the resident was then moved to the floor and CPR was continued. At 11:45 AM an AED was applied to the resident. At 11:48 AM resident # 1 was pronounced dead. Record review of LVN H's facility witness statement dated [DATE] revealed that at 11:42 AM LVN H entered Resident #1's room. Suctioning was started, and bread and bologna were removed. Chest thrust maneuver started. At 11:43 AM LVN H started CPR; at 11:44 AM Resident #1 was moved to floor where CPR was continued by RN J At 11:45 AM an AED was applied to the resident and analyzed, resumed compression with ambu bag; at 11:46 AM, LVN I continued chest compressions. At 11:47 AM the MDS Coordinator continued chest compressions with ambu bag. At 11:48 AM RN J called time of death. Record review of LVN I's facility witness statement dated [DATE] revealed when LVN I entered Resident #1's room, LVN B was performing the [MEDICATION NAME] maneuver on the resident. LVN I performed two mouth sweeps that were unsuccessful. Resident #1 was blue; EMS was called, and staff started CPR. Initial round of compressions were started by RN J, MDS Coordinator took over breaths given by LVN H. At this point they were told to cease CPR due to resident being a DNR. At this point EMS was on seen. (witness statement does not say who instructed them to stop CPR) Record review of Resident #1's CPR timeline, dated [DATE] provided by facility, revealed that on [DATE] at: 11:41 AM A Code Blue was called (meaning there was an emergency situation, such as a resident in cardiopulmonary arrest, choking, or anytime assistance is needed, requiring a team of providers to rush to a specific location and begin immediate resuscitative efforts); EMS was also called. At 11:42 AM suctioning was started At 11:43 AM chest compressions started, and staff went to check the resident's code status At 11:44 AM chest compressions continued with the resident moved to the floor and ambu bag was placed At 11:45 AM CPR continued. Further review revealed that an AED was applied to the resident and no shock was advised At 11:46 AM chest compressions continued while staff was still checking the resident's code status. Further review revealed that at 11:47 AM Resident #1's code status was verified, and CPR was stopped. Record review of Resident #1's care plan, revised [DATE], revealed Resident #1 had an order for [REDACTED]. During an interview with the DON and the Regional Nurse on [DATE] at 10:20 AM, the DON and the Regional Nurse confirmed residents' advanced directive status should be delegated and verified immediately when a code arises. DON and Regional Nurse verified there was a delay in verifying code status, two different staff members were sent to verify code status once after initiating CPR then again after AED applied. During an interview with LVN B and LVN K on [DATE] at 9:53 AM, LVN B and LVN K confirmed residents' code status needed to be verified immediately during an emergency situation. Record review of facility's policy on Do Not Resuscitate orders, revised [DATE], revealed: all validly executed physician orders [REDACTED]. The facility will copy the original DNR form and place a copy in the resident's medical record. The original will be placed in a protective cover in the resident's medical records. The resident's record will have a red sheet of paper as the first page of the record with the words, DNR in black letters located on that sheet of paper. Record review of facility's policy on Do Not Resuscitate orders, revised [DATE], revealed: all validly executed physician orders [REDACTED]. The facility will copy the original DNR form and place a copy in the resident's medical record. The original will be placed in a protective cover in the resident's medical records. The resident's record will have a red sheet of paper as the first page of the record with the words, DNR in black letters located on that sheet of paper. The Administrator was notified of the an IJ on [DATE] at 2:00 PM and a Plan of Removal was requested. The Plan of Removal included the following: Plan of Removal - [DATE] Potential Problem - Staff did not take vital signs in the intervals during a course of CPR for a resident and initiated CPR for a resident with a Do Not Resuscitate order. Interventions - An audit was completed on [DATE] to ensure all residents with a DNR have the order entered into Point Click Care. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. DON/ADON will update DNR binder monthly to ensure accuracy. All licensed nurses were in-serviced by the DON, ADON or Regional Nurse beginning on [DATE] regarding the following: (60% of all staff were in-serviced [DATE] with a completion date [DATE]. Staff will be in-service prior to returning to job duties). Verifying a resident's code status. Locations the code status for a resident can be located. They are as follows: Residents' chart Electronic records - After selecting the resident, look directly below their name on the left side of the screen. Point of Care - After selecting the resident, look directly below their name on the left side of the screen. EMAR - After selecting the resident, look directly below their name on the left side of the screen. In all the locations noted above, if no code status is listed or Full Code; CPR should initiated. If DNR, CPR is not to be started. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. Vital signs during CPR - If a resident is Full Code and is suspected of to be in cardiac and/or respiratory distress, the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. During the course of CPR, about every 2 minutes the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. When documenting an episode of CPR, ensure to include the approximate time the presence of pulse or respirations were checked. BLS Healthcare Provider Adult [MEDICAL CONDITION] Algorithm (see attached) regarding the proper algorithm for CPR for an adult by a healthcare provider according to the (YEAR) guidelines set by the American Heart Association. A copy of this algorithm will placed on the emergency cart on [DATE]. Abuse and Neglect according to facility policy - see attached policy The regional nurse who is a certified CPR instructor will provide in-servicing related to the above topics to the DON and ADONs and all Nursing staff prior to returning to job duties (60% of Nursing were In-Service [DATE]). Any newly hired staff will be provided training to the above topics upon hire by the DON and/or ADON. The Medical Director was notified of this plan on [DATE]. Monitoring The DON and or ADON will ask at least 8 nurses per week how to determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. ADONs will check DNR binders at least 3 times a week x 4 weeks to ensure that all DNRs are accurate and updated, followed by weekly checks from there on after. The binders will be updated immediately upon any code status order change. The DON and/or ADONs will monitor any CPR related documentation to ensure compliance with documentation related to CPR including presence of pulse and respirations The DON and/or ADONs will ensure that at least 1 CPR certified nurse is present 24 hours per day. The Regional Nurse at least weekly will verify that the above monitoring by facility staff is in compliance as stated. Findings will be shared with the QAA committee and changes made as required. Ask at least 8 nurses per week how they would determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. Date_____________________ Name of Nurse___________________ Did the nurse answer each question correctly? Yes or No; If No explain corrective action below. Plan of Removal DNR [DATE] Interventions to prevent reoccurrence. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. Code status can also be verified in the electronic records as well as residents chart, point of care kiosk and EMAR. Staff will be in serviced that in the event of a rapid response charge nurse will designate one person to verify code status. 60% of staff are expected to be in-service by [DATE] with a completion date of [DATE]. Monitoring ADONs will check DNR binders 3 times a week x 4 weeks to ensure that all DNRs are accurate and updated, followed by weekly checks from there on after. Verification of the Plan of Removal was as follows: b. Observation on west wing revealed there was a DNR book was on the crash cart and a Diet binder was at the nurses' station. Further observation of the DNR binder revealed there was a copy of residents' face sheet and DNR forms on file for both units. Record review of DNR residents' revealed code status reflected on Point Click Care and on consolidated physician orders. c. Interviews with 5 LVNs, 3 CNAs, 1 MA, and 2 Hydration Aides revealed they were aware the Administrator was the Abuse Coordinator and they are to report all incidents and accidents to the DON. During further interview they revealed they were aware of the diet roster being kept at the nurses' station and the DNR binder on crash cart. d. Interviews with 4 LVNs revealed they were aware to check residents' code status immediately during an emergency situation, they further revealed they were aware they needed to assess a resident's condition (pulse and respirations) to determine how to respond. e. Record review of facility's in-service training records revealed 13 out of 16 licensed staff were in-serviced from [DATE] to [DATE] on verifying residents' code status, CPR, and the facility's abuse and neglect policy along with other direct care and ancillary staff. Record review of facility's in-service training records, dated [DATE], revealed 60% of the staff were in-serviced on, in the event of a rapid response charge nurse will designate one person to verify code status. Record review of facility's training records, dated [DATE], regarding the diet binder on the hydration carts and the task added to the point of care and the entry to the treatment administration record revealed 60% of the staff were in-serviced. Record review of facility's licensed nurse in-service training records, dated [DATE], on diet orders revealed 11 of 16 nurses received training along with other direct care and ancillary staff. Record review of facility's in-service training, dated [DATE], regarding completion of residents' care plan not reflecting resident current status revealed the DON, ADON x 2 and MDS Coordinator received training. Record review of facility's in-service record, dated [DATE], revealed the DON and the Administrator received training regarding abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. Record review of facility's in-service training, dated [DATE], revealed 46% of the staff received training on abuse and neglect. While the IJ was removed on [DATE] at 12:00 PM, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until all residents were assessed and staff was in-serviced on assessing, documenting interventions and initiating Cardiopulmonary Resuscitation (CPR), verifying code status, and ensuring all residents are being provided with a therapeutic diet.

Based on interviews, observations and record reviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan 1 of 21 residents (Resident #1) reviewed for treatment, in that: 1. (a) Facility staff did not follow process related to CPR administration when staff did not check resident # 1's pulse or respiration prior to administering CPR. (b) Contrary to facility process, staff administered CPR prior to verifying Resident # 1's DNR status. These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of choking and all residents were assessed for DNR status and the staff were in-serviced on assessing residents in emergency situations These deficient practices could affect residents in the facility who are at risk of choking, all residents who are a full code resulting in unnecessary treatment, all residents who are a DNR resulting in their wishes not being honored. The findings were: Record review of Resident #1's face sheet revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Observation on [DATE] at 11:45 AM revealed fire department and EMS were outside the facility, EMS was seen entering the building and leaving, Resident #1 had already expired. Further observation revealed Resident #1 was laying on the floor in his room, face blue. EMS left police department remained Resident # 1 being sent to medical examiners. Record review of Resident #1's consolidated physician orders [REDACTED]. Record review of LVN B's facility witness statement dated [DATE] revealed LVN B was called by CNA D and RA G. They were standing in the hallway in front of Resident #1's room while Resident #1 was sitting in his wheelchair cyanotic, drooling and appeared to have been choking. LVN B then began chest thrust maneuver and instructed aides to call a code blue. At 11:38 AM Resident #1 was then moved to the bed, and LVN I performed a mouth sweep between chest thrust. Other nurses began suctioning and CPR was started at 11:42 AM; at 11:44 AM the resident was then moved to the floor and CPR was continued. At 11:45 AM an AED was applied to the resident. At 11:48 AM resident # 1 was pronounced dead. Record review of LVN H's facility witness statement dated [DATE] revealed that at 11:42 AM LVN H entered Resident #1's room. Suctioning was started, and bread and bologna were removed. Chest thrust maneuver started. At 11:43 AM LVN H started CPR; at 11:44 AM Resident #1 was moved to floor where CPR was continued by RN J At 11:45 AM an AED was applied to the resident and analyzed, resumed compression with ambu bag; at 11:46 AM, LVN I continued chest compressions. At 11:47 AM the MDS Coordinator continued chest compressions with ambu bag. At 11:48 AM RN J called time of death. Record review of LVN I's facility witness statement dated [DATE] revealed when LVN I entered Resident #1's room, LVN B was performing the [MEDICATION NAME] maneuver on the resident. LVN I performed two mouth sweeps that were unsuccessful. Resident #1 was blue; EMS was called, and staff started CPR. Initial round of compressions were started by RN J, MDS Coordinator took over breaths given by LVN H. At this point they were told to cease CPR due to resident being a DNR. At this point EMS was on seen. (witness statement does not say who instructed them to stop CPR) Record review of Resident #1's CPR timeline, dated [DATE] provided by facility, revealed that on [DATE] at: 11:41 AM A Code Blue was called (meaning there was an emergency situation, such as a resident in cardiopulmonary arrest, choking, or anytime assistance is needed, requiring a team of providers to rush to a specific location and begin immediate resuscitative efforts); EMS was also called. At 11:42 AM suctioning was started At 11:43 AM chest compressions started, and staff went to check the resident's code status At 11:44 AM chest compressions continued with the resident moved to the floor and ambu bag was placed At 11:45 AM CPR continued. Further review revealed that an AED was applied to the resident and no shock was advised At 11:46 AM chest compressions continued while staff was still checking the resident's code status. Further review revealed that at 11:47 AM Resident #1's code status was verified, and CPR was stopped. Record review of Resident #1's care plan, revised [DATE], revealed Resident #1 had an order for [REDACTED]. During an interview with the DON and the Regional Nurse on [DATE] at 10:20 AM, the DON and the Regional Nurse confirmed residents' advanced directive status should be delegated and verified immediately when a code arises. DON and Regional Nurse verified there was a delay in verifying code status, two different staff members were sent to verify code status once after initiating CPR then again after AED applied. During an interview with LVN B and LVN K on [DATE] at 9:53 AM, LVN B and LVN K confirmed residents' code status needed to be verified immediately during an emergency situation. Record review of facility's policy on Do Not Resuscitate orders, revised [DATE], revealed: all validly executed physician orders [REDACTED]. The facility will copy the original DNR form and place a copy in the resident's medical record. The original will be placed in a protective cover in the resident's medical records. The resident's record will have a red sheet of paper as the first page of the record with the words, DNR in black letters located on that sheet of paper. Record review of facility's policy on Do Not Resuscitate orders, revised [DATE], revealed: all validly executed physician orders [REDACTED]. The facility will copy the original DNR form and place a copy in the resident's medical record. The original will be placed in a protective cover in the resident's medical records. The resident's record will have a red sheet of paper as the first page of the record with the words, DNR in black letters located on that sheet of paper. The Administrator was notified of an IJ on [DATE] at 2:00 PM and a Plan of Removal was requested. The Plan of Removal included the following: Plan of Removal - [DATE] Potential Problem - Staff did not take vital signs in the intervals during a course of CPR for a resident and initiated CPR for a resident with a Do Not Resuscitate order. Interventions - An audit was completed on [DATE] to ensure all residents with a DNR have the order entered into Point Click Care. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. DON/ADON will update DNR binder monthly to ensure accuracy. All licensed nurses were in-serviced by the DON, ADON or Regional Nurse beginning on [DATE] regarding the following: (60% of all staff were in-serviced [DATE] with a completion date [DATE]. Staff will be in-service prior to returning to job duties). Verifying a resident's code status. Locations the code status for a resident can be located. They are as follows: Residents' chart Electronic records - After selecting the resident, look directly below their name on the left side of the screen. Point of Care - After selecting the resident, look directly below their name on the left side of the screen. EMAR - After selecting the resident, look directly below their name on the left side of the screen. In all the locations noted above, if no code status is listed or Full Code; CPR should initiated. If DNR, CPR is not to be started. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. Vital signs during CPR - If a resident is Full Code and is suspected of to be in cardiac and/or respiratory distress, the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. During the course of CPR, about every 2 minutes the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. When documenting an episode of CPR, ensure to include the approximate time the presence of pulse or respirations were checked. BLS Healthcare Provider Adult [MEDICAL CONDITION] Algorithm (see attached) regarding the proper algorithm for CPR for an adult by a healthcare provider according to the (YEAR) guidelines set by the American Heart Association. A copy of this algorithm will placed on the emergency cart on [DATE]. Abuse and Neglect according to facility policy - see attached policy The regional nurse who is a certified CPR instructor will provide in-servicing related to the above topics to the DON and ADONs and all Nursing staff prior to returning to job duties (60% of Nursing were In-Service [DATE]). Any newly hired staff will be provided training to the above topics upon hire by the DON and/or ADON. The Medical Director was notified of this plan on [DATE]. Monitoring The DON and or ADON will ask at least 8 nurses per week how to determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. ADONs will check DNR binders at least 3 times a week x 4 weeks to ensure that all DNRs are accurate and updated, followed by weekly checks from there on after. The binders will be updated immediately upon any code status order change. The DON and/or ADONs will monitor any CPR related documentation to ensure compliance with documentation related to CPR including presence of pulse and respirations The DON and/or ADONs will ensure that at least 1 CPR certified nurse is present 24 hours per day. The Regional Nurse at least weekly will verify that the above monitoring by facility staff is in compliance as stated. Findings will be shared with the QAA committee and changes made as required. Ask at least 8 nurses per week how they would determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. Date_____________________ Name of Nurse___________________ Did the nurse answer each question correctly? Yes or No; If No explain corrective action below. Plan of Removal DNR [DATE] Interventions to prevent reoccurrence. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. Code status can also be verified in the electronic records as well as residents chart, point of care kiosk and EMAR. Staff will be in serviced that in the event of a rapid response charge nurse will designate one person to verify code status. 60% of staff are expected to be in-service by [DATE] with a completion date of [DATE]. Monitoring ADONs will check DNR binders 3 times a week x 4 weeks to ensure that all DNRs are accurate and updated, followed by weekly checks from there on after. Verification of the Plan of Removal was as follows: b. Observation on west wing revealed there was a DNR book was on the crash cart and a Diet binder was at the nurses' station. Further observation of the DNR binder revealed there was a copy of residents' face sheet and DNR forms on file for both units. Record review of DNR residents' revealed code status reflected on Point Click Care and on consolidated physician orders. c. Interviews with 5 LVNs, 3 CNAs, 1 MA, and 2 Hydration Aides revealed they were aware the Administrator was the Abuse Coordinator and they are to report all incidents and accidents to the DON. During further interview they revealed they were aware of the diet roster being kept at the nurses' station and the DNR binder on crash cart. d. Interviews with 4 LVNs revealed they were aware to check residents' code status immediately during an emergency situation, they further revealed they were aware they needed to assess a resident's condition (pulse and respirations) to determine how to respond. e. Record review of facility's in-service training records revealed 13 out of 16 licensed staff were in-serviced from [DATE] to [DATE] on verifying residents' code status, CPR, and the facility's abuse and neglect policy along with other direct care and ancillary staff. Record review of facility's in-service training records, dated [DATE], revealed 60% of the staff were in-serviced on, in the event of a rapid response charge nurse will designate one person to verify code status. Record review of facility's training records, dated [DATE], regarding the diet binder on the hydration carts and the task added to the point of care and the entry to the treatment administration record revealed 60% of the staff were in-serviced. Record review of facility's licensed nurse in-service training records, dated [DATE], on diet orders revealed 11 of 16 nurses received training along with other direct care and ancillary staff. Record review of facility's in-service training, dated [DATE], regarding completion of residents' care plan not reflecting resident current status revealed the DON, ADON x 2 and MDS Coordinator received training. Record review of facility's in-service record, dated [DATE], revealed the DON and the Administrator received training regarding abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. Record review of facility's in-service training, dated [DATE], revealed 46% of the staff received training on abuse and neglect. While the IJ was removed on [DATE] at 12:00 PM, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until all residents were assessed and staff was in-serviced on assessing, documenting interventions and initiating Cardiopulmonary Resuscitation (CPR), verifying code status, and ensuring all residents are being provided with a therapeutic diet.

Based on observations, record reviews and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 21 residents (Resident #1) reviewed for care, in that: 1. (a). Resident #1 had choked on [DATE], no interventions were implemented. Subsequently Resident # 1 choked again on [DATE] resulting in death. (b). The facility failed to identify residents who grabbed food and were at-risk for choking, for ensuring snacks were not left within residents' reach, and have a process for hydration aides to verify residents' diets when handing out snacks These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of choking. These deficient practices could affect residents in the facility who are at-risk of choking, and place them at-risk for harm, choking or death. The findings were: Record review of Resident #1's face sheet revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Observation on [DATE] at 11:30 AM revealed there was a bologna sandwich on the table in the dining area. Further observation revealed there was no resident nearby. During an interview on [DATE] at 1:50 PM with the activity assistant she revealed Resident # 1 had gone out for smoke break at 11:00 AM, she further revealed she did not see him with any food. She further revealed that Resident # 8 leaves her sandwiches on the table in the dining area if she does not want it. She further revealed it was possible Resident # 1 could have grabbed it. Observation on [DATE] at 11:45 AM revealed fire department and EMS were outside the facility, EMS was seen entering the building and leaving, Resident #1 had already expired. Further observation revealed Resident #1 was laying on the floor in his room, face blue. Further observation revealed EMS left police department at bedside Resident # 1 to be transported to medical examiners. Record review of Resident #1's nursing progress note, dated [DATE] at 1:45 PM written by RN F, revealed: resident propelled self to nurses station and was saying 'hey' over and over again, resident was sweating and somewhat pale and attempting to cough, noted to have a roll of saltine crackers on his lap, oxygen saturation 48, resident was turning blue and [MEDICATION NAME] initiated and was successful, non-rebreather oxygen applied 15 liters Resident # 1 was suctioned orally and watery residual crackers removed from mouth/throat. Resident # 1 got his color back and became more alert. EMS called and transported Resident # 1 to hospital. Further review of Resident #1's progress note revealed DON and physician were made aware, and that interventions were already in place for Resident #1 to eat in the dining room for all meals until roommate finishes his food because resident does not follow redirections to not eat roommates' food. During an interview with Hospitality Aide C on [DATE] at 1:14 PM, Hospitality Aide C revealed she passed out snacks. Hospitality Aide C confirmed Residents #4 and #1 were roommates and were both on pureed diets with thickened liquids (record review of roommate's diet revealed he was on mechanical soft nectar thicken liquid). Hospitality Aide C stated she had not given Resident #1 a sandwich, and further stated the resident had behaviors of taking food that did not belong to him. Hospitality Aide C further revealed two weekends ago he came in from smoke break with a pack of saltine crackers he took for another resident. She further revealed she took the crackers from him and notified the RN. Record review of Resident #1's nursing progress note, dated [DATE] at 5:35 PM by RN F, revealed the resident returned from the hospital with no new orders. Further review of the resident's nursing progress notes revealed there were no other progress notes since the date of the resident's incident on [DATE]. Record review of Resident #1's consolidated physician orders [REDACTED]. Record review of Resident # 1's Quarterly MDS dated [DATE] revealed Resident # 1 did not have any behavioral issues and required extensive one person assist for meals. Further review of MDS revealed Resident # 1 received 51% or more of total calories through parental or tube feeding and was on a mechanically altered therapeutic diet. Record review of Resident #1's care plan, revised on [DATE], revealed the resident's care plan the resident had a swallowing problem related to dysphagia. All staff to be informed of resident's special dietary and safety needs. Check mouth after meals for pocketed food and debris. Instruct resident to eat in an upright position, to eat slowly, thoroughly. Further review of Resident's #1's care plan revealed the resident required one person assist with eating, and had a swallowing problem related to Dysphagia; all staff were to be informed of resident's dietary and safety needs. Further review of care plan did not reflect interventions for Resident # 1 to eat in dining room. Record review of facility's incident reports for (MONTH) 2019 revealed an incident report was not completed for Resident #1's choking incident on [DATE]. There was no documentation of an assessment or interventions after Resident # 1's choking episode. Record review of Resident #1's speech therapy encounters revealed Resident #1 was receiving speech services on [DATE] for cognitive-linguistic therapy to facilitate improved orientation to immediate environment and on [DATE] to improve safety during oral intake. Requires max cueing. Record review of Director of Rehab's facility witness statement dated [DATE] revealed Resident # 1 was in the therapy gym at 9:00 AM, after therapy Resident stayed in therapy room watching television. At approximately 10:55 AM he left for smoke break. He returned and left upset because channel had been changed. Approximately ,[DATE] minutes later code blue was called. Upon arrival on scene was notified he passed away. Resident was known to go to other residents' rooms and trash cans to find food. He was non-compliant with his diet restrictions. During an interview with the MDS Coordinator on [DATE] at 11:50 AM, the MDS Coordinator stated Resident # 1 was choking and MDS Coordinator was able to get a piece of bologna sandwich out of the resident's mouth. The MDS Coordinator confirmed Resident #1 was on a pureed diet. During an interview with the Dietary Manager on [DATE] at 1:04 PM, the Dietary Manager stated the facility offered bologna sandwiches to the residents for snacks on the morning of [DATE]. The Dietary Manager confirmed Resident #1 was on a pureed diet and revealed that when the dietary staff delivered the snacks to the nurses' station, the nurse accepting the snacks had to sign off as receiving them. The Dietary Manager further revealed Resident #1 had a history of [REDACTED]. During an interview on [DATE] at 1:25 PM with RA G she revealed Resident # 1 did have a history of grabbing food if it was left out or from the trash can. She further revealed he would not go into other residents' rooms. During an interview with the MDS Coordinator on [DATE] at 8:25 AM, the MDS Coordinator confirmed there were no interventions placed after Resident #1 returned from the hospital from choking on [DATE]. The MDS Coordinator stated that to her knowledge there were not any records of Resident #1's non-compliance with his diet being monitored by facility staff. During an interview with the Administrator on [DATE] at 9:45 AM, the Administrator stated that he had not been informed by facility staff of Resident #1's previous choking incident on [DATE] until yesterday, [DATE]. The Administrator stated that had he been made aware of the resident's incident on [DATE] he would have reported the incident, and further stated, communication in this building was non-existent. The Administrator further stated that following Resident #1's previous incident the first thing he would have done would have been to review the resident's care plan to see if interventions were in place. Further interview with the Administrator revealed they have not had a QA meeting and that they began to complete 24 hour reports two weeks after he started His primary focus since starting in (MONTH) (YEAR) had been on cosmetics of the building and care of residents. The Administrator further revealed they were having difficulties transitioning from one corporation to the current corporations as a lot of the staff had to be termed due to not meeting the current corporations' standards. He further stated they were having difficulty obtaining employee training records. During an interview with the DON on [DATE] at 10:20 AM, the DON revealed facility staff called her on [DATE] and notified her of Resident #1's choking episode and that the resident had been sent to the hospital. The DON confirmed she had not notified the Administrator of Resident #1's incident and had chosen not to do so because the resident had returned to the facility with no issues. During an interview with NP E on [DATE] at 12:04 PM, NP E revealed that he had never had any issues with Resident #1. NP E stated the resident did not talk much due to his [MEDICAL CONDITION], and further stated the resident did not have any aggressive behaviors; however, the resident was on hospice services for end-stage Dementia. NP E confirmed there was no documentation of Resident #1 being non-compliant with diet. NP E further revealed he was not informed by staff of Resident # 1 non-compliance with diet. NP E stated that if he had been informed the resident had had a choking episode he would have requested for speech therapy to evaluate the resident. (b). During an interview with the Dietary Manager on [DATE] at 1:04 PM, the Dietary Manager revealed that when the dietary staff delivered the snacks to the nurses' station, the nurse accepting the snacks had to sign off as receiving them. During an interview with Hydration Aide C on [DATE] at 2:00 PM, Hydration Aide C stated they were not given a list of the residents' diet. Hydration Aide C further stated they handed out the sandwiches to the residents who wanted a snack. During an interview with Hydration Aide A on [DATE] at 2:05 PM, Hydration Aide A stated they used to have a resident diet list on the hydration cart, but it had been missing for months. Hydration Aide A further stated she just relied on her memory when handing out snacks. During an interview with the DON on [DATE] at 2 :33 PM, the DON revealed they did not have a current list of residents who were at-risk of aspiration. Record review of Resident Dietary Log, dated [DATE], revealed three residents (Residents #2, #3, and #4) were not listed. Record review of care plans for residents at risk of choking, revised [DATE], revealed Residents' at risk for choking care plan reflected behaviors with hoarding food, stealing food, eating off diet plan, but did not address their risk for choking. During an interview with the MDS Coordinator on [DATE] at 4:25 PM, the MDS Coordinator revealed care plans were updated for residents at-risk for choking. Record review of facility's policy on Event Reporting: Completion of dated 2003 revealed the facility will complete an Event form on variances that occur within the facility. All events that require treatment beyond immediate first aide must be reported immediately to the Administrator and/or DON. The investigation should be completed by the DON/Administrator or designee. The investigation report documents a thorough investigation of the events of the reported events including persons, equipment, and materials that were involved. Include and care plan any required interventions to help prevent further occurrence of the event. The Administrator was notified of an IJ on [DATE] at 2:00 PM and a Plan of Removal was requested. The Plan of Removal included the following: Plan of Removal - [DATE] Failure to have accurate diet roster and training. Failure to Intervene and update care plan. Staff training and Knowledge of diet. Interventions to prevent reoccurrence. All residents identified with diet orders were reviewed and verified to determine diet accuracy by [DATE]. All residents that have behaviors related to noncompliance with their diet texture and have the potential to choke were identified by the DON and regional nurse on [DATE]. Any residents identified with a behavior to be non-compliant with the diet texture had a task added to their point of care that states, Resident has a history of hoarding and/or stealing food that is not compliant with their diet order which makes them at risk for choking. If observed, attempt to remove the food and notify your supervisor immediately. Certified Nurse Aide staff will be able to acknowledge this every shift. Any residents identified with a behavior to be non-compliant with the diet texture had an entry added to their treatment administration record (TAR) to communicate to the licensed nurse the potential problem. The nurse will initial this entry every shift. Any residents identified with a behavior to be non-compliant with the diet had their care plan reviewed and if needed updated on [DATE] by the DON, ADON, Regional Nurse, or MDS nurse to reflect interventions to attempt prevent the resident from choking related to their behavior. On [DATE] binders were placed on the East and West hydration carts that included all residents' diet orders for easy review by nursing staff if they have a question to what diet a resident has. Nursing Staff were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the Diet Binder placed on each hydration cart on East and West Hall, the task added to the point of care and the entry to the TAR. Any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties. Licenses nurses were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the following: (any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties). If a diet order is obtained by the Charge Nurse, the following protocol will be followed: - The charge nurse will verify the diet orders and enter orders into electronic records. - The Charge Nurse will complete a Dietary Notification form and give to dietary. - The Charge Nurse will review diet orders at each meal service. - DON/ADON will update dietary binder monthly. - Any new diet orders will be followed as directed by the physician. All staff were in-serviced by the DON, ADON, or Regional Nurse regarding the facility's policy on abuse and neglect. See attached policy. This in-service began on [DATE] and any staff not in-serviced on [DATE], will be in-serviced prior to assuming their duties. Any new staff hired will be trained regarding the above in-services by the DON and/or ADON The DON, ADON, and MDS case managers were in-serviced regarding completion of residents care plan not reflecting resident current status by the regional nurse on [DATE]. The DON and Administrator were in-serviced by the regional nurse regarding reporting abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. The DON and Administrator will in-service staff on reporting abuse, neglect or any other reportable incident prior to staff returning to job duties. Completion date [DATE]. Monitoring The DON and or designee will monitor on a daily basis to ensure any new or readmitted resident has a diet order. The DON and/or ADON will complete a random diet order review on 15 residents per week for 4 weeks by comparing the electronic records orders to the resident dietary tray card for accuracy. The DON and/or designee will ask 10 staff members per week for 4 weeks, if they know how to obtain the residents diet. During the weekly care plan meeting the MDS Case Manager and the DON or Designee will ensure that the residents' Care Plans match the resident's current status. The DON, ADON, or MDS nurse will update a residents diet care as needed for any new diet orders, intervention, or non-compliance The Regional Nurse at least weekly will verify that the above monitoring by facility staff is in compliance as stated. The Regional Nurse and/or area director of operations will monitor incidents/events at least weekly to ensure compliance with reporting guidelines. Findings will be reviewed by the QAA committee and changes made to the plan as needed. All of the above monitoring will be documented on a facility formulated monitoring form. Verification of the Plan of Removal was as follows: a. Observation on [DATE] at 1:20 PM revealed snacks were on west wing nurses' station countertop. Further observation revealed a female resident was reaching for the yogurt and asked me if she could have it. LVN M was sitting at nurses' station documenting on a computer, and the ADON standing behind the desk. During an interview with the ADON and LVN M on [DATE] at 1:20 PM, at the same time as the observation, the ADON confirmed the snack tray was supposed to be placed behind the nurses' station out of resident's reach. LVN M and the ADON further confirmed that neither one had signed for snacks and were not aware who did or when they were delivered. Record review of in-service training revealed staff were in-serviced immediately on procedures for snacks. Interviews with 3 CNAs and 4 LVNs revealed they were aware of ensuring snacks are placed behind nurses' station out of reach of residents. b. Facility identified a list of residents at risk for hoarding/stealing food that are non-compliant with their diet orders which makes them at-risk for choking, dated [DATE], revealed residents were: Residents #3, #5, #6, #7, #8, #9, #10, #11, and #12. During an interview with the DON and the Regional Nurse on [DATE] at 2:39 PM, after surveyor intervention, the DON and Regional Nurse stated they decided which residents were at-risk for choking by interviewing staff to see who had behavioral issues with being non-compliant with diet and reviewed residents' diet orders to determine who was at-risk. The DON and the Regional Nurse confirmed residents' care plans were not updated to reflect residents' risk for choking. Record review of care plans for the above residents revealed residents were noted to have a behavioral problem related to hoarding food, stealing food, eating off diet plan. Further review revealed the residents' Care plans did not address residents as being at-risk for choking. Record review of care plans for Residents #3, #5, #6, #7, #8, #9, #10, #11, and #12 were updated to reflect their risk for choking. Record review of the diet roster, dated [DATE], revealed Residents #13 and #14 did not have type of liquid specified for their diets. Further review revealed Resident #14 was on a pureed diet and Resident #13 had a mechanical soft diet. During an interview with the DON and the Regional Nurse on [DATE] at 2:39 PM, the DON and the Regional Nurse revealed they decided who was at-risk for choking by interviewing staff to see who had behavioral issues with being non-complaint with diet and then reviewed the residents' diet. The DON and the Regional Nurse stated Dietary would deliver snacks either to the nurse or the aide and they would sign for the snacks. The DON and the Regional Nurse stated staff would take the tray the snacks will be passed out, and if they are not ready to pass out snacks, the snacks need to be placed behind the nurses' station. The DON and the Regional Nurse stated staff assisting from sister facilities are being trained before starting on the unit. The DON and the Regional Nurse confirmed the facility's diet roster should include fluid consistency. Record review of the diet roster and census, dated [DATE], revealed the diet roster was updated and every resident had a diet order to include diet type texture and fluid consistency. Random record review of 25 residents revealed the diet roster coincided with the residents' physician orders. b. Observation on west wing revealed there was a DNR book was on the crash cart and a Diet binder was at the nurses' station. Further observation of the DNR binder revealed there was a copy of residents' face sheet and DNR forms on file for both units. c. Interviews with 5 LVNs, 3 CNAs, 1 MA, and 2 Hydration Aides revealed they were aware the Administrator was the Abuse Coordinator and they are to report all incidents and accidents to the DON. During further interview they revealed they were aware of the diet roster being kept at the nurses' station and the DNR binder on crash cart. Record review of facility's training records, dated [DATE], regarding the diet binder on the hydration carts and the task added to the point of care and the entry to the treatment administration record revealed 60% of the staff were in-serviced. Record review of facility's licensed nurse in-service training records, dated [DATE], on diet orders revealed 11 of 16 nurses received training along with other direct care and ancillary staff. Record review of facility's in-service training, dated [DATE], regarding completion of residents' care plan not reflecting resident current status revealed the DON, ADON x 2 and MDS Coordinator received training. Record review of facility's in-service record, dated [DATE], revealed the DON and the Administrator received training regarding abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. Record review of facility's in-service training, dated [DATE], revealed 46% of the staff received training on abuse and neglect. While the IJ was removed on [DATE] at 12:00 PM, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until all residents were assessed and staff was in-serviced on assessing, documenting interventions and initiating Cardiopulmonary Resuscitation (CPR), verifying code status, and ensuring all residents are being provided with a therapeutic diet.

Based on observation, interview and record review, the facility failed to ensure 3 LVNs (LVN B, H, and I) and 1 RN (RN J) had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 residents (Resident #1) observed for care in that: 1a). LVNs B, H, I, and RN J failed to assess Resident #1 for pulse or respiration before initiating CPR. b). LVNs B, H, I, and RN J performed CPR on Resident #1, when he was a DNR. These failures resulted in identification of two Immediate Jeopardy (IJ) on [DATE]. While the IJs were removed [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of choking, all residents were assessed for DNR status and the staff were in-serviced on assessing residents in emergency situations. These deficient practices could affect all residents who are a full code and all resident who are DNR, and place them at-risk of unnecessary treatment and their wishes not being made. The findings were: 1a). Record review of Resident #1's face sheet revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Observation on [DATE] at 11:45 AM revealed fire department and EMS were outside the facility, EMS was seen entering the building and leaving, Resident #1 had already expired. Further observation revealed Resident #1 was laying on the floor in his room, face blue. Record review of LVN B's facility witness statement dated [DATE] revealed LVN B was called by CNA D and RA G. They were standing in the hallway in front of Resident #1's room while Resident #1 was sitting in his wheelchair cyanotic, drooling and appeared to have been choking. LVN B then began chest thrust maneuver and instructed aides to call a code blue. At 11:38 AM Resident #1 was then moved to the bed, and LVN I performed a mouth sweep between chest thrust. Other nurses began suctioning and CPR was started at 11:42 AM; at 11:44 AM the resident was then moved to the floor and CPR was continued. At 11:45 AM an AED was applied to the resident. At 11:48 AM resident # 1 was pronounced dead. Record review of LVN H's facility witness statement dated [DATE] revealed that at 11:42 AM LVN H entered Resident #1's room. Suctioning was started, and bread and bologna were removed. Chest thrust maneuver started. At 11:43 AM LVN H started CPR; at 11:44 AM Resident #1 was moved to floor where CPR was continued by RN J At 11:45 AM an AED was applied to the resident and analyzed, resumed compression with ambu bag; at 11:46 AM, LVN I continued chest compressions. At 11:47 AM the MDS Coordinator continued chest compressions with ambu bag. At 11:48 AM RN J called time of death. Record review of LVN I's facility witness statement dated [DATE] revealed when LVN I entered Resident #1's room, LVN B was performing the [MEDICATION NAME] maneuver on the resident. LVN I performed two mouth sweeps that were unsuccessful. Resident #1 was blue; EMS was called, and staff started CPR. Initial round of compressions were started by RN J, MDS Coordinator took over breaths given by LVN H. At this point they were told to cease CPR due to resident being a DNR. At this point EMS was on seen. (witness statement does not say who instructed them to stop CPR) Record review of Resident #1's SBAR completed by LVN A dated [DATE] at 1:44 PM revealed vital signs were: [DATE] at 2:00 PM blood pressure ,[DATE] [DATE] at 2:46 PM pulse 71 [DATE] at 2:49 PM respirations 18 [DATE] at 2:51 PM temperature 97.1 oral [DATE] at 2:51 PM oxygen saturation was 97% on room air Further review of SBAR revealed the resident's treatment for [REDACTED]. During an interview with the MDS Coordinator on [DATE] at 8:25 AM, the MDS Coordinator confirmed she did not recall anyone performing any vital signs (blood pressure, pulse, respirations) or saying anything about it before initiating CPR on Resident #1 during the incident on [DATE]. During an interview with LVN B on [DATE] at 9:45 AM, LVN B confirmed she did not recall Resident #1's vitals or pulse being taken prior to starting CPR during the incident on [DATE]. Record review of the Basic Life Support Healthcare Provider Adult [MEDICAL CONDITION] Algorithm - (YEAR) update provided by the facility revealed: victim is unresponsive - look for no breathing or only gasping and check for pulse (simultaneously); if no normal breathing and has pulse - provide rescue breathing; if no breathing or only gasping and no pulse - initiate CPR. Record review of facility's policy on [MEDICATION NAME] Maneuver, revised (MONTH) 2007, revealed: . after the abdominal thrust, the rescuer repeats the process of lifting the chin, moving the tongue, feeling for and possibly removing the object. If the airway is not clear, the rescuer repeats the abdominal thrust as long as necessary. If the foreign object is removed but the victim is not breathing, the rescuer starts ventilation at a rate of two breaths every five seconds. If there is no pulse, CPR will be initiated. b. Record review of Resident #1's CPR timeline, dated [DATE] provided by facility, revealed that on [DATE] at 11:41 AM a Code Blue was called (meaning there was an emergency situation, such as a resident in cardiopulmonary arrest, choking, or anytime assistance is needed, requiring a team of providers to rush to a specific location and begin immediate resuscitative efforts); EMS was also called. Further review revealed that at 11:42 AM suctioning was started, 11:43 AM chest compressions started and staff went to check the resident's code status, 11:44 AM chest compressions continued with the resident moved to the floor and ambu bag was placed, 11:45 AM CPR continued. Further review revealed that an AED was applied to the resident and no shock was advised, 11:46 AM chest compressions continued while staff was still checking the resident's code status. Further review revealed that at 11:47 AM Resident #1's code status was verified and CPR was stopped. Record review of Resident #1's care plan, revised [DATE], revealed Resident #1 had an order for [REDACTED]. During an interview with the DON and the Regional Nurse on [DATE] at 10:20 AM, the DON and the Regional Nurse confirmed residents' advanced directive status should be delegated and verified immediately when a code arises. During an interview with LVN B and LVN K on [DATE] at 9:53 AM, LVN B and LVN K confirmed residents' code status needed to be verified immediately during an emergency situation. Record review of facility's policy on Do Not Resuscitate orders, revised [DATE], revealed: all validly executed physician orders [REDACTED]. The facility will copy the original DNR form and place a copy in the resident's medical record. The original will be placed in a protective cover in the resident's medical records. The resident's record will have a red sheet of paper as the first page of the record with the words, DNR in black letters located on that sheet of paper. Record review of LVN B's CPR card revealed she received training on [DATE]. Record review of LVN H's CPR card revealed she received training on [DATE]. Record review of LVN I's training revealed she did not have CPR training. Record review of RN J's BLS instructor card revealed she received training on [DATE]. The Administrator was notified of the two IJs on [DATE] at 2:00 PM and a Plan of Removal was requested. The Plan of Removal included the following: Plan of Removal - [DATE] Potential Problem - Staff did not take vital signs in the intervals during a course of CPR for a resident and initiated CPR for a resident with a Do Not Resuscitate order. Interventions - An audit was completed on [DATE] to ensure all residents with a DNR have the order entered into Point Click Care. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. DON/ADON will update DNR binder monthly to ensure accuracy. All licensed nurses were in-serviced by the DON, ADON or Regional Nurse beginning on [DATE] regarding the following: (60% of all staff were in-serviced [DATE] with a completion date [DATE]. Staff will be in-service prior to returning to job duties). Verifying a resident's code status. Locations the code status for a resident can be located. They are as follows: Residents' chart Electronic records - After selecting the resident, look directly below their name on the left side of the screen. Point of Care - After selecting the resident, look directly below their name on the left side of the screen. EMAR - After selecting the resident, look directly below their name on the left side of the screen. In all the locations noted above, if no code status is listed or Full Code; CPR should initiated. If DNR, CPR is not to be started. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. Vital signs during CPR - If a resident is Full Code and is suspected of to be in cardiac and/or respiratory distress, the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. During the course of CPR, about every 2 minutes the nurse should simultaneously check for the presence of pulse and respirations for 10 seconds by checking for carotid pulse while watching for the chest to rise and fall. When documenting an episode of CPR, ensure to include the approximate time the presence of pulse or respirations were checked. BLS Healthcare Provider Adult [MEDICAL CONDITION] Algorithm (see attached) regarding the proper algorithm for CPR for an adult by a healthcare provider according to the (YEAR) guidelines set by the American Heart Association. A copy of this algorithm will placed on the emergency cart on [DATE]. Abuse and Neglect according to facility policy - see attached policy The regional nurse who is a certified CPR instructor will provide in-servicing related to the above topics to the DON and ADONs and all Nursing staff prior to returning to job duties (60% of Nursing were In-Service [DATE]). Any newly hired staff will be provided training to the above topics upon hire by the DON and/or ADON. The Medical Director was notified of this plan on [DATE]. Monitoring The DON and or ADON will ask at least 8 nurses per week how to determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. ADONs will check DNR binders at least 3 times a week x 4 weeks to ensure that all DNRs are accurate and updated, followed by weekly checks from there on after. The binders will be updated immediately upon any code status order change. The DON and/or ADONs will monitor any CPR related documentation to ensure compliance with documentation related to CPR including presence of pulse and respirations The DON and/or ADONs will ensure that at least 1 CPR certified nurse is present 24 hours per day. The Regional Nurse at least weekly will verify that the above monitoring by facility staff is in compliance as stated. Findings will be shared with the QAA committee and changes made as required. Ask at least 8 nurses per week how they would determine a resident's code status and how often they should check for the presence of pulse and respirations during CPR. Date_____________________ Name of Nurse___________________ Did the nurse answer each question correctly? Yes or No; If No explain corrective action below. Plan of Removal - Failure to have accurate diet roster and training. Failure to Intervene and update care plan. Staff training and Knowledge of diet. Interventions to prevent reoccurrence. All residents identified with diet orders were reviewed and verified to determine diet accuracy by [DATE]. All residents that have behaviors related to noncompliance with their diet texture and have the potential to choke were identified by the DON and regional nurse on [DATE]. Any residents identified with a behavior to be non-compliant with the diet texture had a task added to their point of care that states, Resident has a history of hoarding and/or stealing food that is not compliant with their diet order which makes them at risk for choking. If observed, attempt to remove the food and notify your supervisor immediately. Certified Nurse Aide staff will be able to acknowledge this every shift. Any residents identified with a behavior to be non-compliant with the diet texture had an entry added to their treatment administration record (TAR) to communicate to the licensed nurse the potential problem. The nurse will initial this entry every shift. Any residents identified with a behavior to be non-compliant with the diet had their care plan reviewed and if needed updated on [DATE] by the DON, ADON, Regional Nurse, or MDS nurse to reflect interventions to attempt prevent the resident from choking related to their behavior. On [DATE] binders were placed on the East and West hydration carts that included all residents' diet orders for easy review by nursing staff if they have a question to what diet a resident has. Nursing Staff were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the Diet Binder placed on each hydration cart on East and West Hall, the task added to the point of care and the entry to the TAR. Any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties. Licenses nurses were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the following: (any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties). If a diet order is obtained by the Charge Nurse, the following protocol will be followed: - The charge nurse will verify the diet orders and enter orders into electronic records. - The Charge Nurse will complete a Dietary Notification form and give to dietary. - The Charge Nurse will review diet orders at each meal service. - DON/ADON will update dietary binder monthly. - Any new diet orders will be followed as directed by the physician. All staff were in-serviced by the DON, ADON, or Regional Nurse regarding the facility's policy on abuse and neglect. See attached policy. This in-service began on [DATE] and any staff not in-serviced on [DATE], will be in-serviced prior to assuming their duties. Any new staff hired will be trained regarding the above in-services by the DON and/or ADON The DON, ADON, and MDS case managers were in-serviced regarding completion of residents care plan not reflecting resident current status by the regional nurse on [DATE]. The DON and Administrator were in-serviced by the regional nurse regarding reporting abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. The DON and Administrator will in-service staff on reporting abuse, neglect or any other reportable incident prior to staff returning to job duties. Completion date [DATE]. Monitoring The DON and or designee will monitor on a daily basis to ensure any new or readmitted resident has a diet order. The DON and/or ADON will complete a random diet order review on 15 residents per week for 4 weeks by comparing the electronic records orders to the resident dietary tray card for accuracy. The DON and/or designee will ask 10 staff members per week for 4 weeks, if they know how to obtain the residents diet. During the weekly care plan meeting the MDS Case Manager and the DON or Designee will ensure that the residents' Care Plans match the resident's current status. The DON, ADON, or MDS nurse will update a residents diet care as needed for any new diet orders, intervention, or non-compliance The Regional Nurse at least weekly will verify that the above monitoring by facility staff is in compliance as stated. The Regional Nurse and/or area director of operations will monitor incidents/events at least weekly to ensure compliance with reporting guidelines. Findings will be reviewed by the QAA committee and changes made to the plan as needed. All of the above monitoring will be documented on a facility formulated monitoring form. Plan of Removal DNR [DATE] Interventions to prevent reoccurrence. All residents labeled as DNR, will have a copy of their DNR paper work inside a binder located on top of the crash cart behind the nurse's station where it is easily accessible. Code status can also be verified in the electronic records as well as residents chart, point of care kiosk and EMAR. Staff will be in serviced that in the event of a rapid response charge nurse will designate one person to verify code status. 60% of staff are expected to be in-service by [DATE] with a completion date of [DATE]. Monitoring ADONs will check DNR binders 3 times a week x 4 weeks to ensure that all DNRs are accurate and updated, followed by weekly checks from there on after. Verification of the Plan of Removal was as follows: a. Observation on [DATE] at 1:20 PM revealed snacks were on west wing nurses' station countertop. Further observation revealed a female resident was reaching for the yogurt and asked me if she could have it. LVN M was sitting at nurses' station documenting on a computer, and the ADON standing behind the desk. During an interview with the ADON and LVN M on [DATE] at 1:20 PM, at the same time as the observation, the ADON confirmed the snack tray was supposed to be placed behind the nurses' station out of resident's reach. LVN M and the ADON further confirmed that neither one had signed for snacks and were not aware who did or when they were delivered. Record review of in-service training revealed staff were in-serviced immediately on procedures for snacks. Interviews with 3 CNAs and 4 LVNs revealed they were aware of ensuring snacks are placed behind nurses' station out of reach of residents. b. Facility identified a list of residents at risk for hoarding/stealing food that are non-compliant with their diet orders which makes them at-risk for choking, dated [DATE], revealed residents were: Residents #3, #5, #6, #7, #8, #9, #10, #11, and #12. Record review of care plans for the above residents revealed residents were noted to have a behavioral problem related to hoarding food, stealing food, eating off diet plan. Further review revealed the residents' Care plans did not address residents as being at-risk for choking. Record review of care plans for Residents #3, #5, #6, #7, #8, #9, #10, #11, and #12 were updated to reflect their risk for choking. Record review of the diet roster, dated [DATE], revealed Residents #13 and #14 did not have type of liquid specified for their diets. Further review revealed Resident #14 was on a pureed diet and Resident #13 had a mechanical soft diet. During an interview with the DON and the Regional Nurse on [DATE] at 2:39 PM, the DON and the Regional Nurse revealed they decided who was at-risk for choking by interviewing staff to see who had behavioral issues with being non-complaint with diet and then reviewed the residents' diet. The DON and the Regional Nurse stated Dietary would deliver snacks either to the nurse or the aide and they would sign for the snacks. The DON and the Regional Nurse stated staff would take the tray the snacks will be passed out, and if they are not ready to pass out snacks, the snacks need to be placed behind the nurses' station. The DON and the Regional Nurse stated staff assisting from sister facilities are being trained before starting on the unit. The DON and the Regional Nurse confirmed the facility's diet roster should include fluid consistency. Record review of the diet roster and census, dated [DATE], revealed the diet roster was updated and every resident had a diet order to include diet type texture and fluid consistency. Random record review of 25 residents revealed the diet roster coincided with the residents' physician orders. b. Observation on west wing revealed there was a DNR book was on the crash cart and a Diet binder was at the nurses' station. Further observation of the DNR binder revealed there was a copy of residents' face sheet and DNR forms on file for both units. Record review of DNR residents' revealed code status reflected on Point Click Care and on consolidated physician orders. c. Interviews with 5 LVNs, 3 CNAs, 1 MA, and 2 Hydration Aides revealed they were aware the Administrator was the Abuse Coordinator and they are to report all incidents and accidents to the DON. During further interview they revealed they were aware of the diet roster being kept at the nurses' station and the DNR binder on crash cart. d. Interviews with 4 LVNs revealed they were aware to check residents' code status immediately during an emergency situation, they further revealed they were aware they needed to assess a resident's condition (pulse and respirations) to determine how to respond. e. Record review of facility's in-service training records revealed 13 out of 16 licensed staff were in-serviced from [DATE] to [DATE] on verifying residents' code status, CPR, and the facility's abuse and neglect policy along with other direct care and ancillary staff. Record review of facility's in-service training records, dated [DATE], revealed 60% of the staff were in-serviced on, in the event of a rapid response charge nurse will designate one person to verify code status. Record review of facility's training records, dated [DATE], regarding the diet binder on the hydration carts and the task added to the point of care and the entry to the treatment administration record revealed 60% of the staff were in-serviced. Record review of facility's licensed nurse in-service training records, dated [DATE], on diet orders revealed 11 of 16 nurses received training along with other direct care and ancillary staff. Record review of facility's in-service training, dated [DATE], regarding completion of residents' care plan not reflecting resident current status revealed the DON, ADON x 2 and MDS Coordinator received training. Record review of facility's in-service record, dated [DATE], revealed the DON and the Administrator received training regarding abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. Record review of facility's in-service training, dated [DATE], revealed 46% of the staff received training on abuse and neglect. While the IJ was removed on [DATE] at 12:00 PM, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until all residents were assessed and staff was in-serviced on assessing, documenting interventions and initiating Cardiopulmonary Resuscitation (CPR), verifying code status, and ensuring all residents are being provided with a therapeutic diet.

Based on interviews, observations and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan that includes includes measurable objectives and time frames to meet a resident's medical and nursing needs that are identified in the comprehensive assessment for 1 of 21 residents (Resident #1) reviewed for care plans, in that: The facility failed to ensure Resident # 1's care plan contained interventions for Resident # 1's grabbing off food and choking. These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of choking. This deficient practice could affect residents in the facility who are at risk of choking, and place them at-risk for harm or even death. The findings were: 1. Record review of Resident #1's face sheet revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Observation on [DATE] at 11:45 AM revealed fire department and EMS were outside the facility, EMS was seen entering the building and leaving, Resident #1 had already expired. Further observation revealed Resident #1 was laying on the floor in his room, face blue. Record review of Resident #1's consolidated physician orders [REDACTED]. Record review of Resident #1's nursing progress note, dated [DATE] at 1:45 PM written by RN F, revealed: resident propelled self to nurses station and was saying 'hey' over and over again, resident was sweating and somewhat pale and attempting to cough, noted to have a roll of saltine crackers on his lap, oxygen saturation 48, resident was turning blue and [MEDICATION NAME] initiated and was successful, non-rebreather oxygen applied 15 liters Resident # 1 was suctioned orally and watery residual crackers removed from mouth/throat. Resident # 1 got his color back and became more alert. EMS called and transported Resident # 1 to hospital. Further review of Resident #1's progress note revealed DON and physician were made aware, and that interventions were already in place for Resident #1 to eat in the dining room for all meals until roommate finishes his food because resident does not follow redirections to not eat roommates' food. During an interview with Hospitality Aide C on [DATE] at 1:14 PM, Hospitality Aide C revealed she passed out snacks. Hospitality Aide C confirmed Residents #4 and #1 were roommates and were both on pureed diets with thickened liquids (record review of roommate's diet revealed he was on mechanical soft nectar thicken liquid). Hospitality Aide C stated she had not given Resident #1 a sandwich, and further stated the resident had behaviors of taking food that did not belong to him. Hospitality Aide C further revealed two weekends ago he came in from smoke break with a pack of saltine crackers he took for another resident. She further revealed she took the crackers from him and notified the RN. Record review of Resident #1's nursing progress note, dated [DATE] at 5:35 PM by RN F, revealed the resident returned from the hospital with no new orders. Further review of the resident's nursing progress notes revealed there were no other progress notes since the date of the resident's incident on [DATE]. Record review of Resident # 1's Quarterly MDS dated [DATE] revealed Resident # 1 did not have any behavioral issues and required extensive one person assist for meals. Further review of MDS revealed Resident # 1 received 51% or more of total calories through parental or tube feeding and was on a mechanically altered therapeutic diet. Record review of Resident #1's care plan, revised on [DATE], revealed the resident's care plan the resident had a swallowing problem related to dysphagia. All staff to be informed of resident's special dietary and safety needs. Check mouth after meals for pocketed food and debris. Instruct resident to eat in an upright position, to eat slowly, thoroughly. Further review of Resident's #1's care plan revealed the resident required one person assist with eating, and had a swallowing problem related to Dysphagia; all staff were to be informed of resident's dietary and safety needs. Record review of facility's incident reports for (MONTH) 2019 revealed an incident report was not completed for Resident #1's choking incident on [DATE]. There was no documentation of an assessment or interventions after Resident # 1's choking episode. Record review of Resident #1's speech therapy encounters revealed Resident #1 was receiving speech services on [DATE] for cognitive-linguistic therapy to facilitate improved orientation to immediate environment and on [DATE] to improve safety during oral intake. Requires max cueing. Record review of Director of Rehab's facility witness statement dated [DATE] revealed Resident # 1 was in the therapy gym at 9:00 AM, after therapy Resident stayed in therapy room watching television. At approximately 10:55 AM he left for smoke break. He returned and left upset because channel had been changed. Approximately ,[DATE] minutes later code blue was called. Upon arrival on scene was notified he passed away. Resident was known to go to other residents' rooms and trash cans to find food. He was non-compliant with his diet restrictions. During an interview with the MDS Coordinator on [DATE] at 11:50 AM, the MDS Coordinator stated Resident # 1 was choking and MDS Coordinator was able to get a piece of bologna sandwich out of the resident's mouth. The MDS Coordinator confirmed Resident #1 was on a pureed diet. During an interview with the Dietary Manager on [DATE] at 1:04 PM, the Dietary Manager stated the facility offered bologna sandwiches to the residents for snacks on the morning of [DATE]. The Dietary Manager confirmed Resident #1 was on a pureed diet and revealed that when the dietary staff delivered the snacks to the nurses' station, the nurse accepting the snacks had to sign off as receiving them for. The Dietary Manager further revealed Resident #1 had a history of [REDACTED]. During an interview with the MDS Coordinator on [DATE] at 8:25 AM, the MDS Coordinator confirmed there were no interventions placed after Resident #1 returned from the hospital from choking on [DATE]. The MDS Coordinator stated that to her knowledge there were not any records of Resident #1's non-compliance with his diet being monitored by facility staff. During an interview with the Administrator on [DATE] at 9:45 AM, the Administrator stated that he had not been informed by facility staff of Resident #1's previous choking incident on [DATE] until yesterday, [DATE]. The Administrator stated that had he been made aware of the resident's incident on [DATE] he would have reported the incident, and further stated, communication in this building was non-existent. The Administrator further stated that following Resident #1's previous incident the first thing he would have done would have been to review the resident's care plan to see if interventions were in place. Further interview with the Administrator revealed they have not had a QA meeting and that they began to complete 24 hour reports two weeks after he started. His primary focus since starting in (MONTH) (YEAR) had been on cosmetics of the building and care of residents. The Administrator further revealed they were having difficulties transitioning from one corporation to the current corporations as a lot of the staff had to be termed due to not meeting the current corporations' standards. He further stated they were having difficulty obtaining employee training records. During an interview with the DON on [DATE] at 10:20 AM, the DON revealed facility staff called her on [DATE] and notified her of Resident #1's choking episode and that the resident had been sent to the hospital. The DON confirmed she had not notified the Administrator of Resident #1's incident and had chosen not to do so because the resident had returned to the facility with no issues. During an interview with NP E on [DATE] at 12:04 PM, NP E revealed that he had never had any issues with Resident #1. NP E stated the resident did not talk much due to his [MEDICAL CONDITION], and further stated the resident did not have any aggressive behaviors; however, the resident was on hospice services for end-stage Dementia. NP E confirmed there was no documentation of Resident #1 being non-compliant with diet. NP E further revealed he was not informed by staff of Resident # 1 non-compliance with diet. NP E stated that if he had been informed the resident had had a choking episode he would have requested for speech therapy to evaluate the resident. Record review of the facility's policy on Comprehensive Care Plan (no date) revealed in situations where a resident's choice to decline care or treatment (e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempts to find alternative means to address the identified risk/need should be documented in the care plan. Record review of facility's policy on Event Reporting: Completion of dated 2003 revealed the facility will complete an Event form on variances that occur within the facility. All events that require treatment beyond immediate first aide must be reported immediately to the Administrator and/or DON. The investigation should be completed by the DON/Administrator or designee. The investigation report documents a thorough investigation of the events of the reported events including persons, equipment, and materials that were involved. Include and care plan any required interventions to help prevent further occurrence of the event. The Administrator was notified of an IJ on [DATE] at 2:00 PM and a Plan of Removal was requested. The Plan of Removal included the following: Plan of Removal - [DATE] Failure to have accurate diet roster and training. Failure to Intervene and update care plan. Staff training and Knowledge of diet. Interventions to prevent reoccurrence. All residents identified with diet orders were reviewed and verified to determine diet accuracy by [DATE]. All residents that have behaviors related to noncompliance with their diet texture and have the potential to choke were identified by the DON and regional nurse on [DATE]. Any residents identified with a behavior to be non-compliant with the diet texture had a task added to their point of care that states, Resident has a history of hoarding and/or stealing food that is not compliant with their diet order which makes them at risk for choking. If observed, attempt to remove the food and notify your supervisor immediately. Certified Nurse Aide staff will be able to acknowledge this every shift. Any residents identified with a behavior to be non-compliant with the diet texture had an entry added to their treatment administration record (TAR) to communicate to the licensed nurse the potential problem. The nurse will initial this entry every shift. Any residents identified with a behavior to be non-compliant with the diet had their care plan reviewed and if needed updated on [DATE] by the DON, ADON, Regional Nurse, or MDS nurse to reflect interventions to attempt prevent the resident from choking related to their behavior. On [DATE] binders were placed on the East and West hydration carts that included all residents' diet orders for easy review by nursing staff if they have a question to what diet a resident has. Nursing Staff were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the Diet Binder placed on each hydration cart on East and West Hall, the task added to the point of care and the entry to the TAR. Any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties. Licenses nurses were in-serviced by the DON, ADON, or Regional Nurse beginning on [DATE] regarding the following: (any staff not in-serviced on [DATE] will be in-serviced before returning to their job duties). If a diet order is obtained by the Charge Nurse, the following protocol will be followed: - The charge nurse will verify the diet orders and enter orders into electronic records. - The Charge Nurse will complete a Dietary Notification form and give to dietary. - The Charge Nurse will review diet orders at each meal service. - DON/ADON will update dietary binder monthly. - Any new diet orders will be followed as directed by the physician. All staff were in-serviced by the DON, ADON, or Regional Nurse regarding the facility's policy on abuse and neglect. See attached policy. This in-service began on [DATE] and any staff not in-serviced on [DATE], will be in-serviced prior to assuming their duties. Any new staff hired will be trained regarding the above in-services by the DON and/or ADON The DON, ADON, and MDS case managers were in-serviced regarding completion of residents care plan not reflecting resident current status by the regional nurse on [DATE]. The DON and Administrator were in-serviced by the regional nurse regarding reporting abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. The DON and Administrator will in-service staff on reporting abuse, neglect or any other reportable incident prior to staff returning to job duties. Completion date [DATE]. Monitoring The DON and or designee will monitor on a daily basis to ensure any new or readmitted resident has a diet order. The DON and/or ADON will complete a random diet order review on 15 residents per week for 4 weeks by comparing the electronic records orders to the resident dietary tray card for accuracy. The DON and/or designee will ask 10 staff members per week for 4 weeks, if they know how to obtain the residents diet. During the weekly care plan meeting the MDS Case Manager and the DON or Designee will ensure that the residents' Care Plans match the resident's current status. The DON, ADON, or MDS nurse will update a residents diet care as needed for any new diet orders, intervention, or non-compliance The Regional Nurse at least weekly will verify that the above monitoring by facility staff is in compliance as stated. The Regional Nurse and/or area director of operations will monitor incidents/events at least weekly to ensure compliance with reporting guidelines. Findings will be reviewed by the QAA committee and changes made to the plan as needed. All of the above monitoring will be documented on a facility formulated monitoring form. Verification of the Plan of Removal was as follows: a. Observation on [DATE] at 1:20 PM revealed snacks were on west wing nurses' station countertop. Further observation revealed a female resident was reaching for the yogurt and asked me if she could have it. LVN M was sitting at nurses' station documenting on a computer, and the ADON standing behind the desk. During an interview with the ADON and LVN M on [DATE] at 1:20 PM, at the same time as the observation, the ADON confirmed the snack tray was supposed to be placed behind the nurses' station out of resident's reach. LVN M and the ADON further confirmed that neither one had signed for snacks and were not aware who did or when they were delivered. Record review of in-service training revealed staff were in-serviced immediately on procedures for snacks. Interviews with 3 CNAs and 4 LVNs revealed they were aware of ensuring snacks are placed behind nurses' station out of reach of residents. b. Facility identified a list of residents at risk for hoarding/stealing food that are non-compliant with their diet orders which makes them at-risk for choking, dated [DATE], revealed residents were: Residents #3, #5, #6, #7, #8, #9, #10, #11, and #12. Record review of care plans for the above residents revealed residents were noted to have a behavioral problem related to hoarding food, stealing food, eating off diet plan. Further review revealed the residents' Care plans did not address residents as being at-risk for choking. Record review of care plans for Residents #3, #5, #6, #7, #8, #9, #10, #11, and #12 were updated to reflect their risk for choking. Record review of the diet roster, dated [DATE], revealed Residents #13 and #14 did not have type of liquid specified for their diets. Further review revealed Resident #14 was on a pureed diet and Resident #13 had a mechanical soft diet. During an interview with the DON and the Regional Nurse on [DATE] at 2:39 PM, the DON and the Regional Nurse revealed they decided who was at-risk for choking by interviewing staff to see who had behavioral issues with being non-complaint with diet and then reviewed the residents' diet. The DON and the Regional Nurse stated Dietary would deliver snacks either to the nurse or the aide and they would sign for the snacks. The DON and the Regional Nurse stated staff would take the tray the snacks will be passed out, and if they are not ready to pass out snacks, the snacks need to be placed behind the nurses' station. The DON and the Regional Nurse stated staff assisting from sister facilities are being trained before starting on the unit. The DON and the Regional Nurse confirmed the facility's diet roster should include fluid consistency. Record review of the diet roster and census, dated [DATE], revealed the diet roster was updated and every resident had a diet order to include diet type texture and fluid consistency. Random record review of 25 residents revealed the diet roster coincided with the residents' physician orders. b. Observation on west wing revealed there was a DNR book was on the crash cart and a Diet binder was at the nurses' station. Further observation of the DNR binder revealed there was a copy of residents' face sheet and DNR forms on file for both units. Record review of facility's training records, dated [DATE], regarding the diet binder on the hydration carts and the task added to the point of care and the entry to the treatment administration record revealed 60% of the staff were in-serviced. Record review of facility's licensed nurse in-service training records, dated [DATE], on diet orders revealed 11 of 16 nurses received training along with other direct care and ancillary staff. Record review of facility's in-service training, dated [DATE], regarding completion of residents' care plan not reflecting resident current status revealed the DON, ADON x 2 and MDS Coordinator received training. Record review of facility's in-service record, dated [DATE], revealed the DON and the Administrator received training regarding abuse, neglect or any other reportable incident to the state according to Texas Provider Letter ,[DATE]. Record review of facility's in-service training, dated [DATE], revealed 46% of the staff received training on abuse and neglect. While the IJ was removed on [DATE] at 12:00 PM, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until all residents were assessed and staff was in-serviced on assessing, documenting interventions and initiating Cardiopulmonary Resuscitation (CPR), verifying code status, and ensuring all residents are being provided with a therapeutic diet.

Based on interviews, observation and record reviews, the facility failed to provide emergency lifesaving measures that met professional standards of quality of care for 1 of 15 residents (#13) whose care was reviewed for neglect and services in that: LVN's P, S, and T did not check for an airway and perform the [MEDICATION NAME] maneuver on Resident #13 who choked on sandwiches he had obtained from the East hall nurses' station. The LVN's did not immediately start CPR until they took the resident to his room. They did not perform the [MEDICATION NAME] maneuver after the resident was lifted out of his wheelchair and did not attempt abdominal thrust to dislodge the food from his esophagus. As a result, the airway was blocked and the lungs were not inflated with the Ambu bag. The automatic electronic defibrillator (AED) was not used to detect sinus rhythm and to defibrillate the heart. The AED had not been checked or tested for 5 months. As a result, the resident died in his room. These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed for DNR status and the staff was in-serviced on assessing residents in emergency circumstances, performing the [MEDICATION NAME] maneuver, immediately starting CPR in place and the implementation of the AED. These deficient practices could affect 8 of the 15 sampled residents in the facility who were identified as Full Code in the sample and could result in their wishes not being met leading to death. The findings were: 1. According Texas Board of Nursing, 15.2 , The Role of the Licensed Vocational Nurse in the Pronouncement of Death, LVNs do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas. Regardless of practice setting, the importance of initiating CPR in cases where no clear Do Not Resuscitate (DNR) orders exist is imperative. The Board of Nursing (BON) has investigated cases involving the failure of a LVN to initiate CPR in the absence of a DNR order. It is within the LVN scope of practice as defined by Rule 217.11(1)-(2) (effective [DATE]) and Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice, for a LVN to gather data and perform a focused assessment regarding a patient, to recognize significant changes in a patient ' s condition and to report said data and observation of significant changes to the physician. The LVN ' s focused assessment should include nursing observations to determine the presence or absence of the following presumptive or conclusive signs of death: a. Presumptive Signs of Death: · The patient is unresponsive, · The patient has no respirations, · The patient has no pulse, · Patient ' s pupils are fixed and dilated, · The patient ' s body temperature indicates hypothermia: skin is cold relative to the patient ' s baseline skin temperature, · The patient has generalized cyanosis, and b. Conclusive Sign of Death: · There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin which does blanch with pressure). · While these signs of irreversible death would not be expected to be seen in most practice settings, the American Heart Association also includes the following irreversible signs of death: · decapitation (separation of the head from the body) · decomposition (decay or putrification of the body) · rigor mortis (stiffness of the limbs and body that develops 2 - 4 hours after death and may take up to 12 hours to fully develop). 2. According to the American College of Emergency Physicians for 2017, the use of the [MEDICATION NAME] maneuver is implemented in the following instances by both healthcare professionals and laymenhttp: (//www.emergencycareforyou.org/Emergency-101/Emergencies-A-Z/Choking-([MEDICATION NAME]-Maneuver)/): a. Conscious Adult: . In the event of choking, rescuers should take action if they see signs of severe airway obstructions (including poor air exchange and increased breathing difficulty, a silent cough, and cyanosis or if the person is unable to speak or breathe). . To differentiate between mild airway obstruction and severe airway obstruction, the rescuer should ask, Are you choking? If the victim nods yes, assistance is needed. Choking also often is indicated by the Universal Distress Signal (hands clutching the throat). . If the person can speak, cough or breathe, do not interfere. . If the person cannot speak, cough or breathe, give abdominal thrusts known as the [MEDICATION NAME] maneuver. . To employ the [MEDICATION NAME] maneuver, reach around the person's waist. Position one clenched fist above the navel and below the rib cage. Grasp your fist with your other hand. Pull the clenched fist sharply and directly backward and upward under the rib cage six to 10 times quickly. . In case of obesity or late pregnancy, give chest thrusts. . Continue uninterrupted until the obstruction is relieved or advanced life support is available. In either case, the person should be examined by a physician as soon as possible. b. Unconscious Adult: . Position the person on his or her back, arms by side. . Shout for help. Call 911 or the local emergency number. . Perform a finger sweep to try to remove any foreign body from the mouth. Only remove an object you can see and easily extricate. . Listen for breathing and watch for the chest to rise and fall. If the person is not breathing, perform rescue breathing. If unsuccessful, give six to 10 abdominal thrusts (the [MEDICATION NAME] maneuver). To perform abdominal thrusts on an unconscious person, kneel over the person and place the heel of one hand on the person's abdomen, slightly above the navel. Next, place your other hand on top of the first. Press into the abdomen with quick, upward thrusts. . Repeat sequence: Perform finger sweep, attempt rescue breathing, and perform abdominal thrusts, until successful. . Continue uninterrupted until the obstruction is removed or advanced life support is available. When successful, have the person examined by a physician as soon as possible. . After the obstruction is removed, begin CPR, if necessary. 3. Review of Resident #13's consolidated physician orders [REDACTED]. Review of an annual Minimum (MDS) data set [DATE] revealed that Resident #13 was moderately impaired with a BIMS score of 11 out of 15 (highest level of cognition and ability to make decisions) and had no serious mental illness prior to admission. The MDS indicated that the resident had no evidence of an acute change in mental status, and had a tendency for overeating and weighed 213 pounds. Review of Resident #13's Medication Administration Record [REDACTED] Review of Resident #13's Resident Progress Note dated [DATE] at 5:56 a.m. revealed LVN P documented that Resident #13 was found unresponsive in his wheelchair in the dining room and that CPR and life saving measures and EMS were activated and initiated a [MEDICAL CONDITION]. Review of a self-reported incident investigation worksheet dated [DATE] revealed that at 5:30 a.m. on [DATE] Resident #13 was found unresponsive in his wheelchair in the dining room and that CPR had been initiated. The worksheet documented that Resident #13 was observed by a facility video recording grabbing sandwiches from the nursing station counter off a tray and going to the dining room to eat them. During an observation on [DATE] at approximately 8:55 a.m., Resident #13 was observed lying on the floor of his room covered with a sheet. LVN GG removed the sheet and the resident was dead. A fresh [MEDICAL CONDITION] was in place as well as a puddle of blood on the floor. The upper torso had a used AED [MEDICATION NAME] pad lying on the chest. At approximately 9:10 a.m., the Medical Examiner arrived to examine the body. During the observation, the Medical Examiner turned the body over and blood poured onto the floor from the [MEDICAL CONDITION]. During a viewing at approximately 9:25 a.m. on [DATE], the Administrator showed the recorded video to the Surveyor and the Medical Examiner, which captured the morning activities of Resident #13 propelling in a wheelchair at 5:04 a.m. on [DATE] in front of the nurses station on the East Wing hallway. He was recorded grabbing a sandwich and going into the dining room. At 5:10 a.m., Resident # 13 propelled to the nurses station and grabbed a second sandwich. At 5:14 a.m., Resident #13 wheeled himself to the nurse's station and grabbed a third sandwich. No staff member was observed attempting to monitor the resident. At 5:20 a.m., CNA V was observed pushing a wheelchair into the dining room and a few minutes later running from the dining room. Staff was observed running to the dining room including LVN S and LVN T. A few minutes later the video showed the staff pulling the wheelchair with the resident in it out of the dining room towards the nurse's station on the East Wing. During an interview at approximately 9:40 a.m. on [DATE], the Medical Examiner stated that there would be an autopsy performed to determine the cause of death. At that time, it was possible that the resident asphyxiated on the sandwiches. During an interview at approximately 10:00 a.m. on [DATE], the Administrator reported that the staff was aware that Resident #13 was a big eater and usually left the resident alone. No supervision was required for Resident 13's eating practice. During a telephone interview at 2:55 p.m. on [DATE], CNA V stated that she worked the night shift, 10:00 p.m. to 6:00 a.m. on [DATE] and stated that she did not notice Resident #13 going into the dining room. She stated that when she took a resident into the dining room she noticed Resident #13 sitting in his wheelchair with his head slumped over. Because of the ashen color to the resident's skin, she assumed the resident was not asleep and called Code Blue (Hospital emergency code used worldwide to alert staff to emergencies). The first nurse she spoke to was LVN S, who told the staff to move the resident to his room. CNA V stated that she could see some food stuck in his mouth. When asked, CNA V stated that the [MEDICATION NAME] maneuver was not done. She stated that LVN S instructed the staff to move the resident to the bed. When asked what LVN S was doing at that time, CNA V reported that LVN S was trying to set up the AED device, but the device did not have the right [MEDICATION NAME] pads to fit the device. During an interview and a written statement at 5:45 p.m. on [DATE], LVN S stated that he worked the second shift, 5:45 p.m. to 6:00 a.m., [DATE] to [DATE] and was involved with the resuscitation efforts on Resident #13. He demonstrated on the AED device how the previous [MEDICATION NAME] pad did not fit the device. He acknowledged that the [MEDICATION NAME] pad in the device was the right one. LVN S stated that upon entering the dining room on [DATE], he checked the carotid pulse with his finger and detected a faint pulse. He stated that food was sticking out of the resident's mouth. When asked if he had swept the mouth, he stated No, because other residents were watching. When asked if the [MEDICATION NAME] maneuver was performed, he stated No. When asked why the resident was moved to his room, LVN S stated that he was afraid to set off the other residents. He stated that as soon as the resident was put into his room, LVN T swept the resident's mouth which included a chewed up sandwich. The [MEDICATION NAME] maneuver was not performed at that time. After the resident was lifted out of the wheelchair and placed on his bed, LVN S attempted to start the AED while the other staff performed CPR. He could not use the AED because the [MEDICATION NAME] pad did not fit the device. He stated that at no time during the attempt to push air into the resident's mouth with the ambu. bag did the resident's chest rise to indicate air was passing through the mouth and into the lungs. He stated that at that point, EMS arrived and took over. During an interview and a written statement at 6:45 p.m. on [DATE], LVN T stated that she worked the second shift, 6:00 p.m. to 6:00 a.m., [DATE] to [DATE] on the West Wing with LVN S. She stated that she was new to the facility and was in her second week of employment. She stated that on [DATE] she heard CNA V call Code Blue and was instructed by LVN S to call 911. LVN T stated that she dialed 911, but did not know what to tell the dispatcher. CNA U took the phone while LVN T attempted to assist with Resident #13. LVN T stated that although she had training in the use of the AED device and CPR, she had never attended to a Code Blue. She stated that she followed the staff to Resident #13's room and helped in lifting the resident out of the chair to the bed. She stated that the [MEDICATION NAME] Maneuver was not attempted by any of the staff. LVN T stated that she and CNA V began taking turns performing compressions. She stated that she noticed that color was returning to Resident #13's body. She stated that the chest did not rise and fall when the ambu. bag was being used to indicate air was passing into the lungs. She stated that LVN S was attempting to set up the AED device. Because the chest was not rising, LVN T said that she was about to perform mouth-to-mouth resuscitation when the EMS team arrived and took over. During an interview at 7:10 p.m. on [DATE], LVN D, Medical Records and Supplies, reported that she had ordered replacement [MEDICATION NAME] pads and did not realize that the wrong [MEDICATION NAME] pads had been delivered until the morning incident with Resident #13. She stated that the proper [MEDICATION NAME] were on hand and were replaced after the incident. LVN D gave the Surveyor a copy of the invoice, which revealed that the facility had ordered 2 sets of adult defibrillator pads at $32.52 each on [DATE] and were delivered on the same day from a distributor and not the manufacturer. During observation at approximately 7:15 p.m. on [DATE], it was noted that the AED device was recessed into the wall within the nurse's station on the East Wing. Above the device was a clip board with a log to indicate checking the device on the first day monthly on the night shift. The log was blank for October, November, [DATE] and January and February 2017. Five months were not logged. During an interview at 7:35 p.m. on [DATE], CNA U stated that LVN T had panicked when calling 911 and that she took the phone and gave the dispatcher the name of the facility and address. She stated that she observed Resident #13 in the dining room and the resident's head was tilted and his face was purple colored. During a telephone interview at 2:40 p.m. on [DATE], LVN P stated that she had worked the night shift on [DATE] to [DATE] and had assisted CNA V to get Resident #13 to get out of bed for breakfast. She stated that Resident #13 had asked for a sandwich and she instructed him to take one sandwich. The resident propelled himself to the nurse's station and LVN P entered a room to start an enteral feeding to a resident. She stated that CNA V entered the room and hollered to her that Resident #13 was in distress and needed help. LVN P then clamped the tubing and exited the room. She stated that before she could enter the dining room she retrieved the resident's record to determine his DNR status and to push the crash cart to the Resident's room. When asked why the resident was moved to the room, LVN P stated that the resident needed to be flat in order to perform CPR and that the staff wanted to get the other residents away from the scene. Other residents were asking questions. When questioned, LVN P stated that the [MEDICATION NAME] Maneuver should have been performed and that LVN S was big enough to perform the maneuver. She could not remember if she experienced resistance when holding the ambu. bag on the resident's mouth and compressing the bag. During a second interview and a written statement at 7:15 p.m. on [DATE], LVN P stated that she had placed the tray of sandwiches on the nurse's station counter and had told Resident #13 to take only one sandwich on [DATE]. She stated that when assisting to resuscitate Resident #13, a CNA attempted to sweep the mouth and that the back board was in place under the resident. She stated that she had difficulty with compressions, because the board was too small. She stated that she and LVN T took turns with compressions and the ambu. bag. The Administrator was notified on [DATE] at 4:00 p.m. of the IJ and a Plan of Removal was requested. The Plan of Removal included: a. On [DATE], the facility immediately began providing training to the nursing staff on the use of the AED. A training video was used for the course and each nursing staff member was required to watch the video. A posttest was provided at the end of the certification and return demonstration was documented. The facility planned to educate all nursing staff on the use of the AED upon hire during orientation and annually thereafter. Return demonstrations were to be documented and kept in the personnel files of current and new nursing staff. Prior training from previous facilities in the use of the AED would not be valid. The correct [MEDICATION NAME] pad was placed in the casing of the AED device. b. A mock code on a resident requiring CPR and the [MEDICATION NAME] maneuver was conducted and repeated until all nursing staff achieved 100 % completion. c. On [DATE], 2 CPR training courses were taught by an outside licensed agency and the students included all current nursing staff who did, or did not have their current certification The course included basic CPR training and the [MEDICATION NAME] Maneuver. All nursing staff members demonstrated proficiency in providing the [MEDICATION NAME] Maneuver and CPR. The DON was designated to monitor CPR certification compliance. 19 out of 27 nurses had CPR certification. The remaining 8 nurses were expected to provide proof of certification by end of business on [DATE], or complete a training course provided by the facility before [DATE]. Failure to do either would result in termination of employment. d. On [DATE], 25 out of 29 nurses and 17 out of 18 CNAs completed the training on the [MEDICATION NAME] Maneuver. Non-nursing staff were also required to participate in the training and perform return demonstrations. The remaining PRN CNAs and nurses who had not participated in the training were expected to provide proof of certification by end of business on [DATE], or complete a training course provided by the facility before [DATE]. Failure to do either would result in termination of employment. e. A posttest was administered to both participants in the training courses and to non-participants with current certification. Any wrong answers on the posttest were addressed with each individual on a one-on-one basis. f. On [DATE], nursing staff was trained on the timeline documentation for any lifesaving events. g. A new refrigerator was purchased to store resident snacks such as sandwiches and snacks and distribution of the snack was the responsibility of the nursing staff. h. A 100 % chart review was performed to determine the DNR status of each resident in the building and 5 residents were found to lack Out-of-hospital DNR documents, but were designated DNR in their record. The code status was immediately changed to full code until the documentation was completed, or found in the thinning's. i. The DON or designee was tasked with verifying retention of the training course by conducting mock code/choking emergencies weekly for the next 30 days for each shift and monthly for the next quarters and annually thereafter. The results of the mock code will be evaluated by the interdisciplinary team and progress will be monitored by the monthly quality assurance meetings. Verification of the Plan of Removal was as follows: a. Interviews were conducted with nursing, housekeeping and dietary staff on [DATE], [DATE], [DATE] and [DATE], day, evening and weekend staff to determine participation, certification and retention of the course material and to determine whether the training had been beneficial in increasing confidence in performing the [MEDICATION NAME] maneuver, CPR and in using the AED. These included: 2 RN's; 21 LVN's; 4 CNA's, Food Service Manager, Human Resources Manager and Receptionist. b. Forty-three posttests were reviewed and 2 nursing staff members were interviewed regarding their incorrect answer of when to start CPR. c. Forty-two (42) copies of CPR certifications were reviewed for filing and included participation in the facility's training course, or prior certification. Dates of expiration were noted and all certifications were current. d. Copies of AED certification training were also reviewed and 24 nursing staff were certified in the use of the AED device. e. In-service training reports dated [DATE] included choking and the use of the [MEDICATION NAME] maneuver, CPR and checking the crash cart and emergency supplies were reviewed for consistency and inclusion of nursing staff who were participants in the resuscitation efforts of Resident #13. On [DATE] the Administrator was informed that the Immediate Jeopardy was removed at 1:50 p.m. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility reported on [DATE] that 8 residents had a full code status. All the other residents (81) had Out-of-Hospital DNR forms in place.

Based on interviews, observations and record reviews, the facility failed to provide care and services to ensure the highest practicable physical, mental, and psychosocial well-being for 1 of 15 residents (#3) whose care was reviewed for full code status and emergency lifesaving measures in that: Nursing staff did not perform the [MEDICATION NAME] maneuver immediately after Resident #13 choked on sandwiches before being moved out of the dining room. Instead, the nursing staff moved the resident to his room for privacy. CPR was not imitated until the resident was taken out of the wheelchair and placed on his bed. The AED (automatic electronic defibrillator) was not use to determine sinus rhythm and defibrillate the heart of Resident #13, because the wrong [MEDICATION NAME] pads were in the AED device rendering it unusable. The AED had not been checked or tested for 5 months. As a result, the resident died . These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed for DNR status and the staff was in-serviced on assessing residents in emergency circumstances, performing the [MEDICATION NAME] maneuver, immediately starting CPR in place and the implementation of the AED. These deficient practices could affect 8 residents in the facility who were identified as Full Code in the sample and could result in their wishes not being met leading to death. The findings were: Review of Resident #13's admission orders [REDACTED]Full Code. Resident #13 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of a current recent care plans dated [DATE] did not identify Resident #13's full code status. Review of Resident #13's consolidated physician orders [REDACTED]. Review of an annual Minimum (MDS) data set [DATE] revealed that Resident #13 was moderately impaired with a BIMS score of 11 out of 15 (highest level of cognition and ability to make decisions) and had no serious mental illness prior to admission. The MDS indicated that the resident had no evidence of an acute change in mental status, and had a tendency for overeating and weighed 213 pounds. Review of Resident #13's Medication Administration Record [REDACTED] Review of Resident #13's Resident Progress Note dated [DATE] at 5:56 a.m. revealed LVN P documented that Resident #13 was found unresponsive in his wheelchair in the dining room and that CPR and life saving measures and EMS were activated and initiated a [MEDICAL CONDITION]. Review of a self-reported incident investigation worksheet dated [DATE] revealed that at 5:30 a.m. on [DATE] Resident #13 was found unresponsive in his wheelchair in the dining room and that CPR had been initiated. The worksheet documented that Resident #13 was observed by a facility video recording grabbing sandwiches from the nursing station counter off a tray and going to the dining room to eat them. During an observation on [DATE] at approximately 8:55 a.m., Resident #13 was observed lying on the floor of his room covered with a sheet. LVN GG removed the sheet and the resident was dead. A fresh [MEDICAL CONDITION] was in place as well as a puddle of blood on the floor. The upper torso had a used AED [MEDICATION NAME] pad lying on the chest. At approximately 9:10 a.m., the Medical Examiner arrived to examine the body. During the observation, the Medical Examiner turned the body over and blood poured onto the floor from the [MEDICAL CONDITION]. During a viewing at approximately 9:25 a.m. on [DATE], the Administrator showed the recorded video to the Surveyor and the Medical Examiner, which captured the morning activities of Resident #13 propelling in a wheelchair at 5:04 a.m. on [DATE] in front of the nurses station on the East Wing hallway. He was recorded grabbing a sandwich and going into the dining room. At 5:10 a.m., Resident # 13 propelled to the nurses station and grabbed a second sandwich. At 5:14 a.m., Resident #13 wheeled himself to the nurse's station and grabbed a third sandwich. No staff member was observed attempting to monitor the resident. At 5:20 a.m., CNA V was observed pushing a wheelchair into the dining room and a few minutes later running from the dining room. Staff was observed running to the dining room including LVN S and LVN T. A few minutes later the video showed the staff pulling the wheelchair with the resident in it out of the dining room towards the nurse's station on the East Wing. During an interview at approximately 9:40 a.m. on [DATE], the Medical Examiner stated that there would be an autopsy performed to determine the cause of death. At that time, it was possible that the resident asphyxiated on the sandwiches. During an interview at approximately 10:00 a.m. on [DATE], the Administrator reported that the staff was aware that Resident #13 was a big eater and usually left the resident alone. No supervision was required for Resident 13's eating practice. During a telephone interview at 2:55 p.m. on [DATE], CNA V stated that she worked the night shift, 10:00 p.m. to 6:00 a.m. on [DATE] and stated that she did not notice Resident #13 going into the dining room. She stated that when she took a resident into the dining room she noticed Resident #13 sitting in his wheelchair with his head slumped over. Because of the ashen color to the resident's skin, she assumed the resident was not asleep and called Code Blue (Hospital emergency code used worldwide to alert staff to emergencies). The first nurse she spoke to was LVN S, who told the staff to move the resident to his room. CNA V stated that she could see some food stuck in his mouth. When asked, CNA V stated that the [MEDICATION NAME] maneuver was not done. She stated that LVN S instructed the staff to move the resident to the bed. When asked what LVN S was doing at that time, CNA V reported that LVN S was trying to set up the AED device, but the device did not have the right [MEDICATION NAME] pads to fit the device. During an interview and a written statement at 5:45 p.m. on [DATE], LVN S stated that he worked the second shift, 5:45 p.m. to 6:00 a.m., [DATE] to [DATE] and was involved with the resuscitation efforts on Resident #13. He demonstrated on the AED device how the previous [MEDICATION NAME] pad did not fit the device. He acknowledged that the [MEDICATION NAME] pad in the device was the right one. LVN S stated that upon entering the dining room on [DATE], he checked the carotid pulse with his finger and detected a faint pulse. He stated that food was sticking out of the resident's mouth. When asked if he had swept the mouth, he stated No, because other residents were watching. When asked if the [MEDICATION NAME] maneuver was performed, he stated No. When asked why the resident was moved to his room, LVN S stated that he was afraid to set off the other residents. He stated that as soon as the resident was put into his room, LVN T swept the resident's mouth which included a chewed up sandwich. The [MEDICATION NAME] maneuver was not performed at that time. After the resident was lifted out of the wheelchair and placed on his bed, LVN S attempted to start the AED while the other staff performed CPR. He could not use the AED because the [MEDICATION NAME] pad did not fit the device. He stated that at no time during the attempt to push air into the resident's mouth with the ambu. bag did the resident's chest rise to indicate air was passing through the mouth and into the lungs. He stated that at that point, EMS arrived and took over. During an interview and a written statement at 6:45 p.m. on [DATE], LVN T stated that she worked the second shift, 6:00 p.m. to 6:00 a.m., [DATE] to [DATE] on the West Wing with LVN S. She stated that she was new to the facility and was in her second week of employment. She stated that on [DATE] she heard CNA V call Code Blue and was instructed by LVN S to call 911. LVN T stated that she dialed 911, but did not know what to tell the dispatcher. CNA U took the phone while LVN T attempted to assist with Resident #13. LVN T stated that although she had training in the use of the AED device and CPR, she had never attended to a Code Blue. She stated that she followed the staff to Resident #13's room and helped in lifting the resident out of the chair to the bed. She stated that the [MEDICATION NAME] Maneuver was not attempted by any of the staff. LVN T stated that she and CNA V began taking turns performing compressions. She stated that she noticed that color was returning to Resident #13's body. She stated that the chest did not rise and fall when the ambu. bag was being used to indicate air was passing into the lungs. She stated that LVN S was attempting to set up the AED device. Because the chest was not rising, LVN T said that she was about to perform mouth-to-mouth resuscitation when the EMS team arrived and took over. During an interview at 7:10 p.m. on [DATE], LVN D, Medical Records and Supplies, reported that she had ordered replacement [MEDICATION NAME] pads and did not realize that the wrong [MEDICATION NAME] pads had been delivered until the morning incident with Resident #13. She stated that the proper [MEDICATION NAME] were on hand and were replaced after the incident. LVN D gave the Surveyor a copy of the invoice, which revealed that the facility had ordered 2 sets of adult defibrillator pads at $32.52 each on [DATE] and were delivered on the same day from a distributor and not the manufacturer. During observation at approximately 7:15 p.m. on [DATE], it was noted that the AED device was recessed into the wall within the nurse's station on the East Wing. Above the device was a clip board with a log to indicate checking the device on the first day monthly on the night shift. The log was blank for October, November, [DATE] and January and February 2017. Five months were not logged. During an interview at 7:35 p.m. on [DATE], CNA U stated that LVN T had panicked when calling 911 and that she took the phone and gave the dispatcher the name of the facility and address. She stated that she observed Resident #13 in the dining room and the resident's head was tilted and his face was purple colored. During a telephone interview at 2:40 p.m. on [DATE], LVN P stated that she had worked the night shift on [DATE] to [DATE] and had assisted CNA V to get Resident #13 to get out of bed for breakfast. She stated that Resident #13 had asked for a sandwich and she instructed him to take one sandwich. The resident propelled himself to the nurse's station and LVN P entered a room to start an enteral feeding to a resident. She stated that CNA V entered the room and hollered to her that Resident #13 was in distress and needed help. LVN P then clamped the tubing and exited the room. She stated that before she could enter the dining room she retrieved the resident's record to determine his DNR status and to push the crash cart to the Resident's room. When asked why the resident was moved to the room, LVN P stated that the resident needed to be flat in order to perform CPR and that the staff wanted to get the other residents away from the scene. Other residents were asking questions. When questioned, LVN P stated that the [MEDICATION NAME] Maneuver should have been performed and that LVN S was big enough to perform the maneuver. She could not remember if she experienced resistance when holding the ambu. bag on the resident's mouth and compressing the bag. During a second interview and a written statement at 7:15 p.m. on [DATE], LVN P stated that she had placed the tray of sandwiches on the nurse's station counter and had told Resident #13 to take only one sandwich on [DATE]. She stated that when assisting to resuscitate Resident #13, a CNA attempted to sweep the mouth and that the back board was in place under the resident. She stated that she had difficulty with compressions, because the board was too small. She stated that she and LVN T took turns with compressions and the ambu. bag. Review of the facility's undated Operational/Resident Care Policies revealed that the facility policy prohibited the mistreatment, neglect and abuse of residents and outlined that residents had a right to be free from any type of abuse, neglect and exploitation. The policy referenced Statement of Resident Rights, and the Rights of the Elderly Human Resources Code Chapter 102. Review of the facility's policy on performing the [MEDICATION NAME] maneuver and CPR and the use of the AED was found in the Lifepak CR Plus Defibrillator manual of instructions dated 2009 and was as follows: a. AED shall refer to the automatic defibrillator capable of cardiac rhythm analysis, which will charge and deliver a shock after electronically detecting and assessing [MEDICAL CONDITION] when applied to an unconscious resident with absent respirations and no signs of circulation. An authorized individual refers to an individual who has successfully completed CPR certification and return demonstration on proper use of an AED device. The Medical Director and Facility Administrator shall ensure that all AED regulatory requirements are implemented and maintained. b. Quantity: stock levels, expiration dates will be checked monthly and par levels of inventory shall be maintained if and when applicable. Readiness of AED will be checked monthly and after every use, according to manufacturer's guidelines (Appendix D - AED post use report). c. Training Requirements: The course shall consist of not less than four hours and will include: (1) basic CPR skills; (2) proper use, maintenance, and periodic inspection of an AED; (3) the importance of CPR, defibrillation, advance life support, adequate airway care and the internal emergency response system; (4) how to recognize the warning signs of [MEDICAL CONDITION] and stroke, and overview of local EMS system, including [DATE] access and interaction with EMS; (5) assessment of an unconscious patient to include evaluation of airway, breathing and circulation; (6) to determine if [MEDICAL CONDITION] has occurred and the appropriateness of applying and activation of an AED. According to WebMD dated [DATE], sudden [MEDICAL CONDITION] is not a [MEDICAL CONDITION], but can occur during a [MEDICAL CONDITION]. [MEDICAL CONDITION] occur when there is a blockage in one or more of the arteries to the heart, preventing the heart from receiving enough oxygen-rich blood. If the oxygen in the blood cannot reach the heart muscle, the heart becomes damaged. http://www.webmd.com/heart-disease/guide/sudden-cardiac-death.) Review on [DATE] of How to Do the [MEDICATION NAME] Maneuver on http://www.deaconess-healthcare.com/[MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]/ revealed the following: a. CHOKING ADULTS: A choking victim can't speak or breathe and needs your help immediately. Follow these steps to help a choking victim: From behind, wrap your arms around the victim's waist. Make a fist and place the thumb side of your fist against the victim's upper abdomen, below the ribcage and above the navel. Grasp your fist with your other hand and press into their upper abdomen with a quick upward thrust. Do not squeeze the ribcage; confine the force of the thrust to your hands. Repeat until object is expelled. b. UNCONSCIOUS VICTIM, OR WHEN RESCUER CAN'T REACH AROUND VICTIM: Place the victim on back. Facing the victim, kneel astride the victim's hips. With one of your hands on top of the other, place the heel of your bottom hand on the upper abdomen below the rib cage and above the navel. Use your body weight to press into the victim's upper abdomen with a quick upward thrust. Repeat until object is expelled. If the Victim has not recovered, proceed with CPR. The Victim should see a physician immediately after rescue The Administrator was notified of the IJ on [DATE] at 4:00 p.m. and a Plan of Removal was requested. The Plan of Removal included: a. On [DATE], the facility immediately began providing training to the nursing staff on the use of the AED. A training video was used for the course and each nursing staff member was required to watch the video. A posttest was provided at the end of the certification and return demonstration was documented. The facility planned to educate all nursing staff on the use of the AED upon hire during orientation and annually thereafter. Return demonstrations were to be documented and kept in the personnel files of current and new nursing staff. Prior training from previous facilities in the use of the AED would not be valid. The correct [MEDICATION NAME] pad was placed in the casing of the AED device. b. A mock code on a resident requiring CPR and the [MEDICATION NAME] maneuver was conducted and repeated until all nursing staff achieved 100 % completion. c. On [DATE], 2 CPR training courses were taught by an outside licensed agency and the students included all current nursing staff who did, or did not have their current certification The course included basic CPR training and the [MEDICATION NAME] Maneuver. All nursing staff members demonstrated proficiency in providing the [MEDICATION NAME] Maneuver and CPR. The DON was designated to monitor CPR certification compliance. 19 out of 27 nurses had CPR certification. The remaining 8 nurses were expected to provide proof of certification by end of business on [DATE], or complete a training course provided by the facility before [DATE]. Failure to do either would result in termination of employment. d. On [DATE], 25 out of 29 nurses and 17 out of 18 CNAs completed the training on the [MEDICATION NAME] Maneuver. Non-nursing staff were also required to participate in the training and perform return demonstrations. The remaining PRN CNAs and nurses who had not participated in the training were expected to provide proof of certification by end of business on [DATE], or complete a training course provided by the facility before [DATE]. Failure to do either would result in termination of employment. e. A posttest was administered to both participants in the training courses and to non-participants with current certification. Any wrong answers on the posttest were addressed with each individual on a one-on-one basis. f. On [DATE], nursing staff was trained on the timeline documentation for any lifesaving events. g. A new refrigerator was purchased to store resident snacks such as sandwiches and snacks and distribution of the snack was the responsibility of the nursing staff. h. A 100 % chart review was performed to determine the DNR status of each resident in the building and 5 residents were found to lack Out-of-hospital DNR documents, but were designated DNR in their record. The code status was immediately changed to full code until the documentation was completed, or found in the thinning's. i. The DON or designee was tasked with verifying retention of the training course by conducting mock code/choking emergencies weekly for the next 30 days for each shift and monthly for the next quarters and annually thereafter. The results of the mock code will be evaluated by the interdisciplinary team and progress will be monitored by the monthly quality assurance meetings. Verification of the Plan of Removal was as follows: a. Interviews were conducted with nursing, housekeeping and dietary staff on [DATE], [DATE], [DATE] and [DATE], day, evening and weekend staff to determine participation, certification and retention of the course material and to determine whether the training had been beneficial in increasing confidence in performing the [MEDICATION NAME] maneuver, CPR and in using the AED. These included: 2 RN's; 21 LVN's; 4 CNA's, Food Service Manager, Human Resources Manager and Receptionist. b. Forty-three posttests were reviewed and 2 nursing staff members were interviewed regarding their incorrect answer of when to start CPR. c. Forty-two (42) copies of CPR certifications were reviewed for filing and included participation in the facility's training course, or prior certification. Dates of expiration were noted and all certifications were current. d. Copies of AED certification training were also reviewed and 24 nursing staff were certified in the use of the AED device. e. In-service training reports dated [DATE] included choking and the use of the [MEDICATION NAME] maneuver, CPR and checking the crash cart and emergency supplies were reviewed for consistency and inclusion of nursing staff who were participants in the resuscitation efforts of Resident #13. On [DATE] the Administrator was informed that the Immediate Jeopardy was removed at 1:50 p.m. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility reported on [DATE] that 8 residents had a full code status. All the other residents (81) had Out-of-Hospital DNR forms in place.

Based on interviews, observation and record reviews, the facility failed to implement the facility's written policies and procedures that prohibit neglect of residents for 1 of 15 residents (#13) whose care was reviewed for neglect in that: Nursing staff did not perform the [MEDICATION NAME] maneuver immediately after Resident #13 choked on sandwiches before being moved out of the dining room. Instead, the nursing staff moved the resident to his room for privacy. CPR was not imitated until the resident was taken out of the wheelchair and placed on his bed. The AED (automatic electronic defibrillator) was not use to determine sinus rhythm and defibrillate the heart of Resident #13, because the wrong [MEDICATION NAME] pads were in the AED device rendering it unusable. The AED had not been checked or tested for 5 months. As a result, the resident died . These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed for DNR status and the staff was in-serviced on assessing residents in emergency circumstances, performing the [MEDICATION NAME] maneuver, immediately starting CPR in place and the implementation of the AED. These deficient practices could affect 8 residents in the facility who were identified as Full Code in the sample and could result in their wishes not being met leading to death. The findings were: Review of the facility's undated Operational/Resident Care Policies revealed that the facility policy prohibited the mistreatment, neglect and abuse of residents and outlined that residents had a right to be free from any type of abuse, neglect and exploitation. The policy referenced Statement of Resident Rights, and the Rights of the Elderly Human Resources Code Chapter 102. Review of the facility's policy on performing the [MEDICATION NAME] maneuver and CPR and the use of the AED was found in the Lifepak CR Plus Defibrillator manual of instructions dated 2009 and was as follows: a. AED shall refer to the automatic defibrillator capable of cardiac rhythm analysis, which will charge and deliver a shock after electronically detecting and assessing [MEDICAL CONDITION] when applied to an unconscious resident with absent respirations and no signs of circulation. An authorized individual refers to an individual who has successfully completed CPR certification and return demonstration on proper use of an AED device. The Medical Director and Facility Administrator shall ensure that all AED regulatory requirements are implemented and maintained. b. Quantity: stock levels, expiration dates will be checked monthly and par levels of inventory shall be maintained if and when applicable. Readiness of AED will be checked monthly and after every use, according to manufacturer's guidelines (Appendix D - AED post use report). c. Training Requirements: The course shall consist of not less than four hours and will include: (1) basic CPR skills; (2) proper use, maintenance, and periodic inspection of an AED; (3) the importance of CPR, defibrillation, advance life support, adequate airway care and the internal emergency response system; (4) how to recognize the warning signs of [MEDICAL CONDITION] and stroke, and overview of local EMS system, including [DATE] access and interaction with EMS; (5) assessment of an unconscious patient to include evaluation of airway, breathing and circulation; (6) to determine if [MEDICAL CONDITION] has occurred and the appropriateness of applying and activation of an AED. According to WebMD dated [DATE], sudden [MEDICAL CONDITION] is not a [MEDICAL CONDITION], but can occur during a [MEDICAL CONDITION]. [MEDICAL CONDITION] occur when there is a blockage in one or more of the arteries to the heart, preventing the heart from receiving enough oxygen-rich blood. If the oxygen in the blood cannot reach the heart muscle, the heart becomes damaged. http://www.webmd.com/heart-disease/guide/sudden-cardiac-death.) Review on [DATE] of How to Do the [MEDICATION NAME] Maneuver on http://www.deaconess-healthcare.com/[MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]/ revealed the following: a. CHOKING ADULTS: A choking victim can't speak or breathe and needs your help immediately. Follow these steps to help a choking victim: From behind, wrap your arms around the victim's waist. Make a fist and place the thumb side of your fist against the victim's upper abdomen, below the ribcage and above the navel. Grasp your fist with your other hand and press into their upper abdomen with a quick upward thrust. Do not squeeze the ribcage; confine the force of the thrust to your hands. Repeat until object is expelled. b. UNCONSCIOUS VICTIM, OR WHEN RESCUER CAN'T REACH AROUND VICTIM: Place the victim on back. Facing the victim, kneel astride the victim's hips. With one of your hands on top of the other, place the heel of your bottom hand on the upper abdomen below the rib cage and above the navel. Use your body weight to press into the victim's upper abdomen with a quick upward thrust. Repeat until object is expelled. If the Victim has not recovered, proceed with CPR. The Victim should see a physician immediately after rescue Review of Resident #13's admission orders [REDACTED]Full Code. Resident #13 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of a current recent care plans dated [DATE] did not identify Resident #13's full code status. Review of Resident #13's consolidated physician orders [REDACTED]. Review of an annual Minimum (MDS) data set [DATE] revealed that Resident #13 was moderately impaired with a BIMS score of 11 out of 15 (highest level of cognition and ability to make decisions) and had no serious mental illness prior to admission. The MDS indicated that the resident had no evidence of an acute change in mental status, and had a tendency for overeating and weighed 213 pounds. Review of Resident #13's Medication Administration Record [REDACTED] Review of Resident #13's Resident Progress Note dated [DATE] at 5:56 a.m. revealed LVN P documented that Resident #13 was found unresponsive in his wheelchair in the dining room and that CPR and life saving measures and EMS were activated and initiated a [MEDICAL CONDITION]. Review of a self-reported incident investigation worksheet dated [DATE] revealed that at 5:30 a.m. on [DATE] Resident #13 was found unresponsive in his wheelchair in the dining room and that CPR had been initiated. The worksheet documented that Resident #13 was observed by a facility video recording grabbing sandwiches from the nursing station counter off a tray and going to the dining room to eat them. During an observation on [DATE] at approximately 8:55 a.m., Resident #13 was observed lying on the floor of his room covered with a sheet. LVN GG removed the sheet and the resident was dead. A fresh [MEDICAL CONDITION] was in place as well as a puddle of blood on the floor. The upper torso had a used AED [MEDICATION NAME] pad lying on the chest. At approximately 9:10 a.m., the Medical Examiner arrived to examine the body. During the observation, the Medical Examiner turned the body over and blood poured onto the floor from the [MEDICAL CONDITION]. During a viewing at approximately 9:25 a.m. on [DATE], the Administrator showed the recorded video to the Surveyor and the Medical Examiner, which captured the morning activities of Resident #13 propelling in a wheelchair at 5:04 a.m. on [DATE] in front of the nurses station on the East Wing hallway. He was recorded grabbing a sandwich and going into the dining room. At 5:10 a.m., Resident # 13 propelled to the nurses station and grabbed a second sandwich. At 5:14 a.m., Resident #13 wheeled himself to the nurse's station and grabbed a third sandwich. No staff member was observed attempting to monitor the resident. At 5:20 a.m., CNA V was observed pushing a wheelchair into the dining room and a few minutes later running from the dining room. Staff was observed running to the dining room including LVN S and LVN T. A few minutes later the video showed the staff pulling the wheelchair with the resident in it out of the dining room towards the nurse's station on the East Wing. During an interview at approximately 9:40 a.m. on [DATE], the Medical Examiner stated that there would be an autopsy performed to determine the cause of death. At that time, it was possible that the resident asphyxiated on the sandwiches. During an interview at approximately 10:00 a.m. on [DATE], the Administrator reported that the staff was aware that Resident #13 was a big eater and usually left the resident alone. No supervision was required for Resident 13's eating practice. During a telephone interview at 2:55 p.m. on [DATE], CNA V stated that she worked the night shift, 10:00 p.m. to 6:00 a.m. on [DATE] and stated that she did not notice Resident #13 going into the dining room. She stated that when she took a resident into the dining room she noticed Resident #13 sitting in his wheelchair with his head slumped over. Because of the ashen color to the resident's skin, she assumed the resident was not asleep and called Code Blue (Hospital emergency code used worldwide to alert staff to emergencies). The first nurse she spoke to was LVN S, who told the staff to move the resident to his room. CNA V stated that she could see some food stuck in his mouth. When asked, CNA V stated that the [MEDICATION NAME] maneuver was not done. She stated that LVN S instructed the staff to move the resident to the bed. When asked what LVN S was doing at that time, CNA V reported that LVN S was trying to set up the AED device, but the device did not have the right [MEDICATION NAME] pads to fit the device. During an interview and a written statement at 5:45 p.m. on [DATE], LVN S stated that he worked the second shift, 5:45 p.m. to 6:00 a.m., [DATE] to [DATE] and was involved with the resuscitation efforts on Resident #13. He demonstrated on the AED device how the previous [MEDICATION NAME] pad did not fit the device. He acknowledged that the [MEDICATION NAME] pad in the device was the right one. LVN S stated that upon entering the dining room on [DATE], he checked the carotid pulse with his finger and detected a faint pulse. He stated that food was sticking out of the resident's mouth. When asked if he had swept the mouth, he stated No, because other residents were watching. When asked if the [MEDICATION NAME] maneuver was performed, he stated No. When asked why the resident was moved to his room, LVN S stated that he was afraid to set off the other residents. He stated that as soon as the resident was put into his room, LVN T swept the resident's mouth which included a chewed up sandwich. The [MEDICATION NAME] maneuver was not performed at that time. After the resident was lifted out of the wheelchair and placed on his bed, LVN S attempted to start the AED while the other staff performed CPR. He could not use the AED because the [MEDICATION NAME] pad did not fit the device. He stated that at no time during the attempt to push air into the resident's mouth with the ambu. bag did the resident's chest rise to indicate air was passing through the mouth and into the lungs. He stated that at that point, EMS arrived and took over. During an interview and a written statement at 6:45 p.m. on [DATE], LVN T stated that she worked the second shift, 6:00 p.m. to 6:00 a.m., [DATE] to [DATE] on the West Wing with LVN S. She stated that she was new to the facility and was in her second week of employment. She stated that on [DATE] she heard CNA V call Code Blue and was instructed by LVN S to call 911. LVN T stated that she dialed 911, but did not know what to tell the dispatcher. CNA U took the phone while LVN T attempted to assist with Resident #13. LVN T stated that although she had training in the use of the AED device and CPR, she had never attended to a Code Blue. She stated that she followed the staff to Resident #13's room and helped in lifting the resident out of the chair to the bed. She stated that the [MEDICATION NAME] Maneuver was not attempted by any of the staff. LVN T stated that she and CNA V began taking turns performing compressions. She stated that she noticed that color was returning to Resident #13's body. She stated that the chest did not rise and fall when the ambu. bag was being used to indicate air was passing into the lungs. She stated that LVN S was attempting to set up the AED device. Because the chest was not rising, LVN T said that she was about to perform mouth-to-mouth resuscitation when the EMS team arrived and took over. During an interview at 7:10 p.m. on [DATE], LVN D, Medical Records and Supplies, reported that she had ordered replacement [MEDICATION NAME] pads and did not realize that the wrong [MEDICATION NAME] pads had been delivered until the morning incident with Resident #13. She stated that the proper [MEDICATION NAME] were on hand and were replaced after the incident. LVN D gave the Surveyor a copy of the invoice, which revealed that the facility had ordered 2 sets of adult defibrillator pads at $32.52 each on [DATE] and were delivered on the same day from a distributor and not the manufacturer. During observation at approximately 7:15 p.m. on [DATE], it was noted that the AED device was recessed into the wall within the nurse's station on the East Wing. Above the device was a clip board with a log to indicate checking the device on the first day monthly on the night shift. The log was blank for October, November, [DATE] and January and February 2017. Five months were not logged. During an interview at 7:35 p.m. on [DATE], CNA U stated that LVN T had panicked when calling 911 and that she took the phone and gave the dispatcher the name of the facility and address. She stated that she observed Resident #13 in the dining room and the resident's head was tilted and his face was purple colored. During a telephone interview at 2:40 p.m. on [DATE], LVN P stated that she had worked the night shift on [DATE] to [DATE] and had assisted CNA V to get Resident #13 to get out of bed for breakfast. She stated that Resident #13 had asked for a sandwich and she instructed him to take one sandwich. The resident propelled himself to the nurse's station and LVN P entered a room to start an enteral feeding to a resident. She stated that CNA V entered the room and hollered to her that Resident #13 was in distress and needed help. LVN P then clamped the tubing and exited the room. She stated that before she could enter the dining room she retrieved the resident's record to determine his DNR status and to push the crash cart to the Resident's room. When asked why the resident was moved to the room, LVN P stated that the resident needed to be flat in order to perform CPR and that the staff wanted to get the other residents away from the scene. Other residents were asking questions. When questioned, LVN P stated that the [MEDICATION NAME] Maneuver should have been performed and that LVN S was big enough to perform the maneuver. She could not remember if she experienced resistance when holding the ambu. bag on the resident's mouth and compressing the bag. During a second interview and a written statement at 7:15 p.m. on [DATE], LVN P stated that she had placed the tray of sandwiches on the nurse's station counter and had told Resident #13 to take only one sandwich on [DATE]. She stated that when assisting to resuscitate Resident #13, a CNA attempted to sweep the mouth and that the back board was in place under the resident. She stated that she had difficulty with compressions, because the board was too small. She stated that she and LVN T took turns with compressions and the ambu. bag. The Administrator was notified of the IJ on [DATE] at 4:00 p.m. and a Plan of Removal was requested. The Plan of Removal included: a. On [DATE], the facility immediately began providing training to the nursing staff on the use of the AED. A training video was used for the course and each nursing staff member was required to watch the video. A posttest was provided at the end of the certification and return demonstration was documented. The facility planned to educate all nursing staff on the use of the AED upon hire during orientation and annually thereafter. Return demonstrations were to be documented and kept in the personnel files of current and new nursing staff. Prior training from previous facilities in the use of the AED would not be valid. The correct [MEDICATION NAME] pad was placed in the casing of the AED device. b. A mock code on a resident requiring CPR and the [MEDICATION NAME] maneuver was conducted and repeated until all nursing staff achieved 100 % completion. c. On [DATE], 2 CPR training courses were taught by an outside licensed agency and the students included all current nursing staff who did, or did not have their current certification The course included basic CPR training and the [MEDICATION NAME] Maneuver. All nursing staff members demonstrated proficiency in providing the [MEDICATION NAME] Maneuver and CPR. The DON was designated to monitor CPR certification compliance. 19 out of 27 nurses had CPR certification. The remaining 8 nurses were expected to provide proof of certification by end of business on [DATE], or complete a training course provided by the facility before [DATE]. Failure to do either would result in termination of employment. d. On [DATE], 25 out of 29 nurses and 17 out of 18 CNAs completed the training on the [MEDICATION NAME] Maneuver. Non-nursing staff were also required to participate in the training and perform return demonstrations. The remaining PRN CNAs and nurses who had not participated in the training were expected to provide proof of certification by end of business on [DATE], or complete a training course provided by the facility before [DATE]. Failure to do either would result in termination of employment. e. A posttest was administered to both participants in the training courses and to non-participants with current certification. Any wrong answers on the posttest were addressed with each individual on a one-on-one basis. f. On [DATE], nursing staff was trained on the timeline documentation for any lifesaving events. g. A new refrigerator was purchased to store resident snacks such as sandwiches and snacks and distribution of the snack was the responsibility of the nursing staff. h. A 100 % chart review was performed to determine the DNR status of each resident in the building and 5 residents were found to lack Out-of-hospital DNR documents, but were designated DNR in their record. The code status was immediately changed to full code until the documentation was completed, or found in the thinning's. i. The DON or designee was tasked with verifying retention of the training course by conducting mock code/choking emergencies weekly for the next 30 days for each shift and monthly for the next quarters and annually thereafter. The results of the mock code will be evaluated by the interdisciplinary team and progress will be monitored by the monthly quality assurance meetings. Verification of the Plan of Removal was as follows: a. Interviews were conducted with nursing, housekeeping and dietary staff on [DATE], [DATE], [DATE] and [DATE], day, evening and weekend staff to determine participation, certification and retention of the course material and to determine whether the training had been beneficial in increasing confidence in performing the [MEDICATION NAME] maneuver, CPR and in using the AED. These included: 2 RN's; 21 LVN's; 4 CNA's, Food Service Manager, Human Resources Manager and Receptionist. b. Forty-three posttests were reviewed and 2 nursing staff members were interviewed regarding their incorrect answer of when to start CPR. c. Forty-two (42) copies of CPR certifications were reviewed for filing and included participation in the facility's training course, or prior certification. Dates of expiration were noted and all certifications were current. d. Copies of AED certification training were also reviewed and 24 nursing staff were certified in the use of the AED device. e. In-service training reports dated [DATE] included choking and the use of the [MEDICATION NAME] maneuver, CPR and checking the crash cart and emergency supplies were reviewed for consistency and inclusion of nursing staff who were participants in the resuscitation efforts of Resident #13. On [DATE] the Administrator was informed that the Immediate Jeopardy was removed at 1:50 p.m. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility reported on [DATE] that 8 residents had a full code status. All the other residents (81) had Out-of-Hospital DNR forms in place.

Based on interviews, observation and record reviews, the facility failed to ensure residents were free from neglect for 1 of 15 residents (#13) whose care was reviewed for neglect in that: Nursing staff did not perform the [MEDICATION NAME] maneuver immediately after Resident #13 choked on sandwiches before being moved out of the dining room. Instead, the nursing staff moved the resident to his room for privacy. CPR was not imitated until the resident was taken out of the wheelchair and placed on his bed. The AED (automatic electronic defibrillator) was not used to determine sinus rhythm and defibrillate the heart of Resident #13, because the wrong [MEDICATION NAME] pads were in the AED device rendering it unusable. The AED had not been checked or tested for 5 months. As a result, the resident died . These failures resulted in identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed for DNR status and the staff was in-serviced on assessing residents in emergency circumstances, performing the [MEDICATION NAME] maneuver, immediately starting CPR in place and the implementation of the AED. These deficient practices could affect 8 residents in the facility who were identified as Full Code in the sample and could result in their wishes not being met leading to death. The findings were: Review of Resident #13's admission orders [REDACTED]Full Code. Resident #13 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of a current recent care plans dated [DATE] did not identify Resident #13's full code status. Review of Resident #13's consolidated physician orders [REDACTED]. Review of an annual Minimum (MDS) data set [DATE] revealed that Resident #13 was moderately impaired with a BIMS score of 11 out of 15 (highest level of cognition and ability to make decisions) and had no serious mental illness prior to admission. The MDS indicated that the resident had no evidence of an acute change in mental status, and had a tendency for overeating and weighed 213 pounds. Review of Resident #13's Medication Administration Record [REDACTED] Review of Resident #13's Resident Progress Note dated [DATE] at 5:56 a.m. revealed LVN P documented that Resident #13 was found unresponsive in his wheelchair in the dining room and that CPR and life saving measures and EMS were activated and initiated a [MEDICAL CONDITION]. Review of a self-reported incident investigation worksheet dated [DATE] revealed that at 5:30 a.m. on [DATE] Resident #13 was found unresponsive in his wheelchair in the dining room and that CPR had been initiated. The worksheet documented that Resident #13 was observed by a facility video recording grabbing sandwiches from the nursing station counter off a tray and going to the dining room to eat them. During an observation on [DATE] at approximately 8:55 a.m., Resident #13 was observed lying on the floor of his room covered with a sheet. LVN GG removed the sheet and the resident was dead. A fresh [MEDICAL CONDITION] was in place as well as a puddle of blood on the floor. The upper torso had a used AED [MEDICATION NAME] pad lying on the chest. At approximately 9:10 a.m., the Medical Examiner arrived to examine the body. During the observation, the Medical Examiner turned the body over and blood poured onto the floor from the [MEDICAL CONDITION]. During a viewing at approximately 9:25 a.m. on [DATE], the Administrator showed the recorded video to the Surveyor and the Medical Examiner, which captured the morning activities of Resident #13 propelling in a wheelchair at 5:04 a.m. on [DATE] in front of the nurses station on the East Wing hallway. He was recorded grabbing a sandwich and going into the dining room. At 5:10 a.m., Resident # 13 propelled to the nurses station and grabbed a second sandwich. At 5:14 a.m., Resident #13 wheeled himself to the nurse's station and grabbed a third sandwich. No staff member was observed attempting to monitor the resident. At 5:20 a.m., CNA V was observed pushing a wheelchair into the dining room and a few minutes later running from the dining room. Staff was observed running to the dining room including LVN S and LVN T. A few minutes later the video showed the staff pulling the wheelchair with the resident in it out of the dining room towards the nurse's station on the East Wing. During an interview at approximately 9:40 a.m. on [DATE], the Medical Examiner stated that there would be an autopsy performed to determine the cause of death. At that time, it was possible that the resident asphyxiated on the sandwiches. During an interview at approximately 10:00 a.m. on [DATE], the Administrator reported that the staff was aware that Resident #13 was a big eater and usually left the resident alone. No supervision was required for Resident 13's eating practice. During a telephone interview at 2:55 p.m. on [DATE], CNA V stated that she worked the night shift, 10:00 p.m. to 6:00 a.m. on [DATE] and stated that she did not notice Resident #13 going into the dining room. She stated that when she took a resident into the dining room she noticed Resident #13 sitting in his wheelchair with his head slumped over. Because of the ashen color to the resident's skin, she assumed the resident was not asleep and called Code Blue (Hospital emergency code used worldwide to alert staff to emergencies). The first nurse she spoke to was LVN S, who told the staff to move the resident to his room. CNA V stated that she could see some food stuck in his mouth. When asked, CNA V stated that the [MEDICATION NAME] maneuver was not done. She stated that LVN S instructed the staff to move the resident to the bed. When asked what LVN S was doing at that time, CNA V reported that LVN S was trying to set up the AED device, but the device did not have the right [MEDICATION NAME] pads to fit the device. During an interview and a written statement at 5:45 p.m. on [DATE], LVN S stated that he worked the second shift, 5:45 p.m. to 6:00 a.m., [DATE] to [DATE] and was involved with the resuscitation efforts on Resident #13. He demonstrated on the AED device how the previous [MEDICATION NAME] pad did not fit the device. He acknowledged that the [MEDICATION NAME] pad in the device was the right one. LVN S stated that upon entering the dining room on [DATE], he checked the carotid pulse with his finger and detected a faint pulse. He stated that food was sticking out of the resident's mouth. When asked if he had swept the mouth, he stated No, because other residents were watching. When asked if the [MEDICATION NAME] maneuver was performed, he stated No. When asked why the resident was moved to his room, LVN S stated that he was afraid to set off the other residents. He stated that as soon as the resident was put into his room, LVN T swept the resident's mouth which included a chewed up sandwich. The [MEDICATION NAME] maneuver was not performed at that time. After the resident was lifted out of the wheelchair and placed on his bed, LVN S attempted to start the AED while the other staff performed CPR. He could not use the AED because the [MEDICATION NAME] pad did not fit the device. He stated that at no time during the attempt to push air into the resident's mouth with the ambu. bag did the resident's chest rise to indicate air was passing through the mouth and into the lungs. He stated that at that point, EMS arrived and took over. During an interview and a written statement at 6:45 p.m. on [DATE], LVN T stated that she worked the second shift, 6:00 p.m. to 6:00 a.m., [DATE] to [DATE] on the West Wing with LVN S. She stated that she was new to the facility and was in her second week of employment. She stated that on [DATE] she heard CNA V call Code Blue and was instructed by LVN S to call 911. LVN T stated that she dialed 911, but did not know what to tell the dispatcher. CNA U took the phone while LVN T attempted to assist with Resident #13. LVN T stated that although she had training in the use of the AED device and CPR, she had never attended to a Code Blue. She stated that she followed the staff to Resident #13's room and helped in lifting the resident out of the chair to the bed. She stated that the [MEDICATION NAME] Maneuver was not attempted by any of the staff. LVN T stated that she and CNA V began taking turns performing compressions. She stated that she noticed that color was returning to Resident #13's body. She stated that the chest did not rise and fall when the ambu. bag was being used to indicate air was passing into the lungs. She stated that LVN S was attempting to set up the AED device. Because the chest was not rising, LVN T said that she was about to perform mouth-to-mouth resuscitation when the EMS team arrived and took over. During an interview at 7:10 p.m. on [DATE], LVN D, Medical Records and Supplies, reported that she had ordered replacement [MEDICATION NAME] pads and did not realize that the wrong [MEDICATION NAME] pads had been delivered until the morning incident with Resident #13. She stated that the proper [MEDICATION NAME] were on hand and were replaced after the incident. LVN D gave the Surveyor a copy of the invoice, which revealed that the facility had ordered 2 sets of adult defibrillator pads at $32.52 each on [DATE] and were delivered on the same day from a distributor and not the manufacturer. During observation at approximately 7:15 p.m. on [DATE], it was noted that the AED device was recessed into the wall within the nurse's station on the East Wing. Above the device was a clip board with a log to indicate checking the device on the first day monthly on the night shift. The log was blank for October, November, [DATE] and January and February 2017. Five months were not logged. During an interview at 7:35 p.m. on [DATE], CNA U stated that LVN T had panicked when calling 911 and that she took the phone and gave the dispatcher the name of the facility and address. She stated that she observed Resident #13 in the dining room and the resident's head was tilted and his face was purple colored. During a telephone interview at 2:40 p.m. on [DATE], LVN P stated that she had worked the night shift on [DATE] to [DATE] and had assisted CNA V to get Resident #13 to get out of bed for breakfast. She stated that Resident #13 had asked for a sandwich and she instructed him to take one sandwich. The resident propelled himself to the nurse's station and LVN P entered a room to start an enteral feeding to a resident. She stated that CNA V entered the room and hollered to her that Resident #13 was in distress and needed help. LVN P then clamped the tubing and exited the room. She stated that before she could enter the dining room she retrieved the resident's record to determine his DNR status and to push the crash cart to the Resident's room. When asked why the resident was moved to the room, LVN P stated that the resident needed to be flat in order to perform CPR and that the staff wanted to get the other residents away from the scene. Other residents were asking questions. When questioned, LVN P stated that the [MEDICATION NAME] Maneuver should have been performed and that LVN S was big enough to perform the maneuver. She could not remember if she experienced resistance when holding the ambu. bag on the resident's mouth and compressing the bag. During a second interview and a written statement at 7:15 p.m. on [DATE], LVN P stated that she had placed the tray of sandwiches on the nurse's station counter and had told Resident #13 to take only one sandwich on [DATE]. She stated that when assisting to resuscitate Resident #13, a CNA attempted to sweep the mouth and that the back board was in place under the resident. She stated that she had difficulty with compressions, because the board was too small. She stated that she and LVN T took turns with compressions and the ambu. bag. Review of the facility's undated Operational/Resident Care Policies revealed that the facility policy prohibited the mistreatment, neglect and abuse of residents and outlined that residents had a right to be free from any type of abuse, neglect and exploitation. The policy referenced Statement of Resident Rights, and the Rights of the Elderly Human Resources Code Chapter 102. Review of the facility's policy on performing the [MEDICATION NAME] maneuver and CPR and the use of the AED was found in the Lifepak CR Plus Defibrillator manual of instructions dated 2009 and was as follows: a. AED shall refer to the automatic defibrillator capable of cardiac rhythm analysis, which will charge and deliver a shock after electronically detecting and assessing [MEDICAL CONDITION] when applied to an unconscious resident with absent respirations and no signs of circulation. An authorized individual refers to an individual who has successfully completed CPR certification and return demonstration on proper use of an AED device. The Medical Director and Facility Administrator shall ensure that all AED regulatory requirements are implemented and maintained. b. Quantity: stock levels, expiration dates will be checked monthly and par levels of inventory shall be maintained if and when applicable. Readiness of AED will be checked monthly and after every use, according to manufacturer's guidelines (Appendix D - AED post use report). c. Training Requirements: The course shall consist of not less than four hours and will include: (1) basic CPR skills; (2) proper use, maintenance, and periodic inspection of an AED; (3) the importance of CPR, defibrillation, advance life support, adequate airway care and the internal emergency response system; (4) how to recognize the warning signs of [MEDICAL CONDITION] and stroke, and overview of local EMS system, including [DATE] access and interaction with EMS; (5) assessment of an unconscious patient to include evaluation of airway, breathing and circulation; (6) to determine if [MEDICAL CONDITION] has occurred and the appropriateness of applying and activation of an AED. According to WebMD dated [DATE], sudden [MEDICAL CONDITION] is not a [MEDICAL CONDITION], but can occur during a [MEDICAL CONDITION]. [MEDICAL CONDITION] occur when there is a blockage in one or more of the arteries to the heart, preventing the heart from receiving enough oxygen-rich blood. If the oxygen in the blood cannot reach the heart muscle, the heart becomes damaged. http://www.webmd.com/heart-disease/guide/sudden-cardiac-death.) Review on [DATE] of How to Do the [MEDICATION NAME] Maneuver on http://www.deaconess-healthcare.com/[MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]/ revealed the following: a. CHOKING ADULTS: A choking victim can't speak or breathe and needs your help immediately. Follow these steps to help a choking victim: From behind, wrap your arms around the victim's waist. Make a fist and place the thumb side of your fist against the victim's upper abdomen, below the ribcage and above the navel. Grasp your fist with your other hand and press into their upper abdomen with a quick upward thrust. Do not squeeze the ribcage; confine the force of the thrust to your hands. Repeat until object is expelled. b. UNCONSCIOUS VICTIM, OR WHEN RESCUER CAN'T REACH AROUND VICTIM: Place the victim on back. Facing the victim, kneel astride the victim's hips. With one of your hands on top of the other, place the heel of your bottom hand on the upper abdomen below the rib cage and above the navel. Use your body weight to press into the victim's upper abdomen with a quick upward thrust. Repeat until object is expelled. If the Victim has not recovered, proceed with CPR. The Victim should see a physician immediately after rescue The Administrator was notified of the IJ on [DATE] at 4:00 p.m. and a Plan of Removal was requested. The Plan of Removal included the following: a. On [DATE], the facility immediately began providing training to the nursing staff on the use of the AED. A training video was used for the course and each nursing staff member was required to watch the video. A posttest was provided at the end of the certification and return demonstration was documented. The facility planned to educate all nursing staff on the use of the AED upon hire during orientation and annually thereafter. Return demonstrations were to be documented and kept in the personnel files of current and new nursing staff. Prior training from previous facilities in the use of the AED would not be valid. The correct [MEDICATION NAME] pad was placed in the casing of the AED device. b. A mock code on a resident requiring CPR and the [MEDICATION NAME] maneuver was conducted and repeated until all nursing staff achieved 100 % completion. c. On [DATE], 2 CPR training courses were taught by an outside licensed agency and the students included all current nursing staff who did, or did not have their current certification The course included basic CPR training and the [MEDICATION NAME] Maneuver. All nursing staff members demonstrated proficiency in providing the [MEDICATION NAME] Maneuver and CPR. The DON was designated to monitor CPR certification compliance. 19 out of 27 nurses had CPR certification. The remaining 8 nurses were expected to provide proof of certification by end of business on [DATE], or complete a training course provided by the facility before [DATE]. Failure to do either would result in termination of employment. d. On [DATE], 25 out of 29 nurses and 17 out of 18 CNAs completed the training on the [MEDICATION NAME] Maneuver. Non-nursing staff were also required to participate in the training and perform return demonstrations. The remaining PRN CNAs and nurses who had not participated in the training were expected to provide proof of certification by end of business on [DATE], or complete a training course provided by the facility before [DATE]. Failure to do either would result in termination of employment. e. A posttest was administered to both participants in the training courses and to non-participants with current certification. Any wrong answers on the posttest were addressed with each individual on a one-on-one basis. f. On [DATE], nursing staff was trained on the timeline documentation for any lifesaving events. g. A new refrigerator was purchased to store resident snacks such as sandwiches and snacks and distribution of the snack was the responsibility of the nursing staff. h. A 100 % chart review was performed to determine the DNR status of each resident in the building and 5 residents were found to lack Out-of-hospital DNR documents, but were designated DNR in their record. The code status was immediately changed to full code until the documentation was completed, or found in the thinning's. i. The DON or designee was tasked with verifying retention of the training course by conducting mock code/choking emergencies weekly for the next 30 days for each shift and monthly for the next quarters and annually thereafter. The results of the mock code will be evaluated by the interdisciplinary team and progress will be monitored by the monthly quality assurance meetings. Verification of the Plan of Removal was as follows: a. Interviews were conducted with nursing, housekeeping and dietary staff on [DATE], [DATE], [DATE] and [DATE], day, evening and weekend staff to determine participation, certification and retention of the course material and to determine whether the training had been beneficial in increasing confidence in performing the [MEDICATION NAME] maneuver, CPR and in using the AED. These included: 2 RN's; 21 LVN's; 4 CNA's, Food Service Manager, Human Resources Manager and Receptionist. b. Forty-three posttests were reviewed and 2 nursing staff members were interviewed regarding their incorrect answer of when to start CPR. c. Forty-two (42) copies of CPR certifications were reviewed for filing and included participation in the facility's training course, or prior certification. Dates of expiration were noted and all certifications were current. d. Copies of AED certification training were also reviewed and 24 nursing staff were certified in the use of the AED device. e. In-service training reports dated [DATE] included choking and the use of the [MEDICATION NAME] maneuver, CPR and checking the crash cart and emergency supplies were reviewed for consistency and inclusion of nursing staff who were participants in the resuscitation efforts of Resident #13. On [DATE] the Administrator was informed that the Immediate Jeopardy was removed at 1:50 p.m. However, the facility remained out of compliance with a severity of actual harm with a scope identified as pattern. The facility reported on [DATE] that 8 residents had a full code status. All the other residents (81) had Out-of-Hospital DNR forms in place.

Based on observations, interviews and record reviews the facility failed to ensure that residents who displayed mental and psychological difficulties were provided appropriate care and treatments for assessed problems for 5 of 20 residents (#6, 7, 8, 10, and 11) reviewed for psychosocial care and services in that: 1. Resident #6 had multiple incidents of physically aggressive behavior and was not provided psychiatric services to reduce behaviors. 2. Resident #7 had multiple incidents of multiple physical aggressive behaviors prior to stabbing Resident # 6 in the face. Resident #7 was not provided psychiatric services to reduce behaviors. 3. Resident #8 was noncompliant with medications, pulling her hair, exhibiting disruptive physical and verbal behaviors and needing acute hospitalization and was not provided psychiatrist assessment and hospitalized until almost 3 weeks. 4. Resident #10 was admitted from a psychiatric facility and had a PASSAR Level 1 assessment screening positive for mental illness. Resident #10 immediately became verballyand physically aggressive towards staff and residents. The resident was not asssessed and/or hospitalized , which resulted in emergency detention by police. 5. Resident # 11 was admitted from a psychiatric hospital and had a PASARR Level 1 assessment screening positive for mental illness and intellectual disability. Resident #11 assaulted his roommate (Resident #4) and was verbally aggressive throughout most of the day. The resident was not assessed by a psychiatrist and/or hospitalized . This failure resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/22/16. While the IJ was removed on 2/23/16, the facility remained out of compliance at a scope of widespread and immediate jeopardy to resident health or safety due to all the staff not being in-serviced to monitor, intervene and/or handle residents with aggressive behaviors; not implementing policies and procedures to prevent resident to resident abuse; and not supervising and monitoring residents after altercations. This failure could affect the facility's other 85 residents by placing them at risk for not having their psychological and pyschiatric needs being met. The findings were: 1. Review of Resident #6's undated admission record face sheet revealed the resident was initially admitted on [DATE] and readmitted on [DATE] from another nursing facility with diagnoses, which included dementia, anxiety disorder, diabetes mellitus type 2, major [MEDICAL CONDITION] with severe and recurrent psychotic symptoms, and behavioral disturbances, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of a recent quarterly MDS dated [DATE] assessed the resident's BIMS score a 2 out of a possible 15, which indicated severe cognitive impairment with fluctuating inattentiveness and continuous disorganized thinking. The presence of behavioral symptoms was incorrectly scored a zero in Behaviors, although nursing notes and incident reports had documented disruptive, socially inappropriate and physical aggression towards residents and staff. Review of the most recent care plans dated 9/30/14 to 8/25/15 revealed that Resident #6 had previous episodes of adverse behaviors. A risk for elopement assessment dated [DATE] revealed the resident was at risk for elopement and required a wander guard. A care plan intervention dated 8/25/15 instructed the staff to maintain a calm environment when approaching the resident; to assist the resident in identifying the effects of his behaviors on others; to anticipate behaviors and re-direct the resident when in close proximity of other residents might invoke aggression; and to ensure staff awareness of resident's behaviors and successful interventions such as redirections. This indicated a long term history of disruptive and aggressive behaviors. Review of a care plan dated 8/25/15 instructed staff to maneuver Resident #6 through the hallways when a crowd began to develop in hallways, to aid in decreasing potential behavior issues. Review of the February 2016 MAR indicated [REDACTED]. Review of Resident #6's nursing notes for January and February 2016 revealed that Resident #6's had a history of [REDACTED].#7: (a) On 1/3/16, the resident hit a CNA on the side of their face. The resident was seen eating the roommate's breakfast tray and the CNA told the resident to stop eating the food. Resident #6 then became verbally aggressive, knocked the tray to the floor and, when attempting to redirect, Resident #6 hit the CNA in the face. (b) On 1/14/16, Resident #6 blocked the entrance of the patio door to the smoking area and became combative with residents attempting to push him out of the way. Resident #6 started throwing punches and Resident #7 knocked the resident out of his wheelchair. Resident #6 sustained a bruise and swelling to his left forehead and eyebrow, a skin tear to the left eyebrow and left jaw and an injury to the right lower leg. (c) On 1/17/16, the resident was being assisted from the toilet to the wheelchair when he became combative and hit the CNA in the face and slid to the floor. The resident complained of pain to the right lower extremity and an x-ray order was obtained from the physician. On 1/28/16, the left leg was assessed with [REDACTED]. (d) On 1/25/16, Resident #6 struck another resident on the face while on the patio and the resident retaliated by striking the resident and knocking him onto the ground. (e) On 1/27/16, Resident #6 was sitting in his wheelchair in the doorway exit to the back patio and was asked to move by another resident. Resident #6 became upset and attempted to hit the resident and was instead hit in the face by the resident. Resident #6 sustained a bruise and swelling to the forehead and eyebrow, a small skin tear to the brow and left jaw. (f) On 2/11/16, Residents #6 was blocking the door to the back patio and Resident #7 attempted to move him. Resident #6 became agitated and shoved Resident #7 and hit another resident. The other resident then punched Resident #6 in the face and were separated by staff. The incident described above on the patio between Residents' #6 and #7 then occurred. No documentation was found in Resident #6's clinical record indicating he had received psychiatric or psychological services, besides the administration of medications. 2. Review of Resident #7's undated admission record revealed the resident was re-admitted on [DATE] with a history of anxiety state, depression and [MEDICAL CONDITION] after a hospitalized from [DATE] to 2/17/15 for increased depression, sadness, lack of energy and multiple chronic medical conditions. Review of a February 2016 MAR indicated [REDACTED]. Review of an annual MDS dated [DATE] revealed the resident's BIMS score of 6 out of a possible 15, which indicated moderate to severe cognitive impairment, with no exhibited behaviors being documented in Behaviors, although recent documentation revealed an increase of aggressive behaviors. The resident's functional status was supervision of all ADL's. Review of Resident #7's care plans between 3/3/15 and 8/23/15 revealed that Resident #7 had a history of [REDACTED]. Interventions included assessing for triggers that might prompt or contribute to behaviors; informing staff when Resident #7 exhibited behaviors and/or when interventions were successful (10/29/15). An additional approach was to monitor behaviors that might identify patterns of decreasing the number of episodes. Review of Resident 7's nursing notes revealed that Resident #7 was noncompliant with medications by refusing the evening dose of [MEDICATION NAME] (antipsychotic) from 12/30/15 to 2/18/16. Nursing notes documented that the physician was informed of the noncompliance, but there were no changes of the order. The staff continued to document his refusal. Further review of Resident #7's nursing notes revealed that on 11/24/15, he and another resident were observed in the smoking area punching and kicking a resident in a wheelchair. As the Social Worker was attempting to separate the residents, the resident in the wheelchair tipped over and Resident #7 began to kicking him. Nursing notes documented that the staff then began to monitor him. Review of an incident report dated 1/14/16 revealed Residents # 6 and 7 were in an altercation at the doorway of the back patio at 4:00 p.m. Resident #6's wheelchair blocked the exit and Resident #7 attempted to move him. Resident #6 started punching Resident #7 and Resident #7 knocked him out of the wheelchair. Review of an incident report dated 2/11/16 revealed that Resident #7 had an altercation with Resident #6 at approximately 4:30 p.m. in the designated smoking area. Resident #7 attempted to push Resident # 6's wheelchair out of the way and Resident #6 the resident's rosary, broke it and scratched Resident #7 in the face. When the smoking session ended, Resident #7 followed Resident #6 to his room and attempted to puncture his eyes with a butter knife. Review of Resident's clinical record revealed that the most recent psychiatric assessment conducted on Resident #7 was when he was admitted to the facility on [DATE]. 3. Review of Resident #8's undated admission face sheet revealed the resident was admitted on [DATE] with a medical history of [REDACTED]. Review of the resident's medication orders dated 2/5/16 revealed the resident received [MEDICATION NAME] ([MEDICATION NAME] for involuntary movements related to [MEDICAL CONDITION]) 1 mg BID, [MEDICATION NAME] (treat [MEDICAL CONDITION] and panic attacks) 1 mg BID, Trazadone (hypnotic) 100 mg HS, [MEDICATION NAME] (antipsychotic) 50 mg BID, [MEDICATION NAME] (anti-psychotic for [MEDICAL CONDITION]) 20 mg HS and [MEDICATION NAME] (mood and [MEDICAL CONDITION]) 500 mg HS. Further review revealed that NP J had reviewed the medications on 2/17/16 and added an anti-psychotic drug, [MEDICATION NAME] 15 mg QAM and to be increased to 30 mg in 2 weeks. Review of the PASARR Level 1 screening assessment on 11/27/15 from a psychiatric hospital confirmed the presence of mental illness and warranted psychiatric services. Review of the facility's physician's history and physical assessment on 2/5/16 revealed that Resident # 8 was noncompliant with medications (refusing), pulling her hair, and displaying disruptive physical and verbal behaviors. The Director documented that the resident met the criteria for acute hospitalization , but he could not get the MAT team to come out to the facility and assess the resident for hospitalization . Review of the initial MDS dated [DATE] assessed the Resident's BIMS score at 14 (high cognitive function) with delusional, [MEDICAL CONDITION] and disorganized thinking. Verbal aggressive behaviors were documented in Behaviors. Review of a physician' progress note dated 2/23/16 revealed that Resident #8 had been assessed by a MAT Clinician at 11:33 a.m. after the surveyor's interview with the physician on 2/22/16 at 2:20 p.m. and that the resident met the criteria for inpatient admission to a specialty geriatric psychiatric unit. During interview on 2/22/16 at approximately 3:30 p.m., LVN C, Charge Nurse, reported that the MAT team physician had refused to accept the resident on 2/8/16 at 12:16 p.m. even after being assessed by the team. The team physician instead informed the facility that he knew the resident very well and that her behaviors were just how she was. During interview on 2/23/16 at 11:50 a.m., Resident #8 stated that she did not want to be hospitalized , but that she was mentally ill. She stated that the medications were not working, that she was attempting to interact with any staff member who would listen and that the noise level within the facility was too much. 4. Review of Resident #10's admission face sheet (undated) revealed the resident was admitted on [DATE] with a history of major [MEDICAL CONDITION]; anxiety disorder, [DIAGNOSES REDACTED] with [MEDICAL CONDITION], self-inflected gunshot wound and suicidal ideation. Review of the initial MDS dated [DATE] revealed the resident's BIMS score was 15 which indicated high functioning cognition. Behaviors annotated zero, or not adverse behaviors, although nursing notes and incident reports documented past and recent histories of verbal and physical aggressive behavior towards staff and residents. Review of current medications dated February 2016 revealed the resident was administered [MEDICATION NAME] (anxiety) 0.5 mg TID; [MEDICATION NAME] (anti-depressant) 20 mg QD; [MEDICATION NAME] (anti-depressant) 60 mg QD; [MEDICATION NAME] Sprinkles (mood and [MEDICAL CONDITION]) 750 mg Bid; [MEDICATION NAME] (anti-depressant) 30 mg QID; Trazadone ([MEDICAL CONDITION])100 mg HS and [MEDICATION NAME] ([MEDICAL CONDITION]) 600 mg BID. Review of incident reports revealed that on 2/22/15, the resident had an altercation with his roommate and the roommate wanted to press charges. During counseling at approximately on 2/22/16 at 2:00 pm, Resident #10 punched LVN C (witnessed by the surveyor) and the resident removed from the facility by police to emergency detention that same day, 2/22/16, at approximately 6:00 p.m Review of nursing notes from admission to 2/22/16 revealed that 2 days after admission on 1/15/16, Resident #10 was outside in the patio when he punched a resident in the face without provocation. A second altercation occurred on 2/1/16 when several residents witnessed Resident #10 assaulting another resident. On 2/16/16 nurses documented that the resident's wife had been contacted by phone and was informed about the resident's multiple altercations. The spouse was informed that the next incident would result in the resident being removed from the facility by police and not be allowed to return. Review of the Medical Director's history and physical dated 1/26/16 revealed the resident was admitted from an acute behavioral hospital for being aggressive and sexually inappropriate in a previous nursing facility. Review of the PASARR Level 1 screening assessment on 1/13/16 confirmed that the resident was mentally ill and warranted psychiatric services. However, no psychiatric assessment upon admission and the resident began to exhibit behaviors. Instead, the resident's medications were adjusted by NP J on 2/17/16. Review of a Notification of Emergency Detention dated 2/22/16 prepared by the local police documented that Resident #10 suffered from [MEDICAL CONDITION] and was in a manic state when he struck his roommate and LVN L. The resident reported to the police that he could not control his actions. Review of Resident #10's care plans dated 2/21/16 revealed verbal and physical aggression towards staff and residents including hitting, punching, yelling, cursing and becoming highly demanding at times. The care plan's interventions warned staff to assess for triggers that might prompt and/or contribute to behaviors available reflecting the resident's behaviors; anticipate behaviors and re-direct behaviors and attempt to redirect the resident to a safe area. Observation on 2/22/16 at approximately 6:00 p.m., Resident #10 was overheard reporting to staff that he had an altercation with his roommate. He was propelling in his wheelchair and appeared angry. Four nurses were observed surrounding the resident and speaking to him when he punched LVN C in the abdomen. The facility immediately separated the resident from other residents and staff and placed a 1-on-1 monitor until removed by local police at 6:00 p.m. 5. Review of Resident #11 ' s admission face sheet (undated) revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of a PASARR Level 1 assessment screening dated 1/18/16 was positive for mental illness and intellectual disability warranted psychiatric services. Review of Resident #11's initial MDS dated [DATE] revealed a blank BIMS score due to a lack of cooperation from the resident. Behaviors (section E) triggered for physical and verbal aggression. A care plan had not been prepared to address the behaviors. Review of medications February 2016 revealed the resident was administered Trazadone (hypnotic) 100 mg TID; and [MEDICATION NAME] (antianxiety) 1 mg as needed every 12 hours for agitation. Review of an incident report dated 2/18/16 revealed the resident was found in his room assaulting his roommate and being verbally aggressive throughout most of the day. The resident was not assessed by a psychiatrist and/or hospitalized and the facility was instructed to call the non-emergency police to bring him to an ER. Review of nursing notes dated 2/18/16 revealed the facility was unable to obtain the services of the Mobile Assessment Team from a local psychiatric hospital and the staff was instructed to call the non-emergency police to have the resident removed from the facility to the ER. The facility did not follow through and the resident continued to reside in the facility. Observation at approximately 12:30 p.m. prior to the lunch meal on 2/23/16 revealed Resident #11 sitting quietly in a wheelchair playing dominos with another resident. At approximately 5:10 p.m., the resident had changed and was observed yelling and approaching staff in an aggressive manner. The staff attempted to calm him down. Review of the facility's mental health services agreement/contract dated 8/1/1015 revealed that the contractor was to provide psychological and psychotherapy services as requested by the Facility on a monthly basis . In order to ensure the efficient delivery of appropriate care to Facility residents, through its Administrator and Medical Director and Provider, through its designated representative, shall coordinate their activities in connect with the provision of services hereunder. During interview on 2/22/16 at approximately 2:20 p.m., the Medical Director expressed his frustration in providing psychiatric care and services to help residents reach and maintain their highest level of mental and psychosocial functioning. He stated that he received poor support from the local psychiatric hospitals for residents who were decompensating and that not all staff within the nursing facility was at the same level of competence to work with aggressive residents. He reported that he understood the issue with the psychiatric provider would be resolved in March 2016. During interview on 2/22/16 at approximately 2:23 p.m. and at 4:20 p.m., the Administrator stated that new hires' initial training included 3 days of on the job training and watching videos on providing psychosocial care and services to the residents. He reported that the psychiatric contract provider had not lived up to their agreement and that he had attempted to terminate the contract in writing on 2/1/16 effective 6/1/16, but the provider refused to terminate the agreement. He stated that he had called the service provider in another city several times, but instead of getting a psychiatrist as he had asked for, the agency sent NP J for 2 days to review medications. During interview on 2/22/16 at approximately 2:30 p.m., the Social Worker reported that the psychiatric provider services was lacking in assisting aggressive residents to adjust to the facility and that she spent a lot of her time attempting to find alternate placement for aggressive residents. She stated that the 7:00 p.m. scheduled smoke session had most of the incidents of resident to resident. She reported that the psychiatric provider service came from another city approximately every 5 to 6 weeks instead of every 4 weeks as agreed on. Interview on 2/22/16 at approximately 3:30 p.m., LVN C, Charge Nurse for West Wing, revealed that NP J had reviewed 14 resident records on the West Wing on 2/17/16 and 2/18/16. NP J did not review any of the resident charts on the East Wing. LVN C reported that NP J had stated that she was supposed to review 40 charts, but that doing so was impossible. During Interviews on 2/22/16 at 2:50 p.m. and on 2/23/16 at 10:10 a.m., the DON revealed that the psychiatric provider sent a NP once a month for 2 days to adjust medications of residents. She stated that she provided a list of residents with aggressive behaviors on both sides of the building to NP J and had informed the psychiatric services office that the facility needed a psychiatrist to assess and treat the residents. The DON reported that when the NP did come, the NP ignored the list. The DON stated that she spoke to the provider's psychiatrist but received no response. The NP visited the facility instead on 2/17/16 and 2/18/16. During interview by phone on 2/23/16 at approximately 10:50 a.m., NP J reported that the provider's psychologist had recently quit and that the provider service owner had no intention of sending a psychiatrist to the nursing facility. She stated that the owner had been stalling the facility in sending another consultant. The NP stated that she visited the facility on 2/17/16 and 2/18/16 and reviewed 20 resident medical records. She stated that it was impossible for her to see and review all the residents with mental illness and that for the size of the facility and the number of residents with mental illness, the facility should have a psychiatrist in the building every day. During interview by phone on 2/24/16 at approximately 4:40 p.m., the Ombudsman revealed that the provision of psychiatric services for the mentally ill and aggressive residents had been a major concern. The Ombudsman reported that the Immediate Jeopardy was inevitable due to the multiple incidents of altercations between residents and the lack of psychiatric services for many of the residents. The Ombudsman stated that she had also attempted to obtain psychiatric services through her agency because the needs of the residents were not being met. The facility Administrator was notified on 2/22/16 at 4:40 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. Facility Plan of Removal was provided by the Administrator on 2/23/16 at approximately 9:40 p.m. The Plan of Removal was accepted by the investigator on 2/23/16 at 10:08 p.m. and included the following steps: a. In-servicing of all staff was immediately started and included the in-service included a posttest regarding specific approaches and interventions when working with residents with aggressive behaviors, identifying and reporting all forms of abuse and the scheduling of quarterly in-services to reinforce the training. The facility arranged for a clinician from the MAT team to conduct an in-service to both staff and residents on 2/24/16 and several staff members which included housekeeping, dietary staff, maintenance staff and nursing staff who had attended the on-going in-services were quizzed regarding the importance and application of the material to their employment in the facility. b. The facility terminated the contract with the previous psychiatric services on 2/23/16 and reinstalled the previous psychiatric services on 2/24/16 to begin providing psychiatric assessments and treatments. Six residents were assessed on 2/24/16 and a team was scheduled to begin widespread assessing on 2/26/16. c. On 2/23/16, the facility posted for the residents to see a notice terminating the 7:00 p.m. smoking session and passed out consent forms to all the smoking residents to sign acknowledging understanding and consent for the change. The forms were shown to the investigator. d. On 2/23/16, the MDS's of 11 residents were reassessed and modified to reflect the behaviors of aggressive residents. Twenty-eight care plans had been reviewed and 6 of the 28 were modified to address behaviors. The investigator reviewed 4 of the MDS's with changes to Behaviors. e. On 2/23/16, the investigator observed the 7:00 p.m. scheduled smoking session on the back patio and noted that 4 staff members were present distributing cigarettes and supervising approximately 30 residents. The patio was covered by an over-sized tent which was not illuminated except by 2 small bulbs at the entrance of the building. The lack of illumination was reported to the Administrator, who during the exit conference reported that he had engaged an electrician to put up more lights. f. Both resident #6 and 7 were discharged by 2/24/16. Interviews with nursing, housekeeping and dietary revealed they had received in-services and had increased their understanding of how to identify triggers, implement interventions and monitor residents after altercations or aggressive behaviors. On 2/23/16 at 10:08 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of widespread and immediate jeopardy to resident health or safety. The facility was continuing to monitor resident to resident interactions and aggressive residents and provide in-services to staff that had not received training. Information provided by DON indicated that there were 28 residents with behavioral healthcare needs.

Based on observation, interviews and record reviews, the facility failed to ensure residents were provided adequate supervision for 2 of 8 (# 6 and 7) residents reviewed neglect in that: . After several altercations, the facility did not assess, re-evaluate and put interventions in place to prevent repeated altercations between Residents #6 and #7, resulting in Resident # 7 stabbing Resident #6 in the face with a butter knife. This failure resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/22/16. While the IJ was removed on 2/23/16, the facility remained out of compliance at a scope of widespread that is not immediate jeopardy to resident health or safety due to all the staff not being in-serviced to monitor, intervene and/or handle residents with aggressive behaviors; not implementing policies and procedures to prevent resident to resident abuse; and not supervising and monitoring residents after altercations. This failure could affect the facility's other 85 residents by placing them at risk for abuse and/or mistreatment due to lack of adequate supervision. The findings were: Review of Resident #7's undated admission record revealed the resident was readmitted from a hospital on [DATE] with a history of anxiety state, increased depression, psychosis, lack of energy and multiple chronic medical conditions. Review of Resident #7's February 2016 MAR revealed the resident was being administered 2 antidepressant medications during his stay in the facility: Seroquel (antipsychotic) 50 mg HS and Zoloft (antidepressant) 50 mg QD. Review of an annual MDS dated [DATE] revealed the resident's BIMS score of 6 out of a possible 15, which indicated moderate to severe cognitive impairment, with no exhibited behaviors being documented in Behaviors, although recent documentation revealed an increase of aggressive behaviors. The resident's functional status was supervision of all ADL's. Review of Resident #7's care plans between 3/3/15 and 8/23/15 revealed that Resident #7 had a history of [REDACTED]. Interventions included assessing for triggers that might prompt or contribute to behaviors; informing staff when Resident #7 exhibited behaviors and/or when interventions were successful (10/29/15). An additional approach was to monitor behaviors that might identify patterns of decreasing the number of episodes. Review of Resident 7's nursing notes from 12/30/15 to 2/18/16 revealed that Resident #7 had refused the evening dose of Seroquel (antipsychotic). Nursing notes on 2/03/16, 2/04/16 and 2/11/16 documented that the physician was informed of the refusals. There were no changes of the order. The staff continued to document his refusal. Further review of Resident #7's nursing notes revealed that on 11/24/15, he and another resident were observed in the smoking area punching and kicking Resident #6 in a wheelchair. As the Social Worker was attempting to separate the residents, Resident #6's wheelchair tipped over and Resident #7 began kicking him. Nursing notes documented that the staff then began to monitor him. Review of an incident report dated 1/14/16 revealed Residents # 6 and 7 were in an altercation at the doorway of the back patio at 4:00 p.m. Resident #6's wheelchair blocked the exit and Resident #7 attempted to move him. Resident #6 started punching Resident #7 and Resident #7 knocked Resident #6 out of the wheelchair. Review of an incident report dated 2/11/16 revealed that Resident #7 had an altercation with Resident #6 at approximately 4:30 p.m. in the designated smoking area. Resident #7 attempted to push Resident # 6's wheelchair out of the way and Resident #6 grabbed the rosary around Resident #7's neck, broke it and scratched Resident #7 in the face. When the smoking session ended, Resident #7 followed Resident #6 to his room and stabbed him in the face with a butter knife. Review of Resident's #7's clinical record revealed that the most recent psychiatric assessment conducted was when he was admitted to the facility on [DATE] a year earlier. Review of Resident #6's undated admission record face sheet revealed the resident was initially admitted on [DATE] and readmitted on [DATE] from another nursing facility with diagnoses, which included dementia, anxiety disorder, diabetes mellitus type 2, major depressive disorder with severe and recurrent psychotic symptoms, and behavioral disturbances, schizophrenia and Parkinson's disease. Review of a care plan dated 8/25/15 revealed that Resident #6 had previous episodes of adverse behaviors, which included punching and verbal aggression. A care plan intervention instructed the staff to maintain a calm environment when approaching the resident; to assist the resident in identifying the effects of his behaviors on others; to anticipate behaviors and re-direct the resident when in close proximity of other residents might invoke aggression; and to ensure staff awareness of resident's behaviors and successful interventions such as redirections. Further review of a care plan dated 8/25/15 instructed staff to maneuver Resident #6 through the hallways when a crowd began to develop in hallways, to aid in decreasing potential behavior issues. Review of a Resident #6's recent quarterly MDS dated [DATE] assessed the resident's BIMS score a 2 out of a possible 15, which indicated severe cognitive impairment with fluctuating inattentiveness and continuous disorganized thinking. The presence of behavioral symptoms was scored a zero in Behaviors, although nursing notes and incident reports had documented disruptive, socially inappropriate and physical aggression towards residents and staff. Review of the Resident #6's February 2016 MAR revealed that the resident was administered an Exelon 13.3 mg/24 hours patch (mild, moderate, and severe memory problems such as dementia); Zoloft 200 mg QD (antidepressant) and Zyprexa 10 mg HS (psychotic conditions such as schizophrenia and bipolar disorder). Review of Resident #6's nursing notes for January and February 2016 revealed that Resident #6 had a history of [REDACTED].#7: (a) On 1/3/16, the resident hit a CNA on the side of their face. The resident was seen eating the roommate's breakfast tray and the CNA told the resident to stop eating the food. Resident #6 then became verbally aggressive, knocked the tray to the floor and, when attempting to redirect, Resident #6 hit the CNA in the face. (b) On 1/14/16, Resident #6 blocked the entrance of the patio door to the smoking area and became combative with residents attempting to push him out of the way. Resident #6 started throwing punches and Resident #7 knocked the resident out of his wheelchair. Resident #6 sustained a bruise and swelling to his left forehead and eyebrow, a skin tear to the left eyebrow and left jaw and an injury to the right lower leg. (c) On 1/17/16, the resident was being assisted from the toilet to the wheelchair when he became combative and hit the CNA in the face and slid to the floor. The resident complained of pain to the right lower extremity and an x-ray order was obtained from the physician. On 1/28/16, the left leg was assessed with [REDACTED]. (d) On 1/25/16, Resident #6 struck another resident on the face while on the patio and the resident retaliated by striking the resident and knocking him onto the ground. (e) On 1/27/16, Resident #6 was sitting in his wheelchair in the doorway exit to the back patio and was asked to move by Resident #7. Resident #6 became upset and attempted to hit the resident and was instead hit in the face by the resident. Resident #6 sustained a bruise and swelling to the forehead and eyebrow, a small skin tear to the brow and left jaw. (f) On 2/11/16, Resident #6 was blocking the door to the back patio and Resident #7 attempted to move him. Resident #6 became agitated and shoved Resident #7 and hit another resident. The other resident then punched Resident #6 in the face and were separated by staff. The altercations continued on the patio when Resident #6 broke Resident #7's rosary, scratched him, attempted to burn him with a cigarette and Resident #7 followed Resident #6 to his room to stab him in the face with a butter knife. Review of nursing notes revealed documentation that at approximately 4:34 p.m. on 2/11/16, Resident #7 was in a second altercation with Resident #6 when Resident #7 attempted to enter the back patio and Resident #6's wheelchair blocked the exit. Resident #6 shoved and punched Resident #7. The residents were separated by LVN E. Moments later on the patio, a second altercation occurred between the residents and staff had to separate the residents. Resident #7 had punched Resident #6 in the face and staff had to intervene and separate the residents. Resident #6 then attempted to burn Resident #7 with his cigarette on his back. At the end of the smoking session, Resident #6 was removed from the patio and taken to his room in his wheelchair. Resident #7 also left the patio and was later found in Resident #6's room attempting to stab him in the eyes with a butter knife. Review of the facility's investigation report dated 2/11/16 revealed that Residents # 6 and 7 were smoking on the back porch during their smoke break at approximately 4:30 p.m. when Resident #6 started giving the new employee (Housekeeper D) assisting them a hard time and made an offensive remark. According to the investigation, Resident # 7 was defending the housekeeper's honor. Resident #6 then retaliated by pulling off and breaking Resident #7's rosary from around his neck and scratching his face. In retaliation, Resident #7 later went to Resident #6's room and stabbed him near his right eye. Witness statements collected by the facility revealed that during the first altercation at the door of the patio, someone (unknown) called for help and LVN E, Charge Nurse, from East Wing responded and separated the residents at the door of the patio. LVN E then returned to the nurses' station leaving Housekeeper D by herself to distribute and light cigarettes. Because Resident #6 had parked his wheelchair next to the housekeeper, the housekeeper attempted to move his wheelchair to the side, but Resident #6 stopped her by pushing back with his legs out. Resident #7 also attempted to push the wheelchair and Resident #6 broke his rosary and scratched his face. Resident #7 was directed to sit on a bench and Resident #6 followed him and attempted to burn him with a cigarette. Staffing Coordinator F, who was behind the housekeeper in the patio doorway, intervened and separated the residents. Shortly after the smoke session was over, Resident #6 was taken to his room and the staff was unaware that Resident #7 had followed Resident #6 to the resident's room and began to stab the resident in the right eye with a butter knife. At that time, approximately 5:00 p.m., Staffing Coordinator F was making rounds of the East hallway and observed Resident # 7 with his left hand on the head of Resident #6 and the right hand pulled back with a butter knife about to strike the resident. Resident #6's face and hand had blood when Staffing Coordinator F stopped Resident #7 and called LVN E to assist. Review of the incident report dated 2/11/16 confirmed that at approximately 4:30 P.M., Resident #6 sustained 2 small lacerations to the face and 1 laceration to the left hand from the stabbing attempts of Resident #7. During interview on 2/12/16 at 4:00 P.M., Staffing Coordinator F reported that he was making rounds on 2/11/16 at approximately 4:45 p.m. on the East Hallway and walked past Resident #6's room. He observed Resident # 7 standing over Resident #6, who was sitting in a wheelchair with blood on his face and hands. Resident #7 was holding the resident's head with his left hand and a knife in the right hand. Staffing Coordinator F stated that he grabbed Resident #7's hand with the knife and instructed him to leave the room. Staffing Coordinator F stated that LVN E was sitting at the nurses' station in view of the resident's room and no one had detected any noise or disturbance from the room. He reported that he called LVN E to assess Resident #6's injuries. During interview on 2/12/16 at approximately 3:00 P.M., LVN E, Charge Nurse, reported that he was the charge nurse at the time of the incident on 2/11/16 and if he had known what had occurred on the patio, he could have prevented the incident in Resident #6's bedroom. He reported that he had intervened in the earlier incident on 2/11/16 at the patio doorway, but was not aware of Resident #6 pulling off the rosary, scratching, and burning Resident #7 with the cigarette, and of the residents following each other to their rooms. He reported that Staffing Coordinator F was walking by the resident's door (approximately 10 steps from the nurses' station) and alerted him to Resident #7 attempting to stab Resident #6. During interview on 2/12/16 at approximately 1:45 p.m., with the Administrator reported that the incident on the back porch occurred because Resident #7 had been attempting to protect the honor of the new female employee (Housekeeper D) when he attempted to stick the butter knife into the eyes of Resident #6. The Administrator reported he had Resident #7 immediately removed from the facility after the incident. During interview on 2/12/16 at approximately 2:45 P.M., the DON reported that after the altercations on the patio between Residents #6 and 7, the housekeeper could not leave the patio and consequently the housekeeper could not follow the residents back to their rooms and/or alert the staff of pending and potential altercations. When questioned what would have been the ideal situation to prevent the incident, the DON reported that it would have been appropriate to assign 2 persons to supervise the residents, and that 1 of those 2 persons should have been a nursing staff. During interview on 2/12/16 at approximately 4:25 P.M., the Housekeeping Supervisor reported that times had changed since the additional duties of the housekeeping staff began to supervise the smoking sessions, because of the number of residents had increased. She reported that during the 5 smoking sessions there were usually 30 plus residents on the back porch, which were too many residents to be supervised by 1 person. She stated that the only training the housekeepers received during orientation to the facility was a DVD film (this was confirmed by the Human Resource Supervisor on 2/12/16) on the managing of residents with dementia and that she had instructed the housekeeping staff not to intervene when residents became aggressive and/or during resident to resident altercations. During observation and interview on 2/12/16 at approximately 4:45 P.M. Resident #6, while sitting in a wheelchair on the back patio, reported he had been attacked him in his room while sitting in the wheelchair. He pointed to the swelling to both sides of his eyes and across the bridge of the nose and demonstrated by lifting his hands in front of his face how he had protected his eyes. The bridge his nose and both sides of the eyes and hands were swollen. During interview by phone on 2/12/16 at approximately 5:05 p.m., Housekeeper D reported that she was assigned to watch the residents smoking on 2/11/16 at 4:30 p.m. and was alone with the residents. She reported that watching the residents was part of her job, which she alternated with 2 other housekeepers at the 5:00 p.m. and 7:00 p.m. smoking sessions. She stated that she had not felt physically unsafe until after the incident on 2/11/16. Housekeeper D reported that she was instructed by her supervisor not to intervene during resident to resident altercations, but was unable to report the incidents taking place because she could not leave the other residents unattended. She reported that her only training since start of employment (1/14/16) in managing mentally ill and aggressive residents was during a 1 day orientation session that included watching a short video and observing staff interaction while performing her duties as a housekeeper. During a second interview in person on 2/23/16 at 1:50 p.m., Housekeeper D reported that on 2/11/16 at approximately 4:00 p.m., she was assigned to supervise the smoke session which included dispensing the cigarettes and lighting the cigarettes to approximately 30 plus residents ambulatory and in wheelchairs. She stated that she was standing approximately 10 feet from the patio door and was not aware of the initial altercation between Resident's #6 and #7. She stated that Resident #6 pulled up next to her and would not move to the side to allow other residents to pass. She attempted to push his wheelchair, but he stopped the chair with his feet and called her vieja pendeja, or stupid lady. Resident #7 then attempted to push the wheelchair and Resident #6 broke his rosary and scratched his face. Staffing Coordinator F intervened and separated the residents. Resident #7 was directed to sit on the bench to the right of the patio. The housekeeper turned her back to the 2 residents and began lighting cigarettes. She stated that she did not see the third altercation, but Staffing Coordinator F again intervened. At the end of the smoke session, she stated although she did not see Resident #6 being removed from the patio, she was certain Resident #6 was taken to his room by a staff member because he would not have voluntarily gone by himself. Review of the facility's operational/resident care policies on abuse and neglect (undated) revealed that it was the facility's intent to ensure each employee would receive ongoing training that deal with appropriate interventions to deal with aggressive and/or catastrophic reactions of residents . and assistance to ensure each employee will initiate immediate procedures to ensure that these residents are protected fully from further harm or potential harm . The policy outlined that all employees would be oriented into the facility, taught as part of the nurse aide curriculum . in protecting the residents. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm . Review of the facility's present smoking policy revealed that smoking sessions were scheduled 5 times daily: 9:00 a.m.; 11:00 a.m.; 1:00 p.m.; 4:00 p.m.; and 7:00 p.m. The facility Administrator was notified on 2/22/16 at 4:40 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. Facility Plan of Removal was provided by the Administrator on 2/23/16 at approximately 9:40 p.m. The Plan of Removal was accepted by the investigator on 2/23/16 at 10:08 p.m. and included the following steps: a. In-servicing of all staff was immediately started and included the in-service included a posttest regarding specific approaches and interventions when working with residents with aggressive behaviors, identifying and reporting all forms of abuse and the scheduling of quarterly in-services to reinforce the training. The facility arranged for a clinician from the MAT team to conduct an in-service to both staff and residents on 2/24/16 and several staff members which included housekeeping, dietary staff, maintenance staff and nursing staff who had attended the on-going in-services were quizzed regarding the importance and application of the material to their employment in the facility. b. The facility terminated the contract with the previous psychiatric services on 2/23/16 and reinstalled the previous psychiatric services on 2/24/16 to begin providing psychiatric assessments and treatments. Six residents were assessed on 2/24/16 and a team was scheduled to begin widespread assessing on 2/26/16. c. On 2/23/16, the facility posted for the residents to see a notice terminating the 7:00 p.m. smoking session and passed out consent forms to all the smoking residents to sign acknowledging understanding and consent for the change. The forms were shown to the investigator. d. On 2/23/16, the MDS's of 11 residents were reassessed and modified to reflect the behaviors of aggressive residents. Twenty-eight care plans had been reviewed and 6 of the 28 were modified to address behaviors. The investigator reviewed 4 of the MDS's with changes to Behaviors. e. On 2/23/16, the investigator observed the 7:00 p.m. scheduled smoking session on the back patio and noted that 4 staff members were present distributing cigarettes and supervising approximately 30 residents. The patio was covered by an over-sized tent which was not illuminated except by 2 small bulbs at the entrance of the building. The lack of illumination was reported to the Administrator, who during the exit conference reported that he had engaged an electrician to put up more lights. f. Both resident #6 and 7 were discharged by 2/24/16. Interviews with nursing, housekeeping and dietary revealed they had received in-services and had increased their understanding of how to identify triggers, implement interventions and monitor residents after altercations or aggressive behaviors. On 2/23/16 at 10:08 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of widespread and immediate jeopardy to resident health or safety. The facility was continuing to monitor resident to resident interactions and aggressive residents and provide in-services to staff that had not received training. Information provided by DON indicated that there were 28 residents with behavioral healthcare needs.

Based on observation, interview and record review, the facility failed to implement the facility's policy and procedures to protect residents from neglect for 2 of 20 (# 6 and 7) residents reviewed for neglect in that: . After several altercations, the facility did not assess, re-evaluate and put interventions in place to prevent repeated altercations between Residents #6 and #7, resulting in Resident # 7 stabbing Resident #6 in the face with a butter knife. This failure resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/22/16. While the IJ was removed on 2/23/16, the facility remained out of compliance at a scope of widespread that is not immediate jeopardy to resident health or safety due to all the staff not being in-serviced to monitor, intervene and/or handle residents with aggressive behaviors; not implementing policies and procedures to prevent resident to resident abuse; and not supervising and monitoring residents after altercations. This failure could affect the facility's other 85 residents by placing them at risk for abuse and/or mistreatment. The findings were: Review of Resident #7's undated admission record revealed the resident was readmitted from a hospital on [DATE] with a history of anxiety state, increased depression, [MEDICAL CONDITION], lack of energy and multiple chronic medical conditions. Review of Resident #7's February 2016 MAR indicated [REDACTED]. Review of an annual MDS dated [DATE] revealed the resident's BIMS score of 6 out of a possible 15, which indicated moderate to severe cognitive impairment, with no exhibited behaviors being documented in Behaviors, although recent documentation revealed an increase of aggressive behaviors. The resident's functional status was supervision of all ADL's. Review of Resident #7's care plans between 3/3/15 and 8/23/15 revealed that Resident #7 had a history of [REDACTED]. Interventions included assessing for triggers that might prompt or contribute to behaviors; informing staff when Resident #7 exhibited behaviors and/or when interventions were successful (10/29/15). An additional approach was to monitor behaviors that might identify patterns of decreasing the number of episodes. Review of Resident 7's nursing notes from 12/30/15 to 2/18/16 revealed that Resident #7 had refused the evening dose of [MEDICATION NAME] (antipsychotic). Nursing notes on 2/03/16, 2/04/16 and 2/11/16 documented that the physician was informed of the refusals. There were no changes of the order. The staff continued to document his refusal. Further review of Resident #7's nursing notes revealed that on 11/24/15, he and another resident were observed in the smoking area punching and kicking Resident #6 in a wheelchair. As the Social Worker was attempting to separate the residents, Resident #6's wheelchair tipped over and Resident #7 began kicking him. Nursing notes documented that the staff then began to monitor him. Review of an incident report dated 1/14/16 revealed Residents # 6 and 7 were in an altercation at the doorway of the back patio at 4:00 p.m. Resident #6's wheelchair blocked the exit and Resident #7 attempted to move him. Resident #6 started punching Resident #7 and Resident #7 knocked Resident #6 out of the wheelchair. Review of an incident report dated 2/11/16 revealed that Resident #7 had an altercation with Resident #6 at approximately 4:30 p.m. in the designated smoking area. Resident #7 attempted to push Resident # 6's wheelchair out of the way and Resident #6 grabbed the rosary around Resident #7's neck, broke it and scratched Resident #7 in the face. When the smoking session ended, Resident #7 followed Resident #6 to his room and stabbed him in the face with a butter knife. Review of Resident's #7's clinical record revealed that the most recent psychiatric assessment conducted was when he was admitted to the facility on [DATE] a year earlier. Review of Resident #6's undated admission record face sheet revealed the resident was initially admitted on [DATE] and readmitted on [DATE] from another nursing facility with diagnoses, which included dementia, anxiety disorder, diabetes mellitus type 2, major [MEDICAL CONDITION] with severe and recurrent psychotic symptoms, and behavioral disturbances, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of a care plan dated 8/25/15 revealed that Resident #6 had previous episodes of adverse behaviors, which included punching and verbal aggression. A care plan intervention instructed the staff to maintain a calm environment when approaching the resident; to assist the resident in identifying the effects of his behaviors on others; to anticipate behaviors and re-direct the resident when in close proximity of other residents might invoke aggression; and to ensure staff awareness of resident's behaviors and successful interventions such as redirections. Further review of a care plan dated 8/25/15 instructed staff to maneuver Resident #6 through the hallways when a crowd began to develop in hallways, to aid in decreasing potential behavior issues. Review of a Resident #6's recent quarterly MDS dated [DATE] assessed the resident's BIMS score a 2 out of a possible 15, which indicated severe cognitive impairment with fluctuating inattentiveness and continuous disorganized thinking. The presence of behavioral symptoms was scored a zero in Behaviors, although nursing notes and incident reports had documented disruptive, socially inappropriate and physical aggression towards residents and staff. Review of the Resident #6's February 2016 MAR indicated [REDACTED]. Review of Resident #6's nursing notes for January and February 2016 revealed that Resident #6 had a history of [REDACTED].#7: (a) On 1/3/16, the resident hit a CNA on the side of their face. The resident was seen eating the roommate's breakfast tray and the CNA told the resident to stop eating the food. Resident #6 then became verbally aggressive, knocked the tray to the floor and, when attempting to redirect, Resident #6 hit the CNA in the face. (b) On 1/14/16, Resident #6 blocked the entrance of the patio door to the smoking area and became combative with residents attempting to push him out of the way. Resident #6 started throwing punches and Resident #7 knocked the resident out of his wheelchair. Resident #6 sustained a bruise and swelling to his left forehead and eyebrow, a skin tear to the left eyebrow and left jaw and an injury to the right lower leg. (c) On 1/17/16, the resident was being assisted from the toilet to the wheelchair when he became combative and hit the CNA in the face and slid to the floor. The resident complained of pain to the right lower extremity and an x-ray order was obtained from the physician. On 1/28/16, the left leg was assessed with [REDACTED]. (d) On 1/25/16, Resident #6 struck another resident on the face while on the patio and the resident retaliated by striking the resident and knocking him onto the ground. (e) On 1/27/16, Resident #6 was sitting in his wheelchair in the doorway exit to the back patio and was asked to move by Resident #7. Resident #6 became upset and attempted to hit the resident and was instead hit in the face by the resident. Resident #6 sustained a bruise and swelling to the forehead and eyebrow, a small skin tear to the brow and left jaw. (f) On 2/11/16, Resident #6 was blocking the door to the back patio and Resident #7 attempted to move him. Resident #6 became agitated and shoved Resident #7 and hit another resident. The other resident then punched Resident #6 in the face and were separated by staff. The altercations continued on the patio when Resident #6 broke Resident #7's rosary, scratched him, attempted to burn him with a cigarette and Resident #7 followed Resident #6 to his room to stab him in the face with a butter knife. Review of nursing notes revealed documentation that at approximately 4:34 p.m. on 2/11/16, Resident #7 was in a second altercation with Resident #6 when Resident #7 attempted to enter the back patio and Resident #6's wheelchair blocked the exit. Resident #6 shoved and punched Resident #7. The residents were separated by LVN E. Moments later on the patio, a second altercation occurred between the residents and staff had to separate the residents. Resident #7 had punched Resident #6 in the face and staff had to intervene and separate the residents. Resident #6 then attempted to burn Resident #7 with his cigarette on his back. At the end of the smoking session, Resident #6 was removed from the patio and taken to his room in his wheelchair. Resident #7 also left the patio and was later found in Resident #6's room attempting to stab him in the eyes with a butter knife. Review of the facility's investigation report dated 2/11/16 revealed that Residents # 6 and 7 were smoking on the back porch during their smoke break at approximately 4:30 p.m. when Resident #6 started giving the new employee (Housekeeper D) assisting them a hard time and made an offensive remark. According to the investigation, Resident # 7 was defending the housekeeper's honor. Resident #6 then retaliated by pulling off and breaking Resident #7's rosary from around his neck and scratching his face. In retaliation, Resident #7 later went to Resident #6's room and stabbed him near his right eye. Witness statements collected by the facility revealed that during the first altercation at the door of the patio, someone (unknown) called for help and LVN E, Charge Nurse, from East Wing responded and separated the residents at the door of the patio. LVN E then returned to the nurses' station leaving Housekeeper D by herself to distribute and light cigarettes. Because Resident #6 had parked his wheelchair next to the housekeeper, the housekeeper attempted to move his wheelchair to the side, but Resident #6 stopped her by pushing back with his legs out. Resident #7 also attempted to push the wheelchair and Resident #6 broke his rosary and scratched his face. Resident #7 was directed to sit on a bench and Resident #6 followed him and attempted to burn him with a cigarette. Staffing Coordinator F, who was behind the housekeeper in the patio doorway, intervened and separated the residents. Shortly after the smoke session was over, Resident #6 was taken to his room and the staff was unaware that Resident #7 had followed Resident #6 to the resident's room and began to stab the resident in the right eye with a butter knife. At that time, approximately 5:00 p.m., Staffing Coordinator F was making rounds of the East hallway and observed Resident # 7 with his left hand on the head of Resident #6 and the right hand pulled back with a butter knife about to strike the resident. Resident #6's face and hand had blood when Staffing Coordinator F stopped Resident #7 and called LVN E to assist. Review of the incident report dated 2/11/16 confirmed that at approximately 4:30 P.M., Resident #6 sustained 2 small lacerations to the face and 1 laceration to the left hand from the stabbing attempts of Resident #7. During interview on 2/12/16 at 4:00 P.M., Staffing Coordinator F reported that he was making rounds on 2/11/16 at approximately 4:45 p.m. on the East Hallway and walked past Resident #6's room. He observed Resident # 7 standing over Resident #6, who was sitting in a wheelchair with blood on his face and hands. Resident #7 was holding the resident's head with his left hand and a knife in the right hand. Staffing Coordinator F stated that he grabbed Resident #7's hand with the knife and instructed him to leave the room. Staffing Coordinator F stated that LVN E was sitting at the nurses' station in view of the resident's room and no one had detected any noise or disturbance from the room. He reported that he called LVN E to assess Resident #6's injuries. During interview on 2/12/16 at approximately 3:00 P.M., LVN E, Charge Nurse, reported that he was the charge nurse at the time of the incident on 2/11/16 and if he had known what had occurred on the patio, he could have prevented the incident in Resident #6's bedroom. He reported that he had intervened in the earlier incident on 2/11/16 at the patio doorway, but was not aware of Resident #6 pulling off the rosary, scratching, and burning Resident #7 with the cigarette, and of the residents following each other to their rooms. He reported that Staffing Coordinator F was walking by the resident's door (approximately 10 steps from the nurses' station) and alerted him to Resident #7 attempting to stab Resident #6. During interview on 2/12/16 at approximately 1:45 p.m., with the Administrator reported that the incident on the back porch occurred because Resident #7 had been attempting to protect the honor of the new female employee (Housekeeper D) when he attempted to stick the butter knife into the eyes of Resident #6. The Administrator reported he had Resident #7 immediately removed from the facility after the incident. During interview on 2/12/16 at approximately 2:45 P.M., the DON reported that after the altercations on the patio between Residents #6 and 7, the housekeeper could not leave the patio and consequently the housekeeper could not follow the residents back to their rooms and/or alert the staff of pending and potential altercations. When questioned what would have been the ideal situation to prevent the incident, the DON reported that it would have been appropriate to assign 2 persons to supervise the residents, and that 1 of those 2 persons should have been a nursing staff. During interview on 2/12/16 at approximately 4:25 P.M., the Housekeeping Supervisor reported that times had changed since the additional duties of the housekeeping staff began to supervise the smoking sessions, because of the number of residents had increased. She reported that during the 5 smoking sessions there were usually 30 plus residents on the back porch, which were too many residents to be supervised by 1 person. She stated that the only training the housekeepers received during orientation to the facility was a DVD film (this was confirmed by the Human Resource Supervisor on 2/12/16) on the managing of residents with dementia and that she had instructed the housekeeping staff not to intervene when residents became aggressive and/or during resident to resident altercations. During observation and interview on 2/12/16 at approximately 4:45 P.M. Resident #6, while sitting in a wheelchair on the back patio, reported he had been attacked him in his room while sitting in the wheelchair. He pointed to the swelling to both sides of his eyes and across the bridge of the nose and demonstrated by lifting his hands in front of his face how he had protected his eyes. The bridge his nose and both sides of the eyes and hands were swollen. During interview by phone on 2/12/16 at approximately 5:05 p.m., Housekeeper D reported that she was assigned to watch the residents smoking on 2/11/16 at 4:30 p.m. and was alone with the residents. She reported that watching the residents was part of her job, which she alternated with 2 other housekeepers at the 5:00 p.m. and 7:00 p.m. smoking sessions. She stated that she had not felt physically unsafe until after the incident on 2/11/16. Housekeeper D reported that she was instructed by her supervisor not to intervene during resident to resident altercations, but was unable to report the incidents taking place because she could not leave the other residents unattended. She reported that her only training since start of employment (1/14/16) in managing mentally ill and aggressive residents was during a 1 day orientation session that included watching a short video and observing staff interaction while performing her duties as a housekeeper. During a second interview in person on 2/23/16 at 1:50 p.m., Housekeeper D reported that on 2/11/16 at approximately 4:00 p.m., she was assigned to supervise the smoke session which included dispensing the cigarettes and lighting the cigarettes to approximately 30 plus residents ambulatory and in wheelchairs. She stated that she was standing approximately 10 feet from the patio door and was not aware of the initial altercation between Resident's #6 and #7. She stated that Resident #6 pulled up next to her and would not move to the side to allow other residents to pass. She attempted to push his wheelchair, but he stopped the chair with his feet and called her vieja pendeja, or stupid lady. Resident #7 then attempted to push the wheelchair and Resident #6 broke his rosary and scratched his face. Staffing Coordinator F intervened and separated the residents. Resident #7 was directed to sit on the bench to the right of the patio. The housekeeper turned her back to the 2 residents and began lighting cigarettes. She stated that she did not see the third altercation, but Staffing Coordinator F again intervened. At the end of the smoke session, she stated although she did not see Resident #6 being removed from the patio, she was certain Resident #6 was taken to his room by a staff member because he would not have voluntarily gone by himself. Review of the facility's operational/resident care policies on abuse and neglect (undated) revealed that it was the facility's intent to ensure each employee would receive ongoing training that deal with appropriate interventions to deal with aggressive and/or catastrophic reactions of residents . and assistance to ensure each employee will initiate immediate procedures to ensure that these residents are protected fully from further harm or potential harm . The policy outlined that all employees would be oriented into the facility, taught as part of the nurse aide curriculum . in protecting the residents. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm . Review of the facility's present smoking policy revealed that smoking sessions were scheduled 5 times daily: 9:00 a.m.; 11:00 a.m.; 1:00 p.m.; 4:00 p.m.; and 7:00 p.m. The facility Administrator was notified on 2/22/16 at 4:40 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. Facility Plan of Removal was provided by the Administrator on 2/23/16 at approximately 9:40 p.m. The Plan of Removal was accepted by the investigator on 2/23/16 at 10:08 p.m. and included the following steps: a. In-servicing of all staff was immediately started and included the in-service included a posttest regarding specific approaches and interventions when working with residents with aggressive behaviors, identifying and reporting all forms of abuse and the scheduling of quarterly in-services to reinforce the training. The facility arranged for a clinician from the MAT team to conduct an in-service to both staff and residents on 2/24/16 and several staff members which included housekeeping, dietary staff, maintenance staff and nursing staff who had attended the on-going in-services were quizzed regarding the importance and application of the material to their employment in the facility. b. The facility terminated the contract with the previous psychiatric services on 2/23/16 and reinstalled the previous psychiatric services on 2/24/16 to begin providing psychiatric assessments and treatments. Six residents were assessed on 2/24/16 and a team was scheduled to begin widespread assessing on 2/26/16. c. On 2/23/16, the facility posted for the residents to see a notice terminating the 7:00 p.m. smoking session and passed out consent forms to all the smoking residents to sign acknowledging understanding and consent for the change. The forms were shown to the investigator. d. On 2/23/16, the MDS's of 11 residents were reassessed and modified to reflect the behaviors of aggressive residents. Twenty-eight care plans had been reviewed and 6 of the 28 were modified to address behaviors. The investigator reviewed 4 of the MDS's with changes to Behaviors. e. On 2/23/16, the investigator observed the 7:00 p.m. scheduled smoking session on the back patio and noted that 4 staff members were present distributing cigarettes and supervising approximately 30 residents. The patio was covered by an over-sized tent which was not illuminated except by 2 small bulbs at the entrance of the building. The lack of illumination was reported to the Administrator, who during the exit conference reported that he had engaged an electrician to put up more lights. f. Both resident #6 and 7 were discharged by 2/24/16. Interviews with nursing, housekeeping and dietary revealed they had received in-services and had increased their understanding of how to identify triggers, implement interventions and monitor residents after altercations or aggressive behaviors. On 2/23/16 at 10:08 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of widespread and immediate jeopardy to resident health or safety. The facility was continuing to monitor resident to resident interactions and aggressive residents and provide in-services to staff that had not received training. Information provided by DON indicated that there were 28 residents with behavioral healthcare needs.

Based on observation, interviews and record reviews, the facility failed to implement the facility's policy and procedures that prohibited neglect in the supervision and protection combative residents for 2 of 20 (# 6 and 7) residents reviewed for neglect in that: . After several altercations, the facility did not assess, re-evaluate and put interventions in place to prevent repeated altercations between Residents #6 and #7, resulting in Resident # 7 stabbing Resident #6 in the face with a butter knife. This failure resulted in an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/22/16. While the IJ was removed on 2/23/16, the facility remained out of compliance at a scope of widespread that is not immediate jeopardy to resident health or safety due to all the staff not being in-serviced to monitor, intervene and/or handle residents with aggressive behaviors; not implementing policies and procedures to prevent resident to resident abuse; and not supervising and monitoring residents after altercations. This failure could affect the facility's other 85 residents by placing them at risk for abuse and/or mistreatment. The findings were: Review of the facility's operational/resident care policies on abuse and neglect (undated) revealed that it was the facility's intent to ensure each employee would receive ongoing training that deal with appropriate interventions to deal with aggressive and/or catastrophic reactions of residents . and assistance to ensure each employee will initiate immediate procedures to ensure that these residents are protected fully from further harm or potential harm . The policy outlined that all employees would be oriented into the facility, taught as part of the nurse aide curriculum . in protecting the residents. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm . Review of the facility's present smoking policy revealed that smoking sessions were scheduled 5 times daily: 9:00 a.m.; 11:00 a.m.; 1:00 p.m.; 4:00 p.m.; and 7:00 p.m. Review of Resident #7's undated admission record revealed the resident was readmitted from a hospital on [DATE] with a history of anxiety state, increased depression, [MEDICAL CONDITION], lack of energy and multiple chronic medical conditions. Review of Resident #7's February 2016 MAR indicated [REDACTED]. Review of an annual MDS dated [DATE] revealed the resident's BIMS score of 6 out of a possible 15, which indicated moderate to severe cognitive impairment, with no exhibited behaviors being documented in Behaviors, although recent documentation revealed an increase of aggressive behaviors. The resident's functional status was supervision of all ADL's. Review of Resident #7's care plans between 3/3/15 and 8/23/15 revealed that Resident #7 had a history of [REDACTED]. Interventions included assessing for triggers that might prompt or contribute to behaviors; informing staff when Resident #7 exhibited behaviors and/or when interventions were successful (10/29/15). An additional approach was to monitor behaviors that might identify patterns of decreasing the number of episodes. Review of Resident 7's nursing notes from 12/30/15 to 2/18/16 revealed that Resident #7 had refused the evening dose of [MEDICATION NAME] (antipsychotic). Nursing notes on 2/03/16, 2/04/16 and 2/11/16 documented that the physician was informed of the refusals. There were no changes of the order. The staff continued to document his refusal. Further review of Resident #7's nursing notes revealed that on 11/24/15, he and another resident were observed in the smoking area punching and kicking Resident #6 in a wheelchair. As the Social Worker was attempting to separate the residents, Resident #6's wheelchair tipped over and Resident #7 began kicking him. Nursing notes documented that the staff then began to monitor him. Review of an incident report dated 1/14/16 revealed Residents # 6 and 7 were in an altercation at the doorway of the back patio at 4:00 p.m. Resident #6's wheelchair blocked the exit and Resident #7 attempted to move him. Resident #6 started punching Resident #7 and Resident #7 knocked Resident #6 out of the wheelchair. Review of an incident report dated 2/11/16 revealed that Resident #7 had an altercation with Resident #6 at approximately 4:30 p.m. in the designated smoking area. Resident #7 attempted to push Resident # 6's wheelchair out of the way and Resident #6 grabbed the rosary around Resident #7's neck, broke it and scratched Resident #7 in the face. When the smoking session ended, Resident #7 followed Resident #6 to his room and stabbed him in the face with a butter knife. Review of Resident's #7's clinical record revealed that the most recent psychiatric assessment conducted was when he was admitted to the facility on [DATE] a year earlier. Review of Resident #6's undated admission record face sheet revealed the resident was initially admitted on [DATE] and readmitted on [DATE] from another nursing facility with diagnoses, which included dementia, anxiety disorder, diabetes mellitus type 2, major [MEDICAL CONDITION] with severe and recurrent psychotic symptoms, and behavioral disturbances, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of a care plan dated 8/25/15 revealed that Resident #6 had previous episodes of adverse behaviors, which included punching and verbal aggression. A care plan intervention instructed the staff to maintain a calm environment when approaching the resident; to assist the resident in identifying the effects of his behaviors on others; to anticipate behaviors and re-direct the resident when in close proximity of other residents might invoke aggression; and to ensure staff awareness of resident's behaviors and successful interventions such as redirections. Further review of a care plan dated 8/25/15 instructed staff to maneuver Resident #6 through the hallways when a crowd began to develop in hallways, to aid in decreasing potential behavior issues. Review of a Resident #6's recent quarterly MDS dated [DATE] assessed the resident's BIMS score a 2 out of a possible 15, which indicated severe cognitive impairment with fluctuating inattentiveness and continuous disorganized thinking. The presence of behavioral symptoms was scored a zero in Behaviors, although nursing notes and incident reports had documented disruptive, socially inappropriate and physical aggression towards residents and staff. Review of the Resident #6's February 2016 MAR indicated [REDACTED]. Review of Resident #6's nursing notes for January and February 2016 revealed that Resident #6 had a history of [REDACTED].#7: (a) On 1/3/16, the resident hit a CNA on the side of their face. The resident was seen eating the roommate's breakfast tray and the CNA told the resident to stop eating the food. Resident #6 then became verbally aggressive, knocked the tray to the floor and, when attempting to redirect, Resident #6 hit the CNA in the face. (b) On 1/14/16, Resident #6 blocked the entrance of the patio door to the smoking area and became combative with residents attempting to push him out of the way. Resident #6 started throwing punches and Resident #7 knocked the resident out of his wheelchair. Resident #6 sustained a bruise and swelling to his left forehead and eyebrow, a skin tear to the left eyebrow and left jaw and an injury to the right lower leg. (c) On 1/17/16, the resident was being assisted from the toilet to the wheelchair when he became combative and hit the CNA in the face and slid to the floor. The resident complained of pain to the right lower extremity and an x-ray order was obtained from the physician. On 1/28/16, the left leg was assessed with [REDACTED]. (d) On 1/25/16, Resident #6 struck another resident on the face while on the patio and the resident retaliated by striking the resident and knocking him onto the ground. (e) On 1/27/16, Resident #6 was sitting in his wheelchair in the doorway exit to the back patio and was asked to move by Resident #7. Resident #6 became upset and attempted to hit the resident and was instead hit in the face by the resident. Resident #6 sustained a bruise and swelling to the forehead and eyebrow, a small skin tear to the brow and left jaw. (f) On 2/11/16, Resident #6 was blocking the door to the back patio and Resident #7 attempted to move him. Resident #6 became agitated and shoved Resident #7 and hit another resident. The other resident then punched Resident #6 in the face and were separated by staff. The altercations continued on the patio when Resident #6 broke Resident #7's rosary, scratched him, attempted to burn him with a cigarette and Resident #7 followed Resident #6 to his room to stab him in the face with a butter knife. Review of nursing notes revealed documentation that at approximately 4:34 p.m. on 2/11/16, Resident #7 was in a second altercation with Resident #6 when Resident #7 attempted to enter the back patio and Resident #6's wheelchair blocked the exit. Resident #6 shoved and punched Resident #7. The residents were separated by LVN E. Moments later on the patio, a second altercation occurred between the residents and staff had to separate the residents. Resident #7 had punched Resident #6 in the face and staff had to intervene and separate the residents. Resident #6 then attempted to burn Resident #7 with his cigarette on his back. At the end of the smoking session, Resident #6 was removed from the patio and taken to his room in his wheelchair. Resident #7 also left the patio and was later found in Resident #6's room attempting to stab him in the eyes with a butter knife. Review of the facility's investigation report dated 2/11/16 revealed that Residents # 6 and 7 were smoking on the back porch during their smoke break at approximately 4:30 p.m. when Resident #6 started giving the new employee (Housekeeper D) assisting them a hard time and made an offensive remark. According to the investigation, Resident # 7 was defending the housekeeper's honor. Resident #6 then retaliated by pulling off and breaking Resident #7's rosary from around his neck and scratching his face. In retaliation, Resident #7 later went to Resident #6's room and stabbed him near his right eye. Witness statements collected by the facility revealed that during the first altercation at the door of the patio, someone (unknown) called for help and LVN E, Charge Nurse, from East Wing responded and separated the residents at the door of the patio. LVN E then returned to the nurses' station leaving Housekeeper D by herself to distribute and light cigarettes. Because Resident #6 had parked his wheelchair next to the housekeeper, the housekeeper attempted to move his wheelchair to the side, but Resident #6 stopped her by pushing back with his legs out. Resident #7 also attempted to push the wheelchair and Resident #6 broke his rosary and scratched his face. Resident #7 was directed to sit on a bench and Resident #6 followed him and attempted to burn him with a cigarette. Staffing Coordinator F, who was behind the housekeeper in the patio doorway, intervened and separated the residents. Shortly after the smoke session was over, Resident #6 was taken to his room and the staff was unaware that Resident #7 had followed Resident #6 to the resident's room and began to stab the resident in the right eye with a butter knife. At that time, approximately 5:00 p.m., Staffing Coordinator F was making rounds of the East hallway and observed Resident # 7 with his left hand on the head of Resident #6 and the right hand pulled back with a butter knife about to strike the resident. Resident #6's face and hand had blood when Staffing Coordinator F stopped Resident #7 and called LVN E to assist. Review of the incident report dated 2/11/16 confirmed that at approximately 4:30 P.M., Resident #6 sustained 2 small lacerations to the face and 1 laceration to the left hand from the stabbing attempts of Resident #7. During interview on 2/12/16 at 4:00 P.M., Staffing Coordinator F reported that he was making rounds on 2/11/16 at approximately 4:45 p.m. on the East Hallway and walked past Resident #6's room. He observed Resident # 7 standing over Resident #6, who was sitting in a wheelchair with blood on his face and hands. Resident #7 was holding the resident's head with his left hand and a knife in the right hand. Staffing Coordinator F stated that he grabbed Resident #7's hand with the knife and instructed him to leave the room. Staffing Coordinator F stated that LVN E was sitting at the nurses' station in view of the resident's room and no one had detected any noise or disturbance from the room. He reported that he called LVN E to assess Resident #6's injuries. During interview on 2/12/16 at approximately 3:00 P.M., LVN E, Charge Nurse, reported that he was the charge nurse at the time of the incident on 2/11/16 and if he had known what had occurred on the patio, he could have prevented the incident in Resident #6's bedroom. He reported that he had intervened in the earlier incident on 2/11/16 at the patio doorway, but was not aware of Resident #6 pulling off the rosary, scratching, and burning Resident #7 with the cigarette, and of the residents following each other to their rooms. He reported that Staffing Coordinator F was walking by the resident's door (approximately 10 steps from the nurses' station) and alerted him to Resident #7 attempting to stab Resident #6. During interview on 2/12/16 at approximately 1:45 p.m., with the Administrator reported that the incident on the back porch occurred because Resident #7 had been attempting to protect the honor of the new female employee (Housekeeper D) when he attempted to stick the butter knife into the eyes of Resident #6. The Administrator reported he had Resident #7 immediately removed from the facility after the incident. During interview on 2/12/16 at approximately 2:45 P.M., the DON reported that after the altercations on the patio between Residents #6 and 7, the housekeeper could not leave the patio and consequently the housekeeper could not follow the residents back to their rooms and/or alert the staff of pending and potential altercations. When questioned what would have been the ideal situation to prevent the incident, the DON reported that it would have been appropriate to assign 2 persons to supervise the residents, and that 1 of those 2 persons should have been a nursing staff. During interview on 2/12/16 at approximately 4:25 P.M., the Housekeeping Supervisor reported that times had changed since the additional duties of the housekeeping staff began to supervise the smoking sessions, because of the number of residents had increased. She reported that during the 5 smoking sessions there were usually 30 plus residents on the back porch, which were too many residents to be supervised by 1 person. She stated that the only training the housekeepers received during orientation to the facility was a DVD film (this was confirmed by the Human Resource Supervisor on 2/12/16) on the managing of residents with dementia and that she had instructed the housekeeping staff not to intervene when residents became aggressive and/or during resident to resident altercations. During observation and interview on 2/12/16 at approximately 4:45 P.M. Resident #6, while sitting in a wheelchair on the back patio, reported he had been attacked him in his room while sitting in the wheelchair. He pointed to the swelling to both sides of his eyes and across the bridge of the nose and demonstrated by lifting his hands in front of his face how he had protected his eyes. The bridge his nose and both sides of the eyes and hands were swollen. During interview by phone on 2/12/16 at approximately 5:05 p.m., Housekeeper D reported that she was assigned to watch the residents smoking on 2/11/16 at 4:30 p.m. and was alone with the residents. She reported that watching the residents was part of her job, which she alternated with 2 other housekeepers at the 5:00 p.m. and 7:00 p.m. smoking sessions. She stated that she had not felt physically unsafe until after the incident on 2/11/16. Housekeeper D reported that she was instructed by her supervisor not to intervene during resident to resident altercations, but was unable to report the incidents taking place because she could not leave the other residents unattended. She reported that her only training since start of employment (1/14/16) in managing mentally ill and aggressive residents was during a 1 day orientation session that included watching a short video and observing staff interaction while performing her duties as a housekeeper. During a second interview in person on 2/23/16 at 1:50 p.m., Housekeeper D reported that on 2/11/16 at approximately 4:00 p.m., she was assigned to supervise the smoke session which included dispensing the cigarettes and lighting the cigarettes to approximately 30 plus residents ambulatory and in wheelchairs. She stated that she was standing approximately 10 feet from the patio door and was not aware of the initial altercation between Resident's #6 and #7. She stated that Resident #6 pulled up next to her and would not move to the side to allow other residents to pass. She attempted to push his wheelchair, but he stopped the chair with his feet and called her vieja pendeja, or stupid lady. Resident #7 then attempted to push the wheelchair and Resident #6 broke his rosary and scratched his face. Staffing Coordinator F intervened and separated the residents. Resident #7 was directed to sit on the bench to the right of the patio. The housekeeper turned her back to the 2 residents and began lighting cigarettes. She stated that she did not see the third altercation, but Staffing Coordinator F again intervened. At the end of the smoke session, she stated although she did not see Resident #6 being removed from the patio, she was certain Resident #6 was taken to his room by a staff member because he would not have voluntarily gone by himself. The facility Administrator was notified on 2/22/16 at 4:40 p.m. of an Immediate Jeopardy for the above failures and a Plan of Removal was requested. Facility Plan of Removal was provided by the Administrator on 2/23/16 at approximately 9:40 p.m. The Plan of Removal was accepted by the investigator on 2/23/16 at 10:08 p.m. and included the following steps: a. In-servicing of all staff was immediately started and included the in-service included a posttest regarding specific approaches and interventions when working with residents with aggressive behaviors, identifying and reporting all forms of abuse and the scheduling of quarterly in-services to reinforce the training. The facility arranged for a clinician from the MAT team to conduct an in-service to both staff and residents on 2/24/16 and several staff members which included housekeeping, dietary staff, maintenance staff and nursing staff who had attended the on-going in-services were quizzed regarding the importance and application of the material to their employment in the facility. b. The facility terminated the contract with the previous psychiatric services on 2/23/16 and reinstalled the previous psychiatric services on 2/24/16 to begin providing psychiatric assessments and treatments. Six residents were assessed on 2/24/16 and a team was scheduled to begin widespread assessing on 2/26/16. c. On 2/23/16, the facility posted for the residents to see a notice terminating the 7:00 p.m. smoking session and passed out consent forms to all the smoking residents to sign acknowledging understanding and consent for the change. The forms were shown to the investigator. d. On 2/23/16, the MDS's of 11 residents were reassessed and modified to reflect the behaviors of aggressive residents. Twenty-eight care plans had been reviewed and 6 of the 28 were modified to address behaviors. The investigator reviewed 4 of the MDS's with changes to Behaviors. e. On 2/23/16, the investigator observed the 7:00 p.m. scheduled smoking session on the back patio and noted that 4 staff members were present distributing cigarettes and supervising approximately 30 residents. The patio was covered by an over-sized tent which was not illuminated except by 2 small bulbs at the entrance of the building. The lack of illumination was reported to the Administrator, who during the exit conference reported that he had engaged an electrician to put up more lights. f. Both resident #6 and 7 were discharged by 2/24/16. Interviews with nursing, housekeeping and dietary revealed they had received in-services and had increased their understanding of how to identify triggers, implement interventions and monitor residents after altercations or aggressive behaviors. On 2/23/16 at 10:08 p.m., the Administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity level of widespread and immediate jeopardy to resident health or safety. The facility was continuing to monitor resident to resident interactions and aggressive residents and provide in-services to staff that had not received training. Information provided by DON indicated that there were 28 residents with behavioral healthcare needs.

Based on record review and interview, the facility failed to to implement the facility's policies and procedures that prohibited neglect in the area of notifying physician when the resident's condition showed a significant decline for 1 of 4 residents (Resident #2) reviewed for neglect in that: ? LVN A, LVN I, LVN Q, and the ADON did not consult with Resident # 2's physician or notify Resident #2's family that Resident #2 was experiencing respiratory distress. Facility policy is to consult with the resident's physician if there is a significant change. ? LVN A, LVN I, LVN Q, and the ADON did not send Resident #2 to the hospital when Resident #2 was experiencing respiratory distress. ? Resident #2 was in respiratory distress for 5 days before she was transported to the hospital where she was placed on a ventilator in ICU and died shortly thereafter. ? ADON and LVN I notified the Administrator (who is also a LVN) instead of consulting with a physician when Resident #2's primary physician was unavailable. These failures resulted in an Immediate Jeopardy which was identified on [DATE]. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. This deficient practice could affect 20 residents who were under the care of Physician J, and could result in resident injury and death. The findings were: Review of Resident #2's face sheet dated [DATE] revealed that Resident #2 was [DIAGNOSES REDACTED]. Further review of this same face sheet revealed that Resident #2 was admitted on [DATE] and readmitted on [DATE]. Review of Resident #2's clinical record revealed that Resident #2 had a Medical Power of Attorney, which was dated [DATE]. Review of Resident #2 Psychiatric Progress Note dated [DATE] revealed under "Mental Status Examination" Decreased judgment, Mood Swings, Diminished reality testing, [MEDICAL CONDITION], Aggressive at times, Depression, Decreased memory, [MEDICAL CONDITION], Agitation, Hallucinations, and [MEDICAL CONDITION]. Review of Resident #2's [DATE] CPO included these additional Diagnosis: [REDACTED]. Further review of this document revealed Resident #2 had no orders for oxygen. Review of Resident #2 physician telephone orders revealed there was no order for oxygen. Review of Resident #2's BMP drawn on [DATE] at the facility revealed Creatinine at 0.8 (normal range 0XXX,[DATE].0) and Potassium at 4.0 ( normal range 3XXX,[DATE].2). Review of Resident #2's Nursing Notes dated [DATE] at 3:45 a.m. revealed Resident #2 complained of shortness of breath. Further review of this same document revealed that Resident #2 was "then repositioned & given 1 puff of proventol" (for shortness of breath) "via HHN," oxygen saturation 84%. Further review of this same document revealed that Resident #2 was started on 2 liters of oxygen via nasal cannula. Further review of this document revealed that Resident #2's oxygen saturation level increased to 94%. Further review of this same document revealed that Resident #2 will continue to monitored. Further review of this same document that Resident #2 sounded congested. Further review of this note revealed there was no documentation about calling the physician about Resident #2's oxygen saturation and Resident #2's congestion. During an interview on [DATE] at 3:25 p.m. with LVN A indicated that Resident #2 on [DATE] was in her usual state up in her wheelchair, eating and talking. She further indicated that Resident #2 was independent in the wheelchair for short distances. During an interview on [DATE] at 2:20 p.m. with LVN I, she confirmed there was no telephone order for oxygen for Resident #2 until [DATE]. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2's physician was notified that she had the shortness of breath and was on oxygen. Review of Resident #2's Nursing Notes dated [DATE] at 11:10 a.m. revealed the physician had ordered Resident #2 a stat chest x-ray. Review of Resident #2's telephone order dated [DATE] revealed stat chest x-ray due to complaint of shortness of breath and congestion. Review of Resident #2's Nursing Notes dated [DATE] at 11:30 a.m. revealed that Resident #2 was sitting up in bed eating lunch. The nursing note further revealed she was on oxygen at 2 liters per minute. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that a stat chest x-ray report was received at 1:35 p.m. The nursing notes further revealed the result of the chest x-ray showed mild [MEDICAL CONDITIONS]/[MEDICAL CONDITION]. The nursing note further revealed that a previous x-ray completed on [DATE] revealed mild [MEDICAL CONDITIONS] and that the [MEDICAL CONDITION] was new. Further review of this same document revealed a call was made to the physician's office and that the physician was unavailable at that time. Further review of this same document revealed per the physician office, the physician was expected to be back in the office at 2:10 p.m. Further review of this same document revealed that the facility nurse would notify ,[DATE] shift to follow up with physician. Review of Resident #2's Nursing Notes dated [DATE] at 4:18 p.m. revealed Resident#2 was taken off of oxygen for 30 minutes for room air tolerance. Further review of this document revealed that resident #2 oxygen saturation level dropped from 95% to 76% within that time frame and that Resident #2 was immediately placed back on oxygen at 4 liters. Further review of this document revealed that Resident #2 was lethargic and ate 0% for dinner. Further review of this document revealed that Resident #2's medication were placed on hold per nursing judgment (those that may cause drowsiness). Further review of this document revealed "Unable to call physician back at the time." Further review of this same document revealed that RT was in to assess Resident #2. Further review of this same document revealed that two oxygen tanks and an ambu bag were placed in the room. Further review of this same document revealed that Resident #2 was a full code and that Resident #2 had heavy use of accessory muscles (Signs of respiratory distress include: Retractions " The chest appears to sink in just below the neck and/or under the breastbone with each breath--one way of trying to bring more air into the lungs " . Wexner Medical Center Ohio State University <http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/about/signs/pages/index.aspx>) upon inspiration. Further review of Nursing Notes dated [DATE] at 4:18 p.m. revealed that Resident #2's Oxygen Saturation at 95%. During an interview on [DATE] at 3:25 p.m. with LVN A, indicated she decided to trial Resident #2 without her oxygen as Resident #2 wanted to eat in the dining room. LVN A indicated that Resident #2 was unable to tolerate going without the oxygen. LVN A further indicated that Resident #2 started to use her accessory muscles within twenty minutes. LVN A indicated she took Resident #2 off of her oxygen as she was trying to be proactive. She further indicated that she told the ADON about the lack of oxygen tolerance and the ADON told her to keep the oxygen on Resident #2 and to monitor her. Review of Respiratory note dated [DATE] at 8:00 p.m. revealed Resident #2 was on 4 liters of oxygen. Resident #2 had signs of increased accessory muscle use (Retractions). Further review of this document revealed that Resident #2 was lethargic and that Respiratory staff told the nurse to further assess Resident #2. This documentation also revealed that Resident #2 had diminished breath sounds. During an interview on [DATE] at 11:42 a.m. with CRTT N, she indicated that she went in to care for Resident #2 on [DATE] at 8:00 p.m. because Resident #2 was having respiratory distress. She indicated that she started Resident #2 on 4 liters of oxygen per minute. She indicated that she considered the resident to be stable since Resident #2's vital signs were O2 sat 95%, respiratory rate 18, heart rate 73 on 4 liters per minute of oxygen. She indicated she told the nurse to reassess Resident #2 due to increased accessory muscle use and lethargy. She indicated she had not informed the physician of Resident #2's respiratory distress but that she had only spoken to the nurse. Record review of a respiratory note dated [DATE] revealed at 12:00 a.m. CRTT O had documented patient continued to have respiratory retractions and was lethargic. The patient was still on 4 liters of O2. Record review of respiratory note dated [DATE] revealed at 4:00 a.m. the patient remained on 4 liters of oxygen and continued to use accessory muscles. During an interview on [DATE] at 6:38 p.m. with LVN Q, he indicated he was the night nurse for Resident #2. He also indicated that on [DATE] Resident #2's oxygen saturation level was ,[DATE]%. He further indicated that he left a note on the [DATE] night shift for the next shift that came on duty on [DATE] at 10:00 p.m. He indicated he was surprised that Resident #2 was still at the facility the next day when he came on duty. He indicated he thought that Resident #2 would have been in the hospital. When asked why he did not send Resident #2 to the hospital, he indicated he did not consider sending her out because the other shifts did not send Resident #2 to the hospital. He indicated that the Administrator and DON needed to know before a resident was sent out to the hospital and that there was no discussion with anyone about sending Resident #2 to the hospital. Review of Nursing Note dated [DATE] at 2:30 a.m. revealed Resident #2 was in bed throughout the shift. Resident #2's skin was warm to touch. Further review of nursing note revealed that Resident #2 was alert and oriented x 3 and able to verbalize needs. Further review of this same document revealed that Resident #2 continued to use accessory muscles and was on continuous oxygen at 2 liters per nasal cannula. Review of Respiratory note dated [DATE] at 4:00 a.m. revealed Resident #2 continued to use accessory muscles and her oxygen was at 4 liters per nasal cannula. Record review of Resident #2's respiratory care note dated [DATE] at 9:00 a.m. revealed that the nurse reported that Resident #2 was having respiratory distress. Further review of this same document revealed that Resident #2's nasal cannula was switched to a simple mask and and her oxygen was increased to 7 liters per minute. The note was written by CRTT P. Further review of this note revealed there was no documentation that the physician was consulted. During interview on [DATE] at 2:34 p.m. with CRTT P, he indicated he had changed Resident #2 from a nasal cannula to a simple mask and increased her oxygen to 7 liters per minute. He indicated the MD did not order the oxygen to be increased to 7 liters per minute from 4 liters per minute. CRTT P indicated it was up to the nurse to talk to the physician. CRTT P indicated he just informed the nurse what he did and Resident #2's response Review of Resident #2's Nursing Note dated [DATE] at 9:00 a.m. revealed a new order for [MEDICATION NAME] 20mg by mouth twice a day for [DIAGNOSES REDACTED]. Review of Resident #2's telephone orders dated [DATE] revealed an order for [REDACTED]. Review of physician telephone order (not dated on yellow copy) for Resident #2 to be seen by a hospice revealed that the ADON had signed as the nurse who received the telephone order. Review of Resident #2's Nursing Notes dated [DATE] at 10:00 a.m. revealed that Resident #2 was in bed resting with eyes open. Potassium 20 mEq by mouth daily was discontinued and [MEDICATION NAME] (use to treat fluid retention related to [MEDICAL CONDITION]) 25 mg by mouth daily was started instead. Review of Resident #2 ' s signed physician telephone orders dated [DATE] just received by the facility from the physician revealed that the physician had written "Add O2 at 2L/NC & increase prn if O2 sat. dropping." During an interview on [DATE] at 5:36 p.m. with Medical Records Personnel, she indicated that telephones had come back from the physician on [DATE] to include [DATE] telephone order that included add O2. Review of physician telephone order dated [DATE] revealed that the ADON had signed as the nurse who received the physician telephone order. Further review of this telephone order revealed to discontinue Potassium 20 mEq PO, give [MEDICATION NAME] ([MEDICATION NAME]) 25 mg PO daily. During an interview on [DATE] at 11:04 a.m. with the ADON, she was shown the telephone order for hospice and the telephone order to discontinue potassium and give [MEDICATION NAME] ([MEDICATION NAME]). The ADON verified it was her signature on both of those orders. When asked who she got those orders from, she indicated she received those orders from the Administrator. When asked for the phone number for Resident #2's physician since this physician was not in his office on [DATE], when the surveyor tried to contact the physician, she indicated there wasn't another number, just the office number. When asked who they would call if something was going on with a resident the ADON said the Administrator. She further indicated that the Administrator was the next in line to reach if this physician was not in his office. The ADON also indicated that the Administrator has the authority to make decisions for this physician when this physician is not available and they notify this physician about what orders the Administrator has given later. During an interview on [DATE] at 11:14 a.m., with the Administrator, he indicated that he was the designated agent for Physician J and that he had the authority to prescribe. He further indicated that his authority to prescribe meant that he could refill a Vicoden prescription at the pharmacy using the DEA number. He further indicated that these were some of his duties and he described it similar to working as an employee as a nurse in a physician's office where a nurse would be able to call in a prescription at the pharmacy. He further indicated he could follow standing protocols and provided an example such as the standing orders for [MEDICAL CONDITION] and provided an example of [MEDICATION NAME] and Potassium as being a part of the standing orders. Review of "Heart Failure-[MEDICAL CONDITION]" (standing orders for [MEDICAL CONDITION]) revealed "Admit/Re-Admit Protocols for Medicare A 'Skilled Resident'. Further review of this document revealed no standing orders for Potassium and [MEDICATION NAME]. During an interview on [DATE] at 1:13 p.m. with the Administrator, when told that the [MEDICAL CONDITION] standing orders does not include [MEDICATION NAME] and Potassium, he indicated that they could follow whatever is on that form. During an interview on [DATE] at 1:16 p.m. with the ADON, she indicated that if there was no answer from the physician, they next went to the Administrator, then to the "Medical Examiner". During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator since the doctor could not be reached and the Administrator said that Resident #2 needed to go on hospice. During an interview on [DATE] at 6:53 p.m. with Physician J, he indicated that he thought the orders for the [MEDICATION NAME] had come from another physician because he did not normally prescribe [MEDICATION NAME]. He indicated that he recalled agreeing to a hospice consult because he thought the family had requested it or another physician had requested it. He further indicated he had not personally spoken to Resident #2's family. He further indicated there was a standing order to send residents to the emergency room if needed without having to get in touch with him for an order to send the resident to the emergency room . Review of Resident #2's physician progress notes [REDACTED]. Review of Resident #2's nursing notes revealed no documentation of physician or nurse practitioner visits after [DATE]. Review of Resident #2's Social Services Note revealed that social worker contacted hospice care as per instructions from the Administrator. Further review of this same note revealed that Referral was made for hospice care for resident who has decompensated medically and will benefit from hospice care. During an interview on [DATE] at 6:01 p.m. with the Medical Director, he indicated he had not personally given orders for or been involved with Resident #2's care at the nursing facility. The Medical Director further indicated that he or his nurse practitioner should be contacted if a resident's primary care physician was not available and a physician's input was needed. The Medical Director said they would be very willing to take those calls and they had a system in place that a physician would always be available. During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator when the physician was not available because the Administrator worked with this physician. LVN I indicated that the Administrator gave orders for [MEDICATION NAME] and Potassium and they were sent off to the pharmacy. LVN I further indicated that the Administrator discontinued the order and gave orders for [MEDICATION NAME] due to [MEDICATION NAME] is Potassium sparing. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2 was resting on her left side and that she was being turned every 2 hours. The note further revealed that Resident #2's bilateral extremities were elevated due to increased [MEDICAL CONDITION]. The note further revealed Resident #2 was stable. The note further revealed that hospice had just seen Resident #2. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that Resident #2's sister phoned the facility and called to inquire about the resident and the change of condition was explained to the sister. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that the facility had not called her regarding Resident #2's change in condition. She further indicated she had to call the facility (on [DATE]) to see what was going on with Resident #2 because she had received an unexpected call from a hospice about admitting Resident #2 to their services. Resident #2's family member said she was shocked to be called by hospice because Resident #2 was her normal self when she visited her 3 weeks earlier except for severe bruising around her eye after an incident involving another resident. She also indicated that when she called the facility, the ADON had answered the phone. She then indicated she had told the ADON she wanted to know how Resident #2 was doing, She further indicated that the ADON told her she was sorry and that someone should have called her. Resident #2's family member further indicated that it seemed like the facility staff were taking matters into their own hands. Review of Resident #2's Nursing Notes dated [DATE] for ,[DATE] p.m. shift revealed that Resident #2 had to be reminded to keep her oxygen mask on. Respiratory notes dated [DATE] at 12:00 a.m. revealed Resident #2 was on a simple mask using 8 liters of oxygen. Further review of this note revealed coarse rales ("A loud and low-pitched, discontinuous, ' explosive ' crackling sound heard in patients" http://medical-dictionary.thefreedictionary.com/Coarse+Rales) and diminished breath sounds throughout. Further review of the note revealed Resident #2 was stable. Review of Resident #2's Nursing Notes dated [DATE] at 2:45 a.m. revealed that Resident #2 remained on bed rest. The note further revealed that Resident #2 was on continuous oxygen at 8 liters. Further review of this same document revealed that Resident #2's oxygen saturation was 97% at 2:45 a.m. and that Resident #2 was arouseable to tactile stimulation. Further review of this same document revealed that Resident #2 continued to breathe using her accessory muscles. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 8:00 a.m. revealed Resident #2 refused to eat breakfast. Further review of the note revealed that Resident #2 was using her accessory muscles at that time. Further review of the nurses note revealed that Resident #2's bilateral lower extremities were elevated to decrease [MEDICAL CONDITION]. This nursing note also indicated that Resident #2 was spoon fed two cups of applesauce and tolerated 1 cup of water. During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that on [DATE], Resident #2 was using accessory muscles to breathe. She further indicated that Resident #2 could not eat and breathe at the same time. She also indicated that at 11:30 a.m. she placed a call to the physician and never received a call back from the physician. She indicated that on [DATE] the new problem with swallowing was first noted. She spoon fed Resident #2 applesauce and made a call to get a MBS study. Review of Resident #2's telephone order dated [DATE] and timed 12:30 p.m. revealed swallow study consult with MBSS due to difficulty swallowing and aspiration risk Further review of this telephone order read back to Physician J/LVN I. Review of Resident #2's Nurses notes dated [DATE] at 11:30 revealed "call made to MD to schedule MBSS, pending call back at this time." Observation of the DON at [DATE] at 5:15 p.m. revealed the DON dialing the phone. The message heard from the speaker phone said the doctor's office hours are Monday thru Friday except on Thursday. There was was no option to leave a message or an alternative number given to try to reach the physician. The DON further indicated that he did not have the number to reach Physician J after hours, only the Administrator had the number. During an interview on [DATE] at 7:18 p.m. with the Administrator, he indicated that he was the only one with Physician J's personal cell number. Review of hospice document dated [DATE] titled "Nursing Review of Patient Decline Related to Cardiopulmonary Conditions" in the section titled "Current Clinical Picture" revealed the patient was in bed and unresponsive. 2+ - 3+ generalized [MEDICAL CONDITION] (fluid building up within the body which can include the skin and lung tissues). Vital signs stable, no skin breakdown, lungs are diminished with ronchi ("a continuous snore like sound in the throat or [MEDICATION NAME] tubes, due to a partial obstruction" http://medical-dictionary.thefreedictionary.com/rhonchi ). Uses abdominal muscles to breathe. Patient on diuretics with little output. Has third spacing (accumulation of fluids between the skin and fascia ("A fibrous membrane covering , supporting, and separating muscles" Taber's Cyclopedic Medical Dictionary) http://medical-dictionary.thefreedictionary.com/third+spacing). Bowel Sounds faint. 3 Liters via mask. Sats. 99%. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed Resident #2 was on bed rest due to shortness of breath and decreased oxygen saturation. Resident #2 was on 8 liters of oxygen and continued to use her accessory muscles to breathe. Review of Resident #2's Nursing Notes dated [DATE] at 5:30 a.m. revealed Resident #2 had attempted to get out of bed and slid to the floor. This note also revealed the fall was witnessed. Resident #2 bit her lips/tongue. The note further indicated to call the physician in the a.m. Review of Resident #2's Nursing Notes dated [DATE] at 5:53 p.m. revealed staff had attempted to feed Resident #2 three times during dinner. The note further revealed that Resident #2 was too lethargic and Resident #2 had no output during the shift. The note further revealed that Resident #2 would continue be to monitored. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 9:26 p.m. revealed that no output for Resident #2 had been observed. Further review of this nursing note revealed that Resident #2 was too lethargic to receive hydration times 2 attempts. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed that hospice was notified of Resident #2 having no urine output. Hospice staff called back and said to insert an indwelling catheter. Catheter was inserted and resulted in 400 cc of urine. Review of Resident #2's Nursing Notes dated [DATE], no time, revealed that Resident #2 had bilateral diminished breath sounds. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that she went to the nursing facility on [DATE] and told facility staff she wanted Resident #2 off of hospice and sent to the hospital for treatment. The facility staff told her that they were doing everything for her that the hospital would do. The resident's family continued to insist that Resident #2 be sent to the hospital and further indicated they had trouble getting Resident #2 out. The facility staff told her that she would have to be responsible for the ambulance charges. Resident #2's family member was not sure if she had signed AMA paperwork. Resident #2's family member said that she had been asked by the EMT why Resident #2 had not been sent to the hospital on Monday ([DATE]). The EMT told Resident #2's family member that the EMT needed Resident #2's information including medication list and History and Physical and to please ask the facility staff to provide it to them because EMT had problems getting all the information from the nursing home staff. Resident #2's family member said she had asked the facility staff who the physician was that had been taking care of Resident #2. Resident #2's family member indicated that the facility staff refused to give her contact information for the physician or tell them his name. Resident #2's family member said she still did not know who the physician had been. Resident #2's family member indicated that the facility had never brought up to her the option of taking her to the hospital. Review of Resident #2's Nursing Notes dated [DATE] at 1:50 p.m., revealed that Resident #2's sister wanted Resident #2 off of hospice and transferred to the hospital. Called ADON to inform. Family signed AMA paperwork. Family made aware facility does not cover anything else once AMA is signed. During an interview on [DATE] at 1:16 p.m. with LVN F and ADON, that LVN F indicated that she asked the family to sign AMA because the ADON told her to get the AMA signed. ADON indicated that she went to her "Director" (Administrator) regarding the family request to send Resident #2 to the hospital. ADON indicated that the Administrator is her Director. She further indicated that the Administrator told her to get AMA signed as family was pulling resident out against medical advice. ADON indicated that the Administrator told her this during the only call between ADON and Administrator on that Saturday ([DATE]). LVN F indicated that she did not leave a message for the physician on [DATE]. ADON and LVN F indicated that neither of them spoke to the Medical Director nor any of his Nurse Practitioners on [DATE]. During an interview on [DATE] at 2:36 p.m. with the Administrator, he indicated that the ADON called him and he was at the airport using his cell phone. He further indicated he clicked over and called the physician and then talked to the ADON again. The Administrator indicated that the physician already knew that Resident #2 was leaving AMA because the nurse had left a message earlier for the physician. During this interview with the Administrator the ADON indicated she had called the Administrator and was on a 3 way call and she heard the physician say if the resident goes to the hospital she will be going AMA. During an interview on [DATE] at 11:14 a.m., with the Administrator, he indicated that he was the designated agent for Physician J and that he had the authority to prescribe. He further indicated that his authority to prescribe meant that he could refill a Vicoden prescription at the pharmacy using the DEA number. He further indicated that these were some of his duties and he described it similar to working as an employee as a nurse in a physician's office where a nurse would be able to call in a prescription at the pharmacy. He further indicated he could follow standing protocols and provided an example such as the standing orders for [MEDICAL CONDITION] and provided an example of [MEDICATION NAME] and Potassium as being a part of the standing orders. Review of "Heart Failure-[MEDICAL CONDITION]" (standing orders for [MEDICAL CONDITION]) revealed "Admit/Re-Admit Protocols for Medicare A 'Skilled Resident'. Further review of this document revealed no standing orders for Potassium and [MEDICATION NAME]. During an interview on [DATE] at 1:13 p.m. with the Administrator, when told that the [MEDICAL CONDITION] standing orders does not include [MEDICATION NAME] and Potassium, he indicated that they could follow whatever is on that form. During an interview on [DATE] at 6:53 p.m. with Physician J, he indicated that if a resident's need for oxygen was increasing from 2 liters of oxygen to 4 liters of oxygen, to 7 liters of oxygen to 8 liters of oxygen, they should be sent to the hospital for evaluation and treatment. Physician J indicated that he was not informed that Resident #2's need for oxygen had increased. Physician J further indicated he was not aware that Resident #2 had declined in condition since the initial complaint of shortness of breath and mild [MEDICAL CONDITIONS]. He further indicated there was a standing order to send residents to the emergency room if needed without having to get in touch with him for an order to send the resident to the emergency room . He further indicated it would not have been reasonable to make a resident have to sign out AMA to go to the hospital at the family's request due to decline in condition and family's desire for medical treatment. He further indicated he did not say the resident must sign out AMA to go to the hospital at Resident #2's family's request. He further indicated he did not give the order that Resident #2 must leave AMA to go to the hospital for treatment. He further indicated he was not aware of the family signing out Resident #2 AMA until after Resident #2 had already left the facility to go to the hospital. When asked if Physician J and the Administrator had an agreement or understanding that that Administrator could make decisions regarding resident's medical treatment, Physician J said no, definitely not to order medications just to send resident to the emergency room if needed. Physician J further indicated he gets telephone orders to sign from facilities and only has time to read about half of the orders he signs so he can't say for sure he that he knows if all the telephone orders he signs were from the orders he knows and remembers giving. During interview on [DATE] at 3:25 p.m. with LVN A, she indicated that when she looked back at the condition of Resident #2, LVN A thought Resident #2 probably should have been sent to the hospital on [DATE]. During an interview on [DATE] at 7:32 p.m. with the DON, when asked if he would expect his nursing staff to do anything differently, he indicated he would want his staff to do better documentation. When asked if staff would be expected to provide care any differently he said no because the resident was stable. Review of the hospital History and Physical with admitted [DATE] revealed "The patient is critically ill with as noted [MEDICAL CONDITION], metabolic [MEDICAL CONDITION], acutely decompensated [MEDICAL CONDITION], acute [MEDICAL CONDITION], multiorgan system failure and we will place in ICU. [MEDICAL CONDITION] Critical Care is consulted as is Nephrology was notified by ER doctor". Further review of this same document "Per family, the patient was enrolled in hospice care by nursing home a few days back. The patient had clinically worsened and became comatose, unresponsive and family had rescinded the hospice care and the patient was brought to the ER emergently, comatose deeply, unresponsive with acute [MEDICAL CONDITION], marked hepatic [MEDICAL CONDITION], ammonia level over 1000 (an indication of liver failure)

Based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, status and an accident involving a resident which resulted in injury and had the potential for requiring physician intervention, for 2 of 10 residents (Residents #2 and #10), in that: 1. LVN A, LVN I, LVN Q, and the ADON did not consult with Resident # 2's physician or notify Resident #2's family that Resident #2 was experiencing respiratory distress. Facility policy is to consult with the resident's physician if there is a significant change. Resident #2 was in respiratory distress for 5 days before she was transported to the hospital where she was placed on a ventilator in ICU and died shortly thereafter. These failures resulted in an Immediate Jeopardy which was identified on [DATE]. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. 2. Non-Immediate Jeopardy. The injury (bump on the back of the head) from Resident #10's "unwitnessed" fall was not reported to the physician or APN for the development of an appropriate plan of care. This deficient practice could affect 20 residents under the care of Physician J and 11 residents who had falls in the month of [DATE], and could result in resident injury and death. The findings were: Review of Resident #2's face sheet dated [DATE] revealed that Resident #2 was [DIAGNOSES REDACTED]. Further review of this same face sheet revealed that Resident #2 was admitted on [DATE] and readmitted on [DATE]. Review of Resident #2's clinical record revealed that Resident #2 had a Medical Power of Attorney, which was dated [DATE]. Review of Resident #2 Psychiatric Progress Note dated [DATE] revealed under "Mental Status Examination" Decreased judgment, Mood Swings, Diminished reality testing, [MEDICAL CONDITION], Aggressive at times, Depression, Decreased memory, [MEDICAL CONDITION], Agitation, Hallucinations, and [MEDICAL CONDITION]. Review of Resident #2's [DATE] CPO included these additional Diagnosis: [REDACTED]. Further review of this document revealed Resident #2 had no orders for oxygen. Review of Resident #2 physician telephone orders revealed there was no order for oxygen. Review of Resident #2's BMP drawn on [DATE] at the facility revealed Creatinine at 0.8 (normal range 0XXX,[DATE].0) and Potassium at 4.0 ( normal range 3XXX,[DATE].2). Review of Resident #2's Nursing Notes dated [DATE] at 3:45 a.m. revealed Resident #2 complained of shortness of breath. Further review of this same document revealed that Resident #2 was "then repositioned & given 1 puff of proventol" (for shortness of breath) "via HHN," oxygen saturation 84%. Further review of this same document revealed that Resident #2 was started on 2 liters of oxygen via nasal cannula. Further review of this document revealed that Resident #2's oxygen saturation level increased to 94%. Further review of this same document revealed that Resident #2 will continue to monitored. Further review of this same document that Resident #2 sounded congested. Further review of this note revealed there was no documentation about calling the physician about Resident #2's oxygen saturation and Resident #2's congestion. During an interview on [DATE] at 3:25 p.m. with LVN A indicated that Resident #2 on [DATE] was in her usual state up in her wheelchair, eating and talking. She further indicated that Resident #2 was independent in the wheelchair for short distances. During an interview on [DATE] at 2:20 p.m. with LVN I, she confirmed there was no telephone order for oxygen for Resident #2 until [DATE]. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2's physician was notified that she had the shortness of breath and was on oxygen. Review of Resident #2's Nursing Notes dated [DATE] at 11:10 a.m. revealed the physician had ordered Resident #2 a stat chest x-ray. Review of Resident #2's telephone order dated [DATE] revealed stat chest x-ray due to complaint of shortness of breath and congestion. Review of Resident #2's Nursing Notes dated [DATE] at 11:30 a.m. revealed that Resident #2 was sitting up in bed eating lunch. The nursing note further revealed she was on oxygen at 2 liters per minute. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that a stat chest x-ray report was received at 1:35 p.m. The nursing notes further revealed the result of the chest x-ray showed mild [MEDICAL CONDITIONS]/[MEDICAL CONDITION]. The nursing note further revealed that a previous x-ray completed on [DATE] revealed mild [MEDICAL CONDITIONS] and that the [MEDICAL CONDITION] was new. Further review of this same document revealed a call was made to the physician's office and that the physician was unavailable at that time. Further review of this same document revealed per the physician office, the physician was expected to be back in the office at 2:10 p.m. Further review of this same document revealed that the facility nurse would notify ,[DATE] shift to follow up with physician. Review of Resident #2's Nursing Notes dated [DATE] at 4:18 p.m. revealed Resident#2 was taken off of oxygen for 30 minutes for room air tolerance. Further review of this document revealed that resident #2 oxygen saturation level dropped from 95% to 76% within that time frame and that Resident #2 was immediately placed back on oxygen at 4 liters. Further review of this document revealed that Resident #2 was lethargic and ate 0% for dinner. Further review of this document revealed that Resident #2's medication were placed on hold per nursing judgment (those that may cause drowsiness). Further review of this document revealed "Unable to call physician back at the time." Further review of this same document revealed that RT was in to assess Resident #2. Further review of this same document revealed that two oxygen tanks and an ambu bag were placed in the room. Further review of this same document revealed that Resident #2 was a full code and that Resident #2 had heavy use of accessory muscles (Signs of respiratory distress include: Retractions " The chest appears to sink in just below the neck and/or under the breastbone with each breath--one way of trying to bring more air into the lungs " . Wexner Medical Center Ohio State University <http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/about/signs/pages/index.aspx>) upon inspiration. Further review of Nursing Notes dated [DATE] at 4:18 p.m. revealed that Resident #2's Oxygen Saturation at 95%. During an interview on [DATE] at 3:25 p.m. with LVN A, indicated she decided to trial Resident #2 without her oxygen as Resident #2 wanted to eat in the dining room. LVN A indicated that Resident #2 was unable to tolerate going without the oxygen. LVN A further indicated that Resident #2 started to use her accessory muscles within twenty minutes. LVN A indicated she took Resident #2 off of her oxygen as she was trying to be proactive. She further indicated that she told the ADON about the lack of oxygen tolerance and the ADON told her to keep the oxygen on Resident #2 and to monitor her. Review of Respiratory note dated [DATE] at 8:00 p.m. revealed Resident #2 was on 4 liters of oxygen. Resident #2 had signs of increased accessory muscle use (Retractions). Further review of this document revealed that Resident #2 was lethargic and that Respiratory staff told the nurse to further assess Resident #2. This documentation also revealed that Resident #2 had diminished breath sounds. During an interview on [DATE] at 11:42 a.m. with CRTT N, she indicated that she went in to care for Resident #2 on [DATE] at 8:00 p.m. because Resident #2 was having respiratory distress. She indicated that she started Resident #2 on 4 liters of oxygen per minute. She indicated that she considered the resident to be stable since Resident #2's vital signs were O2 sat 95%, respiratory rate 18, heart rate 73 on 4 liters per minute of oxygen. She indicated she told the nurse to reassess Resident #2 due to increased accessory muscle use and lethargy. She indicated she had not informed the physician of Resident #2's respiratory distress but that she had only spoken to the nurse. Record review of a respiratory note dated [DATE] revealed at 12:00 a.m. CRTT O had documented patient continued to have respiratory retractions and was lethargic. The patient was still on 4 liters of O2. Record review of respiratory note dated [DATE] revealed at 4:00 a.m. the patient remained on 4 liters of oxygen and continued to use accessory muscles. During an interview on [DATE] at 6:38 p.m. with LVN Q, he indicated he was the night nurse for Resident #2. He also indicated that on [DATE] Resident #2's oxygen saturation level was ,[DATE]%. He further indicated that he left a note on the [DATE] night shift for the next shift that came on duty on [DATE] at 10:00 p.m. He indicated he was surprised that Resident #2 was still at the facility the next day when he came on duty. He indicated he thought that Resident #2 would have been in the hospital. When asked why he did not send Resident #2 to the hospital, he indicated he did not consider sending her out because the other shifts did not send Resident #2 to the hospital. He indicated that the Administrator and DON needed to know before a resident was sent out to the hospital and that there was no discussion with anyone about sending Resident #2 to the hospital. Review of Nursing Note dated [DATE] at 2:30 a.m. revealed Resident #2 was in bed throughout the shift. Resident #2's skin was warm to touch. Further review of nursing note revealed that Resident #2 was alert and oriented x 3 and able to verbalize needs. Further review of this same document revealed that Resident #2 continued to use accessory muscles and was on continuous oxygen at 2 liters per nasal cannula. Review of Respiratory note dated [DATE] at 4:00 a.m. revealed Resident #2 continued to use accessory muscles and her oxygen was at 4 liters per nasal cannula. Record review of Resident #2's respiratory care note dated [DATE] at 9:00 a.m. revealed that the nurse reported that Resident #2 was having respiratory distress. Further review of this same document revealed that Resident #2's nasal cannula was switched to a simple mask and and her oxygen was increased to 7 liters per minute. The note was written by CRTT P. Further review of this note revealed there was no documentation that the physician was consulted. During interview on [DATE] at 2:34 p.m. with CRTT P, he indicated he had changed Resident #2 from a nasal cannula to a simple mask and increased her oxygen to 7 liters per minute. He indicated the MD did not order the oxygen to be increased to 7 liters per minute from 4 liters per minute. CRTT P indicated it was up to the nurse to talk to the physician. CRTT P indicated he just informed the nurse what he did and Resident #2's response Review of Resident #2's Nursing Note dated [DATE] at 9:00 a.m. revealed a new order for [MEDICATION NAME] 20mg by mouth twice a day for [DIAGNOSES REDACTED]. Review of Resident #2's telephone orders dated [DATE] revealed an order for [REDACTED]. Review of physician telephone order (not dated on yellow copy) for Resident #2 to be seen by a hospice revealed that the ADON had signed as the nurse who received the telephone order. Review of Resident #2's Nursing Notes dated [DATE] at 10:00 a.m. revealed that Resident #2 was in bed resting with eyes open. Potassium 20 mEq by mouth daily was discontinued and [MEDICATION NAME] (use to treat fluid retention related to [MEDICAL CONDITION]) 25 mg by mouth daily was started instead. Review of Resident #2 ' s signed physician telephone orders dated [DATE] just received by the facility from the physician revealed that the physician had written "Add O2 at 2L/NC & increase prn if O2 sat. dropping." During an interview on [DATE] at 5:36 p.m. with Medical Records Personnel, she indicated that telephones had come back from the physician on [DATE] to include [DATE] telephone order that included add O2. Review of physician telephone order dated [DATE] revealed that the ADON had signed as the nurse who received the physician telephone order. Further review of this telephone order revealed to discontinue Potassium 20 mEq PO, give [MEDICATION NAME] ([MEDICATION NAME]) 25 mg PO daily. During an interview on [DATE] at 11:04 a.m. with the ADON, she was shown the telephone order for hospice and the telephone order to discontinue potassium and give [MEDICATION NAME] ([MEDICATION NAME]). The ADON verified it was her signature on both of those orders. When asked who she got those orders from, she indicated she received those orders from the Administrator. When asked for the phone number for Resident #2's physician since this physician was not in his office on [DATE], when the surveyor tried to contact the physician, she indicated there wasn't another number, just the office number. When asked who they would call if something was going on with a resident the ADON said the Administrator. She further indicated that the Administrator was the next in line to reach if this physician was not in his office. During an interview on [DATE] at 11:14 a.m., with the Administrator, he indicated that he was the designated agent for Physician J and that he had the authority to prescribe. He further indicated that his authority to prescribe meant that he could refill a Vicoden prescription at the pharmacy using the DEA number. He further indicated that these were some of his duties and he described it similar to working as an employee as a nurse in a physician's office where a nurse would be able to call in a prescription at the pharmacy. He further indicated he could follow standing protocols and provided an example such as the standing orders for [MEDICAL CONDITION] and provided an example of [MEDICATION NAME] and Potassium as being a part of the standing orders. Review of "Heart Failure-[MEDICAL CONDITION]" (standing orders for [MEDICAL CONDITION]) revealed "Admit/Re-Admit Protocols for Medicare A 'Skilled Resident'. Further review of this document revealed no standing orders for Potassium and [MEDICATION NAME]. During an interview on [DATE] at 1:13 p.m. with the Administrator, when told that the [MEDICAL CONDITION] standing orders does not include [MEDICATION NAME] and Potassium, he indicated that they could follow whatever is on that form. During an interview on [DATE] at 1:16 p.m. with the ADON, she indicated that if there was no answer from the physician, they next went to the Administrator, then to the "Medical Examiner". During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator since the doctor could not be reached and the Administrator said that Resident #2 needed to go on hospice. During an interview on [DATE] at 6:53 p.m. with Physician J, he indicated that he thought the orders for the [MEDICATION NAME] had come from another physician because he did not normally prescribe [MEDICATION NAME]. He indicated that he recalled agreeing to a hospice consult because he thought the family had requested it or another physician had requested it. He further indicated he had not personally spoken to Resident #2's family. He further indicated there was a standing order to send residents to the emergency room if needed without having to get in touch with him for an order to send the resident to the emergency room . Review of Resident #2's physician progress notes [REDACTED]. Review of Resident #2's nursing notes revealed no documentation of physician or nurse practitioner visits after [DATE]. During an interview on [DATE] at 6:01 p.m. with the Medical Director, he indicated he had not personally given orders for or been involved with Resident #2's care at the nursing facility. The Medical Director further indicated that he or his nurse practitioner should be contacted if a resident's primary care physician was not available and a physician's input was needed. The Medical Director said they would be very willing to take those calls and they had a system in place that a physician would always be available. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2 was resting on her left side and that she was being turned every 2 hours. The note further revealed that Resident #2's bilateral extremities were elevated due to increased [MEDICAL CONDITION]. The note further revealed Resident #2 was stable. The note further revealed that hospice had just seen Resident #2. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that Resident #2's sister phoned the facility and called to inquire about the resident and the change of condition was explained to the sister. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that the facility had not called her regarding Resident #2's change in condition. She further indicated she had to call the facility (on [DATE]) to see what was going on with Resident #2 because she had received an unexpected call from a hospice about admitting Resident #2 to their services. Resident #2's family member said she was shocked to be called by hospice because Resident #2 was her normal self when she visited her 3 weeks earlier except for severe bruising around her eye after an incident involving another resident. She also indicated that when she called the facility, the ADON had answered the phone. She then indicated she had told the ADON she wanted to know how Resident #2 was doing, She further indicated that the ADON told her she was sorry and that someone should have called her. Resident #2's family member further indicated that it seemed like the facility staff were taking matters into their own hands. Review of Resident #2's Nursing Notes dated [DATE] for ,[DATE] p.m. shift revealed that Resident #2 had to be reminded to keep her oxygen mask on. Respiratory notes dated [DATE] at 12:00 a.m. revealed Resident #2 was on a simple mask using 8 liters of oxygen. Further review of this note revealed coarse rales ("A loud and low-pitched, discontinuous, 'explosive' crackling sound heard in patients" http://medical-dictionary.thefreedictionary.com/Coarse+Rales) and diminished breath sounds throughout. Further review of the note revealed Resident #2 was stable. Review of Resident #2's Nursing Notes dated [DATE] at 2:45 a.m. revealed that Resident #2 remained on bed rest. The note further revealed that Resident #2 was on continuous oxygen at 8 liters. Further review of this same document revealed that Resident #2's oxygen saturation was 97% at 2:45 a.m. and that Resident #2 was arouseable to tactile stimulation. Further review of this same document revealed that Resident #2 continued to breathe using her accessory muscles. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 8:00 a.m. revealed Resident #2 refused to eat breakfast. Further review of the note revealed that Resident #2 was using her accessory muscles at that time. Further review of the nurses note revealed that Resident #2's bilateral lower extremities were elevated to decrease [MEDICAL CONDITION]. This nursing note also indicated that Resident #2 was spoon fed two cups of applesauce and tolerated 1 cup of water. During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that on [DATE], Resident #2 was using accessory muscles to breathe. She further indicated that Resident #2 could not eat and breathe at the same time. She also indicated that at 11:30 a.m. she placed a call to the physician and never received a call back from the physician. She indicated that on [DATE] the new problem with swallowing was first noted. She spoon fed Resident #2 applesauce and made a call to get a MBS study. Review of Resident #2's telephone order dated [DATE] and timed 12:30 p.m. revealed swallow study consult with MBSS due to difficulty swallowing and aspiration risk Further review of this telephone order read back to Physician J/LVN I. Review of Resident #2's Nurses notes dated [DATE] at 11:30 revealed "call made to MD to schedule MBSS, pending call back at this time." Observation of the DON at [DATE] at 5:15 p.m. revealed the DON dialing the phone. The message heard from the speaker phone said the doctor's office hours are Monday thru Friday except on Thursday. There was was no option to leave a message or an alternative number given to try to reach the physician. The DON further indicated that he did not have the number to reach Physician J after hours, only the Administrator had the number. During an interview on [DATE] at 7:18 p.m. with the Administrator, he indicated that he was the only one with Physician J's personal cell number. Review of hospice document dated [DATE] titled "Nursing Review of Patient Decline Related to Cardiopulmonary Conditions" in the section titled "Current Clinical Picture" revealed the patient was in bed and unresponsive. 2+ - 3+ generalized [MEDICAL CONDITION] (fluid building up within the body which can include the skin and lung tissues). Vital signs stable, no skin breakdown, lungs are diminished with ronchi ("a continuous snore like sound in the throat or [MEDICATION NAME] tubes, due to a partial obstruction" http://medical-dictionary.thefreedictionary.com/rhonchi ). Uses abdominal muscles to breathe. Patient on diuretics with little output. Has third spacing (accumulation of fluids between the skin and fascia ("A fibrous membrane covering , supporting, and separating muscles" Taber's Cyclopedic Medical Dictionary) http://medical-dictionary.thefreedictionary.com/third+spacing). Bowel Sounds faint. 3 Liters via mask. Sats. 99%. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed Resident #2 was on bed rest due to shortness of breath and decreased oxygen saturation. Resident #2 was on 8 liters of oxygen and continued to use her accessory muscles to breathe. Review of Resident #2's Nursing Notes dated [DATE] at 5:30 a.m. revealed Resident #2 had attempted to get out of bed and slid to the floor. This note also revealed the fall was witnessed. Resident #2 bit her lips/tongue. The note further indicated to call the physician in the a.m. Review of Resident #2's Nursing Notes dated [DATE] at 5:53 p.m. revealed staff had attempted to feed Resident #2 three times during dinner. The note further revealed that Resident #2 was too lethargic and Resident #2 had no output during the shift. The note further revealed that Resident #2 would continue be to monitored. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 9:26 p.m. revealed that no output for Resident #2 had been observed. Further review of this nursing note revealed that Resident #2 was too lethargic to receive hydration times 2 attempts. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed that hospice was notified of Resident #2 having no urine output. Hospice staff called back and said to insert an indwelling catheter. Catheter was inserted and resulted in 400 cc of urine. Review of Resident #2's Nursing Notes dated [DATE], no time, revealed that Resident #2 had bilateral diminished breath sounds. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that she went to the nursing facility on [DATE] and told facility staff she wanted Resident #2 off of hospice and sent to the hospital for treatment. The facility staff told her that they were doing everything for her that the hospital would do. The resident's family continued to insist that Resident #2 be sent to the hospital and further indicated they had trouble getting Resident #2 out. The facility staff told her that she would have to be responsible for the ambulance charges. Resident #2's family member was not sure if she had signed AMA paperwork. Resident #2's family member said that she had been asked by the EMT why Resident #2 had not been sent to the hospital on Monday ([DATE]). Resident #2's family member said she had asked the facility staff who the physician was that had been taking care of Resident #2. Resident #2's family member indicated that the facility staff refused to give her contact information for the physician or tell them his name. Resident #2's family member said she still did not know who the physician had been. Resident #2's family member indicated that the facility had never brought up to her the option of taking her to the hospital. Review of the hospital History and Physical with admitted [DATE] revealed "The patient is critically ill with as noted [MEDICAL CONDITION], metabolic [MEDICAL CONDITION], acutely decompensated [MEDICAL CONDITION], acute [MEDICAL CONDITION], multiorgan system failure and we will place in ICU. [MEDICAL CONDITION] Critical Care is consulted as is Nephrology was notified by ER doctor". Further review of this same document "Per family, the patient was enrolled in hospice care by nursing home a few days back. The patient had clinically worsened and became comatose, unresponsive and family had rescinded the hospice care and the patient was brought to the ER emergently, comatose deeply, unresponsive with acute [MEDICAL CONDITION], marked hepatic [MEDICAL CONDITION], ammonia level over 1000 (an indication of liver failure) (normal is ,[DATE]). The patient at this point is unable to give further detailed history, is deeply unresponsive, no other exacerbating factors noted." Review of Resident #2's hospital laboratory report result date [DATE] revealed creatinine 3.63 (normal range 0XXX,[DATE].24) and potassium 6.8 (normal range 3XXX,[DATE].0). Further review of this document revealed that potassium was a critical level. Interview with Bexar County Medical Examiner's office on [DATE] at 9:45 a.m. indicated that it was reported on [DATE] to the Bexar County Medical Examiner's office that Resident #2 had died . Record review of the facility's policy "Notification of Changes" (undated) revealed the "facility will immediately inform the resident and consult with the resident's physician" about an "accident involving the resident" and about a "significant change in the resident's physical" status. The Administrator was notified on [DATE] at 2:24 p.m. that an Immediate Jeopardy situation was identified due to the above failures. Plan of Removal dated [DATE] and accepted [DATE]: 1. At 3:57 pm Nurse Consultant K RN and the RT Director L began assessing all residents receiving oxygen therapy, ventilator and nebulizer breathing treatments for signs and symptoms of respiratory distress. At 4:35 pm the assessments were completed with no negative findings identified. 2. Nurse Consultant K has in-serviced the Administrator, DON ADON, Charge Nurses, Certified Nurse Aides and Respiratory Therapy director on the following: A. For patients in respiratory distress, the physician must be notified as soon as possible by a licensed nurse, If the physician does not call back within 5 minutes, or sent the patient out. (sic) In extreme life threatening situation call 911 first, then follow up with MD, RP and Notification of DON or administrator. B. Skills validation/Proficiency checklist for charge nurses D. See attached Charge Nurse job description 3. Administrator, DON, ADON, Charge Nurses in-serviced and instructed by Nurse Consultant K on: A. Notifying the primary physician of changes in condition B. Alternate physician is the facility's Medical Director and shall be the go to person for physician orders [REDACTED]. The medical director phone number is posted at both nurses stations. C. Intake and output Facility administrator will not act as a liaison on behalf of a physician as a designated agent. A. A licensed physician may give an order to any licensed nurse, pharmacist or other physician. B. A licensed Administrator who is also a licensed nurse will not take a physicians order. When to call 911 shall be inserted in the new hire packet for direct care staff. A. Not breathing/uneven breathing or labored respirations B. No pulse C. Choking D. [MEDICAL CONDITION] longer than two minutes E. Uncontrolled bleeding F. Head injuries G. Falls and Fractures unless otherwise ordered by MD H. When the physician gives an order to call Plan of Removal Verification: The surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the IJ as follows: 4 LVNs, 1 CNA/Med Aide, 1 CNA/RA, 1 CRTT, and DON were interviewed on [DATE] to verify knowledge of inservice training in relation to when to notify the doctor, signs and symptoms of respiratory distress, who and when they report change of condition, the location of the physician phone numbers, how long the staff waits for a doctor's response, who they can accept an order from and what types of situations to call 911 in. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. B. Non-Immediate Jeopardy. Record review of Resident #10's clinical record revealed the "resident was found on floor c back of head facing the dresser in the room, C/O pain to the back of head. Small bump noted to area" (sic) per a nurse's note dated [DATE]. Further review of nurse's notes revealed Resident #10 received Tylenol 650mg for pain associated with her "head injury," a page was made to APN B, and ice packs were applied to the bump on the resident's head. In an interview with LVN F on [DATE] at 2:25 p.m., she revealed that in the event of a fall, staff were trained to call the resident's physician, Administrator, DON, and ADON. LVN F said if a resident's head was hit in a fall, an X-ray ordered by the physician would be called in and neurological assessments would be conducted. Interview with LVN G, ADON at this time revealed that when asked which physician was contacted about the fall and what plan of care was given, she said the note by APN of [DATE] "addressed the fall." During further interview at this time LVN G revealed the note addressed a fracture to Resident #10's right hip diagnosed by X-ray on [DATE], not the fall on [DATE]. Further interview at this time revealed LVN G could not find a physician's note about Resident #10's [DATE] fall. No further information was provided by LVN G related to the physician being consulted by any staff about Resident #10's fall on [DATE]. Interview with LVN A on [DATE] revealed that Resident #10 had "an unwitnessed fall" on [DATE], and had a "lump in the back of her head." LVN A said she paged APN B, but received no return call, did not reach any other physician, and finally placed Resident #10's fall incident in the "24-Hour Report" to be followed up on by the next shift's nurse. Interview with APN B on [DATE] at 3:17 p.m. revealed that "sometime in the morning of [DATE]," she was notified that Resident #10 "slid out of her wheelchair to her knees with no injury" the previous day ([DATE]). APN B said she was unaware that Resident #10 had a lump to the back of her head from the fall. Information provided by the administrator on [DATE] revealed 20 residents were under the care of Physician J and and 11 residents had falls in the month of [DATE].

Based on interview and record review the facility failed to provide for each resident the necessary care and services to attain or maintain the highest practicable physicial in accordance with the comprehensive assessment and plan of care for 2 of 4 residents (Resident #2 and Resident #10) in that: 1. LVN A, LVN I, LVN Q, and the ADON did not consult with Resident # 2's physician or notify Resident #2's family that Resident #2 was experiencing respiratory distress. Facility policy is to consult with the resident's physician if there is a significant change. ? LVN A, LVN I, LVN Q, and the ADON did not send Resident #2 to the hospital when Resident #2 was experiencing respiratory distress. ? Resident #2 was in respiratory distress for 5 days before she was transported to the hospital where she was placed on a ventilator in ICU and died shortly thereafter. ? The ADON and LVN I notified the Administrator (who is also a LVN) instead of consulting with a physician when Resident #2's primary physician was unavailable. These failures resulted in an Immediate Jeopardy which was identified on [DATE]. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. 2. Non-Immediate Jeopardy. No physician plan of care and no clinical management was done for Resident #10's injury (bump on the back of the head) that resulted from an "unwitnessed" fall. This deficient practice could affect 20 residents who were under the care of Physician J, and 11 residents who had falls in the month of [DATE], and could result in resident injury and death. The findings were: Review of Resident #2's face sheet dated [DATE] revealed that Resident #2 was [DIAGNOSES REDACTED]. Further review of this same face sheet revealed that Resident #2 was admitted on [DATE] and readmitted on [DATE]. Review of Resident #2's clinical record revealed that Resident #2 had a Medical Power of Attorney, which was dated [DATE]. Review of Resident #2 Psychiatric Progress Note dated [DATE] revealed under "Mental Status Examination" Decreased judgment, Mood Swings, Diminished reality testing, [MEDICAL CONDITION], Aggressive at times, Depression, Decreased memory, [MEDICAL CONDITION], Agitation, Hallucinations, and [MEDICAL CONDITION]. Review of Resident #2's [DATE] CPO included these additional Diagnosis: [REDACTED]. Further review of this document revealed Resident #2 had no orders for oxygen. Review of Resident #2 physician telephone orders revealed there was no order for oxygen. Review of Resident #2's BMP drawn on [DATE] at the facility revealed Creatinine at 0.8 (normal range 0XXX,[DATE].0) and Potassium at 4.0 ( normal range 3XXX,[DATE].2). Review of Resident #2's Nursing Notes dated [DATE] at 3:45 a.m. revealed Resident #2 complained of shortness of breath. Further review of this same document revealed that Resident #2 was "then repositioned & given 1 puff of proventol" (for shortness of breath) "via HHN," oxygen saturation 84%. Further review of this same document revealed that Resident #2 was started on 2 liters of oxygen via nasal cannula. Further review of this document revealed that Resident #2's oxygen saturation level increased to 94%. Further review of this same document revealed that Resident #2 will continue to monitored. Further review of this same document that Resident #2 sounded congested. Further review of this note revealed there was no documentation about calling the physician about Resident #2's oxygen saturation and Resident #2 ' s congestion. During an interview on [DATE] at 3:25 p.m. with LVN A indicated that Resident #2 on [DATE] was in her usual state up in her wheelchair, eating and talking. She further indicated that Resident #2 was independent in the wheelchair for short distances. During an interview on [DATE] at 2:20 p.m. with LVN I, she confirmed there was no telephone order for oxygen for Resident #2 until [DATE]. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2's physician was notified that she had the shortness of breath and was on oxygen. Review of Resident #2's Nursing Notes dated [DATE] at 11:10 a.m. revealed the physician had ordered Resident #2 a stat chest x-ray. Review of Resident #2's telephone order dated [DATE] revealed stat chest x-ray due to complaint of shortness of breath and congestion. Review of Resident #2's Nursing Notes dated [DATE] at 11:30 a.m. revealed that Resident #2 was sitting up in bed eating lunch. The nursing note further revealed she was on oxygen at 2 liters per minute. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that a stat chest x-ray report was received at 1:35 p.m. The nursing notes further revealed the result of the chest x-ray showed mild [MEDICAL CONDITIONS]/[MEDICAL CONDITION]. The nursing note further revealed that a previous x-ray completed on [DATE] revealed mild [MEDICAL CONDITIONS] and that the [MEDICAL CONDITION] was new. Further review of this same document revealed a call was made to the physician's office and that the physician was unavailable at that time. Further review of this same document revealed per the physician office, the physician was expected to be back in the office at 2:10 p.m. Further review of this same document revealed that the facility nurse would notify ,[DATE] shift to follow up with physician. Review of Resident #2's Nursing Notes dated [DATE] at 4:18 p.m. revealed Resident#2 was taken off of oxygen for 30 minutes for room air tolerance. Further review of this document revealed that resident #2 oxygen saturation level dropped from 95% to 76% within that time frame and that Resident #2 was immediately placed back on oxygen at 4 liters. Further review of this document revealed that Resident #2 was lethargic and ate 0% for dinner. Further review of this document revealed that Resident #2's medication were placed on hold per nursing judgment (those that may cause drowsiness). Further review of this document revealed "Unable to call physician back at the time." Further review of this same document revealed that RT was in to assess Resident #2. Further review of this same document revealed that two oxygen tanks and an ambu bag were placed in the room. Further review of this same document revealed that Resident #2 was a full code and that Resident #2 had heavy use of accessory muscles (Signs of respiratory distress include: Retractions "The chest appears to sink in just below the neck and/or under the breastbone with each breath--one way of trying to bring more air into the lungs" . Wexner Medical Center Ohio State University <http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/about/signs/pages/index.aspx>) upon inspiration. Further review of Nursing Notes dated [DATE] at 4:18 p.m. revealed that Resident #2's Oxygen Saturation at 95%. During an interview on [DATE] at 3:25 p.m. with LVN A, indicated she decided to trial Resident #2 without her oxygen as Resident #2 wanted to eat in the dining room. LVN A indicated that Resident #2 was unable to tolerate going without the oxygen. LVN A further indicated that Resident #2 started to use her accessory muscles within twenty minutes. LVN A indicated she took Resident #2 off of her oxygen as she was trying to be proactive. She further indicated that she told the ADON about the lack of oxygen tolerance and the ADON told her to keep the oxygen on Resident #2 and to monitor her. Review of Respiratory note dated [DATE] at 8:00 p.m. revealed Resident #2 was on 4 liters of oxygen. Resident #2 had signs of increased accessory muscle use (Retractions). Further review of this document revealed that Resident #2 was lethargic and that Respiratory staff told the nurse to further assess Resident #2. This documentation also revealed that Resident #2 had diminished breath sounds. During an interview on [DATE] at 11:42 a.m. with CRTT N, she indicated that she went in to care for Resident #2 on [DATE] at 8:00 p.m. because Resident #2 was having respiratory distress. She indicated that she started Resident #2 on 4 liters of oxygen per minute. She indicated that she considered the resident to be stable since Resident #2's vital signs were O2 sat 95%, respiratory rate 18, heart rate 73 on 4 liters per minute of oxygen. She indicated she told the nurse to reassess Resident #2 due to increased accessory muscle use and lethargy. She indicated she had not informed the physician of Resident #2's respiratory distress but that she had only spoken to the nurse. Record review of a respiratory note dated [DATE] revealed at 12:00 a.m. CRTT O had documented patient continued to have respiratory retractions and was lethargic. The patient was still on 4 liters of O2. Record review of respiratory note dated [DATE] revealed at 4:00 a.m. the patient remained on 4 liters of oxygen and continued to use accessory muscles. During an interview on [DATE] at 6:38 p.m. with LVN Q, he indicated he was the night nurse for Resident #2. He also indicated that on [DATE] Resident #2's oxygen saturation level was ,[DATE]%. He further indicated that he left a note on the [DATE] night shift for the next shift that came on duty on [DATE] at 10:00 p.m. He indicated he was surprised that Resident #2 was still at the facility the next day when he came on duty. He indicated he thought that Resident #2 would have been in the hospital. When asked why he did not send Resident #2 to the hospital, he indicated he did not consider sending her out because the other shifts did not send Resident #2 to the hospital. He indicated that the Administrator and DON needed to know before a resident was sent out to the hospital and that there was no discussion with anyone about sending Resident #2 to the hospital. Review of Nursing Note dated [DATE] at 2:30 a.m. revealed Resident #2 was in bed throughout the shift. Resident #2's skin was warm to touch. Further review of nursing note revealed that Resident #2 was alert and oriented x 3 and able to verbalize needs. Further review of this same document revealed that Resident #2 continued to use accessory muscles and was on continuous oxygen at 2 liters per nasal cannula. Review of Respiratory note dated [DATE] at 4:00 a.m. revealed Resident #2 continued to use accessory muscles and her oxygen was at 4 liters per nasal cannula. Record review of Resident #2's respiratory care note dated [DATE] at 9:00 a.m. revealed that the nurse reported that Resident #2 was having respiratory distress. Further review of this same document revealed that Resident #2's nasal cannula was switched to a simple mask and and her oxygen was increased to 7 liters per minute. The note was written by CRTT P. Further review of this note revealed there was no documentation that the physician was consulted. During interview on [DATE] at 2:34 p.m. with CRTT P, he indicated he had changed Resident #2 from a nasal cannula to a simple mask and increased her oxygen to 7 liters per minute. He indicated the MD did not order the oxygen to be increased to 7 liters per minute from 4 liters per minute. CRTT P indicated it was up to the nurse to talk to the physician. CRTT P indicated he just informed the nurse what he did and Resident #2's response Review of Resident #2's Nursing Note dated [DATE] at 9:00 a.m. revealed a new order for [MEDICATION NAME] 20mg by mouth twice a day for [DIAGNOSES REDACTED]. Review of Resident #2's telephone orders dated [DATE] revealed an order for [REDACTED]. Review of physician telephone order (not dated on yellow copy) for Resident #2 to be seen by a hospice revealed that the ADON had signed as the nurse who received the telephone order. Review of Resident #2's Nursing Notes dated [DATE] at 10:00 a.m. revealed that Resident #2 was in bed resting with eyes open. Potassium 20 mEq by mouth daily was discontinued and [MEDICATION NAME] (use to treat fluid retention related to [MEDICAL CONDITION]) 25 mg by mouth daily was started instead. Review of Resident #2 ' s signed physician telephone orders dated [DATE] just received by the facility from the physician revealed that the physician had written "Add O2 at 2L/NC & increase prn if O2 sat. dropping." During an interview on [DATE] at 5:36 p.m. with Medical Records Personnel, she indicated that telephones had come back from the physician on [DATE] to include [DATE] telephone order that included add O2. Review of physician telephone order dated [DATE] revealed that the ADON had signed as the nurse who received the physician telephone order. Further review of this telephone order revealed to discontinue Potassium 20 mEq PO, give [MEDICATION NAME] ([MEDICATION NAME]) 25 mg PO daily. During an interview on [DATE] at 11:04 a.m. with the ADON, she was shown the telephone order for hospice and the telephone order to discontinue potassium and give [MEDICATION NAME] ([MEDICATION NAME]). The ADON verified it was her signature on both of those orders. When asked who she got those orders from, she indicated she received those orders from the Administrator. When asked for the phone number for Resident #2's physician since this physician was not in his office on [DATE], when the surveyor tried to contact the physician, she indicated there wasn't another number, just the office number. When asked who they would call if something was going on with a resident the ADON said the Administrator. She further indicated that the Administrator was the next in line to reach if this physician was not in his office. The ADON also indicated that the Administrator has the authority to make decisions for this physician when this physician is not available and they notify this physician about what orders the Administrator has given later. During an interview on [DATE] at 11:14 a.m., with the Administrator, he indicated that he was the designated agent for Physician J and that he had the authority to prescribe. He further indicated that his authority to prescribe meant that he could refill a Vicoden prescription at the pharmacy using the DEA number. He further indicated that these were some of his duties and he described it similar to working as an employee as a nurse in a physician's office where a nurse would be able to call in a prescription at the pharmacy. He further indicated he could follow standing protocols and provided an example such as the standing orders for [MEDICAL CONDITION] and provided an example of [MEDICATION NAME] and Potassium as being a part of the standing orders. Review of "Heart Failure-[MEDICAL CONDITION]" (standing orders for [MEDICAL CONDITION]) revealed "Admit/Re-Admit Protocols for Medicare A 'Skilled Resident'. Further review of this document revealed no standing orders for Potassium and [MEDICATION NAME]. During an interview on [DATE] at 1:13 p.m. with the Administrator, when told that the [MEDICAL CONDITION] standing orders does not include [MEDICATION NAME] and Potassium, he indicated that they could follow whatever is on that form. During an interview on [DATE] at 1:16 p.m. with the ADON, she indicated that if there was no answer from the physician, they next went to the Administrator, then to the "Medical Examiner". During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator since the doctor could not be reached and the Administrator said that Resident #2 needed to go on hospice. During an interview on [DATE] at 6:53 p.m. with Physician J, he indicated that he thought the orders for the [MEDICATION NAME] had come from another physician because he did not normally prescribe [MEDICATION NAME]. He indicated that he recalled agreeing to a hospice consult because he thought the family had requested it or another physician had requested it. He further indicated he had not personally spoken to Resident #2's family. He further indicated there was a standing order to send residents to the emergency room if needed without having to get in touch with him for an order to send the resident to the emergency room . Review of Resident #2's physician progress notes [REDACTED]. Review of Resident #2's nursing notes revealed no documentation of physician or nurse practitioner visits after [DATE]. Review of Resident #2's Social Services Note revealed that social worker contacted hospice care as per instructions from the Administrator. Further review of this same note revealed that Referral was made for hospice care for resident who has decompensated medically and will benefit from hospice care. During an interview on [DATE] at 6:01 p.m. with the Medical Director, he indicated he had not personally given orders for or been involved with Resident #2's care at the nursing facility. The Medical Director further indicated that he or his nurse practitioner should be contacted if a resident's primary care physician was not available and a physician's input was needed. The Medical Director said they would be very willing to take those calls and they had a system in place that a physician would always be available. During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator when the physician was not available because the Administrator worked with this physician. LVN I indicated that the Administrator gave orders for [MEDICATION NAME] and Potassium and they were sent off to the pharmacy. LVN I further indicated that the Administrator discontinued the order and gave orders for [MEDICATION NAME] due to [MEDICATION NAME] is Potassium sparing. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2 was resting on her left side and that she was being turned every 2 hours. The note further revealed that Resident #2's bilateral extremities were elevated due to increased [MEDICAL CONDITION]. The note further revealed Resident #2 was stable. The note further revealed that hospice had just seen Resident #2. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that Resident #2's sister phoned the facility and called to inquire about the resident and the change of condition was explained to the sister. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that the facility had not called her regarding Resident #2's change in condition. She further indicated she had to call the facility (on [DATE]) to see what was going on with Resident #2 because she had received an unexpected call from a hospice about admitting Resident #2 to their services. Resident #2's family member said she was shocked to be called by hospice because Resident #2 was her normal self when she visited her 3 weeks earlier except for severe bruising around her eye after an incident involving another resident. She also indicated that when she called the facility, the ADON had answered the phone. She then indicated she had told the ADON she wanted to know how Resident #2 was doing, She further indicated that the ADON told her she was sorry and that someone should have called her. Resident #2's family member further indicated that it seemed like the facility staff were taking matters into their own hands. Review of Resident #2's Nursing Notes dated [DATE] for ,[DATE] p.m. shift revealed that Resident #2 had to be reminded to keep her oxygen mask on. Respiratory notes dated [DATE] at 12:00 a.m. revealed Resident #2 was on a simple mask using 8 liters of oxygen. Further review of this note revealed coarse rales ("A loud and low-pitched, discontinuous, 'explosive' crackling sound heard in patients" http://medical-dictionary.thefreedictionary.com/Coarse+Rales) and diminished breath sounds throughout. Further review of the note revealed Resident #2 was stable. Review of Resident #2's Nursing Notes dated [DATE] at 2:45 a.m. revealed that Resident #2 remained on bed rest. The note further revealed that Resident #2 was on continuous oxygen at 8 liters. Further review of this same document revealed that Resident #2's oxygen saturation was 97% at 2:45 a.m. and that Resident #2 was arouseable to tactile stimulation. Further review of this same document revealed that Resident #2 continued to breathe using her accessory muscles. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 8:00 a.m. revealed Resident #2 refused to eat breakfast. Further review of the note revealed that Resident #2 was using her accessory muscles at that time. Further review of the nurses note revealed that Resident #2's bilateral lower extremities were elevated to decrease [MEDICAL CONDITION]. This nursing note also indicated that Resident #2 was spoon fed two cups of applesauce and tolerated 1 cup of water. During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that on [DATE], Resident #2 was using accessory muscles to breathe. She further indicated that Resident #2 could not eat and breathe at the same time. She also indicated that at 11:30 a.m. she placed a call to the physician and never received a call back from the physician. She indicated that on [DATE] the new problem with swallowing was first noted. She spoon fed Resident #2 applesauce and made a call to get a MBS study. Review of Resident #2's telephone order dated [DATE] and timed 12:30 p.m. revealed swallow study consult with MBSS due to difficulty swallowing and aspiration risk Further review of this telephone order read back to Physician J/LVN I. Review of Resident #2's Nurses notes dated [DATE] at 11:30 revealed "call made to MD to schedule MBSS, pending call back at this time." Observation of the DON at [DATE] at 5:15 p.m. revealed the DON dialing the phone. The message heard from the speaker phone said the doctor's office hours are Monday thru Friday except on Thursday. There was was no option to leave a message or an alternative number given to try to reach the physician. The DON further indicated that he did not have the number to reach Physician J after hours, only the Administrator had the number. During an interview on [DATE] at 7:18 p.m. with the Administrator, he indicated that he was the only one with Physician J's personal cell number. Review of hospice document dated [DATE] titled "Nursing Review of Patient Decline Related to Cardiopulmonary Conditions" in the section titled "Current Clinical Picture" revealed the patient was in bed and unresponsive. 2+ - 3+ generalized [MEDICAL CONDITION] (fluid building up within the body which can include the skin and lung tissues). Vital signs stable, no skin breakdown, lungs are diminished with ronchi ("a continuous snore like sound in the throat or [MEDICATION NAME] tubes, due to a partial obstruction" http://medical-dictionary.thefreedictionary.com/rhonchi ). Uses abdominal muscles to breathe. Patient on diuretics with little output. Has third spacing (accumulation of fluids between the skin and fascia ("A fibrous membrane covering , supporting, and separating muscles" Taber's Cyclopedic Medical Dictionary) http://medical-dictionary.thefreedictionary.com/third+spacing). Bowel Sounds faint. 3 Liters via mask. Sats. 99%. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed Resident #2 was on bed rest due to shortness of breath and decreased oxygen saturation. Resident #2 was on 8 liters of oxygen and continued to use her accessory muscles to breathe. Review of Resident #2's Nursing Notes dated [DATE] at 5:30 a.m. revealed Resident #2 had attempted to get out of bed and slid to the floor. This note also revealed the fall was witnessed. Resident #2 bit her lips/tongue. The note further indicated to call the physician in the a.m. Review of Resident #2's Nursing Notes dated [DATE] at 5:53 p.m. revealed staff had attempted to feed Resident #2 three times during dinner. The note further revealed that Resident #2 was too lethargic and Resident #2 had no output during the shift. The note further revealed that Resident #2 would continue be to monitored. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 9:26 p.m. revealed that no output for Resident #2 had been observed. Further review of this nursing note revealed that Resident #2 was too lethargic to receive hydration times 2 attempts. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed that hospice was notified of Resident #2 having no urine output. Hospice staff called back and said to insert an indwelling catheter. Catheter was inserted and resulted in 400 cc of urine. Review of Resident #2's Nursing Notes dated [DATE], no time, revealed that Resident #2 had bilateral diminished breath sounds. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that she went to the nursing facility on [DATE] and told facility staff she wanted Resident #2 off of hospice and sent to the hospital for treatment. The facility staff told her that they were doing everything for her that the hospital would do. The resident's family continued to insist that Resident #2 be sent to the hospital and further indicated they had trouble getting Resident #2 out. The facility staff told her that she would have to be responsible for the ambulance charges. Resident #2's family member was not sure if she had signed AMA paperwork. Resident #2's family member said that she had been asked by the EMT why Resident #2 had not been sent to the hospital on Monday ([DATE]). The EMT told Resident #2's family member that the EMT needed Resident #2's information including medication list and History and Physical and to please ask the facility staff to provide it to them because EMT had problems getting all the information from the nursing home staff. Resident #2's family member said she had asked the facility staff who the physician was that had been taking care of Resident #2. Resident #2's family member indicated that the facility staff refused to give her contact information for the physician or tell them his name. Resident #2's family member said she still did not know who the physician had been. Resident #2's family member indicated that the facility had never brought up to her the option of taking her to the hospital. Review of Resident #2's Nursing Notes dated [DATE] at 1:50 p.m., revealed that Resident #2's sister wanted Resident #2 off of hospice and transferred to the hospital. Called ADON to inform. Family signed AMA paperwork. Family made aware facility does not cover anything else once AMA is signed. During an interview on [DATE] at 1:16 p.m. with LVN F and ADON, that LVN F indicated that she asked the family to sign AMA because the ADON told her to get the AMA signed. ADON indicated that she went to her "Director" (Administrator) regarding the family request to send Resident #2 to the hospital. ADON indicated that the Administrator is her Director. She further indicated that the Administrator told her to get AMA signed as family was pulling resident out against medical advice. ADON indicated that the Administrator told her this during the only call between ADON and Administrator on that Saturday ([DATE]). LVN F indicated that she did not leave a message for the physician on [DATE]. ADON and LVN F indicated that neither of them spoke to the Medical Director nor any of his Nurse Practitioners on [DATE]. During an interview on [DATE] at 2:36 p.m. with the Administrator, he indicated that the ADON called him and he was at the airport using his cell phone. He further indicated he clicked over and called the physician and then talked to the ADON again. The Administrator indicated that the physician already knew that Resident #2 was leaving AMA because the nurse had left a message earlier for the physician. During this interview with the Administrator the ADON indicated she had called the Administrator and was on a 3 way call and she heard the physician say if the resident goes to the hospital she will be going AMA. During an interview on [DATE] at 11:14 a.m., with the Administrator, he indicated that he was the designated agent for Physician J and that he had the authority to prescribe. He further indicated that his authority to prescribe meant that he could refill a Vicoden prescription at the pharmacy using the DEA number. He further indicated that these were some of his duties and he described it similar to working as an employee as a nurse in a physician's office where a nurse would be able to call in a prescription at the pharmacy. He further indicated he could follow standing protocols and provided an example such as the standing orders for [MEDICAL CONDITION] and provided an example of [MEDICATION NAME] and Potassium as being a part of the standing orders. Review of "Heart Failure-[MEDICAL CONDITION]" (standing orders for [MEDICAL CONDITION]) revealed "Admit/Re-Admit Protocols for Medicare A 'Skilled Resident'. Further review of this document revealed no standing orders for Potassium and [MEDICATION NAME]. During an interview on [DATE] at 1:13 p.m. with the Administrator, when told that the [MEDICAL CONDITION] standing orders does not include [MEDICATION NAME] and Potassium, he indicated that they could follow whatever is on that form. During an interview on [DATE] at 6:53 p.m. with Physician J, he indicated that if a resident's need for oxygen was increasing from 2 liters of oxygen to 4 liters of oxygen, to 7 liters of oxygen to 8 liters of oxygen, they should be sent to the hospital for evaluation and treatment. Physician J indicated that he was not informed that Resident #2's need for oxygen had increased. Physician J further indicated he was not aware that Resident #2 had declined in condition since the initial complaint of shortness of breath and mild [MEDICAL CONDITIONS]. He further indicated there was a standing order to send residents to the emergency room if needed without having to get in touch with him for an order to send the resident to the emergency room . He further indicated it would not have been reasonable to make a resident have to sign out AMA to go to the hospital at the family's request due to decline in condition and family's desire for medical treatment. He further indicated he did not say the resident must sign out AMA to go to the hospital at Resident #2's family's request. He further indicated he did not give the order that Resident #2 must leave AMA to go to the hospital for treatment. He further indicated he was not aware of the family signing out Resident #2 AMA until after Resident #2 had already left the facility to go to the hospital. When asked if Physician J and the Administrator had an agreement or understanding that that Administrator could make decisions regarding resident's medical treatment, Physician J said no, definitely not to order medications just to send resident to the emergency room if needed. Physician J further indicated he gets telephone orders to sign from facilities and only has time to read about half of the orders he signs so he can't say for sure he that he knows if all the telephone orders he signs were from the orders he knows and remembers giving. During interview on [DATE] at 3:25 p.m. with LVN A, she indicated that when she looked back at the condition of Resident #2, LVN A thought Resident #2 probably should have been sent to the hospital on [DATE]. During an interview on [DATE] at 7:32 p.m. with the DON, when asked if he would expect his nursing staff to do anything differently, he indicated he would want his staff to do better documentation. When asked if staff would be expected to provide care any differently he said no because the resident was stable. Review of the hospital History and Physical with admitted [DATE] revealed "The patient is critically ill with as noted [MEDICAL CONDITION], metabolic [MEDICAL CONDITION], acutely decompensated [MEDICAL CONDITION], acute [MEDICAL CONDITION], multiorgan system failure and we will place in ICU. [MEDICAL CONDITION] Critical Care is consulted as is Nephrology was notified by ER doctor". Further review of this same document "Per family, the patient was enrolled in hospice care by nursing home a few days back. The patient had clinically worsened and became comatose, unrespons

Based on record review and interview, the facility failed to meet professional standards of quality for 1 of 4 residents (Resident #2) reviewed for neglect in that: 1. LVN A, LVN I, LVN Q, and the ADON did not notify the physician or Resident #2's family that Resident #2 was experiencing respiratory distress. ? LVN A, LVN I, LVN Q, and the ADON did not send Resident #2 to the hospital when Resident #2 was experiencing respiratory distress. ? Resident #2 was in respiratory distress for 5 days before she was transported to the hospital where she was placed on a ventilator in ICU and died shortly thereafter. 2. The ADON and LVN I notified the Administrator (who is also a LVN) instead of consulting with a physician when Resident #2's primary physician was unavailable. These failures resulted in an Immediate Jeopardy which was identified on [DATE]. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. This deficient practice could affect 20 residents who were under the care of Physician J, and could result in resident injury and death. The findings were: 1. Review of the Rules and Regulations relating to Nurse Education, Licensure and Practice (Texas Board of Nursing, 2013) revealed "Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications." Review of Resident #2's face sheet dated [DATE] revealed that Resident #2 had the following [DIAGNOSES REDACTED]. Further review of this same face sheet revealed that Resident #2 was admitted on [DATE] and readmitted on [DATE]. Review of Resident #2's clinical record revealed that Resident #2 had a Medical Power of Attorney, which was dated [DATE]. Review of Resident #2 Psychiatric Progress Note dated [DATE] revealed under "Mental Status Examination" Decreased judgment, Mood Swings, Diminished reality testing, [MEDICAL CONDITION], Aggressive at times, Depression, Decreased memory, [MEDICAL CONDITION], Agitation, Hallucinations, and [MEDICAL CONDITION]. Review of Resident #2's [DATE] CPO included these additional Diagnoses: [REDACTED]. Further review of this document revealed Resident #2 had no orders for oxygen. Review of Resident #2 physician telephone orders revealed there was no order for oxygen. Review of Resident #2's BMP drawn on [DATE] at the facility revealed Creatinine at 0.8 (normal range 0XXX,[DATE].0) and Potassium at 4.0 ( normal range 3XXX,[DATE].2). Review of Resident #2's Nursing Notes dated [DATE] at 3:45 a.m. revealed Resident #2 complained of shortness of breath. Further review of this same document revealed that Resident #2 was "then repositioned & given 1 puff of proventol" (for shortness of breath) "via HHN," oxygen saturation 84%. Further review of this same document revealed that Resident #2 was started on 2 liters of oxygen via nasal cannula. Further review of this document revealed that Resident #2's oxygen saturation level increased to 94%. Further review of this same document revealed that Resident #2 will continue to monitored. Further review of this same document that Resident #2 sounded congested. Further review of this note revealed there was no documentation about calling the physician about Resident #2's oxygen saturation and Resident #2's congestion. During an interview on [DATE] at 3:25 p.m. with LVN A indicated that Resident #2 on [DATE] was in her usual state up in her wheelchair, eating and talking. She further indicated that Resident #2 was independent in the wheelchair for short distances. During an interview on [DATE] at 2:20 p.m. with LVN I, she confirmed there was no telephone order for oxygen for Resident #2 until [DATE]. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2's physician was notified that she had the shortness of breath and was on oxygen. Review of Resident #2's Nursing Notes dated [DATE] at 11:10 a.m. revealed the physician had ordered Resident #2 a stat chest x-ray. Review of Resident #2's telephone order dated [DATE] revealed stat chest x-ray due to complaint of shortness of breath and congestion. Review of Resident #2's Nursing Notes dated [DATE] at 11:30 a.m. revealed that Resident #2 was sitting up in bed eating lunch. The nursing note further revealed she was on oxygen at 2 liters per minute. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that a stat chest x-ray report was received at 1:35 p.m. The nursing notes further revealed the result of the chest x-ray showed mild [MEDICAL CONDITIONS]/[MEDICAL CONDITION]. The nursing note further revealed that a previous x-ray completed on [DATE] revealed mild [MEDICAL CONDITIONS] and that the [MEDICAL CONDITION] was new. Further review of this same document revealed a call was made to the physician's office and that the physician was unavailable at that time. Further review of this same document revealed per the physician office, the physician was expected to be back in the office at 2:10 p.m. Further review of this same document revealed that the facility nurse would notify ,[DATE] shift to follow up with physician. Review of Resident #2's Nursing Notes dated [DATE] at 4:18 p.m. revealed Resident#2 was taken off of oxygen for 30 minutes for room air tolerance. Further review of this document revealed that resident #2 oxygen saturation level dropped from 95% to 76% within that time frame and that Resident #2 was immediately placed back on oxygen at 4 liters. Further review of this document revealed that Resident #2 was lethargic and ate 0% for dinner. Further review of this document revealed that Resident #2's medication were placed on hold per nursing judgment (those that may cause drowsiness). Further review of this document revealed "Unable to call physician back at the time."Further review of this same document revealed that RT was in to assess Resident #2. Further review of this same document revealed that two oxygen tanks and an ambu bag were placed in the room. Further review of this same document revealed that Resident #2 was a full code and that Resident #2 had heavy use of accessory muscles (Signs of respiratory distress include: Retractions "The chest appears to sink in just below the neck and/or under the breastbone with each breath--one way of trying to bring more air into the lungs " . Wexner Medical Center Ohio State University <http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/about/signs/pages/index.aspx>) upon inspiration. Further review of Nursing Notes dated [DATE] at 4:18 p.m. revealed that Resident #2's Oxygen Saturation at 95%. During an interview on [DATE] at 3:25 p.m. with LVN A, indicated she decided to trial Resident #2 without her oxygen as Resident #2 wanted to eat in the dining room. LVN A indicated that Resident #2 was unable to tolerate going without the oxygen. LVN A further indicated that Resident #2 started to use her accessory muscles within twenty minutes. LVN A indicated she took Resident #2 off of her oxygen as she was trying to be proactive. She further indicated that she told the ADON about the lack of oxygen tolerance and the ADON told her to keep the oxygen on Resident #2 and to monitor her. Review of Respiratory note dated [DATE] at 8:00 p.m. revealed Resident #2 was on 4 liters of oxygen. Resident #2 had signs of increased accessory muscle use (Retractions). Further review of this document revealed that Resident #2 was lethargic and that Respiratory staff told the nurse to further assess Resident #2. This documentation also revealed that Resident #2 had diminished breath sounds. During an interview on [DATE] at 11:42 a.m. with CRTT N, she indicated that she went in to care for Resident #2 on [DATE] at 8:00 p.m. because Resident #2 was having respiratory distress. She indicated that she started Resident #2 on 4 liters of oxygen per minute. She indicated that she considered the resident to be stable since Resident #2's vital signs were O2 sat 95%, respiratory rate 18, heart rate 73 on 4 liters per minute of oxygen. She indicated she told the nurse to reassess Resident #2 due to increased accessory muscle use and lethargy. She indicated she had not informed the physician of Resident #2's respiratory distress but that she had only spoken to the nurse. Record review of a respiratory note dated [DATE] revealed at 12:00 a.m. CRTT O had documented patient continued to have respiratory retractions and was lethargic. The patient was still on 4 liters of O2. Record review of respiratory note dated [DATE] revealed at 4:00 a.m. the patient remained on 4 liters of oxygen and continued to use accessory muscles. During an interview on [DATE] at 6:38 p.m. with LVN Q, he indicated he was the night nurse for Resident #2. He also indicated that on [DATE] Resident #2's oxygen saturation level was ,[DATE]%. He further indicated that he left a note on the [DATE] night shift for the next shift that came on duty on [DATE] at 10:00 p.m. He indicated he was surprised that Resident #2 was still at the facility the next day when he came on duty. He indicated he thought that Resident #2 would have been in the hospital. When asked why he did not send Resident #2 to the hospital, he indicated he did not consider sending her out because the other shifts did not send Resident #2 to the hospital. He indicated that the Administrator and DON needed to know before a resident was sent out to the hospital and that there was no discussion with anyone about sending Resident #2 to the hospital. Review of Nursing Note dated [DATE] at 2:30 a.m. revealed Resident #2 was in bed throughout the shift. Resident #2's skin was warm to touch. Further review of nursing note revealed that Resident #2 was alert and oriented x 3 and able to verbalize needs. Further review of this same document revealed that Resident #2 continued to use accessory muscles and was on continuous oxygen at 2 liters per nasal cannula. Review of Respiratory note dated [DATE] at 4:00 a.m. revealed Resident #2 continued to use accessory muscles and her oxygen was at 4 liters per nasal cannula. Record review of Resident #2's respiratory care note dated [DATE] at 9:00 a.m. revealed that the nurse reported that Resident #2 was having respiratory distress. Further review of this same document revealed that Resident #2's nasal cannula was switched to a simple mask and and her oxygen was increased to 7 liters per minute. The note was written by CRTT P. Further review of this note revealed there was no documentation that the physician was consulted. During interview on [DATE] at 2:34 p.m. with CRTT P, he indicated he had changed Resident #2 from a nasal cannula to a simple mask and increased her oxygen to 7 liters per minute. He indicated the MD did not order the oxygen to be increased to 7 liters per minute from 4 liters per minute. CRTT P indicated it was up to the nurse to talk to the physician. CRTT P indicated he just informed the nurse what he did and Resident #2's response Review of Resident #2's Nursing Note dated [DATE] at 9:00 a.m. revealed a new order for [MEDICATION NAME] 20mg by mouth twice a day for [DIAGNOSES REDACTED]. Review of Resident #2's telephone orders dated [DATE] revealed an order for [REDACTED]. Review of physician telephone order (not dated on yellow copy) for Resident #2 to be seen by a hospice revealed that the ADON had signed as the nurse who received the telephone order. Review of Resident #2's Nursing Notes dated [DATE] at 10:00 a.m. revealed that Resident #2 was in bed resting with eyes open. Potassium 20 mEq by mouth daily was discontinued and [MEDICATION NAME] (use to treat fluid retention related to [MEDICAL CONDITION]) 25 mg by mouth daily was started instead. Review of Resident #2 ' s signed physician telephone orders dated [DATE] just received by the facility from the physician revealed that the physician had written "Add O2 at 2L/NC & increase prn if O2 sat. dropping." During an interview on [DATE] at 5:36 p.m. with Medical Records Personnel, she indicated that telephones had come back from the physician on [DATE] to include [DATE] telephone order that included add O2. Review of physician telephone order dated [DATE] revealed that the ADON had signed as the nurse who received the physician telephone order. Further review of this telephone order revealed to discontinue Potassium 20 mEq PO, give [MEDICATION NAME] ([MEDICATION NAME]) 25 mg PO daily. During an interview on [DATE] at 11:04 a.m. with the ADON, she was shown the telephone order for hospice and the telephone order to discontinue potassium and give [MEDICATION NAME] ([MEDICATION NAME]). The ADON verified it was her signature on both of those orders. When asked who she got those orders from, she indicated she received those orders from the Administrator. When asked for the phone number for Resident #2's physician since this physician was not in his office on [DATE], when the surveyor tried to contact the physician, she indicated there wasn't another number, just the office number. When asked who they would call if something was going on with a resident the ADON said the Administrator. She further indicated that the Administrator was the next in line to reach if this physician was not in his office. During an interview on [DATE] at 11:14 a.m., with the Administrator, he indicated that he was the designated agent for Physician J and that he had the authority to prescribe. He further indicated that his authority to prescribe meant that he could refill a Vicoden prescription at the pharmacy using the DEA number. He further indicated that these were some of his duties and he described it similar to working as an employee as a nurse in a physician's office where a nurse would be able to call in a prescription at the pharmacy. He further indicated he could follow standing protocols and provided an example such as the standing orders for [MEDICAL CONDITION] and provided an example of [MEDICATION NAME] and Potassium as being a part of the standing orders. Review of "Heart Failure-[MEDICAL CONDITION]" (standing orders for [MEDICAL CONDITION]) revealed "Admit/Re-Admit Protocols for Medicare A 'Skilled Resident'. Further review of this document revealed no standing orders for Potassium and [MEDICATION NAME]. During an interview on [DATE] at 1:13 p.m. with the Administrator, when told that the [MEDICAL CONDITION] standing orders did not include [MEDICATION NAME] and Potassium, he indicated that they could follow whatever is on that form. During an interview on [DATE] at 1:16 p.m. with the ADON, she indicated that if there was no answer from the physician, they next went to the Administrator, then to the "Medical Examiner". During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator since the doctor could not be reached and the Administrator said that Resident #2 needed to go on hospice. During an interview on [DATE] at 6:53 p.m. with Physician J, he indicated that he thought the orders for the [MEDICATION NAME] had come from another physician because he did not normally prescribe [MEDICATION NAME]. He indicated that he recalled agreeing to a hospice consult because he thought the family had requested it or another physician had requested it. He further indicated he had not personally spoken to Resident #2's family. He further indicated there was a standing order to send residents to the emergency room if needed without having to get in touch with him for an order to send the resident to the emergency room . Review of Resident #2's physician progress notes [REDACTED]. Review of Resident #2's nursing notes revealed no documentation of physician or nurse practitioner visits after [DATE]. During an interview on [DATE] at 6:01 p.m. with the Medical Director, he indicated he had not personally given orders for or been involved with Resident #2's care at the nursing facility. The Medical Director further indicated that he or his nurse practitioner should be contacted if a resident's primary care physician was not available and a physician's input was needed. The Medical Director said they would be very willing to take those calls and they had a system in place that a physician would always be available. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2 was resting on her left side and that she was being turned every 2 hours. The note further revealed that Resident #2's bilateral extremities were elevated due to increased [MEDICAL CONDITION]. The note further revealed Resident #2 was stable. The note further revealed that hospice had just seen Resident #2. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that Resident #2's sister phoned the facility and called to inquire about the resident and the change of condition was explained to the sister. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that the facility had not called her regarding Resident #2's change in condition. She further indicated she had to call the facility (on [DATE]) to see what was going on with Resident #2 because she had received an unexpected call from a hospice about admitting Resident #2 to their services. Resident #2's family member said she was shocked to be called by hospice because Resident #2 was her normal self when she visited her 3 weeks earlier except for severe bruising around her eye after an incident involving another resident. She also indicated that when she called the facility, the ADON had answered the phone. She then indicated she had told the ADON she wanted to know how Resident #2 was doing, She further indicated that the ADON told her she was sorry and that someone should have called her. Resident #2's family member further indicated that it seemed like the facility staff were taking matters into their own hands. Review of Resident #2's Nursing Notes dated [DATE] for ,[DATE] p.m. shift revealed that Resident #2 had to be reminded to keep her oxygen mask on. Respiratory notes dated [DATE] at 12:00 a.m. revealed Resident #2 was on a simple mask using 8 liters of oxygen. Further review of this note revealed coarse rales ("A loud and low-pitched, discontinuous, 'explosive' crackling sound heard in patients" http://medical-dictionary.thefreedictionary.com/Coarse+Rales) and diminished breath sounds throughout. Further review of the note revealed Resident #2 was stable. Review of Resident #2's Nursing Notes dated [DATE] at 2:45 a.m. revealed that Resident #2 remained on bed rest. The note further revealed that Resident #2 was on continuous oxygen at 8 liters. Further review of this same document revealed that Resident #2's oxygen saturation was 97% at 2:45 a.m. and that Resident #2 was arouseable to tactile stimulation. Further review of this same document revealed that Resident #2 continued to breathe using her accessory muscles. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 8:00 a.m. revealed Resident #2 refused to eat breakfast. Further review of the note revealed that Resident #2 was using her accessory muscles at that time. Further review of the nurses note revealed that Resident #2's bilateral lower extremities were elevated to decrease [MEDICAL CONDITION]. This nursing note also indicated that Resident #2 was spoon fed two cups of applesauce and tolerated 1 cup of water. During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that on [DATE], Resident #2 was using accessory muscles to breathe. She further indicated that Resident #2 could not eat and breathe at the same time. She also indicated that at 11:30 a.m. she placed a call to the physician and never received a call back from the physician. She indicated that on [DATE] the new problem with swallowing was first noted. She spoon fed Resident #2 applesauce and made a call to get a MBS study. Review of Resident #2's telephone order dated [DATE] and timed 12:30 p.m. revealed swallow study consult with MBSS due to difficulty swallowing and aspiration risk Further review of this telephone order read back to Physician J/LVN I. Review of Resident #2's Nurses notes dated [DATE] at 11:30 revealed "call made to MD to schedule MBSS, pending call back at this time." Observation of the DON at [DATE] at 5:15 p.m. revealed the DON dialing the phone. The message heard from the speaker phone said the doctor's office hours are Monday thru Friday except on Thursday. There was was no option to leave a message or an alternative number given to try to reach the physician. The DON further indicated that he did not have the number to reach Physician J after hours, only the Administrator had the number. During an interview on [DATE] at 7:18 p.m. with the Administrator, he indicated that he was the only one with Physician J's personal cell number. Review of hospice document dated [DATE] titled "Nursing Review of Patient Decline Related to Cardiopulmonary Conditions" in the section titled "Current Clinical Picture" revealed the patient was in bed and unresponsive. 2+ - 3+ generalized [MEDICAL CONDITION] (fluid building up within the body which can include the skin and lung tissues). Vital signs stable, no skin breakdown, lungs are diminished with ronchi ("a continuous snore like sound in the throat or [MEDICATION NAME] tubes, due to a partial obstruction" http://medical-dictionary.thefreedictionary.com/rhonchi ). Uses abdominal muscles to breathe. Patient on diuretics with little output. Has third spacing (accumulation of fluids between the skin and fascia ("A fibrous membrane covering , supporting, and separating muscles" Taber's Cyclopedic Medical Dictionary) http://medical-dictionary.thefreedictionary.com/third+spacing). Bowel Sounds faint. 3 Liters via mask. Sats. 99%. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed Resident #2 was on bed rest due to shortness of breath and decreased oxygen saturation. Resident #2 was on 8 liters of oxygen and continued to use her accessory muscles to breathe. Review of Resident #2's Nursing Notes dated [DATE] at 5:30 a.m. revealed Resident #2 had attempted to get out of bed and slid to the floor. This note also revealed the fall was witnessed. Resident #2 bit her lips/tongue. The note further indicated to call the physician in the a.m. Review of Resident #2's Nursing Notes dated [DATE] at 5:53 p.m. revealed staff had attempted to feed Resident #2 three times during dinner. The note further revealed that Resident #2 was too lethargic and Resident #2 had no output during the shift. The note further revealed that Resident #2 would continue be to monitored. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 9:26 p.m. revealed that no output for Resident #2 had been observed. Further review of this nursing note revealed that Resident #2 was too lethargic to receive hydration times 2 attempts. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed that hospice was notified of Resident #2 having no urine output. Hospice staff called back and said to insert an indwelling catheter. Catheter was inserted and resulted in 400 cc of urine. Review of Resident #2's Nursing Notes dated [DATE], no time, revealed that Resident #2 had bilateral diminished breath sounds. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that she went to the nursing facility on [DATE] and told facility staff she wanted Resident #2 off of hospice and sent to the hospital for treatment. The facility staff told her that they were doing everything for her that the hospital would do. The resident's family continued to insist that Resident #2 be sent to the hospital and further indicated they had trouble getting Resident #2 out. The facility staff told her that she would have to be responsible for the ambulance charges. Resident #2's family member was not sure if she had signed AMA paperwork. Resident #2's family member said that she had been asked by the EMT why Resident #2 had not been sent to the hospital on Monday ([DATE]). Resident #2's family member said she had asked the facility staff who the physician was that had been taking care of Resident #2. Resident #2's family member indicated that the facility staff refused to give her contact information for the physician or tell them his name. Resident #2's family member said she still did not know who the physician had been. Resident #2's family member indicated that the facility had never brought up to her the option of taking her to the hospital. Review of the hospital History and Physical with admitted [DATE] revealed "The patient is critically ill with as noted [MEDICAL CONDITION], metabolic [MEDICAL CONDITION], acutely decompensated [MEDICAL CONDITION], acute [MEDICAL CONDITION], multiorgan system failure and we will place in ICU. [MEDICAL CONDITION] Critical Care is consulted as is Nephrology was notified by ER doctor". Further review of this same document "Per family, the patient was enrolled in hospice care by nursing home a few days back. The patient had clinically worsened and became comatose, unresponsive and family had rescinded the hospice care and the patient was brought to the ER emergently, comatose deeply, unresponsive with acute [MEDICAL CONDITION], marked hepatic [MEDICAL CONDITION], ammonia level over 1000 (an indication of liver failure) (normal is ,[DATE]). The patient at this point is unable to give further detailed history, is deeply unresponsive, no other exacerbating factors noted." Review of Resident #2 ' s hospital laboratory report result date [DATE] revealed creatinine 3.63 (normal range 0XXX,[DATE].24) and potassium 6.8 (normal range 3XXX,[DATE].0). Further review of this document revealed that potassium was a critical level. Interview with Bexar County Medical Examiner's office on [DATE] at 9:45 a.m. indicated that it was reported on [DATE] to the Bexar County Medical Examiner's office that Resident #2 had died . 2. Review Texas Administrative Code Title 4 Part 1 Chapter 18 Subchapter D Rule 18.55 Violations of Standards of Conduct revealed "A licensee must not knowingly or through negligence commit, direct, or allow actions that result or could result in inadequate care, harm, or injury to a nursing facility resident." During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator when the physician was not available because the Administrator worked with this physician. LVN I indicated that the Administrator gave orders for [MEDICATION NAME] and Potassium and they were sent off to the pharmacy. LVN I further indicated that the Administrator discontinued the order and gave orders for [MEDICATION NAME] due to [MEDICATION NAME] is Potassium sparing. During an interview on [DATE] at 11:04 a.m. with the ADON, she was shown the telephone order for hospice and the telephone order to discontinue potassium and give [MEDICATION NAME] ([MEDICATION NAME]). The ADON verified it was her signature on both of those orders. When asked who she got those orders from, she indicated she received those orders from the Administrator. When asked for the phone number for Resident #2's physician since this physician was not in his office on [DATE], she indicated there wasn't another number, just the office number. When asked who they would call if something was going on with a resident the ADON said the Administrator. She further indicated that the Administrator was the next in line to reach if this physician was not in his office. During an interview on [DATE] at 3:25 p.m. with LVN A, she indicated that the Administrator had authority to make decisions for Physician J. She further indicated that they went to the Administrator for orders when Physician J could not be reached. They could not reach Physician J on weekends, evenings or on Thursdays in those cases they went to the Administrator as the Administrator could make decisions for the doctor. During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator since the doctor could not be reached and the Administrator said that Resident #2 needed to go on hospice. Review of Resident #2's Social Services Note revealed that social worker contacted hospice care as per instructions from the Administrator. During an interview on [DATE] at 11:14 a.m., with the Administrator, he indicated that he was the designated agent for Physician J and that he had the authority to prescribe. He further indicated that his authority to prescribe meant that he could refill a Vicoden prescription at the pharmacy using the DEA number. He further indicated that these were some of his duties and he described it similar to working as an employee as a nurse in a physician's office where a nurse would be able to call in a prescription at the pharmacy. He further indicated he could follow standing protocols and provided an example such as the standing orders for [MEDICAL CONDITION] and provided an example of [MEDICATION NAME] and Potassium as being a part of the standing orders. Review of "Heart Failure-[MEDICAL CONDITION]" (standing orders for [MEDICAL CONDITION]) revealed "Admit/Re-Admit Protocols for Medicare A 'Skilled Resident'. Further review of this document revealed no standing orders for Potassium and [MEDICATION NAME]. During an interview on [DATE] at 1:13 p.m. with the Administrator, when told that the [MEDICAL CONDITION] standing orders does not include [MEDICATION NAME] and Potassium, he indicated that they could follow whatever is on that form. Review of Designating Agent of Practitioner For Commmunicating Controlled Substance Prescriptions to Pharmacies revealed I, physician J, the undersigned who is authorized to dispense (including prescribe) controlled substances in Schedules II, III, IV, and V under the Controlled Substances Act, hereby authorize the Adminstrator to act as my agent only for the following limited purposes: 1. To prepare, for my signature, written prescriptions for controlled substances in those instances where I have expressly directed the agent to do so and where I have specified to the agent the required elements of the prescription (set forth in 21 CFR 1306.05). 2. To convey to a pharmacist by telephone oral prescriptions for controlled substances in Schedules III, IV, and V in those instances where I have expressly directed the agent to do so and where I have specified to the agent the required elements of the prescription (set forth in 21 CFR 1306.05). 3. T o transmit by facsimile to a pharmacy prescriptions for controlled substances in those instances where I have expressly directed the agent to do so and where I have specified to the agent the required elements of the prescription (set forth in 21 CFR 1306.05) and I have signed the prescription. This authorization is not subject to further delegation to other persons. Both the undersigned DEA-registered individual practitioner and the undersigned agent understand and agree that the practitioner is solely responsible for making all medical determinations relating to prescriptions for controlled substances communicated by the agent pursuant to this agreement, and for ensuring that all such presciptions conform in all other essential respects to the law and regulations. The undersigned agent understands he or she does not have authority to make any medical determinations. The undersigned DEA-registered prescribing practitioner further understands that the prescribing practitioner must personally communicate all Schedule II oral prescriptions to the pharmacist Both the undersigned practitioner and agent understand that the agent may not call in an emergency oral prescription for a Schedule II controlled substance on behalf of the practitioner. During an interview on [DATE] at 6:53 p.m. with Physician J he indicated when asked if Physician J and the Administrator had an agreement or understanding that that Administrator could make decisions regarding resident's medical treatment

Based on record review, interview the facility failed to implement the facility's written policies and procedures that prohibited neglect in area of notifying physician when the resident's condition showed a significant decline for 1 of 4 residents (Resident #2) reviewed for neglect in that: ? LVN A, LVN I, LVN Q, and the ADON did not consult with Resident # 2's physician or notify Resident #2's family that Resident #2 was experiencing respiratory distress. Facility policy is to consult with the resident's physician if there is a significant change. ? LVN A, LVN I, LVN Q, and the ADON did not send Resident #2 to the hospital when Resident #2 was experiencing respiratory distress. ? Resident #2 was in respiratory distress for 5 days before she was transported to the hospital where she was placed on a ventilator in ICU and died shortly thereafter. ? ADON and LVN I notified the Administrator (who is also a LVN) instead of consulting with a physician when Resident #2's primary physician was unavailable. These failures resulted in an Immediate Jeopardy which was identified on [DATE]. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. This deficient practice could affect 20 residents who were under the care of Physician J, and could result in resident injury and death. The findings were: Review of the facility's Abuse Policy, not dated, revealed "Facility policy to prohibit the mistreatment, neglect and abuse of residents . . ." Further review of this same policy revealed that "Each resident has the right to be free from mistreatment, neglect, and misappropriation of property." Record review of the facility's policy "Notification of Changes" (undated) revealed the "facility will immediately inform the resident and consult with the resident's physician" about an "accident involving the resident" and about a "significant change in the resident's physical" status. Review of Resident #2's face sheet dated [DATE] revealed that Resident #2 had the following Diagnoses: [REDACTED]. Further review of this same face sheet revealed that Resident #2 was admitted on [DATE] and readmitted on [DATE]. Review of Resident #2's clinical record revealed that Resident #2 had a Medical Power of Attorney, which was dated [DATE]. Review of Resident #2 Psychiatric Progress Note dated [DATE] revealed under "Mental Status Examination," Decreased judgment, Mood Swings, Diminished reality testing, [MEDICAL CONDITION], Aggressive at times, Depression, Decreased memory, [MEDICAL CONDITION], Agitation, Hallucinations, and [MEDICAL CONDITION]. Review of Resident #2's [DATE] CPO included these additional Diagnosis: [REDACTED]. Further review of this document revealed Resident #2 had no orders for oxygen. Review of Resident #2 physician telephone orders revealed there was no order for oxygen. Review of Resident #2's BMP drawn on [DATE] at the facility revealed Creatinine at 0.8 (normal range 0XXX,[DATE].0) and Potassium at 4.0 ( normal range 3XXX,[DATE].2). Review of Resident #2's Nursing Notes dated [DATE] at 3:45 a.m. revealed Resident #2 complained of shortness of breath. Further review of this same document revealed that Resident #2 was "then repositioned & given 1 puff of proventol" (for shortness of breath) "via HHN," oxygen saturation 84%. Further review of this same document revealed that Resident #2 was started on 2 liters of oxygen via nasal cannula. Further review of this document revealed that Resident #2's oxygen saturation level increased to 94%. Further review of this same document revealed that Resident #2 will continue to monitored. Further review of this same document revealed that Resident #2 sounded congested. Further review of this note revealed there was no documentation about calling the physician about Resident #2's oxygen saturation and Resident #2's congestion. During an interview on [DATE] at 3:25 p.m. with LVN A indicated that Resident #2 on [DATE] was in her usual state up in her wheelchair, eating and talking. LVN A further indicated that Resident #2 was independent in the wheelchair for short distances. During an interview on [DATE] at 2:20 p.m. with LVN I, she confirmed there was no telephone order for oxygen for Resident #2 until [DATE]. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2's physician was notified that she had the shortness of breath and was on oxygen. Review of Resident #2's Nursing Notes dated [DATE] at 11:10 a.m. revealed the physician had ordered Resident #2 a stat chest x-ray. Review of Resident #2's telephone order dated [DATE] revealed stat chest x-ray due to complaint of shortness of breath and congestion. Review of Resident #2's Nursing Notes dated [DATE] at 11:30 a.m. revealed that Resident #2 was sitting up in bed eating lunch. The nursing note further revealed Resident #2 was on oxygen at 2 liters per minute. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that a stat chest x-ray report was received at 1:35 p.m. The nursing notes further revealed the result of the chest x-ray showed mild [MEDICAL CONDITIONS]/[MEDICAL CONDITION]. The nursing note further revealed that a previous x-ray completed on [DATE] revealed mild [MEDICAL CONDITIONS] and that the [MEDICAL CONDITION] was new. Further review of this same document revealed a call was made to the physician's office and that the physician was unavailable at that time. Further review of this same document revealed per the physician office, the physician was expected to be back in the office at 2:10 p.m. Further review of this same document revealed that the facility nurse would notify ,[DATE] shift to follow up with physician. Review of Resident #2's Nursing Notes dated [DATE] at 4:18 p.m. revealed Resident#2 was taken off of oxygen for 30 minutes for room air tolerance. Further review of this document revealed that resident #2 oxygen saturation level dropped from 95% to 76% within that time frame and that Resident #2 was immediately placed back on oxygen at 4 liters. Further review of this document revealed that Resident #2 was lethargic and ate 0% for dinner. Further review of this document revealed that Resident #2's medication were placed on hold per nursing judgment (those that may cause drowsiness). Further review of this document revealed "Unable to call physician back at the time." Further review of this same document revealed that RT was in to assess Resident #2. Further review of this same document revealed that two oxygen tanks and an ambu bag were placed in the room. Further review of this same document revealed that Resident #2 was a full code and that Resident #2 had heavy use of accessory muscles (Signs of respiratory distress include: Retractions "The chest appears to sink in just below the neck and/or under the breastbone with each breath--one way of trying to bring more air into the lungs " . Wexner Medical Center Ohio State University <http://medicalcenter.osu.edu/patientcare/healthcare_services/lung_diseases/about/signs/pages/index.aspx>) upon inspiration. Further review of Nursing Notes dated [DATE] at 4:18 p.m. revealed that Resident #2's Oxygen Saturation at 95%. During an interview on [DATE] at 3:25 p.m. with LVN A, indicated she decided to trial Resident #2 without her oxygen as Resident #2 wanted to eat in the dining room. LVN A indicated that Resident #2 was unable to tolerate going without the oxygen. LVN A further indicated that Resident #2 started to use her accessory muscles within twenty minutes. LVN A indicated she took Resident #2 off of her oxygen as she was trying to be proactive. She further indicated that she told the ADON about the lack of oxygen tolerance and the ADON told her to keep the oxygen on Resident #2 and to monitor her. Review of Respiratory note dated [DATE] at 8:00 p.m. revealed Resident #2 was on 4 liters of oxygen. Resident #2 had signs of increased accessory muscle use (Retractions). Further review of this document revealed that Resident #2 was lethargic and that Respiratory staff told the nurse to further assess Resident #2. This documentation also revealed that Resident #2 had diminished breath sounds. During an interview on [DATE] at 11:42 a.m. with CRTT N, she indicated that she went in to care for Resident #2 on [DATE] at 8:00 p.m. because Resident #2 was having respiratory distress. She indicated that she started Resident #2 on 4 liters of oxygen per minute. She indicated that she considered the resident to be stable since Resident #2's vital signs were O2 sat 95%, respiratory rate 18, heart rate 73 on 4 liters per minute of oxygen. She indicated she told the nurse to reassess Resident #2 due to increased accessory muscle use and lethargy. She indicated she had not informed the physician of Resident #2's respiratory distress but that she had only spoken to the nurse. Record review of a respiratory note dated [DATE] revealed at 12:00 a.m. CRTT O had documented patient continued to have respiratory retractions and was lethargic. The patient was still on 4 liters of O2. Record review of respiratory note dated [DATE] revealed at 4:00 a.m. the patient remained on 4 liters of oxygen and continued to use accessory muscles. During an interview on [DATE] at 6:38 p.m. with LVN Q, he indicated he was the night nurse for Resident #2. He also indicated that on [DATE] Resident #2's oxygen saturation level was ,[DATE]%. He further indicated that he left a note on the [DATE] night shift for the next shift that came on duty on [DATE] at 10:00 p.m. He indicated he was surprised that Resident #2 was still at the facility the next day when he came on duty. He indicated he thought that Resident #2 would have been in the hospital. When asked why he did not send Resident #2 to the hospital, he indicated he did not consider sending her out because the other shifts did not send Resident #2 to the hospital. He indicated that the Administrator and DON needed to know before a resident was sent out to the hospital and that there was no discussion with anyone about sending Resident #2 to the hospital. Review of Nursing Note dated [DATE] at 2:30 a.m. revealed Resident #2 was in bed throughout the shift. Resident #2's skin was warm to touch. Further review of nursing note revealed that Resident #2 was alert and oriented x 3 and able to verbalize needs. Further review of this same document revealed that Resident #2 continued to use accessory muscles and was on continuous oxygen at 2 liters per nasal cannula. Review of Respiratory note dated [DATE] at 4:00 a.m. revealed Resident #2 continued to use accessory muscles and her oxygen was at 4 liters per nasal cannula. Record review of Resident #2's respiratory care note dated [DATE] at 9:00 a.m. revealed that the nurse reported that Resident #2 was having respiratory distress. Further review of this same document revealed that Resident #2's nasal cannula was switched to a simple mask and and her oxygen was increased to 7 liters per minute. The note was written by CRTT P. Further review of this note revealed there was no documentation that the physician was consulted. During interview on [DATE] at 2:34 p.m. with CRTT P, he indicated he had changed Resident #2 from a nasal cannula to a simple mask and increased her oxygen to 7 liters per minute. He indicated the MD did not order the oxygen to be increased to 7 liters per minute from 4 liters per minute. CRTT P indicated it was up to the nurse to talk to the physician. CRTT P indicated he just informed the nurse what he did and Resident #2's response Review of Resident #2's Nursing Note dated [DATE] at 9:00 a.m. revealed a new order for [MEDICATION NAME] 20mg by mouth twice a day for [DIAGNOSES REDACTED]. Review of Resident #2's telephone orders dated [DATE] revealed an order for [REDACTED]. Review of physician telephone order (not dated on yellow copy) for Resident #2 to be seen by a hospice revealed that the ADON had signed as the nurse who received the telephone order. Review of Resident #2's Nursing Notes dated [DATE] at 10:00 a.m. revealed that Resident #2 was in bed resting with eyes open. Potassium 20 mEq by mouth daily was discontinued and [MEDICATION NAME] (use to treat fluid retention related to [MEDICAL CONDITION]) 25 mg by mouth daily was started instead. Review of Resident #2 ' s signed physician telephone orders dated [DATE] just received by the facility from the physician revealed that the physician had written "Add O2 at 2L/NC & increase prn if O2 sat. dropping." During an interview on [DATE] at 5:36 p.m. with Medical Records Personnel, she indicated that telephones had come back from the physician on [DATE] to include [DATE] telephone order that included add O2. Review of physician telephone order dated [DATE] revealed that the ADON had signed as the nurse who received the physician telephone order. Further review of this telephone order revealed to discontinue Potassium 20 mEq PO, give [MEDICATION NAME] ([MEDICATION NAME]) 25 mg PO daily. During an interview on [DATE] at 11:04 a.m. with the ADON, she was shown the telephone order for hospice and the telephone order to discontinue potassium and give [MEDICATION NAME] ([MEDICATION NAME]). The ADON verified it was her signature on both of those orders. When asked who she got those orders from, she indicated she received those orders from the Administrator. When asked for the phone number for Resident #2's physician since this physician was not in his office on [DATE], when the surveyor tried to contact the physician, she indicated there wasn't another number, just the office number. When asked who they would call if something was going on with a resident the ADON said the Administrator. She further indicated that the Administrator was the next in line to reach if this physician was not in his office. The ADON also indicated that the Administrator has the authority to make decisions for this physician when this physician is not available and they notify this physician about what orders the Administrator has given later. During an interview on [DATE] at 11:14 a.m., with the Administrator, he indicated that he was the designated agent for Physician J and that he had the authority to prescribe. He further indicated that his authority to prescribe meant that he could refill a Vicoden prescription at the pharmacy using the DEA number. He further indicated that these were some of his duties and he described it similar to working as an employee as a nurse in a physician's office where a nurse would be able to call in a prescription at the pharmacy. He further indicated he could follow standing protocols and provided an example such as the standing orders for [MEDICAL CONDITION] and provided an example of [MEDICATION NAME] and Potassium as being a part of the standing orders. Review of "Heart Failure-[MEDICAL CONDITION]" (standing orders for [MEDICAL CONDITION]) revealed "Admit/Re-Admit Protocols for Medicare A 'Skilled Resident'. Further review of this document revealed no standing orders for Potassium and [MEDICATION NAME]. During an interview on [DATE] at 1:13 p.m. with the Administrator, when told that the [MEDICAL CONDITION] standing orders does not include [MEDICATION NAME] and Potassium, he indicated that they could follow whatever is on that form. During an interview on [DATE] at 1:16 p.m. with the ADON, she indicated that if there was no answer from the physician, they next went to the Administrator, then to the "Medical Examiner". During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator since the doctor could not be reached and the Administrator said that Resident #2 needed to go on hospice. During an interview on [DATE] at 6:53 p.m. with Physician J, he indicated that he thought the orders for the [MEDICATION NAME] had come from another physician because he did not normally prescribe [MEDICATION NAME]. He indicated that he recalled agreeing to a hospice consult because he thought the family had requested it or another physician had requested it. He further indicated he had not personally spoken to Resident #2's family. He further indicated there was a standing order to send residents to the emergency room if needed without having to get in touch with him for an order to send the resident to the emergency room . Review of Resident #2's physician progress notes [REDACTED]. Review of Resident #2's nursing notes revealed no documentation of physician or nurse practitioner visits after [DATE]. Review of Resident #2's Social Services Note revealed that social worker contacted hospice care as per instructions from the Administrator. Further review of this same note revealed that Referral was made for hospice care for resident who has decompensated medically and will benefit from hospice care. During an interview on [DATE] at 6:01 p.m. with the Medical Director, he indicated he had not personally given orders for or been involved with Resident #2's care at the nursing facility. The Medical Director further indicated that he or his nurse practitioner should be contacted if a resident's primary care physician was not available and a physician's input was needed. The Medical Director said they would be very willing to take those calls and they had a system in place that a physician would always be available. During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that she talked to the Administrator when the physician was not available because the Administrator worked with this physician. LVN I indicated that the Administrator gave orders for [MEDICATION NAME] and Potassium and they were sent off to the pharmacy. LVN I further indicated that the Administrator discontinued the order and gave orders for [MEDICATION NAME] due to [MEDICATION NAME] is Potassium sparing. Review of Resident #2's Nursing Notes dated [DATE] at 11:00 a.m. revealed Resident #2 was resting on her left side and that she was being turned every 2 hours. The note further revealed that Resident #2's bilateral extremities were elevated due to increased [MEDICAL CONDITION]. The note further revealed Resident #2 was stable. The note further revealed that hospice had just seen Resident #2. Review of Resident #2's Nursing Notes dated [DATE] (no time given) revealed that Resident #2's sister phoned the facility and called to inquire about the resident and the change of condition was explained to the sister. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that the facility had not called her regarding Resident #2's change in condition. She further indicated she had to call the facility (on [DATE]) to see what was going on with Resident #2 because she had received an unexpected call from a hospice about admitting Resident #2 to their services. Resident #2's family member said she was shocked to be called by hospice because Resident #2 was her normal self when she visited her 3 weeks earlier except for severe bruising around her eye after an incident involving another resident. She also indicated that when she called the facility, the ADON had answered the phone. She then indicated she had told the ADON she wanted to know how Resident #2 was doing, She further indicated that the ADON told her she was sorry and that someone should have called her. Resident #2's family member further indicated that it seemed like the facility staff were taking matters into their own hands. Review of Resident #2's Nursing Notes dated [DATE] for ,[DATE] p.m. shift revealed that Resident #2 had to be reminded to keep her oxygen mask on. Respiratory notes dated [DATE] at 12:00 a.m. revealed Resident #2 was on a simple mask using 8 liters of oxygen. Further review of this note revealed coarse rales ("A loud and low-pitched, discontinuous, ' explosive ' crackling sound heard in patients" http://medical-dictionary.thefreedictionary.com/Coarse+Rales) and diminished breath sounds throughout. Further review of the note revealed Resident #2 was stable. Review of Resident #2's Nursing Notes dated [DATE] at 2:45 a.m. revealed that Resident #2 remained on bed rest. The note further revealed that Resident #2 was on continuous oxygen at 8 liters. Further review of this same document revealed that Resident #2's oxygen saturation was 97% at 2:45 a.m. and that Resident #2 was arouseable to tactile stimulation. Further review of this same document revealed that Resident #2 continued to breathe using her accessory muscles. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 8:00 a.m. revealed Resident #2 refused to eat breakfast. Further review of the note revealed that Resident #2 was using her accessory muscles at that time. Further review of the nurses note revealed that Resident #2's bilateral lower extremities were elevated to decrease [MEDICAL CONDITION]. This nursing note also indicated that Resident #2 was spoon fed two cups of applesauce and tolerated 1 cup of water. During an interview on [DATE] at 2:20 p.m. with LVN I, she indicated that on [DATE], Resident #2 was using accessory muscles to breathe. She further indicated that Resident #2 could not eat and breathe at the same time. She also indicated that at 11:30 a.m. she placed a call to the physician and never received a call back from the physician. She indicated that on [DATE] the new problem with swallowing was first noted. She spoon fed Resident #2 applesauce and made a call to get a MBS study. Review of Resident #2's telephone order dated [DATE] and timed 12:30 p.m. revealed swallow study consult with MBSS due to difficulty swallowing and aspiration risk Further review of this telephone order read back to Physician J/LVN I. Review of Resident #2's Nurses notes dated [DATE] at 11:30 revealed "call made to MD to schedule MBSS, pending call back at this time." Observation of the DON at [DATE] at 5:15 p.m. revealed the DON dialing the phone. The message heard from the speaker phone said the doctor's office hours are Monday through Friday except on Thursday. There was was no option to leave a message or an alternative number given to try to reach the physician. The DON further indicated that he did not have the number to reach Physician J after hours, only the Administrator had the number. During an interview on [DATE] at 7:18 p.m. with the Administrator, he indicated that he was the only one at the facility who had Physician J's personal cell number. Review of hospice document dated [DATE] titled "Nursing Review of Patient Decline Related to Cardiopulmonary Conditions" in the section titled "Current Clinical Picture" revealed the patient was in bed and unresponsive. 2+ - 3+ generalized [MEDICAL CONDITION] (fluid building up within the body which can include the skin and lung tissues). Vital signs stable, no skin breakdown, lungs are diminished with ronchi ("a continuous snore like sound in the throat or [MEDICATION NAME] tubes, due to a partial obstruction" http://medical-dictionary.thefreedictionary.com/rhonchi ). Uses abdominal muscles to breathe. Patient on diuretics with little output. Has third spacing (accumulation of fluids between the skin and fascia ("A fibrous membrane covering , supporting, and separating muscles" Taber's Cyclopedic Medical Dictionary) http://medical-dictionary.thefreedictionary.com/third+spacing). Bowel Sounds faint. 3 Liters via mask. Sats. 99%. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed Resident #2 was on bed rest due to shortness of breath and decreased oxygen saturation. Resident #2 was on 8 liters of oxygen and continued to use her accessory muscles to breathe. Review of Resident #2's Nursing Notes dated [DATE] at 5:30 a.m. revealed Resident #2 had attempted to get out of bed and slid to the floor. This note also revealed the fall was witnessed. Resident #2 bit her lips/tongue. The note further indicated to call the physician in the a.m. Review of Resident #2's Nursing Notes dated [DATE] at 5:53 p.m. revealed staff had attempted to feed Resident #2 three times during dinner. The note further revealed that Resident #2 was too lethargic and Resident #2 had no output during the shift. The note further revealed that Resident #2 would continue be to monitored. Further review of this note revealed there was no documentation that the physician was consulted. Review of Resident #2's Nursing Notes dated [DATE] at 9:26 p.m. revealed that no output for Resident #2 had been observed. Further review of this nursing note revealed that Resident #2 was too lethargic to receive hydration times 2 attempts. Review of Resident #2's Nursing Notes dated [DATE] at 2:00 a.m. revealed that hospice was notified of Resident #2 having no urine output. Hospice staff called back and said to insert an indwelling catheter. Catheter was inserted and resulted in 400 cc of urine. Review of Resident #2's Nursing Notes dated [DATE], no time, revealed that Resident #2 had bilateral diminished breath sounds. During an interview on [DATE] at 10:12 a.m. with Resident #2's family member, she indicated that she went to the nursing facility on [DATE] and told facility staff she wanted Resident #2 off of hospice and sent to the hospital for treatment. The facility staff told her that they were doing everything for her that the hospital would do. The resident's family continued to insist that Resident #2 be sent to the hospital and further indicated they had trouble getting Resident #2 out. The facility staff told her that she would have to be responsible for the ambulance charges. Resident #2's family member was not sure if she had signed AMA paperwork. Resident #2's family member said that she had been asked by the EMT why Resident #2 had not been sent to the hospital on Monday ([DATE]). The EMT told Resident #2's family member that the EMT needed Resident #2's information including medication list and History and Physical and to please ask the facility staff to provide it to them because EMT had problems getting all the information from the nursing home staff. Resident #2's family member said she had asked the facility staff who the physician was that had been taking care of Resident #2. Resident #2's family member indicated that the facility staff refused to give her contact information for the physician or tell them his name. Resident #2's family member said she still did not know who the physician had been. Resident #2's family member indicated that the facility had never brought up to her the option of taking her to the hospital. Review of Resident #2's Nursing Notes dated [DATE] at 1:50 p.m., revealed that Resident #2's sister wanted Resident #2 off of hospice and transferred to the hospital. Called ADON to inform. Family signed AMA paperwork. Family made aware facility does not cover anything else once AMA is signed. During an interview on [DATE] at 1:16 p.m. with LVN F and ADON, that LVN F indicated that she asked the family to sign AMA because the ADON told her to get the AMA signed. ADON indicated that she went to her "Director" (Administrator) regarding the family request to send Resident #2 to the hospital. ADON indicated that the Administrator is her Director. She further indicated that the Administrator told her to get AMA signed as family was pulling resident out against medical advice. ADON indicated that the Administrator told her this during the only call between ADON and Administrator on that Saturday ([DATE]). LVN F indicated that she did not leave a message for the physician on [DATE]. ADON and LVN F indicated that neither of them spoke to the Medical Director nor any of his Nurse Practitioners on [DATE]. During an interview on [DATE] at 2:36 p.m. with the Administrator, he indicated that the ADON called him and he was at the airport using his cell phone. He further indicated he clicked over and called the physician and then talked to the ADON again. The Administrator indicated that the physician already knew that Resident #2 was leaving AMA because the nurse had left a message earlier for the physician. During this interview with the Administrator the ADON indicated she had called the Administrator and was on a 3 way call and she heard the physician say if the resident goes to the hospital she will be going AMA. During an interview on [DATE] at 11:14 a.m., with the Administrator, he indicated that he was the designated agent for Physician J and that he had the authority to prescribe. He further indicated that his authority to prescribe meant that he could refill a Vicoden prescription at the pharmacy using the DEA number. He further indicated that these were some of his duties and he described it similar to working as an employee as a nurse in a physician's office where a nurse would be able to call in a prescription at the pharmacy. He further indicated he could follow standing protocols and provided an example such as the standing orders for [MEDICAL CONDITION] and provided an example of [MEDICATION NAME] and Potassium as being a part of the standing orders. Review of "Heart Failure-[MEDICAL CONDITION]" (standing orders for [MEDICAL CONDITION]) revealed "Admit/Re-Admit Protocols for Medicare A 'Skilled Resident'. Further review of this document revealed no standing orders for Potassium and [MEDICATION NAME]. During an interview on [DATE] at 1:13 p.m. with the Administrator, when told that the [MEDICAL CONDITION] standing orders does not include [MEDICATION NAME] and Potassium, he indicated that they could follow whatever is on that form. During an interview on [DATE] at 6:53 p.m. with Physician J, he indicated that if a resident's need for oxygen was increasing from 2 liters of oxygen to 4 liters of oxygen, to 7 liters of oxygen to 8 liters of oxygen, they should be sent to the hospital for evaluation and treatment. Physician J indicated that he was not informed that Resident #2's need for oxygen had increased. Physician J further indicated he was not aware that Resident #2 had declined in condition since the initial complaint of shortness of breath and mild [MEDICAL CONDITIONS]. He further indicated there was a standing order to send residents to the emergency room if needed without having to get in touch with him for an order to send the resident to the emergency room . He further indicated it would not have been reasonable to make a resident have to sign out AMA to go to the hospital at the family's request due to decline in condition and family's desire for medical treatment. He further indicated he did not say the resident must sign out AMA to go to the hospital at Resident #2's family's request. He further indicated he did not give the order that Resident #2 must leave AMA to go to the hospital for treatment. He further indicated he was not aware of the family signing out Resident #2 AMA until after Resident #2 had already left the facility to go to the hospital. When asked if Physician J and the Administrator had an agreement or understanding that that Administrator could make decisions regarding resident's medical treatment, Physician J said no, definitely not to order medications just to send resident to the emergency room if needed. Physician J further indicated he gets telephone orders to sign from facilities and only has time to read about half of the orders he signs so he can't say for sure he that he knows if all the telephone orders he signs were from the orders he knows and remembers giving. During interview on [DATE] at 3:25 p.m. with LVN A, she indicated that when she looked back at the condition of Resident #2, LVN A thought Resident #2 probably should have been sent to the hospital on [DATE]. During an interview on [DATE] at 7:32 p.m. with the DON, when asked if he would expect his nursing staff to do anything differently, he indicated he would want his staff to do better documentation. When asked if staff would be expected to provide care any differently he said no because the resident was stable. Review of the hospital History and Physical with admitted [DATE] revealed "The patient is critically ill with as noted [MEDICAL CONDITION], metabolic [MEDICAL CONDITION], acutely decompensa

Based on observations, interviews and record reviews, the facility failed to ensure 6 (#3, #5, #6, #7, #8 and #9) of 8 residents reviewed with indwelling catheters received the appropriate treatment and services to prevent Urinary Tract Infections. 1.) Resident #3's indwelling urinary catheter was not changed every 30 days as ordered by the physician. The residents indwelling urinary catheter was not changed for 60 days and she was sent to the hospital with a distended abdomen and had 8,125 cc's of urine drained from her bladder in the ER. According to the National Kidney and Urologic Diseases Information Clearinghouse "If the bladder becomes stretched too far or for long periods of time, the muscle may permanently be damaged and lose ability to contract...and if urine backs up into the kidneys permanent kidney damage could occur". (National Kidney & Urologic Diseases Information Clearinghouse) found at website http:kidney.niddk.nih.gov/Kudiseases/pubs/[MEDICAL CONDITION]/ dated 9/23/11. She was in acute pain and diagnosed with [REDACTED]. The facility was aware of Resident #3's problem problem of [MEDICAL CONDITION] since 3/4/11 when a care plan was initiated. 2.) Resident #5's indwelling urinary catheter was not changed every 30 days as there was no physician's order. No routine orders for Resident #5's indwelling urinary catheter to be changed every 30 days, PRN or catheter care to be given every shift could be found. The resident had ongoing UTI's and was transported to the hospital with a distended bladder, no urinary output, was in acute pain, hospitalized and diagnosed with [REDACTED]. 3.) Resident #6 had an indwelling urinary catheter that was not changed for 30 days as ordered by the physician. She had an indwelling urinary catheter placed for a Stage IV wound to heal. The wound was healed on 7/14/11 and Resident #6 had the indwelling catheter in place for an extra 54 days. Resident #6 was placed on antibiotics on 9/9/11 for a UTI. 4). Resident #7 had no physician's orders for his indwelling urinary catheter for almost 60 days after admission to the facility. Resident #7's urinary catheter was changed without a physician's order. He was placed on antibiotics on 8/5/11. 5. Resident #8's indwelling urinary catheter was not changed monthly as ordered by the physician for over 60 days. 6. Resident #9 did not have physician's orders for an indwelling urinary cather for 9 days (from admission to discharge). An Immediate Jeopardy (IJ) was identified on 9/8/11. While the IJ was removed on 9/9/11, the facility remained out of compliance at a severity level of "Actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of a "pattern" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. Failure to ensure infection control and catheter care policies and procedures are followed regarding indwelling urinary catheters could adversely affect the 8 residents in the facility with indwelling urinary catheters. The findings were: A. Record review of Resident #3's clinical record face sheet (undated) revealed that she was [AGE] years old and admitted to the facility on [DATE]. She had diagnoses of: Unspecified mental [MEDICAL CONDITIONS] and anxiety. Further review of a nurse's note, dated 9/5/11 at 11:00 a.m., revealed the following: that her abdomen was distended and that she complained of pain to her left side with palpation (touch). The doctor was notified and she was transported out of the facility by ambulance at 12:00 p.m. Further review revealed that another nursing note was written at 3:10 p.m. that stated the physician called to report that the hospital had removed 6 liters of urine from Resident #3's bladder. Review of the "Transfer Form", dated 9/5/11 revealed "stomach hard and distended and painful to touch on left side. Jumps when touched". Review of Resident #3's comprehensive care plans dated 3/4/11, revealed she had an indwelling urinary catheter for "[MEDICAL CONDITION]" and also one for "risk for fluid overload". Record review of Resident #3's hospital record face sheet (undated) revealed diagnoses of "urine retention", bladder infection, urinary tract infection [MEDICAL CONDITION]. She was admitted to the hospital with [REDACTED]. She had an elevated temperature of 101 degrees Fahrenheit (F) (normal temperature 98.6 degrees F), and the chief complaint was abdominal distention with pain. Review of a lab report obtained at time of admission to the hospital revealed a urine culture with growth of Pseudomonas Aeruginosa. The website http://emedicine.medscape.com/article/ 8-overview, accessed 9/23/11 indicated (gram-negative rods that are a frequent cause of infections to include UTI's and are complicated and can be life threatening) Observation on 9/7/11 at 10:10 a.m. of Resident #3 in the hospital revealed she was receiving IV antibiotic and had a new urinary catheter. In an interview at the same time with the resident she was asked to demonstrate with open arms how much pain she had before she came to the hospital, and she opened her arms wide. Observation on 9/7/11 at 11:00 a.m. of the urinary catheter bag, in the hospital that ER RN W had taken when removed from Resident #3 on 9/5/11 at 12:15 p.m. and placed in her locker, revealed that the leg bag was a green and yellow in color and that the latex catheter bulb that was deflated had partially deteriorated. The latex tubing was half green and yellow in color. In an interview at the same time with ER RN X, who was working on 9/5/11 when Resident #3 came to the ER, she stated that Resident #3 looked like she was pregnant when she first arrived. In an interview on 9/7/11 at 09:00 a.m. with a family member of Resident #3, she stated that Resident #3 came to the hospital with a bladder infection. She stated that the indwelling catheter wasn't being changed and that Resident #3 was emptying her own drainage bag. In an interview on 9/7/11 at 11:20 a.m. with the ER RN Y, who replaced Resident #3's indwelling urinary catheter, she stated that the catheter balloon was deteriorating and that the odor was the foulest she had smelled in her whole nursing career. She stated that the leg bag strap also was dirty with a horrible odor. Review of Resident #3's quarterly MDS assessment dated [DATE] revealed she "usually understood and sometimes understands". Review of Resident #3's physician orders for September 2011 revealed orders for "Urinary Catheter Care Q shift and PRN, and to change the foley catheter Q 30 days". Review of Resident #3's physician orders dated 8/15/11 revealed "start [MEDICATION NAME] (antibiotic) 1 GM IM q 12 hours" for treatment of [REDACTED]. Review of Resident #3's labs revealed she had a positive urine culture on 5/23/11 and on 8/13/11 she had a positive urine culture that was growing Pseudomonas Aeruginosa. Review of Resident #3's Comprehensive Care Plans dated 3/4/11 for "Problem Noted" as "Urinary Catheter" revealed approaches to include "Change urinary catheter, tubing and bag per order...monitor urine for odor, color, sediments, amount of urine". Another problem noted was "at risk for fluid overload" and interventions included: "Observe for signs and symptoms of fluid overload and to monitor output". In an interview on 9/7/11 at 1:35 p.m. with CNA V, she stated that Resident #3 always had a leg bag and that she would empty her own bag. She stated that the resident's urinary catheter was supposed to be changed every month. In an interview on 9/8/11 at 12:30 p.m. with LVN C who had worked on 9/5/11, she stated that the resident had a distended abdomen and that she took herself to the rest room. She stated that the resident emptied her own bag and was non-compliant with letting staff help her with her care. She stated that the doctor was called about the distended abdomen. Review of Resident #3's I & O sheet from September 2011 revealed she had an average urinary output per shift of approximately 700 cc's prior to being sent to the ER and that several output sections on the I & O sheet reflected no cc measurements were noted but the word "self" was written. Review of Resident #3's nursing notes dated 4/4/11 (untimed) revealed she had her urinary leg bag changed. No other evidence could be found of a urinary leg bag being changed. In an interview on 9/7/11 at 11:50 a.m. with the facility ADON she stated that Resident #3 was sent to the hospital with abdominal distention and pain and that the resident looked like she was 9 months pregnant. In an interview on 9/7/11 at 1:40 p.m. with LVN F, she stated that she worked on Resident #3's hall on the day she was sent out to the ER. She stated that the resident was sitting in a chair in the hallway and that her stomach was distended. She stated that she checked Resident #3's stomach and it was really hard. She stated that her urine leg bag had 500cc's of urine in it prior to going to the hospital. Review of Resident #3's Nurse MARs from March 2011 to July 2011 revealed no annotation of Resident #3's urinary catheter being changed. In July 2011 Resident #3's Nurse MAR reflected that 2 nurses had initialed off for 3 urinary catheter changes (once for LVN I and twice for LVN N). In August 2011, LVN J initialed off that the indwelling urinary catheter had been changed. In an interview on 9/8/11 at 11:25 a.m. with LVN J, he stated that he had never changed Resident #3's indwelling urinary catheter and he would never change it without help because she would resist care. He stated his initial was a mistake. In an interview on 9/8/11 at 11:30 a.m. with LVN N, she stated that she had not changed Resident #3's urinary catheter and that she made an error in documentation. In an interview on 9/8/11 at 11:40 a.m. with LVN I, she stated that she had changed Resident #3's indwelling urinary catheter on 7/3/11 because it had become clogged. She did not know why it had not been changed for August 2011. In an interview on 9/8/11 at 12:00 p.m. with the ADON, she stated that catheter care was supposed to be done once a shift and the indwelling urinary catheter changed once every 30 days. She had no answer as to why the catheters were not changed and shrugged her shoulders and shook her head. In an interview on 9/8/11 at 4:10 p.m. with the Urologist that treated Resident #3 at the hospital, he stated that it was possible for a resident's bladder to gradually stretch over time with urine retention to the extent that Resident #3s had and that it could have been caused from an indwelling urinary catheter not being changed routinely. He stated that the latex catheter tubing would become encrusted and block the flow of urine. In an interview on 9/8/11 at 5:00 p.m. with RN A, who was the corporate nurse sitting in for the DON, she acknowledged that the facility had problems with managing and monitoring the care and maintenance of indwelling urinary catheters. She stated that the facility did not have a steady DON for over 4 months. B. Record review of Resident #5's clinical record (face sheet) dated 12/07/10 revealed resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #5's clinical record (physician's orders) dated 9/01/11 through 9/30/11 (printed on 8/29/11) revealed diagnoses that included: Unspecified Complications Type II Diabetes; and Malignant Neoplasm of the Prostate. Observation on 9/07/11 at 11:30 a.m. revealed Resident #5 had an indwelling urinary catheter connected to a drainage bag. In an interview on 9/12/11 at 5:45 p.m. with LVN C she stated she completed a skin assessment on Resident #5 on 1/24/11 when Resident #5 returned to the facility from the hospital. LVN C stated Resident #5 had a urinary catheter which she documented on the assessment sheet. Record review of Resident #5's clinical record (Admission Skin Assessment Form) dated 1/24/11 revealed Resident #5 was assessed and had an indwelling urinary catheter. Record review of a 5 day MDS assessment dated [DATE] revealed resident #5 was assessed and had an indwelling urinary catheter. In an interview on 9/12/11 at 8:50 a.m. with LVN H she stated when residents return to the facility from the hospital, they were assessed prior to being cared for. She stated if a resident had a urinary catheter and did not have a doctor's orders for the indwelling urinary catheter; the procedure was to call the physician for an order as urinary catheters were changed monthly and PRN. She indicated the urinary catheter was cleaned each shift and changed monthly and PRN and this was documented on the nursing MARS. LVN H stated Resident #5 had a urinary catheter upon admission to the facility from the hospital in January 2011. She stated she was not aware Resident #5 did not have doctor's orders for the urinary catheter or that the care and changing of the urinary catheter was not being documented on the MARS. In an interview on 9/12/11 at 2:30 p.m. with RN A, who was the corporate nurse, she stated nurses had a checklist to go by whenever a resident enters the facility. She stated when a resident comes to the facility from the hospital with a urinary catheter and no orders, the nurse should contact the doctor to obtain an order for [REDACTED]. She acknowledged, after reviewing Resident #5's clinical record, there was no documentation that an order had not been obtained from the doctor since 1/24/11 for catheter care or that the urinary catheter had been changed by the nurses monthly and PRN. Record review of Resident #5's clinical record (nurse's notes) revealed the following: On 5/23/11 Resident #5's urinary catheter was removed. The balloon with 5 cc was withdrawn with 3 cc. Resident voided out 100 cc of rose colored urine with sediments, mucus and blood. The catheter was inserted and 16 cc of rose colored urine flowed into the tube with thick mucus sediment. On 6/12/11 Resident #5's urinary catheter was changed and resident voided 1000 cc of yellow, cloudy urine. The urine was noted to have mucus in it. On 6/14/11 Resident #5's urinary catheter was leaking and an attempt was made to reposition the urinary catheter at which time the catheter came out. When the catheter came out, a half dollar size amount of thick green pus came out with it. The catheter was changed and thick cloudy yellow urine came out. Record review of Resident #5's clinical record (physician's telephone orders) from 1/24/11 through 9/08/11 revealed 2 physician's orders on 5/23/11 and 6/12/11 to change out Resident #5's urinary catheter related to problems. In an interview on 9/7/11 at 12:05 p.m. with the ADON, she stated catheter care was supposed to be done every shift and the indwelling urinary catheter was to be changed monthly and PRN. Record review of Resident #5's clinical record (nursing notes and resident transfer and hospital discharge) indicated Resident #5 was sent to the hospital on [DATE], 5/24/11 and 8/17/11 with UTIs. Record review of Resident #5's clinical record (labs) revealed Resident #5 had urinary tract infections on 5/23/11, 6/12/11, 6/15/11, 7/11/11 and 8/30/11. On 5/23/11, labs indicated WBC was 29,000. On 6/12/11, labs indicated [DIAGNOSES REDACTED] Pneumoniae, bacteria. On 6/15/11, labs revealed gram negative lactose fermenting isolated. On 7/11/11, labs revealed gram negatrive lactose fermenting, colony count 100,000, Providencia Stuartii, bacteria. On 8/30/11, labs revealed E-Coli, bacteria. Record review of Resident #5's clinical record (Nursing Notes) from 1/24/11 through 9/08/11 revealed documentation that Resident #5 had a urinary catheter changed on 5/23/11 and 6/12/11. Record review of the comprehensive care plan for Resident #5 dated 5/10/11, revealed that the indwelling urinary catheter was not addressed in the care plan. On 9/08/11, a care plan was developed to include interventions to address Resident #5's urinary incontinence and catheter care. In an interview on 9/07/11 at 11:30 a.m. with LVN H, she stated resident #5 had an indwelling urinary catheter since his admission from the hospital on [DATE]. LVN H stated catheter care was done on her shift and the indwelling urinary catheter was changed monthly and PRN. Resident #5 had only been on LVN H's hall for about one month. Interview on 9/12/11 at 8:30 a.m. with LVN L, MDS Coordinator, confirmed that the indwelling urinary catheter had not been addressed in the care plan for Resident #5 when resident returned to the facility from the hospital with the indwelling urinary catheter on 1/24/11. LVN L indicated she relied on information provided by nurses who assessed Resident #5 before she completed the MDS. LVN L stated she had completed MDS's since March 2011. In an interview on 9/12/11 at 4:30 p.m. with LVN M she stated she began working at the facility in March 2011. She stated she changed Resident #5's urinary catheter once in June 2011, but failed to document this on the MARS or nurse's notes. C. Resident #6 was admitted to the facility on [DATE] with diagnoses of chronic [MEDICAL CONDITION], coronary [MEDICAL CONDITION], and muscle weakness per the undated face sheet. Observation of Resident #6 on 9/7/11at 1:00 p.m. revealed she had an indwelling urinary catheter. In an interview at the same time she stated that she had not had her urinary catheter changed in over a month. Review of Resident #6's labs revealed she had a U/A and C&S done on 8/26/11 and that the identification and sensitivity of the bacteria was received by the facility on 9/4/11. Resident #6 was started on an antibiotic on 9/9/11 for her UTI. Review of Resident #6's annual MDS assessment dated [DATE] revealed she had an indwelling urinary catheter connected to a drainage bag. The MDS did not reflect that the resident had a pressure sore. There were no diagnoses or medical conditions listed that would support Resident #6's having an indwelling urinary catheter. The MDS reflected that she was "usually understood and "usually understands". Review of Resident #6's physician's orders from 5/13/11 to 9/12/11 revealed she had orders to "Change Foley q month and PRN". Review of Resident #6's clinical record revealed she was given the indwelling urinary catheter on 3/15/11 for a Stage IV pressure sore on her coccyx to heal. Review of Resident #6's comprehensive care plans revealed she did not have a care plan for an indwelling urinary catheter. Interview on 9/12/11 at 8:30 a.m. with MDS Coordinator L, she stated that the indwelling urinary catheter had not been addressed in the care plan for Resident #6. Interview on 9/12/11 with LVN C, the treatment nurse, revealed Resident #6 did not have any pressure ulcers and that the Stage IV she had was healed on 7/14/11. LVN C stated she did not know why the resident had an indwelling urinary catheter. Review of Resident #6's TAR revealed her pressure ulcer had healed on 7/14/11. Review of Resident #6's Nurse MARs and Nursing Notes from 3/15/11 to 9/12/11 revealed that Resident #6 had 2 documented changes of her indwelling urinary catheter on 7/15/11 and 7/21/11 because it had come out. D. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] per the Record of Admission sheet dated 7/14/11. Review of a H&P dated 7/15/11 revealed diagnoses that included SP MVA, cervical spine fracture, ventilator dependence, and [MEDICAL CONDITION]. Review of Admission Nursing Assessments dated 7/14/11 and 9/2/11 revealed documentation that Resident #7 had an indwelling urinary catheter. Interview on 9/9/11 at 5:00 p.m. with LVN D confirmed he admitted resident #7 on 7/14/11 and did not obtain a physician's order for the urinary catheter that resident #7 was admitted with. LVN D confirmed that he changed resident #7's urinary catheter on 8/1/11 without an order to do so. LVN D said he changed the catheter because resident #7 had no urinary output and the catheter was apparently clogged. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #7 was assessed as having a urinary catheter. Observation on 9/8/11 at 1:20 p.m. revealed Resident #7 had an indwelling urinary catheter connected to a drainage bag. Review of the comprehensive care plan for Resident #7, dated 7/25/11, revealed that the indwelling urinary catheter was not addressed. Review of admission physician's orders for Resident #7 dated 7/14/11 and 9/2/11 and of consolidated orders dated 8/1/11-8/31/11 revealed no order for the indwelling urinary catheter. Review of physician's telephone orders from admission on 7/14/11 to 9/8/11 revealed no order for the urinary catheter for Resident #7. Interview with the DON on 9/8/11 at 1:40 p.m. confirmed there were no orders for the urinary catheter for Resident #7. Further interview with the DON on 9/8/11 at 2:50 p.m. revealed that Resident #7 had an indwelling urinary catheter since his admission on 7/14/11. Review of nurse's notes dated 8/1/11 revealed documentation that Resident #7's urinary catheter was changed and that urine obtained was foul in odor with thick sediment. In addition, hematuria (blood in the urine) was noted. Further review of this documentation revealed that 1200 cc of urine was obtained when the catheter was changed. Review of urine culture results dated 8/2/11 revealed that Resident #7 had a UTI. Review of a physician's telephone order dated 8/5/11 revealed an order for [REDACTED]. E. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pressure ulcer Stage IV, chronic osteo[DIAGNOSES REDACTED] pelvic region, and [MEDICAL CONDITION] per the Record of Admission sheet dated 7/19/11. Review of an Admit/Discharge Report revealed resident #8 was readmitted on [DATE]. Observation of Resident #8 on 9/9/11 at 1:25 p.m. revealed he had an indwelling urinary catheter attached to a leg bag for drainage. Review of physician's consolidated orders dated 7/1/11-7/31/11, 8/4/11, and 9/1/11-9/30/11 revealed an order for [REDACTED]. Review of the treatment sheets and "Nurse MARs" for the months of June, July, and August 2011 revealed no documentation that the urinary catheter was changed. Review of nurses' notes from 6/29/11-9/7/11 revealed no documentation that the urinary catheter was changed as ordered by the physician. Further review of nurse's notes dated 9/8/11 revealed documentation that the urinary catheter was changed on that date (after surveyor intervention). Interview on 9/9/11 at 10:30 a.m. with RN A confirmed there was no evidence that Resident #8's urinary catheter had been changed from 6/29/11 until it was changed on 9/8/11. Interview on 9/9/11 at 10:30 a.m. with RN A revealed that Resident #8 had an indwelling urinary catheter since his first admission to the facility on [DATE]. She stated she did not know why the catheter had not been changed. Review of an Admission Skin Assessment Form dated 6/29/11 revealed Resident #8 was assessed as having a urinary catheter. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #8 was assessed as having a urinary catheter. Review of a care plan for Resident #8, dated 7/22/11, revealed " to change the catheter, tubing, and bag as ordered". F. Resident #9 was admitted to the facility on [DATE] with diagnoses that included [MEDICAL CONDITION] and [MEDICAL CONDITION] per the record of Admission sheet dated 8/30/11. Review of nurse's notes dated 9/4/11 revealed Resident #9 was discharged to the hospital on that date. Review of an Admission Skin Assessment Form dated 8/25/11 revealed Resident #9 was admitted to the facility with an indwelling urinary catheter. Review of nurse's notes dated 9/3/11 revealed documentation that Resident #9 had a urinary catheter. Review of admission orders [REDACTED]. Interview on 9/9/11 at 2:15 p.m. with RN A confirmed Resident #9 had no orders for the indwelling urinary catheter from her admission on 8/25/11 until her discharge on 9/4/11. Review of facility policy and procedure on "Catheter Care" revealed the number one purpose was to prevent infection...and to change each month or as ordered or needed". Review of facility Infection Control Manual for Long Term Care, "Urinary Catheters" dated 2007 revealed "care and maintenance of urinary catheters is important for unobstructed flow". The facility submitted a plan of removal for the Immediate Jeopardy on 9/9/11 at 12:24 p.m., as follows: Nursing administration has assessed all residents with indwelling &/or supra pubic .catheters to identify needs. Three residents had catheters changed out on 9/8/11. One resident with referral for possible supra pubic catheter placement. DON responsible for follow-up. Clarification of all resident's orders with urinary catheters and updated on MARS as of 9/8/11. DON responsible for compliance monitoring. Verification via Input/Output (I & O) Sheets regarding adverse conditions, etc. regarding urinary catheter monitoring - implemented on 9/8/11. DON & ADON responsible for compliance monitoring. In-service all Nurses and Nurse Aides regarding importance of I & O documentation in the monitoring and management of catheter use. On-going in-servicing. Verification as of 9/8/11 of the appropriate resident diagnoses for use of urinary catheters. DON responsible for compliance monitoring. Monthly urinary catheter change scheduled for the 6:00 a.m. - 2:00 p.m. shift. All catheter changes updated on current MARS. DON responsible for compliance. In-service to all nursing staff regarding proper policy and procedure regarding monitoring and management of catheter use & regarding catheter use and justification for use. Nursing administration in-serviced by corporate nurse on 9/8/11 & ongoing in-servicing for all shifts. Verification on 9/8/11 of resident care plans regarding interventions to ensure adequate monitoring and management of catheter care. Administrator and DON responsible for compliance. Catheter output to be emptied per nurse aide before the end of each shift, and the aide will communicate amount to charge nurse who will record output on I & O sheet. The 24 hour report will be used to communicate & each shift is responsible for notifying the next shift of any issues of concerns and/or changes in condition. DON is responsible for picking up the 24 hour report each morning for review. The charge nurse is responsible for the verification of the catheter anchoring and this will be documented each shift. If there is no urinary output for a resident during a shift, the Nurse Aide is responsible for notifying the charge nurse. The charge nurse will then perform an assessment of the resident and notify the MD of findings, etc. When a resident is determined to be independent in emptying their own urinary output, the facility will provide education regarding the possible consequences of their actions along with an informed consent completed. The resident will be required to participate in a skills validation check and if resident is unable to comply, then the staff will continue to verbally ask the resident post each encounter of self performance of emptying urinary output the amount of urinary output to enable staff to document on the I & O form. Confirmation of compliance included: Random interviews, observations of staff and residents present on 9/9/11 and record reviews. Education and training was being provided and processes such as audits were being put into place to prevent a reoccurrence of the problems. While the IJ was removed on 9/9/11, the facility remained out of compliance at a severity level of "Actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of a "pattern" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. Review of Form CMS-672 revealed 8 residents with indwelling catheters.

Based on observations, interviews and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being related to management of indwelling urinary catheters for 6 of 8 residents with indwelling catheters (#3, #5, #6, #7 #8 and #9) in that: 1.) Resident #3's indwelling urinary catheter was not changed every 30 days as ordered by the physician. The residents indwelling urinary catheter was not changed for 60 days and she was sent to the hospital with a distended abdomen and had 8,125 cc's of urine drained from her bladder in the ER. According to the National Kidney and Urologic Diseases Information Clearinghouse "If the bladder becomes stretched too far or for long periods of time, the muscle may permanently be damaged and lose ability to contract...and if urine backs up into the kidneys permanent kidney damage could occur". (National Kidney & Urologic Diseases Information Clearinghouse) found at website http:kidney.niddk.nih.gov/Kudiseases/pubs/[MEDICAL CONDITION]/ dated 9/23/11. She was in acute pain and diagnosed with [REDACTED]. The facility was aware of Resident #3's problem problem of [MEDICAL CONDITION] since 3/4/11 when a care plan was initiated. 2.) Resident #5's indwelling urinary catheter was not changed every 30 days as there was no physician's order. No routine orders for Resident #5's indwelling urinary catheter to be changed every 30 days, PRN or catheter care to be given every shift could be found. The resident had ongoing UTI's and was transported to the hospital with a distended bladder, no urinary output, was in acute pain, hospitalized and diagnosed with [REDACTED]. 3.) Resident #6 had an indwelling urinary catheter that was not changed for 30 days as ordered by the physician. She had an indwelling urinary catheter placed for a Stage IV wound to heal. The wound was healed on 7/14/11 and Resident #6 had the indwelling catheter in place for an extra 54 days. Resident #6 was placed on antibiotics on 9/9/11 for a UTI. 4). Resident #7 had no physician's orders for his indwelling urinary catheter for almost 60 days after admission to the facility. Resident #7's urinary catheter was changed without a physician's order. He was placed on antibiotics on 8/5/11. 5. Resident #8's indwelling urinary catheter was not changed monthly as ordered by the physician for over 60 days. 6. Resident #9 did not have physician's orders for an indwelling urinary cather for 9 days (from admission to discharge). An Immediate Jeopardy (IJ) was identified on 9/8/11. While the IJ was removed on 9/9/11, the facility remained out of compliance at a severity level of "Actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of a "pattern" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. Failure to ensure infection control and catheter care policies and procedures are followed regarding indwelling urinary catheters could adversely affect the 8 residents in the facility with indwelling urinary catheters. The findings were: A. Record review of Resident #3's clinical record face sheet (undated) revealed that she was [AGE] years old and admitted to the facility on [DATE]. She had diagnoses of: Unspecified mental [MEDICAL CONDITIONS] and anxiety. Further review of a nurse's note, dated 9/5/11 at 11:00 a.m., revealed the following: that her abdomen was distended and that she complained of pain to her left side with palpation (touch). The doctor was notified and she was transported out of the facility by ambulance at 12:00 p.m. Further review revealed that another nursing note was written at 3:10 p.m. that stated the physician called to report that the hospital had removed 6 liters of urine from Resident #3's bladder. Review of the "Transfer Form", dated 9/5/11 revealed "stomach hard and distended and painful to touch on left side. Jumps when touched". Review of Resident #3's comprehensive care plans dated 3/4/11, revealed she had an indwelling urinary catheter for "[MEDICAL CONDITION]" and also one for "risk for fluid overload". Record review of Resident #3's hospital record face sheet (undated) revealed diagnoses of "urine retention", bladder infection, urinary tract infection [MEDICAL CONDITION]. She was admitted to the hospital with [REDACTED]. She had an elevated temperature of 101 degrees Fahrenheit (F) (normal temperature 98.6 degrees F), and the chief complaint was abdominal distention with pain. Review of a lab report obtained at time of admission to the hospital revealed a urine culture with growth of Pseudomonas Aeruginosa. The website http://emedicine.medscape.com/article/ 8-overview, accessed 9/23/11 indicated (gram-negative rods that are a frequent cause of infections to include UTI's and are complicated and can be life threatening) Observation on 9/7/11 at 10:10 a.m. of Resident #3 in the hospital revealed she was receiving IV antibiotic and had a new urinary catheter. In an interview at the same time with the resident she was asked to demonstrate with open arms how much pain she had before she came to the hospital, and she opened her arms wide. Observation on 9/7/11 at 11:00 a.m. of the urinary catheter bag, in the hospital that ER RN W had taken when removed from Resident #3 on 9/5/11 at 12:15 p.m. and placed in her locker, revealed that the leg bag was a green and yellow in color and that the latex catheter bulb that was deflated had partially deteriorated. The latex tubing was half green and yellow in color. In an interview at the same time with ER RN X, who was working on 9/5/11 when Resident #3 came to the ER, she stated that Resident #3 looked like she was pregnant when she first arrived. In an interview on 9/7/11 at 09:00 a.m. with a family member of Resident #3, she stated that Resident #3 came to the hospital with a bladder infection. She stated that the indwelling catheter wasn't being changed and that Resident #3 was emptying her own drainage bag. In an interview on 9/7/11 at 11:20 a.m. with the ER RN Y, who replaced Resident #3's indwelling urinary catheter, she stated that the catheter balloon was deteriorating and that the odor was the foulest she had smelled in her whole nursing career. She stated that the leg bag strap also was dirty with a horrible odor. Review of Resident #3's quarterly MDS assessment dated [DATE] revealed she "usually understood and sometimes understands". Review of Resident #3's physician orders for September 2011 revealed orders for "Urinary Catheter Care Q shift and PRN, and to change the foley catheter Q 30 days". Review of Resident #3's physician orders dated 8/15/11 revealed "start [MEDICATION NAME] (antibiotic) 1 GM IM q 12 hours" for treatment of [REDACTED]. Review of Resident #3's labs revealed she had a positive urine culture on 5/23/11 and on 8/13/11 she had a positive urine culture that was growing Pseudomonas Aeruginosa. Review of Resident #3's Comprehensive Care Plans dated 3/4/11 for "Problem Noted" as "Urinary Catheter" revealed approaches to include "Change urinary catheter, tubing and bag per order...monitor urine for odor, color, sediments, amount of urine". Another problem noted was "at risk for fluid overload" and interventions included: "Observe for signs and symptoms of fluid overload and to monitor output". In an interview on 9/7/11 at 1:35 p.m. with CNA V, she stated that Resident #3 always had a leg bag and that she would empty her own bag. She stated that the resident's urinary catheter was supposed to be changed every month. In an interview on 9/8/11 at 12:30 p.m. with LVN C who had worked on 9/5/11, she stated that the resident had a distended abdomen and that she took herself to the rest room. She stated that the resident emptied her own bag and was non-compliant with letting staff help her with her care. She stated that the doctor was called about the distended abdomen. Review of Resident #3's I & O sheet from September 2011 revealed she had an average urinary output per shift of approximately 700 cc's prior to being sent to the ER and that several output sections on the I & O sheet reflected no cc measurements were noted but the word "self" was written. Review of Resident #3's nursing notes dated 4/4/11 (untimed) revealed she had her urinary leg bag changed. No other evidence could be found of a urinary leg bag being changed. In an interview on 9/7/11 at 11:50 a.m. with the facility ADON she stated that Resident #3 was sent to the hospital with abdominal distention and pain and that the resident looked like she was 9 months pregnant. In an interview on 9/7/11 at 1:40 p.m. with LVN F, she stated that she worked on Resident #3's hall on the day she was sent out to the ER. She stated that the resident was sitting in a chair in the hallway and that her stomach was distended. She stated that she checked Resident #3's stomach and it was really hard. She stated that her urine leg bag had 500cc's of urine in it prior to going to the hospital. Review of Resident #3's Nurse MARs from March 2011 to July 2011 revealed no annotation of Resident #3's urinary catheter being changed. In July 2011 Resident #3's Nurse MAR reflected that 2 nurses had initialed off for 3 urinary catheter changes (once for LVN I and twice for LVN N). In August 2011, LVN J initialed off that the indwelling urinary catheter had been changed. In an interview on 9/8/11 at 11:25 a.m. with LVN J, he stated that he had never changed Resident #3's indwelling urinary catheter and he would never change it without help because she would resist care. He stated his initial was a mistake. In an interview on 9/8/11 at 11:30 a.m. with LVN N, she stated that she had not changed Resident #3's urinary catheter and that she made an error in documentation. In an interview on 9/8/11 at 11:40 a.m. with LVN I, she stated that she had changed Resident #3's indwelling urinary catheter on 7/3/11 because it had become clogged. She did not know why it had not been changed for August 2011. In an interview on 9/8/11 at 12:00 p.m. with the ADON, she stated that catheter care was supposed to be done once a shift and the indwelling urinary catheter changed once every 30 days. She had no answer as to why the catheters were not changed and shrugged her shoulders and shook her head. In an interview on 9/8/11 at 4:10 p.m. with the Urologist that treated Resident #3 at the hospital, he stated that it was possible for a resident's bladder to gradually stretch over time with urine retention to the extent that Resident #3s had and that it could have been caused from an indwelling urinary catheter not being changed routinely. He stated that the latex catheter tubing would become encrusted and block the flow of urine. In an interview on 9/8/11 at 5:00 p.m. with RN A, who was the corporate nurse sitting in for the DON, she acknowledged that the facility had problems with managing and monitoring the care and maintenance of indwelling urinary catheters. She stated that the facility did not have a steady DON for over 4 months. B. Record review of Resident #5's clinical record (face sheet) dated 12/07/10 revealed resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #5's clinical record (physician's orders) dated 9/01/11 through 9/30/11 (printed on 8/29/11) revealed diagnoses that included: Unspecified Complications Type II Diabetes; and Malignant Neoplasm of the Prostate. Observation on 9/07/11 at 11:30 a.m. revealed Resident #5 had an indwelling urinary catheter connected to a drainage bag. In an interview on 9/12/11 at 5:45 p.m. with LVN C she stated she completed a skin assessment on Resident #5 on 1/24/11 when Resident #5 returned to the facility from the hospital. LVN C stated Resident #5 had a urinary catheter which she documented on the assessment sheet. Record review of Resident #5's clinical record (Admission Skin Assessment Form) dated 1/24/11 revealed Resident #5 was assessed and had an indwelling urinary catheter. Record review of a 5 day MDS assessment dated [DATE] revealed resident #5 was assessed and had an indwelling urinary catheter. In an interview on 9/12/11 at 8:50 a.m. with LVN H she stated when residents return to the facility from the hospital, they were assessed prior to being cared for. She stated if a resident had a urinary catheter and did not have a doctor's orders for the indwelling urinary catheter; the procedure was to call the physician for an order as urinary catheters were changed monthly and PRN. She indicated the urinary catheter was cleaned each shift and changed monthly and PRN and this was documented on the nursing MARS. LVN H stated Resident #5 had a urinary catheter upon admission to the facility from the hospital in January 2011. She stated she was not aware Resident #5 did not have doctor's orders for the urinary catheter or that the care and changing of the urinary catheter was not being documented on the MARS. In an interview on 9/12/11 at 2:30 p.m. with RN A, who was the corporate nurse, she stated nurses had a checklist to go by whenever a resident enters the facility. She stated when a resident comes to the facility from the hospital with a urinary catheter and no orders, the nurse should contact the doctor to obtain an order for [REDACTED]. She acknowledged, after reviewing Resident #5's clinical record, there was no documentation that an order had not been obtained from the doctor since 1/24/11 for catheter care or that the urinary catheter had been changed by the nurses monthly and PRN. Record review of Resident #5's clinical record (nurse's notes) revealed the following: On 5/23/11 Resident #5's urinary catheter was removed. The balloon with 5 cc was withdrawn with 3 cc. Resident voided out 100 cc of rose colored urine with sediments, mucus and blood. The catheter was inserted and 16 cc of rose colored urine flowed into the tube with thick mucus sediment. On 6/12/11 Resident #5's urinary catheter was changed and resident voided 1000 cc of yellow, cloudy urine. The urine was noted to have mucus in it. On 6/14/11 Resident #5's urinary catheter was leaking and an attempt was made to reposition the urinary catheter at which time the catheter came out. When the catheter came out, a half dollar size amount of thick green pus came out with it. The catheter was changed and thick cloudy yellow urine came out. Record review of Resident #5's clinical record (physician's telephone orders) from 1/24/11 through 9/08/11 revealed 2 physician's orders on 5/23/11 and 6/12/11 to change out Resident #5's urinary catheter related to problems. In an interview on 9/7/11 at 12:05 p.m. with the ADON, she stated catheter care was supposed to be done every shift and the indwelling urinary catheter was to be changed monthly and PRN. Record review of Resident #5's clinical record (nursing notes and resident transfer and hospital discharge) indicated Resident #5 was sent to the hospital on [DATE], 5/24/11 and 8/17/11 with UTIs. Record review of Resident #5's clinical record (labs) revealed Resident #5 had urinary tract infections on 5/23/11, 6/12/11, 6/15/11, 7/11/11 and 8/30/11. On 5/23/11, labs indicated WBC was 29,000. On 6/12/11, labs indicated [DIAGNOSES REDACTED] Pneumoniae, bacteria. On 6/15/11, labs revealed gram negative lactose fermenting isolated. On 7/11/11, labs revealed gram negatrive lactose fermenting, colony count 100,000, Providencia Stuartii, bacteria. On 8/30/11, labs revealed E-Coli, bacteria. Record review of Resident #5's clinical record (Nursing Notes) from 1/24/11 through 9/08/11 revealed documentation that Resident #5 had a urinary catheter changed on 5/23/11 and 6/12/11. Record review of the comprehensive care plan for Resident #5 dated 5/10/11, revealed that the indwelling urinary catheter was not addressed in the care plan. On 9/08/11, a care plan was developed to include interventions to address Resident #5's urinary incontinence and catheter care. In an interview on 9/07/11 at 11:30 a.m. with LVN H, she stated resident #5 had an indwelling urinary catheter since his admission from the hospital on [DATE]. LVN H stated catheter care was done on her shift and the indwelling urinary catheter was changed monthly and PRN. Resident #5 had only been on LVN H's hall for about one month. Interview on 9/12/11 at 8:30 a.m. with LVN L, MDS Coordinator, confirmed that the indwelling urinary catheter had not been addressed in the care plan for Resident #5 when resident returned to the facility from the hospital with the indwelling urinary catheter on 1/24/11. LVN L indicated she relied on information provided by nurses who assessed Resident #5 before she completed the MDS. LVN L stated she had completed MDS's since March 2011. In an interview on 9/12/11 at 4:30 p.m. with LVN M she stated she began working at the facility in March 2011. She stated she changed Resident #5's urinary catheter once in June 2011, but failed to document this on the MARS or nurse's notes. C. Resident #6 was admitted to the facility on [DATE] with diagnoses of chronic [MEDICAL CONDITION], coronary [MEDICAL CONDITION], and muscle weakness per the undated face sheet. Observation of Resident #6 on 9/7/11at 1:00 p.m. revealed she had an indwelling urinary catheter. In an interview at the same time she stated that she had not had her urinary catheter changed in over a month. Review of Resident #6's labs revealed she had a U/A and C&S done on 8/26/11 and that the identification and sensitivity of the bacteria was received by the facility on 9/4/11. Resident #6 was started on an antibiotic on 9/9/11 for her UTI. Review of Resident #6's annual MDS assessment dated [DATE] revealed she had an indwelling urinary catheter connected to a drainage bag. The MDS did not reflect that the resident had a pressure sore. There were no diagnoses or medical conditions listed that would support Resident #6's having an indwelling urinary catheter. The MDS reflected that she was "usually understood and "usually understands". Review of Resident #6's physician's orders from 5/13/11 to 9/12/11 revealed she had orders to "Change Foley q month and PRN". Review of Resident #6's clinical record revealed she was given the indwelling urinary catheter on 3/15/11 for a Stage IV pressure sore on her coccyx to heal. Review of Resident #6's comprehensive care plans revealed she did not have a care plan for an indwelling urinary catheter. Interview on 9/12/11 at 8:30 a.m. with MDS Coordinator L, she stated that the indwelling urinary catheter had not been addressed in the care plan for Resident #6. Interview on 9/12/11 with LVN C, the treatment nurse, revealed Resident #6 did not have any pressure ulcers and that the Stage IV she had was healed on 7/14/11. LVN C stated she did not know why the resident had an indwelling urinary catheter. Review of Resident #6's TAR revealed her pressure ulcer had healed on 7/14/11. Review of Resident #6's Nurse MARs and Nursing Notes from 3/15/11 to 9/12/11 revealed that Resident #6 had 2 documented changes of her indwelling urinary catheter on 7/15/11 and 7/21/11 because it had come out. D. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] per the Record of Admission sheet dated 7/14/11. Review of a H&P dated 7/15/11 revealed diagnoses that included SP MVA, cervical spine fracture, ventilator dependence, and [MEDICAL CONDITION]. Review of Admission Nursing Assessments dated 7/14/11 and 9/2/11 revealed documentation that Resident #7 had an indwelling urinary catheter. Interview on 9/9/11 at 5:00 p.m. with LVN D confirmed he admitted resident #7 on 7/14/11 and did not obtain a physician's order for the urinary catheter that resident #7 was admitted with. LVN D confirmed that he changed resident #7's urinary catheter on 8/1/11 without an order to do so. LVN D said he changed the catheter because resident #7 had no urinary output and the catheter was apparently clogged. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #7 was assessed as having a urinary catheter. Observation on 9/8/11 at 1:20 p.m. revealed Resident #7 had an indwelling urinary catheter connected to a drainage bag. Review of the comprehensive care plan for Resident #7, dated 7/25/11, revealed that the indwelling urinary catheter was not addressed. Review of admission physician's orders for Resident #7 dated 7/14/11 and 9/2/11 and of consolidated orders dated 8/1/11-8/31/11 revealed no order for the indwelling urinary catheter. Review of physician's telephone orders from admission on 7/14/11 to 9/8/11 revealed no order for the urinary catheter for Resident #7. Interview with the DON on 9/8/11 at 1:40 p.m. confirmed there were no orders for the urinary catheter for Resident #7. Further interview with the DON on 9/8/11 at 2:50 p.m. revealed that Resident #7 had an indwelling urinary catheter since his admission on 7/14/11. Review of nurse's notes dated 8/1/11 revealed documentation that Resident #7's urinary catheter was changed and that urine obtained was foul in odor with thick sediment. In addition, hematuria (blood in the urine) was noted. Further review of this documentation revealed that 1200 cc of urine was obtained when the catheter was changed. Review of urine culture results dated 8/2/11 revealed that Resident #7 had a UTI. Review of a physician's telephone order dated 8/5/11 revealed an order for [REDACTED]. E. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pressure ulcer Stage IV, chronic osteo[DIAGNOSES REDACTED] pelvic region, and [MEDICAL CONDITION] per the Record of Admission sheet dated 7/19/11. Review of an Admit/Discharge Report revealed resident #8 was readmitted on [DATE]. Observation of Resident #8 on 9/9/11 at 1:25 p.m. revealed he had an indwelling urinary catheter attached to a leg bag for drainage. Review of physician's consolidated orders dated 7/1/11-7/31/11, 8/4/11, and 9/1/11-9/30/11 revealed an order for [REDACTED]. Review of the treatment sheets and "Nurse MARs" for the months of June, July, and August 2011 revealed no documentation that the urinary catheter was changed. Review of nurses' notes from 6/29/11-9/7/11 revealed no documentation that the urinary catheter was changed as ordered by the physician. Further review of nurse's notes dated 9/8/11 revealed documentation that the urinary catheter was changed on that date (after surveyor intervention). Interview on 9/9/11 at 10:30 a.m. with RN A confirmed there was no evidence that Resident #8's urinary catheter had been changed from 6/29/11 until it was changed on 9/8/11. Interview on 9/9/11 at 10:30 a.m. with RN A revealed that Resident #8 had an indwelling urinary catheter since his first admission to the facility on [DATE]. She stated she did not know why the catheter had not been changed. Review of an Admission Skin Assessment Form dated 6/29/11 revealed Resident #8 was assessed as having a urinary catheter. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #8 was assessed as having a urinary catheter. Review of a care plan for Resident #8, dated 7/22/11, revealed " to change the catheter, tubing, and bag as ordered". F. Resident #9 was admitted to the facility on [DATE] with diagnoses that included [MEDICAL CONDITION] and [MEDICAL CONDITION] per the record of Admission sheet dated 8/30/11. Review of nurse's notes dated 9/4/11 revealed Resident #9 was discharged to the hospital on that date. Review of an Admission Skin Assessment Form dated 8/25/11 revealed Resident #9 was admitted to the facility with an indwelling urinary catheter. Review of nurse's notes dated 9/3/11 revealed documentation that Resident #9 had a urinary catheter. Review of admission orders [REDACTED]. Interview on 9/9/11 at 2:15 p.m. with RN A confirmed Resident #9 had no orders for the indwelling urinary catheter from her admission on 8/25/11 until her discharge on 9/4/11. Review of facility policy and procedure on "Catheter Care" revealed the number one purpose was to prevent infection...and to change each month or as ordered or needed". Review of facility Infection Control Manual for Long Term Care, "Urinary Catheters" dated 2007 revealed "care and maintenance of urinary catheters is important for unobstructed flow". The facility submitted a plan of removal for the Immediate Jeopardy on 9/9/11 at 12:24 p.m., as follows: Nursing administration has assessed all residents with indwelling &/or supra pubic .catheters to identify needs. Three residents had catheters changed out on 9/8/11. One resident with referral for possible supra pubic catheter placement. DON responsible for follow-up. Clarification of all resident's orders with urinary catheters and updated on MARS as of 9/8/11. DON responsible for compliance monitoring. Verification via Input/Output (I & O) Sheets regarding adverse conditions, etc. regarding urinary catheter monitoring - implemented on 9/8/11. DON & ADON responsible for compliance monitoring. In-service all Nurses and Nurse Aides regarding importance of I & O documentation in the monitoring and management of catheter use. On-going in-servicing. Verification as of 9/8/11 of the appropriate resident diagnoses for use of urinary catheters. DON responsible for compliance monitoring. Monthly urinary catheter change scheduled for the 6:00 a.m. - 2:00 p.m. shift. All catheter changes updated on current MARS. DON responsible for compliance. In-service to all nursing staff regarding proper policy and procedure regarding monitoring and management of catheter use & regarding catheter use and justification for use. Nursing administration in-serviced by corporate nurse on 9/8/11 & ongoing in-servicing for all shifts. Verification on 9/8/11 of resident care plans regarding interventions to ensure adequate monitoring and management of catheter care. Administrator and DON responsible for compliance. Catheter output to be emptied per nurse aide before the end of each shift, and the aide will communicate amount to charge nurse who will record output on I & O sheet. The 24 hour report will be used to communicate & each shift is responsible for notifying the next shift of any issues of concerns and/or changes in condition. DON is responsible for picking up the 24 hour report each morning for review. The charge nurse is responsible for the verification of the catheter anchoring and this will be documented each shift. If there is no urinary output for a resident during a shift, the Nurse Aide is responsible for notifying the charge nurse. The charge nurse will then perform an assessment of the resident and notify the MD of findings, etc. When a resident is determined to be independent in emptying their own urinary output, the facility will provide education regarding the possible consequences of their actions along with an informed consent completed. The resident will be required to participate in a skills validation check and if resident is unable to comply, then the staff will continue to verbally ask the resident post each encounter of self performance of emptying urinary output the amount of urinary output to enable staff to document on the I & O form. Confirmation of compliance included: Random interviews, observations of staff and residents present on 9/9/11 and record reviews. Education and training was being provided and processes such as audits were being put into place to prevent a reoccurrence of the problems. While the IJ was removed on 9/9/11, the facility remained out of compliance at a severity level of "Actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of a "pattern" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. Review of Form CMS-672 revealed 8 residents with indwelling catheters.

Based on observations, interviews and record reviews, the facility failed to implement their written policies and procedures to prohibit neglect regarding care and management of indwelling urinary catheters for 6 of 8 residents with indwelling catheters (#3, #5, #6, #7 and #8): Review of facility policy on "Abuse Prevention Program" undated revealed that neglect "is defined as failure to provide goods and services to avoid physical harm, mental anguish, mental illness or the deterioration of the resident's physical or mental condition." Review of facility policy and procedure on "Catheter Care" revealed the number one purpose was to prevent infection...and to change each month or as ordered or needed. Review of facility Infection Control Manual for Long Term Care, "Urinary Catheters" dated 2007 revealed "care and maintenance of urinary catheters is important for unobstructed flow". 1.) Resident #3's indwelling urinary catheter was not changed every 30 days as ordered by the physician. The residents indwelling urinary catheter was not changed for 60 days and she was sent to the hospital with a distended abdomen and had 8,125 cc's of urine drained from her bladder in the ER. According to the National Kidney and Urologic Diseases Information Clearinghouse "If the bladder becomes stretched too far or for long periods of time, the muscle may permanently be damaged and lose ability to contract...and if urine backs up into the kidneys permanent kidney damage could occur". (National Kidney & Urologic Diseases Information Clearinghouse) found at website http:kidney.niddk.nih.gov/Kudiseases/pubs/[MEDICAL CONDITION]/ dated 9/23/11. She was in acute pain and diagnosed with [REDACTED]. The facility was aware of Resident #3's problem problem of [MEDICAL CONDITION] since 3/4/11 when a care plan was initiated. 2.) Resident #5's indwelling urinary catheter was not changed every 30 days as there was no physician's order. No routine orders for Resident #5's indwelling urinary catheter to be changed every 30 days, PRN or catheter care to be given every shift could be found. The resident had ongoing UTI's and was transported to the hospital with a distended bladder, no urinary output, was in acute pain, hospitalized and diagnosed with [REDACTED]. 3.) Resident #6 had an indwelling urinary catheter that was not changed for 30 days as ordered by the physician. She had an indwelling urinary catheter placed for a Stage IV wound to heal. The wound was healed on 7/14/11 and Resident #6 had the indwelling catheter in place for an extra 54 days. Resident #6 was placed on antibiotics on 9/9/11 for a UTI. 4). Resident #7 had no physician's orders for his indwelling urinary catheter for almost 60 days after admission to the facility. Resident #7's urinary catheter was changed without a physician's order. He was placed on antibiotics on 8/5/11. 5. Resident #8's indwelling urinary catheter was not changed monthly as ordered by the physician for over 60 days. 6. Resident #9 did not have physician's orders for an indwelling urinary cather for 9 days (from admission to discharge). An Immediate Jeopardy (IJ) was identified on 9/8/11. While the IJ was removed on 9/9/11, the facility remained out of compliance at a severity level of "Actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of a "pattern" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. Failure to ensure infection control and catheter care policies and procedures are followed regarding indwelling urinary catheters could adversely affect the 8 residents in the facility with indwelling urinary catheters. The findings were: A. Record review of Resident #3's clinical record face sheet (undated) revealed that she was [AGE] years old and admitted to the facility on [DATE]. She had diagnoses of: Unspecified mental [MEDICAL CONDITIONS] and anxiety. Further review of a nurse's note, dated 9/5/11 at 11:00 a.m., revealed the following: that her abdomen was distended and that she complained of pain to her left side with palpation (touch). The doctor was notified and she was transported out of the facility by ambulance at 12:00 p.m. Further review revealed that another nursing note was written at 3:10 p.m. that stated the physician called to report that the hospital had removed 6 liters of urine from Resident #3's bladder. Review of the "Transfer Form", dated 9/5/11 revealed "stomach hard and distended and painful to touch on left side. Jumps when touched". Review of Resident #3's comprehensive care plans dated 3/4/11, revealed she had an indwelling urinary catheter for "[MEDICAL CONDITION]" and also one for "risk for fluid overload". Record review of Resident #3's hospital record face sheet (undated) revealed diagnoses of "urine retention", bladder infection, urinary tract infection [MEDICAL CONDITION]. She was admitted to the hospital with [REDACTED]. She had an elevated temperature of 101 degrees Fahrenheit (F) (normal temperature 98.6 degrees F), and the chief complaint was abdominal distention with pain. Review of a lab report obtained at time of admission to the hospital revealed a urine culture with growth of Pseudomonas Aeruginosa. The website http://emedicine.medscape.com/article/ 8-overview, accessed 9/23/11 indicated (gram-negative rods that are a frequent cause of infections to include UTI's and are complicated and can be life threatening) Observation on 9/7/11 at 10:10 a.m. of Resident #3 in the hospital revealed she was receiving IV antibiotic and had a new urinary catheter. In an interview at the same time with the resident she was asked to demonstrate with open arms how much pain she had before she came to the hospital, and she opened her arms wide. Observation on 9/7/11 at 11:00 a.m. of the urinary catheter bag, in the hospital that ER RN W had taken when removed from Resident #3 on 9/5/11 at 12:15 p.m. and placed in her locker, revealed that the leg bag was a green and yellow in color and that the latex catheter bulb that was deflated had partially deteriorated. The latex tubing was half green and yellow in color. In an interview at the same time with ER RN X, who was working on 9/5/11 when Resident #3 came to the ER, she stated that Resident #3 looked like she was pregnant when she first arrived. In an interview on 9/7/11 at 09:00 a.m. with a family member of Resident #3, she stated that Resident #3 came to the hospital with a bladder infection. She stated that the indwelling catheter wasn't being changed and that Resident #3 was emptying her own drainage bag. In an interview on 9/7/11 at 11:20 a.m. with the ER RN Y, who replaced Resident #3's indwelling urinary catheter, she stated that the catheter balloon was deteriorating and that the odor was the foulest she had smelled in her whole nursing career. She stated that the leg bag strap also was dirty with a horrible odor. Review of Resident #3's quarterly MDS assessment dated [DATE] revealed she "usually understood and sometimes understands". Review of Resident #3's physician orders for September 2011 revealed orders for "Urinary Catheter Care Q shift and PRN, and to change the foley catheter Q 30 days". Review of Resident #3's physician orders dated 8/15/11 revealed "start [MEDICATION NAME] (antibiotic) 1 GM IM q 12 hours" for treatment of [REDACTED]. Review of Resident #3's labs revealed she had a positive urine culture on 5/23/11 and on 8/13/11 she had a positive urine culture that was growing Pseudomonas Aeruginosa. Review of Resident #3's Comprehensive Care Plans dated 3/4/11 for "Problem Noted" as "Urinary Catheter" revealed approaches to include "Change urinary catheter, tubing and bag per order...monitor urine for odor, color, sediments, amount of urine". Another problem noted was "at risk for fluid overload" and interventions included: "Observe for signs and symptoms of fluid overload and to monitor output". In an interview on 9/7/11 at 1:35 p.m. with CNA V, she stated that Resident #3 always had a leg bag and that she would empty her own bag. She stated that the resident's urinary catheter was supposed to be changed every month. In an interview on 9/8/11 at 12:30 p.m. with LVN C who had worked on 9/5/11, she stated that the resident had a distended abdomen and that she took herself to the rest room. She stated that the resident emptied her own bag and was non-compliant with letting staff help her with her care. She stated that the doctor was called about the distended abdomen. Review of Resident #3's I & O sheet from September 2011 revealed she had an average urinary output per shift of approximately 700 cc's prior to being sent to the ER and that several output sections on the I & O sheet reflected no cc measurements were noted but the word "self" was written. Review of Resident #3's nursing notes dated 4/4/11 (untimed) revealed she had her urinary leg bag changed. No other evidence could be found of a urinary leg bag being changed. In an interview on 9/7/11 at 11:50 a.m. with the facility ADON she stated that Resident #3 was sent to the hospital with abdominal distention and pain and that the resident looked like she was 9 months pregnant. In an interview on 9/7/11 at 1:40 p.m. with LVN F, she stated that she worked on Resident #3's hall on the day she was sent out to the ER. She stated that the resident was sitting in a chair in the hallway and that her stomach was distended. She stated that she checked Resident #3's stomach and it was really hard. She stated that her urine leg bag had 500cc's of urine in it prior to going to the hospital. Review of Resident #3's Nurse MARs from March 2011 to July 2011 revealed no annotation of Resident #3's urinary catheter being changed. In July 2011 Resident #3's Nurse MAR reflected that 2 nurses had initialed off for 3 urinary catheter changes (once for LVN I and twice for LVN N). In August 2011, LVN J initialed off that the indwelling urinary catheter had been changed. In an interview on 9/8/11 at 11:25 a.m. with LVN J, he stated that he had never changed Resident #3's indwelling urinary catheter and he would never change it without help because she would resist care. He stated his initial was a mistake. In an interview on 9/8/11 at 11:30 a.m. with LVN N, she stated that she had not changed Resident #3's urinary catheter and that she made an error in documentation. In an interview on 9/8/11 at 11:40 a.m. with LVN I, she stated that she had changed Resident #3's indwelling urinary catheter on 7/3/11 because it had become clogged. She did not know why it had not been changed for August 2011. In an interview on 9/8/11 at 12:00 p.m. with the ADON, she stated that catheter care was supposed to be done once a shift and the indwelling urinary catheter changed once every 30 days. She had no answer as to why the catheters were not changed and shrugged her shoulders and shook her head. In an interview on 9/8/11 at 4:10 p.m. with the Urologist that treated Resident #3 at the hospital, he stated that it was possible for a resident's bladder to gradually stretch over time with urine retention to the extent that Resident #3s had and that it could have been caused from an indwelling urinary catheter not being changed routinely. He stated that the latex catheter tubing would become encrusted and block the flow of urine. In an interview on 9/8/11 at 5:00 p.m. with RN A, who was the corporate nurse sitting in for the DON, she acknowledged that the facility had problems with managing and monitoring the care and maintenance of indwelling urinary catheters. She stated that the facility did not have a steady DON for over 4 months. B. Record review of Resident #5's clinical record (face sheet) dated 12/07/10 revealed resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #5's clinical record (physician's orders) dated 9/01/11 through 9/30/11 (printed on 8/29/11) revealed diagnoses that included: Unspecified Complications Type II Diabetes; and Malignant Neoplasm of the Prostate. Observation on 9/07/11 at 11:30 a.m. revealed Resident #5 had an indwelling urinary catheter connected to a drainage bag. In an interview on 9/12/11 at 5:45 p.m. with LVN C she stated she completed a skin assessment on Resident #5 on 1/24/11 when Resident #5 returned to the facility from the hospital. LVN C stated Resident #5 had a urinary catheter which she documented on the assessment sheet. Record review of Resident #5's clinical record (Admission Skin Assessment Form) dated 1/24/11 revealed Resident #5 was assessed and had an indwelling urinary catheter. Record review of a 5 day MDS assessment dated [DATE] revealed resident #5 was assessed and had an indwelling urinary catheter. In an interview on 9/12/11 at 8:50 a.m. with LVN H she stated when residents return to the facility from the hospital, they were assessed prior to being cared for. She stated if a resident had a urinary catheter and did not have a doctor's orders for the indwelling urinary catheter; the procedure was to call the physician for an order as urinary catheters were changed monthly and PRN. She indicated the urinary catheter was cleaned each shift and changed monthly and PRN and this was documented on the nursing MARS. LVN H stated Resident #5 had a urinary catheter upon admission to the facility from the hospital in January 2011. She stated she was not aware Resident #5 did not have doctor's orders for the urinary catheter or that the care and changing of the urinary catheter was not being documented on the MARS. In an interview on 9/12/11 at 2:30 p.m. with RN A, who was the corporate nurse, she stated nurses had a checklist to go by whenever a resident enters the facility. She stated when a resident comes to the facility from the hospital with a urinary catheter and no orders, the nurse should contact the doctor to obtain an order for [REDACTED]. She acknowledged, after reviewing Resident #5's clinical record, there was no documentation that an order had not been obtained from the doctor since 1/24/11 for catheter care or that the urinary catheter had been changed by the nurses monthly and PRN. Record review of Resident #5's clinical record (nurse's notes) revealed the following: On 5/23/11 Resident #5's urinary catheter was removed. The balloon with 5 cc was withdrawn with 3 cc. Resident voided out 100 cc of rose colored urine with sediments, mucus and blood. The catheter was inserted and 16 cc of rose colored urine flowed into the tube with thick mucus sediment. On 6/12/11 Resident #5's urinary catheter was changed and resident voided 1000 cc of yellow, cloudy urine. The urine was noted to have mucus in it. On 6/14/11 Resident #5's urinary catheter was leaking and an attempt was made to reposition the urinary catheter at which time the catheter came out. When the catheter came out, a half dollar size amount of thick green pus came out with it. The catheter was changed and thick cloudy yellow urine came out. Record review of Resident #5's clinical record (physician's telephone orders) from 1/24/11 through 9/08/11 revealed 2 physician's orders on 5/23/11 and 6/12/11 to change out Resident #5's urinary catheter related to problems. In an interview on 9/7/11 at 12:05 p.m. with the ADON, she stated catheter care was supposed to be done every shift and the indwelling urinary catheter was to be changed monthly and PRN. Record review of Resident #5's clinical record (nursing notes and resident transfer and hospital discharge) indicated Resident #5 was sent to the hospital on [DATE], 5/24/11 and 8/17/11 with UTIs. Record review of Resident #5's clinical record (labs) revealed Resident #5 had urinary tract infections on 5/23/11, 6/12/11, 6/15/11, 7/11/11 and 8/30/11. On 5/23/11, labs indicated WBC was 29,000. On 6/12/11, labs indicated [DIAGNOSES REDACTED] Pneumoniae, bacteria. On 6/15/11, labs revealed gram negative lactose fermenting isolated. On 7/11/11, labs revealed gram negatrive lactose fermenting, colony count 100,000, Providencia Stuartii, bacteria. On 8/30/11, labs revealed E-Coli, bacteria. Record review of Resident #5's clinical record (Nursing Notes) from 1/24/11 through 9/08/11 revealed documentation that Resident #5 had a urinary catheter changed on 5/23/11 and 6/12/11. Record review of the comprehensive care plan for Resident #5 dated 5/10/11, revealed that the indwelling urinary catheter was not addressed in the care plan. On 9/08/11, a care plan was developed to include interventions to address Resident #5's urinary incontinence and catheter care. In an interview on 9/07/11 at 11:30 a.m. with LVN H, she stated resident #5 had an indwelling urinary catheter since his admission from the hospital on [DATE]. LVN H stated catheter care was done on her shift and the indwelling urinary catheter was changed monthly and PRN. Resident #5 had only been on LVN H's hall for about one month. Interview on 9/12/11 at 8:30 a.m. with LVN L, MDS Coordinator, confirmed that the indwelling urinary catheter had not been addressed in the care plan for Resident #5 when resident returned to the facility from the hospital with the indwelling urinary catheter on 1/24/11. LVN L indicated she relied on information provided by nurses who assessed Resident #5 before she completed the MDS. LVN L stated she had completed MDS's since March 2011. In an interview on 9/12/11 at 4:30 p.m. with LVN M she stated she began working at the facility in March 2011. She stated she changed Resident #5's urinary catheter once in June 2011, but failed to document this on the MARS or nurse's notes. C. Resident #6 was admitted to the facility on [DATE] with diagnoses of chronic [MEDICAL CONDITION], coronary [MEDICAL CONDITION], and muscle weakness per the undated face sheet. Observation of Resident #6 on 9/7/11at 1:00 p.m. revealed she had an indwelling urinary catheter. In an interview at the same time she stated that she had not had her urinary catheter changed in over a month. Review of Resident #6's labs revealed she had a U/A and C&S done on 8/26/11 and that the identification and sensitivity of the bacteria was received by the facility on 9/4/11. Resident #6 was started on an antibiotic on 9/9/11 for her UTI. Review of Resident #6's annual MDS assessment dated [DATE] revealed she had an indwelling urinary catheter connected to a drainage bag. The MDS did not reflect that the resident had a pressure sore. There were no diagnoses or medical conditions listed that would support Resident #6's having an indwelling urinary catheter. The MDS reflected that she was "usually understood and "usually understands". Review of Resident #6's physician's orders from 5/13/11 to 9/12/11 revealed she had orders to "Change Foley q month and PRN". Review of Resident #6's clinical record revealed she was given the indwelling urinary catheter on 3/15/11 for a Stage IV pressure sore on her coccyx to heal. Review of Resident #6's comprehensive care plans revealed she did not have a care plan for an indwelling urinary catheter. Interview on 9/12/11 at 8:30 a.m. with MDS Coordinator L, she stated that the indwelling urinary catheter had not been addressed in the care plan for Resident #6. Interview on 9/12/11 with LVN C, the treatment nurse, revealed Resident #6 did not have any pressure ulcers and that the Stage IV she had was healed on 7/14/11. LVN C stated she did not know why the resident had an indwelling urinary catheter. Review of Resident #6's TAR revealed her pressure ulcer had healed on 7/14/11. Review of Resident #6's Nurse MARs and Nursing Notes from 3/15/11 to 9/12/11 revealed that Resident #6 had 2 documented changes of her indwelling urinary catheter on 7/15/11 and 7/21/11 because it had come out. D. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] per the Record of Admission sheet dated 7/14/11. Review of a H&P dated 7/15/11 revealed diagnoses that included SP MVA, cervical spine fracture, ventilator dependence, and [MEDICAL CONDITION]. Review of Admission Nursing Assessments dated 7/14/11 and 9/2/11 revealed documentation that Resident #7 had an indwelling urinary catheter. Interview on 9/9/11 at 5:00 p.m. with LVN D confirmed he admitted resident #7 on 7/14/11 and did not obtain a physician's order for the urinary catheter that resident #7 was admitted with. LVN D confirmed that he changed resident #7's urinary catheter on 8/1/11 without an order to do so. LVN D said he changed the catheter because resident #7 had no urinary output and the catheter was apparently clogged. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #7 was assessed as having a urinary catheter. Observation on 9/8/11 at 1:20 p.m. revealed Resident #7 had an indwelling urinary catheter connected to a drainage bag. Review of the comprehensive care plan for Resident #7, dated 7/25/11, revealed that the indwelling urinary catheter was not addressed. Review of admission physician's orders for Resident #7 dated 7/14/11 and 9/2/11 and of consolidated orders dated 8/1/11-8/31/11 revealed no order for the indwelling urinary catheter. Review of physician's telephone orders from admission on 7/14/11 to 9/8/11 revealed no order for the urinary catheter for Resident #7. Interview with the DON on 9/8/11 at 1:40 p.m. confirmed there were no orders for the urinary catheter for Resident #7. Further interview with the DON on 9/8/11 at 2:50 p.m. revealed that Resident #7 had an indwelling urinary catheter since his admission on 7/14/11. Review of nurse's notes dated 8/1/11 revealed documentation that Resident #7's urinary catheter was changed and that urine obtained was foul in odor with thick sediment. In addition, hematuria (blood in the urine) was noted. Further review of this documentation revealed that 1200 cc of urine was obtained when the catheter was changed. Review of urine culture results dated 8/2/11 revealed that Resident #7 had a UTI. Review of a physician's telephone order dated 8/5/11 revealed an order for [REDACTED]. E. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pressure ulcer Stage IV, chronic osteo[DIAGNOSES REDACTED] pelvic region, and [MEDICAL CONDITION] per the Record of Admission sheet dated 7/19/11. Review of an Admit/Discharge Report revealed resident #8 was readmitted on [DATE]. Observation of Resident #8 on 9/9/11 at 1:25 p.m. revealed he had an indwelling urinary catheter attached to a leg bag for drainage. Review of physician's consolidated orders dated 7/1/11-7/31/11, 8/4/11, and 9/1/11-9/30/11 revealed an order for [REDACTED]. Review of the treatment sheets and "Nurse MARs" for the months of June, July, and August 2011 revealed no documentation that the urinary catheter was changed. Review of nurses' notes from 6/29/11-9/7/11 revealed no documentation that the urinary catheter was changed as ordered by the physician. Further review of nurse's notes dated 9/8/11 revealed documentation that the urinary catheter was changed on that date (after surveyor intervention). Interview on 9/9/11 at 10:30 a.m. with RN A confirmed there was no evidence that Resident #8's urinary catheter had been changed from 6/29/11 until it was changed on 9/8/11. Interview on 9/9/11 at 10:30 a.m. with RN A revealed that Resident #8 had an indwelling urinary catheter since his first admission to the facility on [DATE]. She stated she did not know why the catheter had not been changed. Review of an Admission Skin Assessment Form dated 6/29/11 revealed Resident #8 was assessed as having a urinary catheter. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #8 was assessed as having a urinary catheter. Review of a care plan for Resident #8, dated 7/22/11, revealed " to change the catheter, tubing, and bag as ordered". F. Resident #9 was admitted to the facility on [DATE] with diagnoses that included [MEDICAL CONDITION] and [MEDICAL CONDITION] per the record of Admission sheet dated 8/30/11. Review of nurse's notes dated 9/4/11 revealed Resident #9 was discharged to the hospital on that date. Review of an Admission Skin Assessment Form dated 8/25/11 revealed Resident #9 was admitted to the facility with an indwelling urinary catheter. Review of nurse's notes dated 9/3/11 revealed documentation that Resident #9 had a urinary catheter. Review of admission orders [REDACTED]. Interview on 9/9/11 at 2:15 p.m. with RN A confirmed Resident #9 had no orders for the indwelling urinary catheter from her admission on 8/25/11 until her discharge on 9/4/11. The facility submitted a plan of removal for the Immediate Jeopardy on 9/9/11 at 12:24 p.m., as follows: Nursing administration has assessed all residents with indwelling &/or supra pubic .catheters to identify needs. Three residents had catheters changed out on 9/8/11. One resident with referral for possible supra pubic catheter placement. DON responsible for follow-up. Clarification of all resident's orders with urinary catheters and updated on MARS as of 9/8/11. DON responsible for compliance monitoring. Verification via Input/Output (I & O) Sheets regarding adverse conditions, etc. regarding urinary catheter monitoring - implemented on 9/8/11. DON & ADON responsible for compliance monitoring. In-service all Nurses and Nurse Aides regarding importance of I & O documentation in the monitoring and management of catheter use. On-going in-servicing. Verification as of 9/8/11 of the appropriate resident diagnoses for use of urinary catheters. DON responsible for compliance monitoring. Monthly urinary catheter change scheduled for the 6:00 a.m. - 2:00 p.m. shift. All catheter changes updated on current MARS. DON responsible for compliance. In-service to all nursing staff regarding proper policy and procedure regarding monitoring and management of catheter use & regarding catheter use and justification for use. Nursing administration in-serviced by corporate nurse on 9/8/11 & ongoing in-servicing for all shifts. Verification on 9/8/11 of resident care plans regarding interventions to ensure adequate monitoring and management of catheter care. Administrator and DON responsible for compliance. Catheter output to be emptied per nurse aide before the end of each shift, and the aide will communicate amount to charge nurse who will record output on I & O sheet. The 24 hour report will be used to communicate & each shift is responsible for notifying the next shift of any issues of concerns and/or changes in condition. DON is responsible for picking up the 24 hour report each morning for review. The charge nurse is responsible for the verification of the catheter anchoring and this will be documented each shift. If there is no urinary output for a resident during a shift, the Nurse Aide is responsible for notifying the charge nurse. The charge nurse will then perform an assessment of the resident and notify the MD of findings, etc. When a resident is determined to be independent in emptying their own urinary output, the facility will provide education regarding the possible consequences of their actions along with an informed consent completed. The resident will be required to participate in a skills validation check and if resident is unable to comply, then the staff will continue to verbally ask the resident post each encounter of self performance of emptying urinary output the amount of urinary output to enable staff to document on the I & O form. Confirmation of compliance included: Random interviews, observations of staff and residents present on 9/9/11 and record reviews. Education and training was being provided and processes such as audits were being put into place to prevent a reoccurrence of the problems. While the IJ was removed on 9/9/11, the facility remained out of compliance at a severity level of "Actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of a "pattern" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. Review of Form CMS-672 revealed 8 residents with indwelling catheters.

Based on observations, interviews and record reviews, the facility failed to implement their policies and procedures to prohibit neglect regarding care and management of indwelling urinary catheters for 6 of 8 residents with indwelling catheters (#3, #5, #6, #7 and #8): 1.) Resident #3's indwelling urinary catheter was not changed every 30 days as ordered by the physician. The residents indwelling urinary catheter was not changed for 60 days and she was sent to the hospital with a distended abdomen and had 8,125 cc's of urine drained from her bladder in the ER. According to the National Kidney and Urologic Diseases Information Clearinghouse "If the bladder becomes stretched too far or for long periods of time, the muscle may permanently be damaged and lose ability to contract...and if urine backs up into the kidneys permanent kidney damage could occur". (National Kidney & Urologic Diseases Information Clearinghouse) found at website http:kidney.niddk.nih.gov/Kudiseases/pubs/[MEDICAL CONDITION]/ dated 9/23/11. She was in acute pain and diagnosed with [REDACTED]. The facility was aware of Resident #3's problem problem of [MEDICAL CONDITION] since 3/4/11 when a care plan was initiated. 2.) Resident #5's indwelling urinary catheter was not changed every 30 days as there was no physician's order. No routine orders for Resident #5's indwelling urinary catheter to be changed every 30 days, PRN or catheter care to be given every shift could be found. The resident had ongoing UTI's and was transported to the hospital with a distended bladder, no urinary output, was in acute pain, hospitalized and diagnosed with [REDACTED]. 3.) Resident #6 had an indwelling urinary catheter that was not changed for 30 days as ordered by the physician. She had an indwelling urinary catheter placed for a Stage IV wound to heal. The wound was healed on 7/14/11 and Resident #6 had the indwelling catheter in place for an extra 54 days. Resident #6 was placed on antibiotics on 9/9/11 for a UTI. 4). Resident #7 had no physician's orders for his indwelling urinary catheter for almost 60 days after admission to the facility. Resident #7's urinary catheter was changed without a physician's order. He was placed on antibiotics on 8/5/11. 5. Resident #8's indwelling urinary catheter was not changed monthly as ordered by the physician for over 60 days. 6. Resident #9 did not have physician's orders for an indwelling urinary cather for 9 days (from admission to discharge). An Immediate Jeopardy (IJ) was identified on 9/8/11. While the IJ was removed on 9/9/11, the facility remained out of compliance at a severity level of "Actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of a "pattern" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. Failure to ensure infection control and catheter care policies and procedures are followed regarding indwelling urinary catheters could adversely affect the 8 residents in the facility with indwelling urinary catheters. The findings were: A. Record review of Resident #3's clinical record face sheet (undated) revealed that she was [AGE] years old and admitted to the facility on [DATE]. She had diagnoses of: Unspecified mental [MEDICAL CONDITIONS] and anxiety. Further review of a nurse's note, dated 9/5/11 at 11:00 a.m., revealed the following: that her abdomen was distended and that she complained of pain to her left side with palpation (touch). The doctor was notified and she was transported out of the facility by ambulance at 12:00 p.m. Further review revealed that another nursing note was written at 3:10 p.m. that stated the physician called to report that the hospital had removed 6 liters of urine from Resident #3's bladder. Review of the "Transfer Form", dated 9/5/11 revealed "stomach hard and distended and painful to touch on left side. Jumps when touched". Review of Resident #3's comprehensive care plans dated 3/4/11, revealed she had an indwelling urinary catheter for "[MEDICAL CONDITION]" and also one for "risk for fluid overload". Record review of Resident #3's hospital record face sheet (undated) revealed diagnoses of "urine retention", bladder infection, urinary tract infection [MEDICAL CONDITION]. She was admitted to the hospital with [REDACTED]. She had an elevated temperature of 101 degrees Fahrenheit (F) (normal temperature 98.6 degrees F), and the chief complaint was abdominal distention with pain. Review of a lab report obtained at time of admission to the hospital revealed a urine culture with growth of Pseudomonas Aeruginosa. The website http://emedicine.medscape.com/article/ 8-overview, accessed 9/23/11 indicated (gram-negative rods that are a frequent cause of infections to include UTI's and are complicated and can be life threatening) Observation on 9/7/11 at 10:10 a.m. of Resident #3 in the hospital revealed she was receiving IV antibiotic and had a new urinary catheter. In an interview at the same time with the resident she was asked to demonstrate with open arms how much pain she had before she came to the hospital, and she opened her arms wide. Observation on 9/7/11 at 11:00 a.m. of the urinary catheter bag, in the hospital that ER RN W had taken when removed from Resident #3 on 9/5/11 at 12:15 p.m. and placed in her locker, revealed that the leg bag was a green and yellow in color and that the latex catheter bulb that was deflated had partially deteriorated. The latex tubing was half green and yellow in color. In an interview at the same time with ER RN X, who was working on 9/5/11 when Resident #3 came to the ER, she stated that Resident #3 looked like she was pregnant when she first arrived. In an interview on 9/7/11 at 09:00 a.m. with a family member of Resident #3, she stated that Resident #3 came to the hospital with a bladder infection. She stated that the indwelling catheter wasn't being changed and that Resident #3 was emptying her own drainage bag. In an interview on 9/7/11 at 11:20 a.m. with the ER RN Y, who replaced Resident #3's indwelling urinary catheter, she stated that the catheter balloon was deteriorating and that the odor was the foulest she had smelled in her whole nursing career. She stated that the leg bag strap also was dirty with a horrible odor. Review of Resident #3's quarterly MDS assessment dated [DATE] revealed she "usually understood and sometimes understands". Review of Resident #3's physician orders for September 2011 revealed orders for "Urinary Catheter Care Q shift and PRN, and to change the foley catheter Q 30 days". Review of Resident #3's physician orders dated 8/15/11 revealed "start [MEDICATION NAME] (antibiotic) 1 GM IM q 12 hours" for treatment of [REDACTED]. Review of Resident #3's labs revealed she had a positive urine culture on 5/23/11 and on 8/13/11 she had a positive urine culture that was growing Pseudomonas Aeruginosa. Review of Resident #3's Comprehensive Care Plans dated 3/4/11 for "Problem Noted" as "Urinary Catheter" revealed approaches to include "Change urinary catheter, tubing and bag per order...monitor urine for odor, color, sediments, amount of urine". Another problem noted was "at risk for fluid overload" and interventions included: "Observe for signs and symptoms of fluid overload and to monitor output". In an interview on 9/7/11 at 1:35 p.m. with CNA V, she stated that Resident #3 always had a leg bag and that she would empty her own bag. She stated that the resident's urinary catheter was supposed to be changed every month. In an interview on 9/8/11 at 12:30 p.m. with LVN C who had worked on 9/5/11, she stated that the resident had a distended abdomen and that she took herself to the rest room. She stated that the resident emptied her own bag and was non-compliant with letting staff help her with her care. She stated that the doctor was called about the distended abdomen. Review of Resident #3's I & O sheet from September 2011 revealed she had an average urinary output per shift of approximately 700 cc's prior to being sent to the ER and that several output sections on the I & O sheet reflected no cc measurements were noted but the word "self" was written. Review of Resident #3's nursing notes dated 4/4/11 (untimed) revealed she had her urinary leg bag changed. No other evidence could be found of a urinary leg bag being changed. In an interview on 9/7/11 at 11:50 a.m. with the facility ADON she stated that Resident #3 was sent to the hospital with abdominal distention and pain and that the resident looked like she was 9 months pregnant. In an interview on 9/7/11 at 1:40 p.m. with LVN F, she stated that she worked on Resident #3's hall on the day she was sent out to the ER. She stated that the resident was sitting in a chair in the hallway and that her stomach was distended. She stated that she checked Resident #3's stomach and it was really hard. She stated that her urine leg bag had 500cc's of urine in it prior to going to the hospital. Review of Resident #3's Nurse MARs from March 2011 to July 2011 revealed no annotation of Resident #3's urinary catheter being changed. In July 2011 Resident #3's Nurse MAR reflected that 2 nurses had initialed off for 3 urinary catheter changes (once for LVN I and twice for LVN N). In August 2011, LVN J initialed off that the indwelling urinary catheter had been changed. In an interview on 9/8/11 at 11:25 a.m. with LVN J, he stated that he had never changed Resident #3's indwelling urinary catheter and he would never change it without help because she would resist care. He stated his initial was a mistake. In an interview on 9/8/11 at 11:30 a.m. with LVN N, she stated that she had not changed Resident #3's urinary catheter and that she made an error in documentation. In an interview on 9/8/11 at 11:40 a.m. with LVN I, she stated that she had changed Resident #3's indwelling urinary catheter on 7/3/11 because it had become clogged. She did not know why it had not been changed for August 2011. In an interview on 9/8/11 at 12:00 p.m. with the ADON, she stated that catheter care was supposed to be done once a shift and the indwelling urinary catheter changed once every 30 days. She had no answer as to why the catheters were not changed and shrugged her shoulders and shook her head. In an interview on 9/8/11 at 4:10 p.m. with the Urologist that treated Resident #3 at the hospital, he stated that it was possible for a resident's bladder to gradually stretch over time with urine retention to the extent that Resident #3s had and that it could have been caused from an indwelling urinary catheter not being changed routinely. He stated that the latex catheter tubing would become encrusted and block the flow of urine. In an interview on 9/8/11 at 5:00 p.m. with RN A, who was the corporate nurse sitting in for the DON, she acknowledged that the facility had problems with managing and monitoring the care and maintenance of indwelling urinary catheters. She stated that the facility did not have a steady DON for over 4 months. B. Record review of Resident #5's clinical record (face sheet) dated 12/07/10 revealed resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of Resident #5's clinical record (physician's orders) dated 9/01/11 through 9/30/11 (printed on 8/29/11) revealed diagnoses that included: Unspecified Complications Type II Diabetes; and Malignant Neoplasm of the Prostate. Observation on 9/07/11 at 11:30 a.m. revealed Resident #5 had an indwelling urinary catheter connected to a drainage bag. In an interview on 9/12/11 at 5:45 p.m. with LVN C she stated she completed a skin assessment on Resident #5 on 1/24/11 when Resident #5 returned to the facility from the hospital. LVN C stated Resident #5 had a urinary catheter which she documented on the assessment sheet. Record review of Resident #5's clinical record (Admission Skin Assessment Form) dated 1/24/11 revealed Resident #5 was assessed and had an indwelling urinary catheter. Record review of a 5 day MDS assessment dated [DATE] revealed resident #5 was assessed and had an indwelling urinary catheter. In an interview on 9/12/11 at 8:50 a.m. with LVN H she stated when residents return to the facility from the hospital, they were assessed prior to being cared for. She stated if a resident had a urinary catheter and did not have a doctor's orders for the indwelling urinary catheter; the procedure was to call the physician for an order as urinary catheters were changed monthly and PRN. She indicated the urinary catheter was cleaned each shift and changed monthly and PRN and this was documented on the nursing MARS. LVN H stated Resident #5 had a urinary catheter upon admission to the facility from the hospital in January 2011. She stated she was not aware Resident #5 did not have doctor's orders for the urinary catheter or that the care and changing of the urinary catheter was not being documented on the MARS. In an interview on 9/12/11 at 2:30 p.m. with RN A, who was the corporate nurse, she stated nurses had a checklist to go by whenever a resident enters the facility. She stated when a resident comes to the facility from the hospital with a urinary catheter and no orders, the nurse should contact the doctor to obtain an order for [REDACTED]. She acknowledged, after reviewing Resident #5's clinical record, there was no documentation that an order had not been obtained from the doctor since 1/24/11 for catheter care or that the urinary catheter had been changed by the nurses monthly and PRN. Record review of Resident #5's clinical record (nurse's notes) revealed the following: On 5/23/11 Resident #5's urinary catheter was removed. The balloon with 5 cc was withdrawn with 3 cc. Resident voided out 100 cc of rose colored urine with sediments, mucus and blood. The catheter was inserted and 16 cc of rose colored urine flowed into the tube with thick mucus sediment. On 6/12/11 Resident #5's urinary catheter was changed and resident voided 1000 cc of yellow, cloudy urine. The urine was noted to have mucus in it. On 6/14/11 Resident #5's urinary catheter was leaking and an attempt was made to reposition the urinary catheter at which time the catheter came out. When the catheter came out, a half dollar size amount of thick green pus came out with it. The catheter was changed and thick cloudy yellow urine came out. Record review of Resident #5's clinical record (physician's telephone orders) from 1/24/11 through 9/08/11 revealed 2 physician's orders on 5/23/11 and 6/12/11 to change out Resident #5's urinary catheter related to problems. In an interview on 9/7/11 at 12:05 p.m. with the ADON, she stated catheter care was supposed to be done every shift and the indwelling urinary catheter was to be changed monthly and PRN. Record review of Resident #5's clinical record (nursing notes and resident transfer and hospital discharge) indicated Resident #5 was sent to the hospital on [DATE], 5/24/11 and 8/17/11 with UTIs. Record review of Resident #5's clinical record (labs) revealed Resident #5 had urinary tract infections on 5/23/11, 6/12/11, 6/15/11, 7/11/11 and 8/30/11. On 5/23/11, labs indicated WBC was 29,000. On 6/12/11, labs indicated [DIAGNOSES REDACTED] Pneumoniae, bacteria. On 6/15/11, labs revealed gram negative lactose fermenting isolated. On 7/11/11, labs revealed gram negatrive lactose fermenting, colony count 100,000, Providencia Stuartii, bacteria. On 8/30/11, labs revealed E-Coli, bacteria. Record review of Resident #5's clinical record (Nursing Notes) from 1/24/11 through 9/08/11 revealed documentation that Resident #5 had a urinary catheter changed on 5/23/11 and 6/12/11. Record review of the comprehensive care plan for Resident #5 dated 5/10/11, revealed that the indwelling urinary catheter was not addressed in the care plan. On 9/08/11, a care plan was developed to include interventions to address Resident #5's urinary incontinence and catheter care. In an interview on 9/07/11 at 11:30 a.m. with LVN H, she stated resident #5 had an indwelling urinary catheter since his admission from the hospital on [DATE]. LVN H stated catheter care was done on her shift and the indwelling urinary catheter was changed monthly and PRN. Resident #5 had only been on LVN H's hall for about one month. Interview on 9/12/11 at 8:30 a.m. with LVN L, MDS Coordinator, confirmed that the indwelling urinary catheter had not been addressed in the care plan for Resident #5 when resident returned to the facility from the hospital with the indwelling urinary catheter on 1/24/11. LVN L indicated she relied on information provided by nurses who assessed Resident #5 before she completed the MDS. LVN L stated she had completed MDS's since March 2011. In an interview on 9/12/11 at 4:30 p.m. with LVN M she stated she began working at the facility in March 2011. She stated she changed Resident #5's urinary catheter once in June 2011, but failed to document this on the MARS or nurse's notes. C. Resident #6 was admitted to the facility on [DATE] with diagnoses of chronic [MEDICAL CONDITION], coronary [MEDICAL CONDITION], and muscle weakness per the undated face sheet. Observation of Resident #6 on 9/7/11at 1:00 p.m. revealed she had an indwelling urinary catheter. In an interview at the same time she stated that she had not had her urinary catheter changed in over a month. Review of Resident #6's labs revealed she had a U/A and C&S done on 8/26/11 and that the identification and sensitivity of the bacteria was received by the facility on 9/4/11. Resident #6 was started on an antibiotic on 9/9/11 for her UTI. Review of Resident #6's annual MDS assessment dated [DATE] revealed she had an indwelling urinary catheter connected to a drainage bag. The MDS did not reflect that the resident had a pressure sore. There were no diagnoses or medical conditions listed that would support Resident #6's having an indwelling urinary catheter. The MDS reflected that she was "usually understood and "usually understands". Review of Resident #6's physician's orders from 5/13/11 to 9/12/11 revealed she had orders to "Change Foley q month and PRN". Review of Resident #6's clinical record revealed she was given the indwelling urinary catheter on 3/15/11 for a Stage IV pressure sore on her coccyx to heal. Review of Resident #6's comprehensive care plans revealed she did not have a care plan for an indwelling urinary catheter. Interview on 9/12/11 at 8:30 a.m. with MDS Coordinator L, she stated that the indwelling urinary catheter had not been addressed in the care plan for Resident #6. Interview on 9/12/11 with LVN C, the treatment nurse, revealed Resident #6 did not have any pressure ulcers and that the Stage IV she had was healed on 7/14/11. LVN C stated she did not know why the resident had an indwelling urinary catheter. Review of Resident #6's TAR revealed her pressure ulcer had healed on 7/14/11. Review of Resident #6's Nurse MARs and Nursing Notes from 3/15/11 to 9/12/11 revealed that Resident #6 had 2 documented changes of her indwelling urinary catheter on 7/15/11 and 7/21/11 because it had come out. D. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] per the Record of Admission sheet dated 7/14/11. Review of a H&P dated 7/15/11 revealed diagnoses that included SP MVA, cervical spine fracture, ventilator dependence, and [MEDICAL CONDITION]. Review of Admission Nursing Assessments dated 7/14/11 and 9/2/11 revealed documentation that Resident #7 had an indwelling urinary catheter. Interview on 9/9/11 at 5:00 p.m. with LVN D confirmed he admitted resident #7 on 7/14/11 and did not obtain a physician's order for the urinary catheter that resident #7 was admitted with. LVN D confirmed that he changed resident #7's urinary catheter on 8/1/11 without an order to do so. LVN D said he changed the catheter because resident #7 had no urinary output and the catheter was apparently clogged. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #7 was assessed as having a urinary catheter. Observation on 9/8/11 at 1:20 p.m. revealed Resident #7 had an indwelling urinary catheter connected to a drainage bag. Review of the comprehensive care plan for Resident #7, dated 7/25/11, revealed that the indwelling urinary catheter was not addressed. Review of admission physician's orders for Resident #7 dated 7/14/11 and 9/2/11 and of consolidated orders dated 8/1/11-8/31/11 revealed no order for the indwelling urinary catheter. Review of physician's telephone orders from admission on 7/14/11 to 9/8/11 revealed no order for the urinary catheter for Resident #7. Interview with the DON on 9/8/11 at 1:40 p.m. confirmed there were no orders for the urinary catheter for Resident #7. Further interview with the DON on 9/8/11 at 2:50 p.m. revealed that Resident #7 had an indwelling urinary catheter since his admission on 7/14/11. Review of nurse's notes dated 8/1/11 revealed documentation that Resident #7's urinary catheter was changed and that urine obtained was foul in odor with thick sediment. In addition, hematuria (blood in the urine) was noted. Further review of this documentation revealed that 1200 cc of urine was obtained when the catheter was changed. Review of urine culture results dated 8/2/11 revealed that Resident #7 had a UTI. Review of a physician's telephone order dated 8/5/11 revealed an order for [REDACTED]. E. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pressure ulcer Stage IV, chronic osteo[DIAGNOSES REDACTED] pelvic region, and [MEDICAL CONDITION] per the Record of Admission sheet dated 7/19/11. Review of an Admit/Discharge Report revealed resident #8 was readmitted on [DATE]. Observation of Resident #8 on 9/9/11 at 1:25 p.m. revealed he had an indwelling urinary catheter attached to a leg bag for drainage. Review of physician's consolidated orders dated 7/1/11-7/31/11, 8/4/11, and 9/1/11-9/30/11 revealed an order for [REDACTED]. Review of the treatment sheets and "Nurse MARs" for the months of June, July, and August 2011 revealed no documentation that the urinary catheter was changed. Review of nurses' notes from 6/29/11-9/7/11 revealed no documentation that the urinary catheter was changed as ordered by the physician. Further review of nurse's notes dated 9/8/11 revealed documentation that the urinary catheter was changed on that date (after surveyor intervention). Interview on 9/9/11 at 10:30 a.m. with RN A confirmed there was no evidence that Resident #8's urinary catheter had been changed from 6/29/11 until it was changed on 9/8/11. Interview on 9/9/11 at 10:30 a.m. with RN A revealed that Resident #8 had an indwelling urinary catheter since his first admission to the facility on [DATE]. She stated she did not know why the catheter had not been changed. Review of an Admission Skin Assessment Form dated 6/29/11 revealed Resident #8 was assessed as having a urinary catheter. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #8 was assessed as having a urinary catheter. Review of a care plan for Resident #8, dated 7/22/11, revealed " to change the catheter, tubing, and bag as ordered". F. Resident #9 was admitted to the facility on [DATE] with diagnoses that included [MEDICAL CONDITION] and [MEDICAL CONDITION] per the record of Admission sheet dated 8/30/11. Review of nurse's notes dated 9/4/11 revealed Resident #9 was discharged to the hospital on that date. Review of an Admission Skin Assessment Form dated 8/25/11 revealed Resident #9 was admitted to the facility with an indwelling urinary catheter. Review of nurse's notes dated 9/3/11 revealed documentation that Resident #9 had a urinary catheter. Review of admission orders [REDACTED]. Interview on 9/9/11 at 2:15 p.m. with RN A confirmed Resident #9 had no orders for the indwelling urinary catheter from her admission on 8/25/11 until her discharge on 9/4/11. Review of facility policy and procedure on "Catheter Care" revealed the number one purpose was to prevent infection...and to change each month or as ordered or needed". Review of facility Infection Control Manual for Long Term Care, "Urinary Catheters" dated 2007 revealed "care and maintenance of urinary catheters is important for unobstructed flow". The facility submitted a plan of removal for the Immediate Jeopardy on 9/9/11 at 12:24 p.m., as follows: Nursing administration has assessed all residents with indwelling &/or supra pubic .catheters to identify needs. Three residents had catheters changed out on 9/8/11. One resident with referral for possible supra pubic catheter placement. DON responsible for follow-up. Clarification of all resident's orders with urinary catheters and updated on MARS as of 9/8/11. DON responsible for compliance monitoring. Verification via Input/Output (I & O) Sheets regarding adverse conditions, etc. regarding urinary catheter monitoring - implemented on 9/8/11. DON & ADON responsible for compliance monitoring. In-service all Nurses and Nurse Aides regarding importance of I & O documentation in the monitoring and management of catheter use. On-going in-servicing. Verification as of 9/8/11 of the appropriate resident diagnoses for use of urinary catheters. DON responsible for compliance monitoring. Monthly urinary catheter change scheduled for the 6:00 a.m. - 2:00 p.m. shift. All catheter changes updated on current MARS. DON responsible for compliance. In-service to all nursing staff regarding proper policy and procedure regarding monitoring and management of catheter use & regarding catheter use and justification for use. Nursing administration in-serviced by corporate nurse on 9/8/11 & ongoing in-servicing for all shifts. Verification on 9/8/11 of resident care plans regarding interventions to ensure adequate monitoring and management of catheter care. Administrator and DON responsible for compliance. Catheter output to be emptied per nurse aide before the end of each shift, and the aide will communicate amount to charge nurse who will record output on I & O sheet. The 24 hour report will be used to communicate & each shift is responsible for notifying the next shift of any issues of concerns and/or changes in condition. DON is responsible for picking up the 24 hour report each morning for review. The charge nurse is responsible for the verification of the catheter anchoring and this will be documented each shift. If there is no urinary output for a resident during a shift, the Nurse Aide is responsible for notifying the charge nurse. The charge nurse will then perform an assessment of the resident and notify the MD of findings, etc. When a resident is determined to be independent in emptying their own urinary output, the facility will provide education regarding the possible consequences of their actions along with an informed consent completed. The resident will be required to participate in a skills validation check and if resident is unable to comply, then the staff will continue to verbally ask the resident post each encounter of self performance of emptying urinary output the amount of urinary output to enable staff to document on the I & O form. Confirmation of compliance included: Random interviews, observations of staff and residents present on 9/9/11 and record reviews. Education and training was being provided and processes such as audits were being put into place to prevent a reoccurrence of the problems. While the IJ was removed on 9/9/11, the facility remained out of compliance at a severity level of "Actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of a "pattern" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. Review of Form CMS-672 revealed 8 residents with indwelling catheters.