Every finding on record at River Towne Center

Based on observations, record reviews, and interviews, the facility pharmacy services failed to ensure medication irregularities were identified and addressed when ordered medications were not available for administration for one resident (Resident (R) 147) out of four newly admitted residents reviewed for medication irregularities. This failure had the potential to result in a decline of the resident's condition due to missed medication. Findings include: Review of R147's Admissions Record, located under the Admissions tab of the electronic medical record (EMR), revealed R147 was initially admitted to the facility on [DATE] and expired in the facility on [DATE], with diagnoses to include acute respiratory failure with hypoxia, hyperlipidemia, and tracheostomy. Review of R147's Physician Orders, dated [DATE] and located under the Orders tab of the EMR, revealed R147 was prescribed Budesonide Inhalation Suspension 9.5 via trach two times a day for the diagnosis of respiratory failure. The physician orders also revealed that R147 was prescribed Naloxegol Oxalate Oral tablet 12.5 via feeding tube one time a day for constipation, and Latanoprost Ophthalmic Solution for glaucoma in both eyes. Review of R147's Medication Administration Record (MAR), located under the Orders tab of the EMR, revealed R147 did not receive the ordered Budesonide Inhalation Suspension, the Naloxegol Oxalate tablet, Isosorbide Dinitrate oral tablet, or the Latanoprost Ophthalmic Solution during her three day stay in the facility. Review of R147's Progress Notes, dated [DATE] at 8:59 AM and located under the Progress Notes tab of the EMR, written by Licensed Practical Nurse (LPN) 8, documented the facility was awaiting delivery of Budesonide Inhalation Suspension, the Naloxegol Oxalate tablet, Isosorbide Dinitrate oral tablet, and the Latanoprost Ophthalmic Solution. Review of R147's Progress Notes, dated [DATE] at 2:02 PM and located under the Progress Notes tab of the EMR, documented R147 was missing the Latanoprost eye drops, budesonide inhalant, and Naloxegol tablets. The writer documented how she spoke with the pharmacy and was told the medications were on back order. Review R147's Nursing Progress Notes, dated [DATE] at 2:22 PM and located under the Progress Notes tab of the EMR, documented R147 had been assessed for shortness of breath and indicated her vital signs were checked and recorded at baseline, before and after respiratory assessments every shift. The progress notes documented that R147 had a lot of anxiety, pulling on lines and devices. Review of R147's Progress Notes, dated [DATE] 10:37 AM and located under the Progress Notes tab of the EMR, documented the missing medications were on back order and may arrive [DATE]. Review of R147's MAR, dated [DATE] and located under the Orders tab of the EMR, revealed R147's respiratory assessments were documented every shift, and her vital signs were checked and recorded every shift before and after respiratory assessments and appeared normal for her baseline vital signs. During an interview on [DATE] at 10:30 AM, LPN8 stated that she was consistent to document that R147's missing medications were on back order but that she failed to look in the Omnicell for the medication and failed to call the prescribing physician regarding the status of the unavailable medication for an update to the order or for an available substitute. During an interview with the Director of Nursing (DON), she stated she was a new employee to the facility since [DATE] and was not aware of any previous medication issues. She stated the previous DON was on maternity leave. During an interview with the Administrator on [DATE] at 11:58 AM, he initially stated he had stepped into the role of DON during the previous DON's maternity leave on [DATE] and was not aware of the missing medications that had been ordered for R147. He stated his expectation for the nursing staff was to inform the physician of any medications that were not available within the initial 12 hours of admission to the facility. He said if the ordered medications have not arrived within 12 hours of a new admission, the nurse should check the Omnicell for the medication and then notify the physician for a change in the order for similar medications that were readily available. Review of the undated policy titled, Administering Medication, revealed, . The DON supervises and directs all personnel who administer medications and/or have related functions, and that medications are administered in accordance with prescriber orders, including any required time frame.

Based on observations, record reviews, interviews, and review of the facility policy titled, Medication Therapy, the facility failed to ensure residents or resident representatives were informed in advance of the risks and benefits of a prescribed psychotropic medication or an alternative treatment for two of three residents (Resident (R) 46, and R61) reviewed. This failure had the potential for residents to receive the medication without informed consent or understanding of the treatment, and/or alternative treatment available. Findings include: Review of R46's admission Record, in the electronic medical record (EMR), under the Admissions tab revealed R46 was initially admitted to the facility on [DATE]. Review of R46's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 12/20/25 and located under the MDS tab of the EMR, revealed R46 had a Brief Interview for Mental Status (BIMS) score of nine of 15, indicating she had moderately impaired cognition. Review of R46's Resident Medication Summary, dated March 2026 and located under the Orders tab of the EMR, revealed R46 had a physician's order for two psychotropic medications, Bupropion and Effexor, prescribed for her diagnosis of depression disorder. Review of R46's EMR revealed no documentation of any informed consent documentation reviewed/signed by the resident or the resident's representative, in advance of administering the psychotropic medication. 2. Review of R61's admission Record, located under the Admissions tab of the EMR, revealed R61 was initially admitted to the facility on [DATE]. Review of R61's MDS, with an ARD of 02/19/26 and located under the MDS tab of the EMR, revealed R61 had a BIMS score of zero of 15, indicating he had severe cognitive impairment. Review of R61's Resident Medication Summary, dated March 2026 and located under the Orders tab in the EMR, revealed R61 had a physician's order for two psychotropic medications, Sertraline and Trazodone, prescribed for his diagnosis of depression disorder. Review of all documents in the EMR under the Documents tab revealed R61 had no documentation of any informed consent document reviewed/signed by the resident or the resident's representative, in advance of administering the psychotropic medication. During an interview on 03/30/26 at 11:24 AM, Social Service Director (SSD) 1 stated she was not familiar with a document required prior to administering a high-risk medication/psychotropic and was not responsible for obtaining a document of informed consent for any prescribed medication. During an interview on 03/30/26 at 1:45 PM, Unit Manager (UM) 2 stated she was not familiar with a document required prior to administering a high-risk medication/psychotropic and was not responsible for the document. She stated she thought the Director of Nursing (DON), the Physician, or Nurse Practitioner (NP) was responsible for obtaining informed consents for high-risk medications. During an interview on 03/31/26 at 12:48 PM, the DON stated she had only been in the facility for a week and assumed the charge nurses were responsible for obtaining informed consents for high-risk medication. She said she would expect informed consent to be obtained when the prescriber wrote the medication order. During an interview with the Administrator on 03/31/26 at 3:10 PM, he stated he would expect the nurse manager to confirm that an advance signed consent had been acquired prior to administering high risk medications. Review of the undated policy titled, Medication Therapy, revealed, . All medication orders would be supported by appropriate care processes and practices. The subtitle named Policy Interpretation and Implementation revealed.All decisions related to medications shall include appropriate elements of the care process, such as each resident's wishes, values, goals, condition, and prognosis.

Based on record review, interviews, and review of the facility's policy titled, Administering Medications, the facility failed to administer medications timely for one of six residents (Resident (R) 141) reviewed for medications out of a total sample of 38 residents. This failure had the potential to alter the effectiveness of the medication with the potential for overdosing if medications were given too close together. Findings include: Review of R141's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE] and discharged on 06/21/25. The resident had diagnoses which included anemia, encounter for orthopedic aftercare following surgical amputation, and muscle weakness. Review of R141's discharge Minimum Data Set (MDS), with an assessment reference date (ARD) date of 06/21/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) was not conducted and the staff assessment for mental status indicated the resident had moderately impaired cognition. During an interview on 03/30/26 at 1:56 PM, the Resident Representative (RP) 1 stated she did not think the resident received any medications for the first 24 hours. Review of the Medication Admin [Administration] Audit Report, scheduled for 06/18/25-06/21/25 and provided by the facility, revealed the following: -Omeprazole DR [delayed release] 20 MG [milligram] Capsule- give one capsule by mouth one time a day for GERD [gastroesophageal reflux disease] was scheduled for 06/19/15 at 09:00 [9:00 AM] and was documented as administered on 06/19/25 at 14:33 [2:33 PM]. -Losartan Potassium 100 MG tab- give one tablet by mouth one time a day for HTN [hypertension] was scheduled for 06/19/25 at 09:00 and was documented as administered on 06/19/25 at 14:33. -Oxycodone-Acetaminophen oral tablet 5-325 MG- give one tablet by mouth every 8 [eight] hours for Pain was scheduled for 06/21/25 at 0800 [8:00 AM] and was documented as administered on 06/21/25 at 13:01 [1:01 PM]. Review of the Omnicell inventory list, located in the printer room on the wall, revealed the above medications were listed as available. During an interview on 03/30/26 at 2:53 PM, Unit Manager (UM) 2 stated for medication pass, they had one hour before and one hour after the designated time to administer the medication. She stated she did not audit the medication administration times and was unaware there were late meds. During an interview on 03/30/26 at 3:41 PM, UM1 stated for medication pass, they had one hour before and one hour after the designated time to administer the medication. She stated she did not audit the medication administration times and was unaware there were late meds. During an interview on 03/31/26 at 10:09 AM, the Administrator stated they had one hour before and one hour after the designated times to administer the medication. He stated they should have pulled the medication from the Omnicell. He said nobody was auditing for late medication administration. Review of the facility's policy titled, Administering Medications, revised December 2012, revealed . Medications should be administered within one (1) hour of their prescribed time.

Based on observations, interviews, and facility policy review titled Environment, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for one of one kitchen affecting 103 residents who consume food from the kitchen. This failure had the potential to contribute to contamination and infection control concerns. During a kitchen observation, alongside the Dietary Manager (DM), on 04/01/26 at 6:02 AM, a large section of non-slip flooring in front of the steam table was worn through to show the underneath tile, and some missing grout for the tile.-Two sections of non-slip flooring in front of the three-pan sink were worn through, showing the underneath tile and concrete. The sections were flooded with standing water.-Underneath the steamer, there was broken and worn non-slip flooring to reveal exposed tile.-A long section of broken, worn-through non-slip flooring at the drink station revealed rocky concrete/ tile areas and was flooded with water.-The non-slip flooring in front of the dish machine had broken, worn sections revealing the underneath concrete.-The non-slip flooring to the left side of the stove revealed open/worn/broken/cracked, and buckled areas. The DM acknowledged that the floor was not a cleanable surface.-The dry storage area, lower right-side wall, revealed drywall debris coming down onto the floor.-The entrance to the walk-in refrigerator revealed that the non-slip flooring was worn through, which revealed the underlying tile.-The back side of the hood filter revealed broken slats on the left side.-The piping underneath the three-pan sink was observed as rusted through, exposed to the inside.-The walls throughout the kitchen were dirty with food spatter, including behind the prep station, behind the hand-washing sink, behind the three-pan sink, and surrounding the clean knife storage container.-The clean knife storage was located on the left side of the three-pan sink on the wall. The unit was dirty with spatter and lint along the outside, top, and behind the storage box.-The oven was dirty with grime; food spattered on the outside windows and sides.During an interview on 04/01/26 at 6:13 AM, the DM stated there were holes in the metal ramp for the dish machine, so the water went down to the floor. He acknowledged that the flooring needed to be repaired. At 6:17 AM, after observing the flooring, he confirmed that the flooring was a non-cleanable surface. At 6:22 AM, the DM stated he thought the walls had been cleaned about two to three months ago. At 6:43 AM, the DM confirmed the dirty knife rack.During an observation on 04/01/26 at 6:30 AM, Dietary staff (D) 1 was preparing pureed bread. He laid the measuring spoons on top of the dirty microwave. There was a paper attached to the top of the microwave, and food spatter along the outside top and sides of the microwave. The microwave was located on the left side of the puree prep table and the blending machine. He added thickener to the pureed mixture using the measuring spoons and placed it back on top of the dirty microwave. At 6:53 AM, the DM confirmed the microwave was dirty and proceeded to clean it.During an interview on 04/01/26 at 7:43 AM, the Administrator stated they were looking at the cost for the flooring, but did not have any estimates. He stated the hood vent needed to be replaced.Review of the facility's policy titled, Environment, revised June 2025, revealed . All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.

Based on observations, staff interviews, and review of the facility policy titled Food Receiving and Storage, the facility failed to ensure food items were discarded upon expiration. This deficient practice had the potential to promote foodborne illnesses in the 110 residents receiving an oral diet from the kitchen. Findings include: Review of the facility's policy titled Food Receiving and Storage, dated [DATE], revealed that the Policy Statement stated, Foods shall be received and stored in a manner that complies with safe food handling practices. During a tour of the kitchen on [DATE], beginning at 9:50 am with the Dietary Manager (DM), observations revealed: One container of ground allspice seasoning with an expiration date of [DATE]. One container of ground ginger seasoning with an expiration date of [DATE]. One box of French-style dressing packets with an expiration date of [DATE]. One box of gelatin expired [DATE]. Observations of the walk-in cooler with the DM revealed: Two boxes of cabbage with expiration dates of [DATE] and [DATE]. One container of cream cheese with an expiration date of [DATE]. One container of cottage cheese with an expiration date of [DATE]. One container of ricotta cheese with an expiration date of [DATE]. In an interview on [DATE] at 10:15 am, the DM confirmed the findings in the kitchen. The DM stated that inventory checks were conducted, and expired food items should be discarded. In an interview on [DATE] at 12:30 pm, the Administrator stated that his expectation for the kitchen staff was to ensure all expired food items were discarded.

Based on record review, observations, staff interviews, and review of the facility's policy titled Departmental (Respiratory Therapy) -Prevention of Infection Level I the facility failed to ensure the safe handling, labeling, and storage of nebulizer equipment to prevent contamination for one Resident(R)(R1) of 23 sampled residents. This deficient practice had the potential to contribute to the spread of infection and respiratory illness. Findings include: A review of the facility's policy titled Departmental (Respiratory Therapy) -Prevention of Infection Level I Purpose-The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 2.Take care not to contaminate internal nebulizer tubes. 3.Wipe the mouthpiece with damp paper towel or gauze sponge. 4.Store the circuit in plastic bag, marked with date and residents. Review of R1's medical record revealed she was admission on 8/6/2021 with diagnoses including chronic obstructive pulmonary disease (COPD), HIV disease, dementia, schizophrenia, and muscle weakness. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Section J documented shortness of breath when lying flat and with exertion. Review of physician orders dated 1/16/2025 revealed an active order for Ipratropium-Albuterol inhalation solution, 3ml inhaled orally every 6 hours as needed for shortness of breath. Observation on 4/22/2025 at 2:04 pm revealed R1's nebulizer mask sitting on the nightstand unbagged and unlabeled. Observation on 4/23/2025 at 10:15 am revealed R1's nebulizer mask again sitting on the nightstand unbagged and unlabeled. Observation /interview on 4/23/2025 at 11:03 am with Certified Nursing Assistant (CNA), CNA UU, confirmed that R1's nebulizer mask was not bagged or labeled. CNA UU stated she was unsure if it was required. Interview and observation on 4/23/2025 at 3:25 pm with Licensed Practical Nurse, ( LPN) LL, LPN LL confirmed that the nebulizer mask was not bagged or labeled. LPN LL stated that, according to infection control procedures, the mask should have been properly bagged and labeled. Interview on 4/23/2025 at 6:13 pm with the Director of Nursing (DON) confirmed that nebulizer masks should be bagged after use to prevent contamination and comply with infection control standards. XXXXXXXXXXX 49138 Based on observations, resident interviews, staff interviews, record review, and review of the facility policies titled Departmental (Respiratory Therapy) Prevention of Infection and Gastrostomy/Jejunostomy Site Care, the facility failed to ensure that respiratory masks were stored in a sanitary manner for two of five residents (R) (R1 and R70) reviewed for respiratory care. In addition, the facility failed to ensure dressing changes were performed as ordered for one of 31 R (R23) with a feeding tube. These deficient practices had the potential to place R1, R70, and R23 at risk of avoidable infections due to cross-contamination. Findings include: Review of the facility policy titled Departmental (Respiratory Therapy)Prevention of Infection, revised 11/2011, revealed the Purpose section stated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The Steps in the Procedure section included, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: . 7. Store the circuit in a plastic bag, marked with date and resident's name, between uses. Review of the facility policy titled Gastrostomy/Jejunostomy Site Care, revised 10/2011, revealed the Purpose section stated, The purposes of this procedure are to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown and infection. 1. Review of R1's Admission Record revealed diagnoses, including but not limited to pneumonia and chronic obstructive pulmonary disease (COPD). Review of R1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed that Section J documented that R1 had shortness of breath when lying flat and with exertion. Review of R1's Order Summary Report revealed an order dated 1/16/2025 for ipratropium-albuterol inhalation solution (a medication used to treat wheezing, shortness of breath, and coughing), 3 milliliters (ml) inhaled orally every six hours as needed for shortness of breath. Observation on 4/22/2025 at 2:04 pm and 4/23/2025 at 10:15 am revealed R1's nebulizer mask lying on the nightstand, unbagged and exposed to the environment. In a concurrent observation and interview on 4/23/2025 at 11:03 am, Certified Nursing Assistant (CNA) UU confirmed that R1's nebulizer mask was not stored in a protective bag. CNA UU stated she was unsure if the mask was required to be stored in a protective bag. In a concurrent observation and interview on 4/23/2025 at 3:25 pm, Licensed Practical Nurse (LPN) LL confirmed that the nebulizer mask was exposed to the environment and not in a protective bag. LPN LL stated that, according to infection control procedures, the mask should have been properly stored in a protective bag. In an interview on 4/23/2025 at 6:13 pm, the Director of Nursing (DON) stated that nebulizer masks should be placed in a protective bag after use to prevent contamination and comply with infection control standards. 51557 2. Review of R70's Admission Record revealed diagnoses including, but not limited to, pneumonia, chronic pulmonary edema, cardiomegaly, chronic respiratory failure, tracheostomy status, COPD, and acute pulmonary edema. Review of R70's Annual MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented R70 received oxygen therapy, suctioning, tracheostomy care, and non-invasive mechanical ventilator while a resident. Review of R70's Physicians' Orders revealed an order dated 2/16/2025 to clean BiPAP (Bilevel Positive Airway Pressure [a medical device that assists with breathing]) wash, tubing, and reservoir with soap and water, rinse with sterile water, and allow to dry. Observations on 4/22/2025 at 10:03 am and 4/23/2025 at 7:47 am and 10:29 am, in R70's room, revealed a BiPAP mask lying on the bedside table, unbagged and exposed to the environment. In an interview on 4/22/2025 at 10:00 am, R70 stated the BiPAP equipment was washed two days prior. In an interview on 4/23/2025 at 10:44 am, R70 stated that staff often allowed the BiPAP mask to fall on the floor and that staff do not place the mask in a protective bag. In an interview on 4/23/2025 at 10:52 am, LPN AA confirmed that the BiPAP mask was not in a protective bag and was exposed to the environment. In an interview on 4/24/2025 at 9:57 am, the DON stated that BiPAP tubing and masks should be stored in a protective bag when not in use. 3. Review of R23's Admission Record revealed diagnoses including, but not limited to, gastrostomy status. Review of R23's Physicians' Orders revealed an order dated 4/14/2025 for PEG Tube (percutaneous endoscopic gastrostomy [a feeding tube placed into the stomach through the abdominal wall]) site care and dressing change every shift. Observation on 4/22/2025 at 9:42 am revealed R23's PEG tube site dressing was discolored with dark brown drainage and was dated 4/16/2025. In a concurrent observation and interview on 4/22/2025 at 10:07 am, LPN AA confirmed R23's PEG tube site dressing was soiled and dated 4/16/2025. In an interview on 4/24/2025 at 9:52 am, the DON stated that her expectation was for PEG tube site dressings to be changed daily. She stated nursing staff was responsible for PEG site dressing changes.

Based on observations, staff interviews, and review of the facility policy titled Medication Labeling and Storage, the facility failed to ensure expired medications were discarded after the expiration date in one of two medication rooms. This deficient practice had the potential to place residents at risk of receiving medications with altered effectiveness. Findings include: Review of the facility policy titled Medication Labeling and Storage, revised February 2023, revealed the Policy Interpretation and Implementation Medication Storage section included, . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observations on 4/23/2025 at 4:53 pm in the [NAME] Side Medication Storage Room revealed three boxes of bisacodyl suppositories expired 1/2025, one opened container of Tylenol 325 milligrams (mg) expired 11/25/2024, and three containers of Renavite expired 10/2023 were stored with other unexpired medications on the storage shelves. In an interview on 4/23/2025 at 5:20 pm, Registered Nurse (RN) CC verified the findings and stated that discontinued medications should be placed in a box in the medication room and picked up by the pharmacy to be destroyed monthly. In an interview on 4/24/2025 at 10:14 am, the Director of Nursing (DON) stated that expired and discontinued medications should be removed from the shelves and placed in a box in the medication storage room for the pharmacy to destroy.

Based on staff interviews, resident family interviews, record review, and review of the facility policy titled Pain Assessment and Management, the facility failed to provide pain management for one of 49 sampled residents (R) (R385). Findings include: Review of the facility's policy titled Pain Assessment and Management, revised 10/2022, revealed the General Guidelines section included, 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The Steps in the Procedure section included, Assessing Pain 1. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. and Monitoring and Modifying Approaches . 5. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled. Review of R385's Admission Minimum Data Set (MDS), dated [DATE], revealed Section J (Health Conditions) documented R385 received PRN (as-needed) pain medication, pain frequency was occasional, pain interfered with sleep occasionally, and the pain intensity score was three (indicating severe pain). Review of R385's Admission Record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses including, but not limited to, encounter for other orthopedic aftercare, muscle weakness, and spinal stenosis, cervical region. Review of R385's Nursing Admission Screening/History assessment, dated 12/11/2024, revealed the reason for admission was neck surgery, the resident had pain, and pain was assessed at a level of five on a scale of one to ten. Review of R385's Physician's Orders revealed an order dated 12/11/2024 at 1:57 pm for oxycodone-acetaminophen tablet (a medication used to treat moderate to severe pain) 7.5-325 milligrams (mg) one tablet every six hours as needed for pain. Review of R385's Medication Administration Record (MARS) dated 12/2024 revealed a physician's order dated 12/11/2024 at 1:57 pm for oxycodone-acetaminophen tablet 7.5-325 mg one tablet every six hours as needed for pain. Review revealed R385 did not receive the medication on 12/11/2025. Further review revealed R385 did not receive the medication on 12/12/2024 at 2:22 pm. In a telephone interview on 4/24/2025 at 7:59 am, R385's family member stated R385 had complained of pain all night after her admission to the facility and did not receive any pain medication. R385's family member stated the nurse had informed her that the order for the pain medication was not sent to the facility from the hospital, and the physician was not notified. In an interview at 4/24/2025 5:45 pm, Admissions Director RR and Registered Nurse (RN)/Hospital Liaison SS stated that the process for opiod pain medication was for the hospital to send a hard copy of the prescription with the resident, the nurse receiving the resident should fax the hard copy of the prescription to the pharmacy, and the pharmacy should send the nurse a code to access the emergency medication supply and obtain the ordered medication. In an interview on 4/24/2025 at 6:00 pm, the Director of Nursing (DON) reviewed R385's electronic medical record (EMR) and stated she was unable to locate the hard copy of the prescription for R358's pain medication in the scanned documents. She stated the hard copy of the prescription was not received upon the resident's admission, and the receiving nurse did not call the physician to obtain an order for overnight pain relief. The DON confirmed that the facility's normal process for narcotic pain medication was for the hospital to send over a hard copy of the prescription so the receiving nurse could fax it to the pharmacy and then receive a code from the pharmacy to be able to pull the narcotic out of the emergency stock until the pharmacy delivered the residents medication.

Based on observations, resident interviews, and staff interviews, the facility failed to ensure an environment free from accident hazards on one of seven medication carts and in three of 49 sampled residents' (R) (R12, R87, and R36) rooms. This deficient practice had the potential to place the residents at risk of accident hazards. Findings include: 1. Observation 4/22/2025 9:37 am of the medication cart located on the 200 Hall revealed an unpackaged three cubic centimeter (cc) syringe, with an uncapped needle attached, lying on top of a biohazard container attached to the medication cart. In a concurrent observation and interview on 4/22/2025 at 9:46 am, Registered Nurse (RN) MM verified the syringe location. She stated the syringe should have been placed completely in the biohazard container. She further stated there was a potential for a resident to pick up the syringe with the attached needle and have an adverse outcome. In an interview on 4/22/2025 at 9:50 am, Unit Manager (UM) CC revealed that syringes and needles should be disposed of by placing them completely inside the biohazard containers. UM CC stated he expected all syringes and needles to be disposed of properly. In an interview on 4/22/2025 at 9:53 am, the Director of Nursing (DON) revealed that opened syringes and needles should not be sticking out of the biohazard container. The DON revealed that the syringe should be in the biohazard container and the top should be closed. In an interview on 4/22/2025 at 9:55 am, the Administrator stated that syringes and needles should be disposed of by ensuring they were completely in the biohazard container to avoid injuries. 49138 2. a. Observation on 4/22/2025 at 11:47 am revealed a container of an aerosol disinfecting spray sitting on R12's bedside table, within easy reach of a resident. During an observation and interview on 4/22/2025 at 12:25 pm, RN TT confirmed that aerosol disinfecting spray should not be left at the resident's bedside. In an interview on 4/23/2025 at 6:13 pm, the DON confirmed that hazardous chemicals, including aerosol disinfecting spray, should not be accessible to residents. In an interview on 4/24/2025 at 6:30 pm, the Administrator stated that cleaning products or aerosol items, such as household cleaners, should not be in resident rooms. 50941 b. Observation on 4/22/2025 at 9:52 am in R87's room revealed a multi-purpose cleanser sitting on top of the toilet tissue dispenser in the bathroom. In an interview on 4/22/2025 at 12:49 pm, Certified Nursing Assistant (CNA) HH verified that the multi-purpose cleanser was sitting on the toilet tissue dispenser. She stated that R87's family member brings in cleaner to clean R87's bedroom. In an interview on 4/22/2025 at 12:59 pm, RN ZZ stated she knew that the chemical was not supposed to be there, but the family member brought it in. During a concurrent observation and interview on 4/22/2025 at 1:07 pm, LPN JJ stated that staff were supposed to remove the chemicals from resident rooms, and she was unaware of any chemicals in R87's room. In an interview on 4/22/2025 at 1:15 pm, the DON stated she was unaware that the family member was bringing the chemical in. c. Observation on 4/22/2025 at 10:20 am, in R36's room, revealed a container of disinfecting cleaner under the sink in the bathroom. In an observation and interview on 4/22/2025, the DON verified that the container of disinfecting cleaner was under the sink and that it should not be there. She stated R36's family had brought it in.

Based on observations, resident interviews, staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADL), Supporting, the facility failed to ensure that two of 49 sampled residents (R) (R12 and R43) received activities of daily living (ADL) care related to receiving scheduled showers to maintain good personal hygiene. This deficient practice had the potential to place R12 and R43 at risk of being unclean and feeling insecure about their appearance. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised 3/2018, revealed the Policy Statement stated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The Policy Interpretation and Implementation section included, . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the residents and in accordance with the care plan, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). 1. Review of R12's Admission Record revealed diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic neuropathy, end-stage renal disease, muscle weakness, morbid obesity, depression, and anxiety. Review of R12's Quarterly Minimum Data Set (MDS) assessment, dated 4/11/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented upper extremity impairment on both sides, lower impairment on one side, and required substantial to maximum assistance with showering or bathing. Section O (Special Treatments, Procedures, and Programs) documented that R12 received dialysis. Review of R12's Care Plan Report, dated 11/29/2022, revealed a Focus area, dated 11/29/2022, of ADL self-care performance deficit related to decreased mobility. Interventions included assisting the resident with hygiene and grooming. Review of R12's Bath Skin Assessment Forms for April 2025 revealed forms dated 4/1/2025, 4/8/2025, 4/15/2025, and 4/23/2025. Documentation revealed R12 refused on 4/1/2025 and 4/15/2025. There was no documentation of baths or showers for any other dates in April 2025. In an interview on 4/22/2025 at 11:47 am, R12 revealed she was in and out of the facility for dialysis and was not offered showers. R12 stated she has not received a bed bath or shower for about a month. She stated she had asked staff for a shower and was informed her scheduled shower days were on Monday, Wednesday, and Friday. R12 stated she was out of the facility for dialysis on her scheduled shower days. In an interview on 4/23/2025 at 11:03 am, Certified Nursing Assistant (CNA) UU stated R12 received a shower on Monday and Friday and a bed bath on other days and the showers or baths were documented on the shower sheets. 2. Review of R43's Admission Record revealed diagnoses including, but not limited to, legal blindness, muscle weakness, glaucoma, and schizophrenia. Review of R43's Quarterly MDS assessment, dated 3/6/2025, revealed Section C (Cognitive Patterns) documented a BIMS of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented R43 required partial to moderate assistance with showering or bathing. Review of R43's Care Plan Report revealed a Focus area, initiated 11/6/2018, of ADL self-care performance deficit related to confusion, impaired balance, visual impairment of being legally blind, and glaucoma. Interventions include requiring the assistance of one person with ADLs and providing a sponge bath when a full bath or shower cannot be tolerated. Review of R43's Bath Skin Assessment Forms for one month revealed forms dated 3/31/2025, 4/4/2025, 4/7/2025, and 4/11/2025. There was no documentation of baths or showers for any other dates in April 2025. In an interview on 4/22/2025 at 11:47 am, R43 stated she did not receive showers as scheduled. In an interview on 4/23/2025 at 10:36 am, R43 stated her shower days were Monday and Friday, and she did not receive showers as scheduled. Observation revealed R43 wearing the same pants as on 4/22/2025. In an interview on 4/23/2025 at 11:03 am, CNA UU stated R43 was provided a shower on Monday and Friday and a bed bath on the other days. CNA UU stated R43 did not refuse showers and the showers or baths were documented on the shower sheets. In an interview on 4/23/2025 at 11:12 am, Licensed Practical Nurse (LPN) LL stated that residents should receive showers as scheduled. In an interview on 4/24/2025 at 6:13 pm, the Director of Nursing (DON) stated that showers should be provided as scheduled. She further stated that if a resident refused, staff should inform the nurse and reattempt. In an interview on 4/24/2025 at 6:30 pm, the Administrator stated residents should receive showers as scheduled.

Based on record review, observations, staff and family interviews, and review of the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a comprehensive, person-centered care plan for two of 49 sampled residents (R) (R70 and R385). This deficient practice had the potential to place R70 and R385 at risk of unmet needs, medical complications, and a diminished quality of life. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the Policy Statement stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation section included, . 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment . 7. The comprehensive, person-centered care plan: 1. includes measurable objectives and timeframes; 2. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . 3. which professional services are responsible for each element of care. 1. Review of R1's Admission Record revealed diagnoses, including but not limited to pneumonia and chronic obstructive pulmonary disease (COPD). Review of R1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed that Section J documented that R1 had shortness of breath when lying flat and with exertion. Review of R1's Order Summary Report revealed an order dated 1/16/2025 for ipratropium-albuterol inhalation solution (a medication used to treat wheezing, shortness of breath, and coughing), 3 milliliters (ml) inhaled orally every six hours as needed for shortness of breath. Review of the resident's comprehensive care plan dated 3/7/2024 revealed no care plan interventions addressing nebulizer use or shortness of breath management. In an interview on 4/24/2025 at 2:58 pm, MDS DD verified that R1's respiratory needs were not included in the care plan. MDS DD confirmed that nebulizer use for shortness of breath should have been assessed and incorporated into the care plan to guide staff interventions. In an interview on 4/23/2025 at 6:13 pm, the Director of Nursing (DON) stated that specific resident needs, such as nebulizer treatments, should be included in the resident's care plan to ensure appropriate respiratory care and monitoring. 51557 2. Review of R385's Admission Minimum Data Set (MDS), dated [DATE], revealed Section J (Health Conditions) documented R385 received as-needed (PRN) pain medication, pain frequency was occasional, pain interfered with sleep occasionally, and the pain intensity score was three (indicating severe pain). Review of R385's Admission Record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses including, but not limited to, encounter for other orthopedic aftercare, muscle weakness, and spinal stenosis, cervical region. Review of R385's Physician's Orders revealed an order dated 12/11/2024 for oxycodone-acetaminophen tablet (a medication used to treat moderate to severe pain) 7.5-325 milligrams (mg) one tablet every six hours as needed for pain. Review of R385's Care Plan Report revealed there were no focus areas or interventions addressing pain. In an interview on 4/24/2025 at 10:52 am, MDS DD confirmed R358's comprehensive care plan did not address pain. She stated the care plan was completed using information in the MDS assessments and should address pain. In an interview on 4/24/2025 at 6:00 pm, the DON stated her expectation was for care plans to accurately reflect the resident's needs. She further stated she expected collaboration with the MDS Coordinator and the nursing staff to identify problems that need to be addressed in the care plans. Cross-Reference F697

Based on staff interviews, record review and review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, the facility failed to assess pressure ulcers and initiate pressure ulcer treatments timely for three of 12 sampled Residents (R) (R2, R6 and R10). Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated March 2014 under the section titled Assessment and Recognition revealed, 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin. 1. Review of medical records revealed R2 was admitted to the facility on [DATE] with a Stage two (2) pressure ulcer to the sacrum. Review of the Wound Summary report revealed the pressure ulcer to the resident's sacrum was not assessed until 12/6/2023 and noted the wound was a Stage four (4) that measured 7.1 centimeters(cm) x 8.5 cm x 0.1cm. However, review of the 12/6/2023 Physician Assistant (PA) wound consult note documented the sacrum as Stage 2 pressure ulcer, not a Stage 4. The PA noted the pressure ulcer measured 7.1cm x 8.5cm x 0.1cm and the wound bed had granulation, 50% epithelialization with no slough or eschar present. Review of the December 2023 Treatment Administration Record (TAR) revealed there was no documentation treatment was done to the sacrum until 12/10/2023. Review of R2's Nurse Progress Note dated 12/10/2023 stated, Called to the room by Certified Nursing Assistant (CNA) stating the resident needed wound care for his sacrum. The area was cleaned with normal saline, Santyl and collagen applied, covered with calcium alginate and a foam dressing. Reviewed the resident's chart but unable to locate an order. Nurse does state the wound care was being done for that area. The Nurse Practitioner was notified and received new orders. Review of the Progress Note Details dated 12/13/2023 revealed the sacrum had deteriorated to an unstageable pressure ulcer with 60% slough, 10% granulation and 30% epithelialization and measured 12.6cm x 11.2cm x 0.1cm. Review of Progress Note Details dated 12/20/2023 revealed wound order to cleanse the wound with Dakin's one-fourth (1/4) strength, skin prep to peri wound, apply Gentamicin and cover with foam dressing every day and as needed. However, review of the 12/2023 TAR revealed the treatment was not started until 12/25/2023. 2. Review of medical records revealed R6 was admitted to the facility on [DATE]. Review of the Wound Summary report indicated the resident was admitted with a Stage 2 pressure ulcer to the sacrum. However, there was no descriptive documentation of the pressure ulcer until 1/11/2024 documenting the wound as a Stage 2 measuring 0.4cm x 0.5cmx 0.1cm. Review of the January 2024 TAR revealed there was no documentation treatment was done to the sacrum until 1/26/2024 when a physician's order was obtained to clean the sacrum with normal saline, apply skin prep to peri skin, collagen, and zinc barrier, cover with dry dressing every Monday, Wednesday, and Friday. Review of medical records revealed on 2/9/2024 the order was changed to clean the sacrum with normal saline, apply zinc to peri wound, collagen, cover with dry dressing every day. However, review of the February TAR revealed there was no documentation treatment was done on 2/10/2024 and 2/11/2024. During an interview with the Treatment Nurse on 2/13/2024 at 3:45 pm, she could not explain why there was lack of documentation of treatment from 1/11/2024 to 1/26/2024. She also stated she did provide treatment to the sacrum although the documentation does not reflect that. 3. Review of medical records revealed R10 was admitted to the facility on [DATE] with a Stage 4 pressure ulcer to the left ischial tuberosity and an unstageable pressure ulcer to the sacrum. However, review of the February 2024 TAR revealed there was no documentation of treatment to the two wounds until 2/5/2024 when a physician's order was obtained to clean the wounds with Dakins, apply Dakins moistened gauze and cover with a dry dressing every Monday, Wednesday, and Friday. Review of medical records revealed on 2/9/2024 a new physician's order was obtained to clean the sacrum and the left ischial tuberosity with 0.25% Dakins, apply collagen and cover with a dry protective dressing every day. However, review of the February 2024 TAR revealed there was no documentation treatment was done on 2/10/2024 and 2/11/2024 as ordered. During an interview with the Administrator on 2/14/2024 at 11:45 am, he stated that the past weekend on 2/10/2024 and 2/11/2024, they did not have a treatment nurse scheduled to work because the nurse who usually did treatments on the weekends was off and the staffing coordinator did not schedule anyone to cover for her. He stated it would have been the floor nurse's responsibility to do the treatments. Cross Reference F656

Based on staff interview and record review, the facility failed to provide treatment timely for one of 12 sampled Residents (R) (R10) with a venous stasis ulcer. Findings include: Review of medical records revealed R10 was admitted to the facility on [DATE] with a venous stasis ulcer to the right rear knee. There was no documentation of treatment being initiated until 2/5/2024 when orders were obtained to clean with normal saline, apply collagen and cover with dry dressing every Monday, Wednesday, and Friday. Review of R10's physician's order dated 2/8/2024 revealed orders were changed to clean with normal saline, apply Santyl to slough and dry protective dressing every day. Review of the 2/2024 Treatment Administration Record (TAR) revealed there was no documentation that the treatment was done as ordered on 2/10/2024 and 2/11/2024. During an interview with the Treatment nurse on 2/14/2024 at 3:25 pm, she stated it must have been an oversight pertaining to the lack of documentation for treatment until 2/5/2024 because she knew she did the treatments.

Based on staff interview and record review, the facility failed to implement care plan interventions for pressure ulcer treatments as ordered and provide descriptive wound documentation for two of 12 sampled Residents (R) (R2 and R6). These failures increased the potential for the residents not to receive treatment and/or care according to their needs. Findings include: 1. Review of R2's care plan dated on 12/13/2023 revealed the resident had a care plan for a declining unstageable pressure wound to the sacrum with interventions for weekly treatment documentation to include measurements of each area skin breakdown's width, length, depth, type of tissue and exudate. Review of medical records revealed R2 was admitted to the facility on [DATE] with a Stage two (2) pressure ulcer to the sacrum. Review of the Wound Summary report revealed the pressure ulcer to the resident's sacrum was not assessed until 12/6/2023 and noted the wound was a Stage four (4) that measured 7.1 centimeters(cm) x 8.5 cm x 0.1cm. Review of Physician Assistant (PA) wound consult note dated 12/6/2023 documented the sacrum as Stage 2 pressure ulcer, not a Stage 4. The PA noted the pressure ulcer measured 7.1cm x 8.5cm x 0.1cm and the wound bed had granulation, 50% epithelialization with no slough or eschar present. Review of the December 2023 Treatment Administration Record (TAR) revealed no documentation that treatment had been done to the sacrum until 12/10/2023. Review of the Progress Note Details dated 12/13/2023 revealed the sacrum had deteriorated to an unstageable pressure ulcer with 60% slough, 10% granulation and 30% epithelialization and measured 12.6cm x 11.2cm x 0.1cm. Review Progress Note Details dated 12/20/2023 revealed wound orders to cleanse with Dakin's 1/4 strength, skin prep to peri wound, apply Gentamicin and cover with foam dressing every day and as needed. However, review of the 12/2023 TAR revealed the treatment was not started until 12/25/2023. 2. Review of R6's care plan dated 2/6/2024 revealed the resident had a care plan for an unstageable pressure ulcer to the sacrum with interventions to administer treatments as ordered and to assess, record, monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Review of the Wound Summary report indicated the resident was admitted with a Stage 2 pressure ulcer to the sacrum. However, there was no descriptive documentation of the pressure ulcer until 1/11/2024 documenting the wound as a Stage 2 measuring 0.4cm x 0.5cmx 0.1cm. Review of the January 2024 TAR revealed there was no documentation that treatment was done to the sacrum until 1/26/2024 when a physician's order was obtained to clean the sacrum with normal saline, apply skin prep to peri skin, collagen, and zinc barrier, cover with dry dressing every Monday, Wednesday, and Friday. Review of medical records revealed on 2/9/2024 the order was changed to clean the sacrum with normal saline, apply zinc to peri wound, collagen, cover with dry dressing every day. However, review of the February TAR revealed there was no documentation that treatment was done on 2/10/2024 and 2/11/2024. During an interview with the Treatment Nurse on 2/13/2024 at 3:45 pm, revealed that the facility failed to provide descriptive wound documentation and failed to provide treatment records that supported the treatment was provided per R2 and R6 care plans. Cross Reference F686

Based on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the facility's COVID -19 Response, the facility failed to implement initial and ongoing testing of residents and staff as recommended by the CDC to lessen the exposure of COVID-19 during an outbreak, failed to ensure source control was used during outbreak, ensure the safety of all residents in the facility by not following current guidelines related to COVID-19 for resident and staff testing, infection control, monitoring and documenting COVID-19 symptoms for residents, notification of staff and family of outbreak status during an outbreak and source control that resulted in five residents (R)(R15, R89, R94, R111, and R433) and two staff testing positive for COVID-19. On 10/4/2023, a determination was made that a situation in which the facilities noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, serious harm, impairment, or death to residents. The Administrator, the Director of Nurses, and the Regional [NAME] President were notified on 10/4/2023 at 6:20 pm of the Immediate Jeopardy (IJ). The noncompliance related to the IJ was identified to have existed on 9/18/2023. An Acceptable IJ Removal Plan was received on 10/6/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/6/2023. Findings included: Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, that was updated on 5/8/2023, recommends the following: Patient Placement - Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If limited single rooms are available, residents should remain in their current location. Review of the COVID-19 Response, undated, revealed the following: Procedural guidelines that were listed included but were not limited to: 8). Each skilled nursing facility shall maintain room(s) or units set up for transmission-based precautions. Reporting 5. The facility shall post notification of an outbreak and ongoing testing at all points of entry into the facility. Residents 1. all residents shall be screened for fever and respiratory symptoms once per shift. This screening includes but is not limited to: A. Assessing signs and symptoms of COVID-19/respiratory symptoms. B. Temperature. C. Oxygen saturation by pulse oximetry as indicated by respiratory symptoms. Outbreak Testing Residents: 1. Resident tested should be initiated within 24 hours of the positive test being reported and be completed as soon as possible. 5. All residents who test negative must be tested every 3 to 7 days until no new cases for at least 14 days since the most recent positive result, regardless of their vaccination status. Employees 3. All employees who test negative must be tested every 3 to 7 days until no new cases for at least 14 days since the most recent positive result, regardless of their vaccination status. The following residents were positive for COVID-19 and reviewed related to the outbreak in the facility: 1.On 9/18/2023 R94 was noted to have symptoms that included a cough. R94 was tested for COVID-19 and had a positive test result. R94 was the roommate to R89 in room [ROOM NUMBER]. 2. On 9/18/2023 R89 was moved from room [ROOM NUMBER] with R94 once R94 tested positive for COVID-19. R89 was then placed into room [ROOM NUMBER] with R15. R89 tested positive for COVID-19 on 9/20/2023 and was then moved back into her original room with R94. 3.On 9/24/2023 R15 tested positive for COVID-19. 4. On 9/25/2023 R111 tested positive for COVID-19. R90 remained the roommate of R111 and was COVID-19 negative when tested . There is no evidence that R90 was monitored for COVID symptoms. 5. On 9/25/2023 R433 tested positive for COVID-19. R119 remained the roommate of R433 and was COVID-19 negative when tested . There is no evidence that R119 was monitored for COVID symptoms. The testing schedule for residents revealed two residents were tested on [DATE] and both were COVID-19 positive. There were 89 residents tested on [DATE] resulting in one positive resident. On 9/20/2023 there were 18 residents tested and they were all negative. On 9/24/2023 one resident was tested and was COVID-19 positive. There were 18 residents tested on [DATE] resulting in two residents being COVID-19 positive. Other resident testing dates included 9/27/2023 and 9/28/2023 of which one resident was tested each day resulting in a COVID-19 negative status. Review of the staff testing scheduled revealed 49 staff were tested for COVID-19 on 9/19/2023 and there was no evidence of any other outbreak staff testing until 10/4/2023. During the initial entrance into the facility on [DATE] at 10:45 am the receptionist at the front desk was unable to confirm if there were any COVID-19 positive cases in the facility. There were screening sheets on the counter but there was no thermometer to check temperature. The Administrator then reported that there were three residents that were COVID-19 positive and on transmission-based precautions (TBP). It was noted that there was no signage at the front to inform visitors of any positive COVID cases, or to inform visitors of the proper use of source control. Observation on 10/3/2023 at 11:30 am revealed the door to room [ROOM NUMBER] was open. The door had signage and PPE on the door, that alerted staff and visitors that the residents in the room were on aerosol contact precautions. Observation on 10/3/2023 at 12:02 pm revealed signage and PPE on the door to room [ROOM NUMBER]. The signage on the door alerted that the resident (R15) was in Aerosol Contact Precautions and that proper PPE was needed that included N-95 mask. The signage also alerted staff that the door was to remain closed. The door was observed to be open. Observation on 10/3/2023 at 1:17 pm revealed the door to room [ROOM NUMBER] had signage indicating aerosol contact precautions and PPE. The door was open and there were two residents in the room and the privacy curtain was not pulled. R90 was COVID-19 negative and R111 was COVID-19 positive. Observation on 10/3/2023 at 1:24 pm revealed the door to room [ROOM NUMBER] remained open. Observation on 10/3/2023 at 3:45 pm revealed that the doors were open for rooms [ROOM NUMBER]. It was also noted that room [ROOM NUMBER] and room [ROOM NUMBER] each had two residents in each and the privacy curtain was not pulled. On 10/3/2023 at 4:30 pm a visitor for R90 expressed that he/she was not notified why his/her family member was requiring isolation. Observation on 10/4/2023 at 7:45 am revealed the receptionist at the front desk without a mask on. There was a thermometer on the counter, but the receptionist reported that she did not know how to work it. The receptionist denied any knowledge of the facility's COVID-19 status. There also was no signage alerting staff or visitors that the facility was in outbreak status. Interview on 10/4/2023 at 2:30 pm with the Assistant Director of Nurses (ADON)/Infection Preventionist (IP) who revealed that he was doing contact tracing for the current outbreak. It was reported that the initial COVID-19 positive resident probably contracted it from family and the other positive residents are likely from the original resident. ADON/IP explained that R94 had symptoms that included a cough and tested positive for COVID-19 ON 9/18/2023. R94's roommate, R89, was then moved into the room with R15. R89 tested positive for COVID-19 on 9/20/2023 and was then moved back into the room with R94. On 9/24/2023 R15 tested positive for COVID-19. It was further reported that more residents on 800 hall were tested out of caution which resulted in R111 and R433 testing positive. The roommate for R111 was R90 and the roommate for R433 was R119. R90 and R119 both were COVID-19 negative when tested . ADON/IP further reported that the cart nurse is responsible for testing the residents and the cart nurse had the responsibility of setting up the transmission-based precautions and moving residents once they tested positive for COVID-19. The ADON/IP reported that on 9/22/2023 an agency nurse was working her shift when she tested positive for COVID-19 and was sent home after noon on that day. He could not initially recall which hall the nurse worked on but later said she worked on 400 hall. Lastly, it was reported that a mass message is sent to residents and families related to COVID-19 status in the facility. He also reported that the receptionist should offer a mask to visitors as they enter the facility. During a subsequent interview on 10/4/2023 at 3:10 pm with the ADON/IP it was reported that staff and residents were tested on [DATE] but he confirmed that outbreak testing had not been done. He further reported that CDC does not recommend routine testing. He reported that he had not reached out to the Department of Community Health (DPH) or any other agency for guidance related to the facility's COVID-19 status. Lastly, it was reported that COVID-19 positive and COVID-19 negative residents had not been moved because there were no empty rooms to move them to. Observation on 10/4/2023 at 3:35 pm revealed the door to room [ROOM NUMBER] was half open and the door to room [ROOM NUMBER] was fully open and the privacy curtains were not pulled between the residents residing in those rooms. The resident that resided in room [ROOM NUMBER] and had a COVID-19 positive status. There were two residents that resided in room [ROOM NUMBER] with one being COVID-19 negative and one being COVID-19 positive. Interview on 10/4/2023 at 4:20 pm with CNA ZZZ revealed that both residents in room [ROOM NUMBER] were COVID-19 positive. Interview on 10/4/2023 at 4:25 pm with CNA AAAAA revealed that one of the residents in room [ROOM NUMBER] was COVID-19 negative and the other was COVID-19 positive. She reported that she would provide care to the resident that was COVID-19 negative first and care to the COVID-19 positive resident last. Interview on 10/5/2023 at 11:17 am with ADON/IP revealed that the nurse managers are responsible for educating staff about residents COVID status. ADON/IP responded that he was not sure why all staff and all residents had not been tested . He reported that he completed rounds for the residents in rooms with TBP but he was unsure as to why residents on TBP doors were left open. It was reported that whoever becomes aware of the COVID-19 outbreak is responsible for putting signage at the front entrance to alert staff and visitors of the facility's outbreak status. Interview on 10/5/2023 at 11:45 am with Licensed Practical Nurse (LPN) SSS revealed that the cart nurses are responsible for completing the resident testing. She revealed that the residents were scheduled to be COVID tested on [DATE] because they were in outbreak. LPN SSS was observed not wearing a mask, but she revealed that she was not told that she needed to wear a mask. Interview on 10/5/2023 at 12:25 pm with Agency CNA II who was not wearing a mask, revealed that she was not told that she needed to wear a mask. She also acknowledged that she was aware that the door to the isolation rooms were supposed to be closed. Interview on 10/5/2023 at 12:29 pm with CNA ZZZ who revealed that she knew that the door was supposed to be closed and had no excuse for the door to the isolation room to be open. She also revealed that she was not told that she needed to wear a mask. Interview on 10/5/2023 at 1:15 pm with Receptionist BBBBB who reported that she was not aware that the facility was in outbreak status until she received a call from a family member on 10/4/2023 stating that they had received a text message from the facility. Receptionist BBBBB also reported that she was never informed to offer visitors a mask. Interview on 10/5/2023 at 1:28 pm with the Medical Director revealed that it was his desire to keep the residents on the East side of the facility separate from the [NAME] side residents, due to the severity of the disease processes of the residents on 200 hall. He also revealed that he was not aware that there were no available beds to move COVID-19 negative residents out of the room from their COVID-19 positive roommates. Interview on 10/12/2023 at 8:15 am with the Administrator who reported that he thought the ADON/IP was doing his job but he was not. It was further reported that he had to let the ADON/IP go, because he did not like sloppy work. The Administrator stated that he had his certificate for IP and would be doing the infection control aspect for the facility until he was able to hire someone new. The facility implemented the following actions to remove the IJ: 1. R#94 tested positive for COVID-19 on 09/18/23 and came off precautions on 09/28/23, R#89 tested positive for COVID-19 on 09/21/23 and came off precautions on 10/01/23, R#15 tested positive for COVID-19 on 09/24/23 and came off precautions on 10/04/23, R#111 tested positive for COVID-19 on 09/25/23 and came off precautions on 10/05/23, and R#433 tested positive for COVID-19 on 09/25/23 and came off precautions on 10/05/23. R#94, R#89, R15, R#111, and R#433 were identified in the deficient practice. The status of each resident (R#94, R#89, R15, R#111, and R#433) is that they are all off COVID precautions and asymptomatic. 2. All staff and residents were tested for COVID-19 on 10/04/23 and 10/05/23 by facility Nursing staff. 119 residents were tested , 7 residents refused to be tested and will be monitored for signs and symptoms of cough, shortness of breath or fever. 95 staff members have been tested . No new positive residents and 1 new positive staff member. Outbreak total positive residents is 5 and total positive staff is 1. 3. Following testing results, cohorting of current residents was reviewed by Administrator, DON and ADON and room assignments meet recommendations via CDC COVID-19 Infection Control Guidelines. 4. The facility COVID-19 Infection Control Guidelines policy was reviewed by Administrator and Regional [NAME] President on 10/04/2023. No revisions were made but review was noted. 5. On 10/04/23, staff, residents and family were notified via mass messaging system, signage at front entrance, time clock and nurses' stations of COVID-19 outbreak, recommended actions to prevent COVID-19 spread, and source control to help prevent the spread of COVID-19. 234 family members were notified, and 106 staff members were notified. 6. Education on COVID-19 Infection Control Guidelines to include outbreak testing procedure and notification, cohorting of COVID-19 positive and COVID-19 negative residents, use of Transmission Based Precautions, performing contact tracing, screening of staff and visitors during an outbreak and properly informing staff, visitors and family was initiated on 10/04/23 and will be completed on 10/05/23. 8 of 8 RN's, 26 of 27 LPN's, 27 of 34 CNA's, 17 of 17 Therapists (PT/OT/ST/PTA/OTA), 10 of 10 Respiratory Therapists, 7 of 7 Housekeeping, 2 of 2 Maintenance, 5 of 5 Dietary, 2 of 2 Social Workers, 2 of 2 MDS Nurses, 2 of 2 Business Office Staff, 1 of 1 Receptionist, and 3 of 3 Administration Staff have been in-serviced. 106 of 120 total stall members or 88% have been in-serviced. 7. No staff member shall work until they have completed in-service education. Staff members will be educated on COVID-19 Infection Control Guidelines to include outbreak testing procedure and notification, cohorting of COVID-19 positive and COVID-19 negative residents, use of Transmission Based Precautions, performing contact tracing, screening of staff and visitors during an outbreak and properly informing staff, visitors and family by the DON and/or ADON prior to being allowed to work. 8. Newly hired staff will be in-serviced during orientation upon hire by the DON and/or ADON on COVID-19 Infection Control Guidelines to include outbreak testing procedure and notification, cohorting of COVID-19 positive and COVID-19 negative residents, use of Transmission Based Precautions, performing contact tracing, screening of staff and visitors during an outbreak and properly informing staff, visitors and family. Newly hired staff members will not work until they have received COVID-19 education. 9. Facility implemented interventions of testing all residents and staff initially on 10/04/23 and every 7 days thereafter until no new positive cases are identified for 14 days, review of the cohorting of resident room assignments and education on COVID-19 Infection Control guidelines. Documentation included consists of testing results for all residents and staff, copy of the COVID-19 Infection Control Guideline, copies of education and sign in sheets conducted with staff members. 10. Audits will be completed for outbreak testing procedures, notification and screening of staff and visitors, cohorting of residents, use of TBP, and contact tracing daily during a COVID-19 outbreak and will be monitored by the Administrator daily using a COVID-19 Guideline Tracking Tool to ensure the deficient practice does not reoccur. If a problem is identified it will be addressed via corrective action and education with the staff member(s). 11. An Ad Hoc QAPI Meeting was conducted on 10/05/2023 with the Administrator, DON, ADON/Infection Preventionist, Medical Director, Unit Managers, and Social Worker to discuss jeopardy findings and plan of removal and correction. The Medical Director was informed of the Immediate Jeopardy on 10/05/2023. A RCA (Root Cause Analysis) was conducted on 10/05/2023 to identify causes and prevent them from reoccurring. Infection Preventionist education, staff education and oversight and auditing by the Administrator and DON were deemed as root causes. Administrator completed an audit using a COVID-19 Guideline Tracking Tool on 10/05/2023 to ensure testing frequency and results followed CDC COVID-10 Infection Control Guidelines. Administrator contacted DPH and Alliant Quality for assistance with educational materials, handouts and in-servicing for following COVID-19 Infection Control Guidelines. 12. The tracking form will be brought to QAPI and reviewed by the Administrator. 13. All corrective actions were completed on 10/5/2023. The facility alleges that the Immediate Jeopardy is removed on 10/06/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the documentation confirmed COVID-19 status for R#94, R#89, R15, R#111, and R#433. All resident's isolation status was discontinued by 10/4/2023. 2. Review of COVID-19 Rapid Antigen Testing confirmed the testing of 119 residents and testing of 95 staff persons. 3. Review of Line List for COVID-19 Outbreaks in Long Term Care Facilities included each resident's COVID status and room number. 4. Review of COVID-19 policy by the Administrator, Director of Nursing (DON), and the Medical Director verified by signature on policy with no changes in policy indicated. 5. An email dated 10/4/2023 reviewed confirming notification a blast email to resident family members/responsible parties and staff members notifying of COVID outbreak status. Interview on 10/10/2023 at 12:40 pm with the family member of R19 revealed information had been received from the facility about the current outbreak status. 6. Confirmation of education to staff as evidenced by staff sign in sheets beginning 10/4/2023. Staff education included COVID-19 Infection Control Guidelines, outbreak testing, cohorting of positive and negative patients, contact tracing, transmission based precautions, screening of staff and visitors, informing staff and visitors, and personal protective equipment. During an interview on 10/10/2023 at 8:45 am with LPN FF; at 8:48 am with Agency LPN GGG; at 8:53 am with LPN HHH; at 9:11 am with LPN/MDS Coordinator JJJ; at 9:14 am with LPN/MDS Coordinator KKKK; at 9:20 am with Restorative CNA BB; at 9:26 am with Restorative CNA LLL; at 10 am with LPN CC; at 10:06 am with LPN MMM; at 10:10 am with Housekeeping Aide DD; at 10:16 am with CNA HH; at 10:20 am with Respiratory Therapist EE; at 10:27 am with CNA OOO; at 10:30 am with Respiratory Therapist FF; at 10:50 am CNA HH; at 11 am CNA II; at 11:20 am Agency CNA; at 5:19 pm via telephone with CNA LLLL; at 6:30 pm via telephone with CNA VVVV; at 6:45 pm with LPN WWWW with all staff confirming education related to outbreak testing procedure and notification, cohorting of COVID-19 positive and COVID-19 negative residents, use of Transmission Based Precautions, performing contact tracing, and screening of staff and visitors during an outbreak. 7. Verification of staff education confirmed via interviews with staff and review of signed education sheet. During an interview on 10/10/2023 at 11:30 am with Housekeeper AA; at 11:55 am with CNA UU; at 12:10 pm with Physical Therapy Assistant (PTA) XX; at 12:15 pm with Supply Manager WW; at 12:20 pm with Occupational Therapist (OT) ZZ; 12:30 pm with Dietary Aide AAA; at 12:45 pm with CNA YYY; at 12:50 pm with CNA AAAA; at 12:55 pm with CNA ZZZ; at 1:10 pm with Floor Tech EEE; at 2:10 pm with Dietary Manager; at 2:15 pm Dietary Aide CCCC; at 2:25 pm with Maintenance Director; at 2:35 pm with Maintenance Director Assistant; at 2:50 pm with Occupational Therapy Assistant (OTA) PPPP; at 2:55 pm with Speech Language Pathologist (SLP) QQQQ; at 3:35 pm with Rehab Director who confirmed receiving education. 8. There were no new staff identified. 9. Testing confirmed via review of testing results of residents and staff beginning on 10/4/2023. 10. Confirmed daily tracking via use of COVID-19 GUIDELINE TRACKING TOOL with start date of 10/5/2023. 11. Quality Assurance Process Improvement (QAPI) Committee document dated 10/5/2023 confirmed QAPI meeting with Administrator, DON, and Medical Director present, related to IJ related to infection control. The root cause analysis completion was verified by review of Root Cause Analysis Report Form. Confirmed daily tracking via use of COVID-19 GUIDELINE TRACKING TOOL with start date of 10/5/2023. 12. It was verified that all corrective actions were completed by 10/5/2023 and the Immediate Jeopardy was removed on 10/6/2023.

Based on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the job description for the Administrator, the facility Administration failed to ensure the health and safety of the residents by not maintaining an effective Infection Prevention Control Program (IPCP) that would identify and investigate an infection outbreak to prevent or reduce the spread of Covid-19 by not following current guidelines for resident and staff testing (contact tracing or broad based testing). This failure resulted in a total of five residents and two staff members who tested positive for COVID-19. The facility census was 131. On 10/4/2023, a determination was made that a situation in which the facilities noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, serious harm, impairment, or death to residents. The Administrator, the Director of Nurses, and the Regional [NAME] President were notified on 10/4/2023 at 6:20 pm of the Immediate Jeopardy (IJ). The noncompliance related to the IJ was identified to have existed on 9/18/2023. An Acceptable IJ Removal Plan was received on 10/6/2023. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 10/6/2023. Findings included: Review of the Administrator's job description revealed that the responsibility of the Administrator is to assist the Infection Control Coordinator and/or committee in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks involving potential exposure to blood/body fluids are properly identified and resolved. They are to also consult with departmental directors concerning the operation of their departments to assist in eliminating / correcting problem areas, and /or improvement of services. Review of the Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on May 8, 2023, recommends source control for individuals in healthcare settings who: have suspected or confirmed COVID -19 infection or had close contact with someone who has COVID-19 infection , for 10 days after exposure. It also recommends that patients be placed in a single-person room. The door should be kept closed. If co-horting, only residents with the same respiratory pathogen should be housed in the same room. Testing is recommended immediately, usually day 1, 3 and 5. They also recommend a process to make everyone entering the facility aware of recommended actions to prevent transmission to others. Interview on 10/4/2023 at 3:10 pm with the Assistant Director of Nurses/Infection Preventionist (ADON/IP) it was reported that staff and residents were tested on [DATE] but he confirmed that outbreak testing had not been done. He further reported that CDC does not recommend routine testing. He reported that he had not reached out to the Department of Community Health (DPH) or any other agency for guidance related to the facility's COVID-19 status. Lastly, it was reported that COVID-19 positive and COVID-19 negative residents had not been moved because there were no empty rooms to move them to. Interview on 10/5/2023 at 11:00 am with the Administrator who revealed that he believed that the facility had some issues to work out, but he did not believe the problems rose to the IJ level. He reported that residents and staff were tested after the initial outbreak but acknowledged that the facility was not testing consistently until there were no other positives. It was reported that the residents in the Transmission Based Precautions (TBP) rooms could request that their doors be opened but he did not provide any documentation to confirm the doors being open were the residents' choice. The Administrator reported that staff and visitors were to be screened on entry to the facility and he was not aware of the inconsistency in the screenings. Interview on 10/5/2023 at 11:17 am with ADON/IP revealed that the nurse managers are responsible for educating staff about residents COVID status. ADON/IP responded that he was not sure why all staff and all residents had not been tested . He reported that he completed rounds for the residents in rooms with TBP, but he was unsure as to why residents on TBP doors were left open. It was reported that whoever becomes aware of the COVID-19 outbreak is responsible for putting signage at the front entrance to alert staff and visitors of the facility's outbreak status. Interview on 10/12/2023 at 8:15 am with the Administrator who reported that he thought the ADON/IP was doing his job, but he was not. It was further reported that he had to let the ADON/IP go, because he did not like sloppy work. The Administrator stated that he had his certificate for IP and would be doing the infection control aspect for the facility until he was able to hire someone new. The facility implemented the following actions to remove the IJ: 1. R#94 tested positive for COVID-19 on 09/18/23 and came off precautions on 09/28/23, R#89 tested positive for COVID-19 on 09/21/23 and came off precautions on 10/01/23, R#15 tested positive for COVID-19 on 09/24/23 and came off precautions on 10/04/23, R#111 tested positive for COVID-19 on 09/25/23 and came off precautions on 10/05/23, and R#433 tested positive for COVID-19 on 09/25/23 and came off precautions on 10/05/23. R#94, R#89, R15, R#111, and R#433 were identified in the deficient practice. The status of each resident (R#94, R#89, R15, R#111, and R#433) is that they are all off COVID precautions and asymptomatic. 2. All staff and residents were tested for COVID-19 on 10/04/23 and 10/05/23 by facility Nursing staff. 119 residents were tested , 7 residents refused to be tested and will be monitored for signs and symptoms of cough, shortness of breath or fever. 95 staff members have been tested . No new positive residents and 1 new positive staff member. Outbreak total positive residents is 5 and total positive staff is 1. 3. Following testing results, cohorting of current residents was reviewed by Administrator, DON and ADON and room assignments meet recommendations via CDC COVID-19 Infection Control Guidelines. 4. Review of the following job descriptions was completed by the Administrator, DON, ADON/Infection Preventionist and each employee acknowledged their responsibilities. 5. Education was provided to Administrator by Regional [NAME] President on responsibilities related to ensuring the safety of all residents in the facility, current guidelines related to COVID-19 for resident and staff testing, infection control, monitoring and documenting COVID-19 symptoms for residents during an outbreak on 10/04/2023. 6. Education was provided by Administrator to Infection Preventionist and DON on COVID-19 Infection Control Guidelines to include outbreak testing procedure and notification, cohorting of COVID-19 positive and COVID-19 negative residents, use of Transmission Based Precautions, performing contact tracing, screening of staff and visitors during an outbreak and properly informing staff, visitors and family on 10/04/2023. 7. The facility COVID-19 Infection Control Guidelines policy was reviewed by Administrator and Regional [NAME] President on 10/04/2023. No revisions were made but review was noted. 8. On 10/04/23, staff, residents and family were notified via mass messaging system, signage at front entrance, time clock and nurses' stations of COVID-19 outbreak, recommended actions to prevent COVID-19 spread, and source control to help prevent the spread of COVID-19. 234 family members were notified, and 106 staff members were notified. 9. Education on COVID-19 Infection Control Guidelines to include outbreak testing procedure and notification, cohorting of COVID-19 positive and COVID-19 negative residents, use of Transmission Based Precautions, performing contact tracing, screening of staff and visitors during an outbreak and properly informing staff, visitors and family was initiated on 10/04/23 and will be completed on 10/05/23. 8 of 8 RN's, 26 of 27 LPN's, 27 of 34 CNA's, 17 of 17 Therapists (PT/OT/ST/PTA/OTA), 10 of 10 Respiratory Therapists, 7 of 7 Housekeeping, 2 of 2 Maintenance, 5 of 5 Dietary, 2 of 2 Social Workers, 2 of 2 MDS Nurses, 2 of 2 Business Office Staff, 1 of 1 Receptionist, and 3 of 3 Administration Staff have been in-serviced. 106 of 120 total stall members or 88% have been in-serviced. 10. No staff member shall work until they have completed in-service education. Staff members will be educated on COVID-19 Infection Control Guidelines to include outbreak testing procedure and notification, cohorting of COVID-19 positive and COVID-19 negative residents, use of Transmission Based Precautions, performing contact tracing, screening of staff and visitors during an outbreak and properly informing staff, visitors and family by the DON and/or ADON prior to being allowed to work. 11. Newly hired staff will be in-serviced during orientation upon hire by the DON and/or ADON on COVID-19 Infection Control Guidelines to include outbreak testing procedure and notification, cohorting of COVID-19 positive and COVID-19 negative residents, use of Transmission Based Precautions, performing contact tracing, screening of staff and visitors during an outbreak and properly informing staff, visitors and family. Newly hired staff members will not work until they have received COVID-19 education. 12. Facility implemented interventions of testing all residents and staff, review of the cohorting of resident room assignments and education on COVID-19 Infection Control guidelines. Documentation included consists of testing results for all residents and staff, copy of the COVID-19 Infection Control Guideline, copies of education and sign in sheets conducted with staff members. 13. Audits will be completed for outbreak testing procedures, notification and screening of staff and visitors, cohorting of residents, use of TBP, and contact tracing daily during a COVID-19 outbreak and will be monitored by the Administrator daily using a COVID-19 Guideline Tracking Tool to ensure the deficient practice does not reoccur. If a problem is identified it will be addressed via corrective action and education with the staff member(s). 14. An Ad Hoc QAPI Meeting was conducted on 10/05/2023 with the Administrator, DON, ADON/Infection Preventionist, Medical Director, Unit Managers, and Social Worker to discuss jeopardy findings and plan of removal and correction. The Medical Director was informed of the Immediate Jeopardy on 10/05/2023. A RCA (Root Cause Analysis) was conducted on 10/05/2023 to identify causes and prevent them from reoccurring. Infection Preventionist education, staff education and oversight and auditing by the Administrator and DON were deemed as root causes. Administrator completed an audit using a COVID-19 Guideline Tracking Tool on 10/05/2023 to ensure testing frequency and results followed CDC COVID-10 Infection Control Guidelines. Administrator contacted DPH and Alliant Quality for assistance with educational materials, handouts and in-servicing for following COVID-19 Infection Control Guidelines. 15. The tracking form will be brought to QAPI and reviewed by the Administrator. 16. All corrective actions were completed on 10/5/2023. The facility alleges that the Immediate Jeopardy is removed on 10/06/2023. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the documentation confirmed COVID-19 status for R#94, R#89, R15, R#111, and R#433. All resident's isolation status was discontinued by 10/4/2023. 2. Review of COVID-19 Rapid Antigen Testing confirmed the testing of 119 residents and testing of 95 staff persons. 3. Review of Line List for COVID-19 Outbreaks in Long Term Care Facilities included each resident's COVID status and room number. 4. Confirmation of review of job descriptions for the Administrator, DON, ADON/Infection Preventionist all completed on 10/5/2023 as evidenced by signature of each respective job description. 5. Education to the Administrator was confirmed via in-service sign in sheet dated 10/4/2023 with the education provided by the Regional [NAME] President. 6. Education to the DON and ADON was confirmed via in-service sign in sheet dated 10/4/2023 with education provided by the Administrator. 7. Review of COVID-19 policy by the Administrator and Regional [NAME] President as evidenced by sign in sheet date 10/4/2023. 8. An email dated 10/4/2023 reviewed confirming notification of a blast email to resident family members/responsible parties and staff members notifying of COVID outbreak status. Interview on 10/10/2023 at 12:40 pm with the family member of R19 revealed information had been received from the facility about the current outbreak status. 9. Verification of staff education beginning on 10/4/2023 included the following topics: COVID-19 Infection Control Guidelines, outbreak testing, cohorting of positive and negative patients, contact tracing, transmission based precautions, screening of staff and visitors, informing staff and visitors, and personal protective equipment. During an interview on 10/10/2023 at 8:45 am with LPN FF; at 8:48 am with Agency LPN GGG; at 8:53 am with LPN HHH; at 9:11 am with LPN/MDS Coordinator JJJ; at 9:14 am with LPN/MDS Coordinator KKKK; at 9:20 am with Restorative CNA BB; at 9:26 am with Restorative CNA LLL; at 10 am with LPN CC; at 10:06 am with LPN MMM; at 10:10 am with Housekeeping Aide DD; at 10:16 am with CNA HH; at 10:20 am with Respiratory Therapist EE; at 10:27 am with CNA OOO; at 10:30 am with Respiratory Therapist FF; at 10:50 am CNA HH; at 11 am CNA II; at 11:20 am Agency CNA; at 5:19 pm via telephone with CNA LLLL; at 6:30 pm via telephone with CNA VVVV; at 6:45 pm with LPN WWWW with all staff confirming education related to outbreak testing procedure and notification, cohorting of COVID-19 positive and COVID-19 negative residents, use of Transmission Based Precautions, performing contact tracing, and screening of staff and visitors during an outbreak. 10. Verification of staff education confirmed via interviews with staff and review of signed education sheet. 11. There were no new staff identified. 12. Testing confirmed via review of testing results of residents and staff beginning on 10/4/2023. 13. Confirmed daily tracking via use of COVID-19 GUIDELINE TRACKING TOOL with start date of 10/5/2023. 14. Quality Assurance Process Improvement (QAPI) Committee document dated 10/5/2023 confirmed QAPI meeting with Administrator, DON, and Medical Director present, related to IJ related to infection control. The root cause analysis completion was verified by review of Root Cause Analysis Report Form. Confirmed daily tracking via use of COVID-19 GUIDELINE TRACKING TOOL with start date of 10/5/2023. Review of email dated 10/5/2023 confirmed Administrator request for resources and response from vendors. 15. Confirmed daily tracking via use of COVID-19 GUIDELINE TRACKING TOOL with start date of 10/5/2023 and QAPI held on 10/5/2023. 16. It was verified that all corrective actions were completed by 10/5/2023 and the Immediate Jeopardy was removed on 10/6/2023.

Based on record review, staff interviews, and review of facility policy titled Care Plans - Baseline revealed the facility failed to ensure the baseline care plan for one resident (R) (R98) of 59 sampled residents was completed to include goals and interventions for fall risk. Findings include: Review of the facility policy titled Care Plans-Baseline last revised December 2016 revealed Policy Interpretation and Implementation (1.) To ensure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. (2.) The Interdisciplinary Team will review the health care practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs. Review of hospital records for her hospital stay from 6/10/2023 -6/22/2023 revealed R98 had fallen out of the bed during the night on 6/16/2023. Further review of the medical record revealed that R98 was admitted to the facility on [DATE]. R98 was hospitalized and had a readmission on 7/20/2023. Review of the Admission History & Physical Examination dated 6/22/2023 completed by the facility Medical Director upon admission revealed R98's functional capacity: fully dependent, fall risk and needs help. The initial baseline care plans were dated 6/27/2023 and 7/21/2023 respectively and did not include a fall risk care plan. Record review revealed the Morse Fall Scale had been completed by the facility on 6/22/2023 with a calculated score of 40 indicating a moderate fall risk. An interview on 10/10/2023 at 4:06 pm with Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator JJJ revealed Morse Fall Scale assessments were completed for R98 upon the admissions dated 6/22/2023 and 7/20/2023. She confirmed R98 was scored as a moderate fall risk on both occasions, and a fall risk base line care plan was not initiated, but a fall care plan should have been initiated. A fall care plan was initiated on 8/9/23, after R98 sustained a fall.

Based on observation, resident and staff interviews, record reviews, and review of the policy titled Residents Rights, the facility failed to allow four residents (R) (75, 86, 105, and 125) of 59 sampled residents the choice to take showers instead of bed baths. Findings include: Based on the facility's policy Residents Rights last revised February 2021, Policy Interpretation and Implementation 1., e. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-determination. 1.Record review revealed that R125 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) with a completion date of 9/15/2023 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated an intact cognition. The facility's shower list revealed that all residents in even room numbers on the 400 hall were scheduled to receive a shower or bed bath every Monday. Further review of the medical record revealed R125 had been receiving a bath on a regular basis for the past 30 days. During an interview on 10/3/2023 at 1:26 pm with R125 it was revealed that she had been asking for a shower but had not received one for almost two and a half weeks. An interview with Certified Nurse Aid (CNA)/Unit Secretary III on 10/5/2023 at 9:00 am revealed that due to short staffing, they were not able to have a bath team. She confirmed that residents were not able to get showers like they should have been. She stated that there used to be enough staff, but for about three months, they just didn't have the staff. It was further reported that a CNA had been hired as a full-time bath CNA but due to health issues the CNA is unable to work at this time. Lastly, it was reported that most of the residents were getting bed baths now since they didn't have the help to give them a shower. An interview on 10/5/2023 at 1:07 pm with R125 revealed she still had not had a shower for two and a half weeks. She reported that she had received a couple of bed baths, and they have used a shower cap to clean her hair, but she expressed that she wanted to have a real shower with soap and water. R125 revealed that her skin is starting to itch, her hair feels greasy and not clean and that she just needs a real bath. On 10/5/2023 at 1:30 pm Registered Nurse (RN) SSSS was notified of R125's request to take a shower and indicated she would get the Certified Nurse Assistant (CNA) to assist R125 with a shower. An interview with RN/Unit Manager NNNN on 10/5/2023 at 1:35 pm revealed the facility no longer uses a bath or shower log to document when the residents receive their baths. She revealed that everything is now documented in the electronic medical record. She also revealed there was not a way to specify what type of bath the resident had received, so it was not possible to know if the resident had a shower or bed bath. She revealed residents are supposed to be bathed according to the bath/shower schedule, and able to get a shower any time they wanted one, all they had to do is ask. She also stated, A bath is a bath. An interview on 10/6/23 at 9:30 am with R125 revealed she had been given a real shower and was able to wash her hair. An interview with the Director of Nursing (DON) on 10/11/2023 at 3:00 pm revealed that all residents are on the shower/bath schedule and can choose what type of bath they receive. DON further reported that if residents wanted a shower or bath anytime between their scheduled bath or shower, they would be assisted to receive one. She also stated that there was a bath team, and all residents were given the choice of how they wanted to be bathed. 2. Record review revealed that R86 admitted to the facility on [DATE]. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated an intact cognition. R86 has resided in her current room since 4/5/2022. The facility's shower list revealed that all residents in even room numbers on the 300 hall were scheduled to receive a shower or bed bath every Friday. An interview on 10/3/2023 at 3:14 pm with R86 revealed she hadn't had a shower in about two weeks. R86 stated that she had asked for a shower several times but had not received one yet. An interview on 10/5/2023 at 9:40 am with R86 revealed that she had received a bed bath today but would have preferred a shower. She revealed that she was told that they were short staffed, so they could not assist her with a shower today. An interview on 10/10/23 at 3:00 pm with R86 revealed that she wanted to take a shower. She revealed she had a bed bath last week, but her hair needed to be washed because it was oily. She revealed she had mentioned her request for a shower to the CNA and nurse but had not received one yet. 38154 3. Review of the ADL (activities of daily living)/Bathing Task in the electronic medical record (EMR) for R75 revealed she was totally dependent on staff for bathing. There was no distinction for the type of bath given. In an observation/interview with R75, in her room, on 10/4/2023 at 2:00 pm, she was alert and oriented. She stated she couldn't remember the last time she had a shower, but she would like to have one more often. 4. Review of the ADL/Bathing Task for R105 dated 9/14/2023 through 10/8/2023 revealed he required partial help in part of bathing to total dependence for bathing. There was no distinction for the type of bath given. Observation and interview with R105 in his room on 10/4/2023 at 2:20 pm, revealed that he was alert and oriented with a tracheostomy (trach) and speaking valve on room air. He stated last week was the first shower he had since his admission in December 2022. He stated he was satisfied with the frequency of his bed baths but sometimes he needed to feel soap and water running all over his whole body. Review of the Shower List revealed R75 and R105 were scheduled for showers on Tuesdays; boats and Hoyer lifts require two people and can only be done on the 200 Hall (vent unit) with the help of a respiratory therapist (RT). During an interview with Certified Nursing Assistant CNA SS on 10/12/2023 at 2:50 pm, she stated R75 had not had a shower since sometime in July 2023. CNA SS further stated, during the same interview, that R105 had showers since his admission but she confirmed he did not receive his showers as scheduled. She stated she gave her residents bed baths every day but residents with trach tubes must have three people to give showers including an RT. In an interview with Licensed Practical Nurse (LPN) CC on 10/12/2023 at 3:00 pm, she confirmed R75 and R105 did not receive their showers as scheduled and further stated both residents would require three or more staff to provide a shower including an RT because they both had tracheostomies. She stated there was no shower team for that unit, but residents received bed baths daily and as needed.

Based on observations, record reviews, resident and staff interviews, and review of facility policy titled Shower/Tub Bath, the facility failed to ensure Activities of Daily Living (ADL) was provided related to bathing for one resident, (R) (R80), of 59 sampled residents. Findings include: Review of the facility policy titled Shower/Tub Bath last revised October 2010, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Record review revealed R80 had resided in room [ROOM NUMBER]A since her admission to the facility on [DATE]. The facility's Shower List revealed all residents in even room numbers on the 400 hall were scheduled to receive a shower or bed bath every Monday. The Admission Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental status (BIMS) score of 99, which indicated the assessment was unable to be completed due to cognitive impairment. It further indicated that R80 is dependent on staff for dressing, toileting, and bathing. Record review from Task: ADL-Bathing with documentation answering the question BATHING: SELF PERFORMANCE - How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair) revealed that R80 has had one bath with required physical help in part of bathing activity on 9/20/2023 at 5:28 pm. Record review reveals that on 9/15/2023 at 1:36 pm, 9/17/2023 at 1:15 pm and 9/21/2023 at 6:37 pm bathing was marked as not applicable No further documentation was present since 9/21/2023 indicating R80 had been bathed. Record review from Task-Personal Hygiene question 1 with documentation answering the question PERSONAL HYGIENE: SELF PERFORMANCE - How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) revealed the resident had personal hygiene once a day from 9/13/2023 through 10/6/2023 with the exception of 9/15/2023 and 9/17/2023 which were marked Not applicable and no documentation for 9/30/2023. During an observation and interview on 10/3/2023 at 2:08 pm R80 was lying in her bed in her room and a foul odor was noted coming from the room. R80 was unable to verbalize if she needed to be changed at the current time. During an observation and interview on 10/4/2023 at 3:45 pm R80 was lying in bed with the head of bed nearly flat. She appeared drowsy, and a foul odor was noted in the room. R80 was unable to verbalize if she needed her brief changed. An interview on 10/5/23 at 12:35 pm with the Director of Nursing (DON) confirmed there was not any additional documentation available to verify additional baths or showers had been given from 9/15/2023 through 10/5/2023. She also revealed that all residents could request and get assistance with a bath or shower anytime they wanted one. An interview with Registered Nurse/Unit Manager NNNN on 10/5/2023 at 1:35 pm revealed the facility no longer used a bath or shower logs to document when the residents receive their baths. It was reported that everything is now documented in the electronic record. She also revealed there was not a way to specify what type of bath the resident had received, so it was not possible to know if the resident had a shower or bed bath. She revealed residents are supposed to be bathed according to the bath/shower schedule but were able to get a shower any time they wanted one, all they had to do is ask. She also stated, A bath is a bath. An observation on 10/10/2023 at 1:45 pm revealed R80 lying in bed supine, with urine smell noted in room. An observation on 10/10/23 at 3:10 pm revealed R80 lying in her bed and a urine odor present. An interview on 10/10/2023 at 3:24 pm with the DON revealed that she had spoken to R80, but R80 was unable to tell her if she had a bath recently. The DON stated that the nurse assigned to R80 today stated R80 had different clothes on than she had on yesterday.

Based on observations, resident and staff interviews, record reviews, and the review of the facility policy titled Resident Rights, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity for one resident (R) (R11) of 59 sampled residents. Findings include: A review of the facility policy titled Resident Rights, last revised February 2021, revealed Policy Interpretation and Implementation 1., a. A dignified existence and b., be treated with respect kindness and dignity. Record review revealed R11 admitted to the facility on [DATE]. R11 has diagnoses that include but are not limited to major depressive disorder, generalized muscle weakness, and unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. R11 is also noted as being dependent on staff for chair/bed to chair transfer, toileting, and shower/bathe self. During an observation on 10/12/23 at 10:32 am Certified Nurse Aid (CNA) IIII was observed using a mechanical lift to transfer R11 from the bed in his room into his wheelchair in the hallway. An interview with CNA IIII on 10/12/23 at 10:34 am revealed she used the mechanical lift to place him in the wheelchair in the hallway because there was not enough room in his room to complete this task. An interview with R11 on 10/12/23 at 10:52 am revealed this was the first time he had been placed in the chair with a lift in the hallway. He stated that he did not understand why the CNA had done that because they usually do this in his room. He stated that it really hurt his feelings being placed in his chair in the hallway. An interview with the Director of Nursing on 10/12/2023 at 1:18 pm revealed R11 may have been being cared for by someone new and did not know there was enough space for the procedure to be completed in his room. She also confirmed transferring residents from their beds to the shower stretcher located in the hallway with a mechanical lift was commonly practiced.

Based on interview and record review and review of the facility's Administrator job description Administration failed to ensure that the facility was administered in a manner to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. The facility's Administration failed to ensure interventions related to monitoring for signs and symptoms of bleeding for R#1, a resident receiving anticoagulant medication, were in place. Administration failed to ensure R#1 who was unresponsive received timely medical care. Administration failed to ensure that Physician orders [REDACTED].#1. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Assistant Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 12:00 p.m. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The Immediate Jeopardy is outlined as follows: R#1 was identified on admission as having a history of falls and being at high risk for future falls. R#1 was admitted with orders for [MEDICATION NAME] (an anticoagulant/blood thinner). R#1 had an unwitnessed fall and was found under his bed on [DATE] at 9:00 p.m. R#1's vital signs were obtained and revealed a blood pressure of ,[DATE], oxygen saturation at 90%, and a new irregular pulse rate of 100. The Physician was called, and orders were received to monitor R#1. On [DATE] at 1:22 a.m., R#1's blood pressure dropped to ,[DATE]. At this time, R#1 was unresponsive and required a sternal rub. The Physician was notified with orders given for oxygen to be started and for staff to continue to monitor R#1. However, there was not any evidence that R#1 was monitored and at 3:44 a.m. R#1 was found to be in cardiac and respiratory arrest (he was not breathing and did not have a pulse). R#1 also was observed to have a brown substance coming from his mouth. CPR was performed, however, R#1 died . The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.21 (b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: J); 42 C.F.R. 483.25 (F684, Scope/Severity: J); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: J). Substandard Quality of Care was identified with the requirements 42 C.F.R. 483.12 (a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.25 (F684, Scope/Severity: J). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents at that have fallen to ensure the continuity of the residents' safety. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate identification of residents at risk for falls, monitoring of residents including checking vital signs, neurochecks, monitoring for signs and symptoms of bleeding, identifying change in conditions, and following Physician orders. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing falls and fall risks. In-service materials were reviewed to ensure appropriate training was giving to the staff regarding falls and anticoagulant use which included monitoring, neurochecks and identifying changes in a resident's condition. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions and to ensure monitoring was being conducted for residents' receiving anticoagulant therapy. At the time of exit, on [DATE], the Immediate Jeopardy was removed. Additionally, actual harm was identified when R#10 had an unwitnessed fall on [DATE] at 6:00 p.m. when he fell asleep and fell out of a wheelchair. The Physician was not notified of the fall until [DATE] at 2:00 p.m. The ordered an x-ray of the elbow revealed that R#10 had a left distal humerus fracture. Findings include: Review of the facility's Administrator job description dated [DATE] revealed, Purpose of Your Job Position: The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. Further review revealed the Administrator is to plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board . Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed . Assist in Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies . Evaluate and implement recommendations from the facility's committees as necessary . Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . However, facility administrative and nursing administrative staff neglected to provide effective supervision and monitoring for R#1 and failed to provide timely assessment and care for R#10. 1. F600 - Administration neglected to monitor one resident, who was receiving an anticoagulant (blood thinner) after the resident had an unwitnessed fall, and the facility neglected to send the resident to the emergency room (ER) after the resident experienced a change in condition including a drop in his blood pressure and a decreased level of consciousness, after he fell . 2. F656 - Administration failed to implement interventions for monitoring and assessing a resident after a fall for two of 51 residents, the facility failed to develop comprehensive person-centered care plans for anticoagulant use for one of 51 residents, and the facility failed to develop comprehensive care plan for cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status for one of 51 residents (R#10) 3. F684 - Administration failed to identify a change in condition and failed to follow the Physicians orders to provide ongoing monitoring, and failed to send the resident out to the emergency room when he was found to have a change in condition after a fall for one resident (R#1) . Interview was conducted in the conference room on [DATE] at 10:00 a.m. with the Assistant Administrator (AA) revealed that he defined neglect as not providing needed care and services to prevent physical or emotional harm to a resident. AA also stated that LPN HH's failure was being unable to identify R#1's change in condition. He revealed when a resident had a change of condition, he would expect any nurse to assess the level of consciousness, movement, and vital signs. He stated if a resident had an unwitnessed fall, the nurse would be expected to assess for change in level of consciousness which should include neuro-checks. He also stated the nurse should have used basic nursing judgement to identify the resident being hard to arouse with a drop in BP and heart rate as a major change in condition. The AA revealed LPN HH didn't have the critical nursing judgement to realize R#1 need additional medical care. The facility implemented the following actions to remove the Immediate Jeopardy: F835- A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. 1. Rl was admitted on [DATE] to Rivertowne Center. On [DATE], the resident had an unwitnessed fall. On [DATE] the patient became unresponsive and expired in the facility on [DATE]. 2. On [DATE]th and 20th of 2020, the Administrator and owner reviewed an 85-point job description, covering administrative functions, committee functions, staff development functions, safety and sanitation functions, equipment and supply functions, budget and planning functions, and resident rights. On [DATE] the Regional Vice-President and the Administrator reviewed F600 on neglect and corrective measures, F656 on comprehensive person-centered care planning and corrective measures, F689 on environment that is free from accident hazards and corrective measures, F835 on administration and corrective measures, and F867 on quality assessment and assurance and corrective measures. The Regional VP also reviewed our removal plan. The administrator and Regional VP have weekly calls to ensure compliance by all departments stated in the removal plan. Weekly updates will be provided, and data supplied for QAPI will be included. 3. An Ad-Hoc QAPI meeting was held the afternoon of [DATE], in attendance was the Administrator, Medical Director, Assistant Administrator, Director of Nursing, Assistant Director of Nursing, all unit managers, Social Service, Infection Preventionist, Nurse Educator, and MDS Coordinator. At which time a review was given of the IJ's on tag number F600, F656, F689, F835, and F867 that were received on [DATE]. They were in serviced by the Administrator on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. Review of the sign-in sheet revealed an Ad Hoc QAPI Meeting was completed on [DATE] to review the IJ's on tag number F600, F656, F689, F835, and F867. They were in serviced by the Administrator on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. Staff attending the AdHoc QAPI was in attendance was the Medical Director, Assistant Administrator, Director of Nursing, Assistant Director of Nursing, all unit managers, Social Service, Infection Preventionist, Nurse Educator, and MDS Coordinator. 4. On [DATE], the Administrator, Director of Nursing, and Medical Director reviewed the current policies and procedures dealing with Standards on Nursing related to performing neuro checks and monitoring for s/sx of bleeding, ensuring that a person¿ centered care plan is developed. Providing monitoring and adequate supervision after falls and ensuring that residents receive timely medical care when a resident experience a change of condition. Director of Nursing will develop and implement audit tools that will be conducted and given to the Administrator Monday through Friday for one week starting [DATE] and then every Wednesday thereafter for 3 months. These audit tools include neglect to include was there a change of condition and did that resident receive nursing or medical care, fall prevention which includes when the resident fail, was it witnessed or unwitnessed, was the MD and RP notified, any new orders, care plan, risk management, and change of condition assessment done, performing neurological checks after an unwitnessed fall or fall with head injury which includes performing neurological checks after a fall every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours, monitoring sis of bleeding which includes bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring a person centered care plan is developed, and ensuring that residents receive timely medical care when a resident experiences a change of condition and audits will then be given to the QAA committee for review. 5. Administrator and Medial Director will review audit tool every Wednesday morning during weekly UM (Utilization Medical), for other action needed. 6. Administrator will review the 24-hour Nursing Summary in EMR Monday through Friday starting [DATE] and report to Clinical Stand Up any updates or concerns. On weekends, holidays, and when the Administrator is unavailable the Nursing Unit Managers will take on this duty. 7. All corrective action was completed on [DATE] 8. The immediacy of the IJ was removed on [DATE] The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Rl was admitted on [DATE] to Rivertowne Center. On [DATE], the resident had an unwitnessed fall. On [DATE] the patient became unresponsive and expired in the facility on [DATE]. 2. An interview with the Administrator on [DATE] 20 at 1:26 p.m. revealed he reviewed, with the owner on [DATE], an 85-point job description, covering administrative functions, committee functions, staff development functions, safety and sanitation functions, equipment and supply functions, budget and planning functions, and resident rights. On [DATE] the Regional Vice-President and the Administrator reviewed F600 on neglect and corrective measures, F656 on comprehensive person-centered care planning and corrective measures, F689 on environment that is free from accident hazards and corrective measures, F835 on administration and corrective measures, and F867 on quality assessment and assurance and corrective measures. The Regional VP also reviewed our removal plan. The administrator and Regional VP have weekly calls to ensure compliance by all departments stated in the removal plan. Weekly updates will be provided, and data supplied for QAPI will be included. 3. An interview with the Assistant Administrator on [DATE] at 12:00 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. An interview with the Director of Nursing on ,[DATE]//2020 at 12:01 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. An interview with the Assistant Director of Nursing on [DATE] at 12:02 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. An interview with the Unit Manager AAA on [DATE] at 12:05 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. An interview with the Unit Manager BBB on [DATE] at 12:08 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. An interview with Social Worker AAA on [DATE] at 12:10 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. An interview with Social Worker BBB on [DATE] at 12:15 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. An interview with Infection Preventionist on [DATE] at 12:30 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. An interview with RN Nurse Educator on [DATE] at 12:40 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. An interview with the MDS Coordinator on [DATE] at 12:50 p.m. revealed the Administrator reviewed tag number F600, F656, F689, F835 and F867. The Administrator also completed education on Committee's responsibilities, QAPI policies/procedures used to monitor, facility operations and areas to improve to include properly implement PIP's and monitor and monitoring of quality measures. A performance improvement plan was created on [DATE] to address performing neuro checks done every 15 minutes for one hour every 30 minutes for 1 hour every hour for four hours and every shift for the remaining 72 hours, monitoring for signs and symptoms of bleeding for patients on anticoagulation therapy including bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring that a person-centered care plan is developed for falls and anticoagulation therapy, monitoring and adequate supervision after falls, and ensuring residents receive timely medical care when a resident experience a change of condition to include a resident that is unresponsive calling emergency services and the RP and MD. 4.An interview with the Administrator on [DATE] at 11:59 a.m. revealed the current policies and procedures dealing with Standards on Nursing related to performing neuro checks and monitoring for s/sx of bleeding, ensuring that a person¿ centered care plan is developed. Providing monitoring and adequate supervision after falls and ensuring that residents receive timely medical care when a resident experience a change of condition. Director of Nursing will develop and implement audit tools that will be conducted and given to the Administrator Monday through Friday for one week starting [DATE] and then every Wednesday thereafter for 3 months. An interview with the Assistant Administrator on [DATE] at 12:00 p.m. revealed the current policies and procedures dealing with Standards on Nursing related to performing neuro checks and monitoring for s/sx of bleeding, ensuring that a person¿ centered care plan is developed. Providing monitoring and adequate supervision after falls and ensuring that residents receive timely medical care when a resident experience a change of condition. Director of Nursing will develop and implement audit tools that will be conducted and given to the Administrator Monday through Friday for one week starting [DATE] and then every Wednesday thereafter for 3 months. An interview with the Director of Nursing on ,[DATE]//2020 at 12:01 p.m. revealed the current policies and procedures dealing with Standards on Nursing related to performing neuro checks and monitoring for s/sx of bleeding, ensuring that a person¿ centered care plan is developed. Providing monitoring and adequate supervision after falls and ensuring that residents receive timely medical care when a resident experience a change of condition. Director of Nursing will develop and implement audit tools that will be conducted and given to the Administrator Monday through Friday for one week starting [DATE] and then every Wednesday thereafter for 3 months. An interview with the Medical Director on [DATE] at 12:02 p.m. revealed the current policies and procedures dealing with Standards on Nursing related to performing neuro checks and monitoring for s/sx of bleeding, ensuring that a person¿ centered care plan is developed. Providing monitoring and adequate supervision after falls and ensuring that residents receive timely medical care when a resident experience a change of condition. Director of Nursing will develop and implement audit tools that will be conducted and given to the Administrator Monday through Friday for one week starting [DATE] and then every Wednesday thereafter for 3 months. 5. An interview with the Administrator on [DATE] at 11:59 a.m. revealed he will review the audit tool every Wednesday morning during weekly UM. An interview with the Medical Director on [DATE] at 12:02 p.m. revealed he will review the audit tool every Wednesday morning during the weekly UM. 6. An interview with the Administrator on [DATE] at 11:59 a.m. revealed he will review the 24-hour Nursing Summary in EMR Monday through Friday starting [DATE]. 7. All corrective action was completed on [DATE] 8. The immediacy of the IJ was removed on [DATE]

Based on record review, observations, staff interview, and review of the facility policies titled, Resident Rights Guideline for All Nursing Procedures, Abuse and Neglect- Clinical Protocol, the facility neglected to monitor one resident, who was receiving an anticoagulant (blood thinner) after the resident had an unwitnessed fall, and the facility neglected to send the resident to the emergency room (ER) after the resident experienced a change in condition including a drop in his blood pressure and a decreased level of consciousness, after a fall for one of 51 residents (R#1). In addition, actual harm was identified when R#10 had an unwitnessed fall on [DATE] at 6:00 p.m. but did not receive medical care until [DATE] after complaining of left elbow pain. The resident was sent to the emergency room (ER) where x-ray revealed the resident had a left distal humerus fracture. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Assistant Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 12:00 p.m. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The Immediate Jeopardy is outlined as follows: R#1 was identified on admission as having a history of falls and being at high risk for future falls. R#1 was admitted with orders for [MEDICATION NAME] (an anticoagulant/blood thinner). R#1 had an unwitnessed fall and was found under his bed on [DATE] at 9:00 p.m. R#1's vital signs were obtained and revealed a blood pressure of ,[DATE], oxygen saturation at 90%, and a new irregular pulse rate of 100. The Physician was called, and orders were received to monitor R#1. On [DATE] at 1:22 a.m., R#1's blood pressure dropped to ,[DATE]. At this time, R#1 was unresponsive and required a sternal rub. The Physician was notified with orders given for oxygen to be started and for staff to continue to monitor R#1. However, there was not any evidence that R#1 was monitored and at 3:44 a.m. R#1 was found to be in cardiac and respiratory arrest (he was not breathing and did not have a pulse). R#1 also was observed to have a brown substance coming from his mouth. CPR was performed, however, R#1 died . The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.21 (b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: J); 42 C.F.R. 483.25 (F684, Scope/Severity: J); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: J). Substandard Quality of Care was identified with the requirements 42 C.F.R. 483.12 (a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.25 (F684, Scope/Severity: J). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents at that have fallen to ensure the continuity of the residents' safety. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate identification of residents at risk for falls, monitoring of residents including checking vital signs, neurochecks, monitoring for signs and symptoms of bleeding, identifying change in conditions, and following Physician orders. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing falls and fall risks. In-service materials were reviewed to ensure appropriate training was giving to the staff regarding falls and anticoagulant use which included monitoring, neurochecks and identifying changes in a resident's condition. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions and to ensure monitoring was being conducted for residents' receiving anticoagulant therapy. At the time of exit, on [DATE], the Immediate Jeopardy was removed. Additionally, actual harm was identified when R#10 had an unwitnessed fall on [DATE] at 6:00 p.m. when he fell asleep and fell out of a wheelchair. The Physician was not notified of the fall until [DATE] at 2:00 p.m. The ordered an x-ray of the elbow revealed that R#10 had a left distal humerus fracture. Findings include: Review of Resident Rights Guideline for All Nursing Procedures, revised [DATE], revealed before staff cared for residents, resident right training must be completed. The training included but was not limited to the prevention, recognition and reporting of resident abuse. Review of the document titled, Abuse and Neglect- Clinical Protocol, revised [DATE] documented in pertinent part, neglect was defined as the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility nurse will assess, recognize, and document any individual related findings. The assessment findings should include: -Injury assessment (bleeding, bruising, deformity, swelling etc.) -Pain assessment -Current behavior -All current medications, especially anticoagulants, NSAIDs (nonsteroidal anti-[MEDICAL CONDITION] drugs), [MEDICATION NAME], -Other platelet inhibitors -Vital signs -Behavior over last 24 hours (bruise could be related movement disorder or aggressive behavior) -History of any tendency towards bruising -All active diagnoses, and -Any recent labs Review of the document titled, Abuse and Neglect- Clinical Protocol, revised [DATE] revealed the focus on prevention of abuse and neglect was to have the nurse communicate findings to the Physician. Identifying risk factors for abuse such as, but not inclusive of, problems related to adequate staffing, poor preparation, and training; and the lack of knowledge, skills or performance that might affect how the residents are being care for. The Physician will help identify situations that might constitute neglect. The facility will identify the causes by utilizing the Physician's input, will investigate occurrences to clarify what happened and identify possible causes. The facility will monitor and follow-up on any abuse concerns, utilizing the Medical Director on systems to ensure basic medical functional, and psychosocial needs. The Medical Director will advise, review and address abuse and neglect issues as part of quality assurance process. 1. Closed record review for R#1 revealed the resident was admitted into the facility on [DATE] that included the following Diagnoses: [REDACTED]. Review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven (7) indicating severely impaired cognition. Review of the Functional Status section revealed the resident did not ambulate in or out of his room. R#1 required extensive assistance of one (1) person with bed mobility (how resident moved to and from lying position, turning side to side and positions body while in bed), transfers, and personal hygiene. The resident required limited assistance of one (1) person with dressing and toilet use. R#1's range of motion was assessed as having no impairment to the upper extremities and having impairment on one (1) side of the lower extremities. The MDS documented R#1 experienced a fall with fracture prior to admission. Record review revealed that R#1 was to be a Full Code meaning R#1 wanted to have Cardiopulmonary Resuscitation (CPR) performed in the event of [MEDICAL CONDITION] and/or respiratory arrest occurred. Review of R#1's admission Morse Fall Scale score dated [DATE] revealed a score of 75 indicating that R#1 was at a high risk for falls (>51). The fall scale revealed R#1 had a history of [REDACTED].#1 would overestimate or forget his limits when assessing his own ability. Review of the Medication Administration Record [REDACTED]. Review of Change in Condition Evaluation report dated [DATE] at 9:06 p.m., documented the following: R#1 on floor lying under bed. Writer did a head to toe assessment. Resident was removed from floor. No injuries noted at this time. Resident stated he was trying to sit up and fell out of bed. Page 2 of the Change in Condition form documented: 4. Is the resident on [MEDICATION NAME]/[MEDICATION NAME]: No. 4c. Resident is on other anticoagulant: No. Also documented on page two were R#1's vital signs after the fall. 2. Blood pressure: ,[DATE], 3. pulse: 100, pulse type: Irregular-New. 3a. Although it was observed that R#1 had a new irregular pulse (heartrate) when further prompted with the following question the following answers were documented: Is the resting pulse rate: greater than 100 or less than 50? (blank) New irregular pulse? (blank) Or None of the above - was selected. O2 (oxygen) was documented to be 90%. Although, R#1 had a new irregular heartrate, none of the above was selected as the answer. Page 7 documents the fall was reported to the Physician on [DATE] at 6:30 p.m. with the recommendation for neuro checks to be conducted if R#1 hit his head. The facility failed to recognize that R#1 had been receiving an anticoagulant since [DATE]. The facility failed to determine whether the resident hit his head and failed to implement standard nursing practice to evaluate neuro checks following the initial assessment and failed to monitor R#1 for signs and symptoms of bleeding. Review of the progress notes dated [DATE] at 1:22 a.m. documented the following: Staff to residents room staff called out to resident name he opened his eyes sternum rub performed and he pushed staff hand away. Vitals were taken and staff called Physician. He stated to keep him on oxygen for a couple of hours and to monitor him (R#1) for any changes. Documentation revealed that R#1's vital signs had changed. His blood pressure had dropped to ,[DATE], heartrate was 62, Respirations was 22 breaths per minute, temperature 96.7 and oxygen saturation on 2 liters of oxygen was 94%. (sic) Even though R#1 was found to be unresponsive and required a sternal rub there was not any evidence that staff continued to monitor R#1. Review of the final progress note for R#1 dated [DATE] at 3:44 a.m. documented: Resident was noted having brown liquid coming from his mouth staff called Dr. and informed him of the resident change in condition and he gave order to send resident to medical center EMT was called staff had started CPR when EMT arrived they gave order to stop staff called Dr and informed him that the resident had expired. (sic) Interview was conducted on [DATE] at 10:05 a.m. in the 300 hallway during the initial tour with Registered Nurse (RN) AA, who was the Charge Nurse. She revealed being employed as an agency nurse since [DATE]. She revealed being trained on Abuse and Neglect through her agency as well as in the facility. She defined neglect as not providing the needed care and services that could potentially cause harm to a resident. RN AA stated based on nursing standard of practice if a resident had and unwitnessed fall, she would assess neuro check with the initial fall assessment. She continued to state the importance of neuro checks was to monitor for a change in level of consciousness. Interview with Licensed Practical Nurse (LPN) HH on [DATE] at 11:02 a.m. revealed she was employed at the facility for two years (prior to termination). LPN HH defined neglect as not providing needed care and services prevent harm to a resident. LPN HH acknowledged being responsible for R#1 the night of [DATE] (from 9:00 p.m.-7:00 a.m.) - early morning of [DATE]. LPN HH stated that with the change of shift; staff provided a hand off report of each resident. LPN HH further stated that nurse LPN EEE did not inform her of R#1's unwitnessed fall. LPN HH stated if she were aware that R#1 had fallen she would have requested the resident to be transferred to the hospital. Interview was conducted in the current DON's office on [DATE] at 11:25 a.m. with LPN EEE, who revealed she was employed at the facility for three (3) years. LPN EEE defined neglect as not providing required care and services that could cause harm to a resident. LPN EEE revealed the facility's protocol following a fall was to perform a head to toe assessment, assess the head for any bruises, hematomas, or knots. She stated if a resident exhibited any signs or symptoms of head injury the Physician ordered a transfer to the hospital. She recalled working the day R#1 fell . LPN EEE stated the resident denied hitting his head. She stated because the resident was able to make needs known and there were no signs of head trauma, neuro checks were not initiated. LPN EE stated she recalled completing the change in condition report and giving the hand off report to LPN HH. Review of LPN EEE's timecard revealed she clocked out on [DATE] at 9:35 p.m. (approximately five minutes after the change in condition report was completed). Interview was conducted in the conference room on [DATE] at 10:00 a.m. with the Assistant Administrator (AA) revealed being aware of R#1's fall on [DATE] and stated LPN HH's failure was being unable to identify R#1's change in condition. AA stated that after investigating the incident, LPN HH was terminated from the facility for this incident among other concerns. AA defined neglect as not providing needed care and services to prevent physical or emotional harm to a resident. AA revealed when a resident had a change of condition, he would expect any nurse to assess the level of consciousness, movement, and vital signs. He stated if a resident had an unwitnessed fall, the nurse would be expected to assess for change in level of consciousness which should include neuro-checks. He also stated the nurse should have used basic nursing judgement to identify that when the resident was hard to arouse with a drop in BP and heart rate as a major change in condition. AA revealed LPN HH didn't have the critical nursing judgement to realize R#1 needed additional medical care. AA verbalized [MEDICATION NAME] is located on R#1's Medication Administration Record [REDACTED]. Interview was conducted in the conference room, on [DATE] at 12:30 p.m. with the Medical Director. The Medical Director revealed R#1 was admitted to the facility for rehabilitation. The Medical Director revealed his expectations would be the same for either a witnessed or an unwitnessed fall. He expected the nurse to assess the resident's vital signs, extremities, and to monitor orientation. He concluded when a person had a lowering of B/P, heart rate and required a sternal rub for arousal, it may indicate a change in the level of consciousness. The Medical Director acknowledged being notified of the resident's fall. However, he revealed at 1:22 a.m. if the nurse had informed him of the complete assessment (the decrease in B/P and heart rate), he would have ordered the resident to be transferred to the hospital. 2. Review of R#10's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Review of the Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed R#10 had a Brief Interview for Mental Status (BIMS) score of ten out of 15 indicating the resident was moderately impaired in cognition. R#10 was assessed as requiring limited assistance of one (1) person with bed mobility, extensive assistance of two (2) persons with transfers, limited assistance with one (1) person with dressing, supervision of one (1) person with eating, limited assistance with toilet use and personal hygiene, and physical assistance with bathing with one (1) person assistance. R#10 had bilateral lower extremity impairment in range of motion (ROM) and used a wheelchair for mobility. R#10 had no behaviors, wandering or rejection of care. R#10 was always incontinent of bowel and bladder was not rated and due to use of a urinary catheter. R#10 had no history of falls. Review of R#10's Morse Fall Scale, dated [DATE], revealed he scored a 15 which indicated he was at low risk for falling. Review of R#10's Nurse's Progress Notes, dated [DATE] at 3:46 p.m., documented the following: The Unit Manager was informed the resident had a fall on [DATE]. No fall was documented. Upon investigation and staff interviews, it was determined the resident (R#10) activated the call light to be put back to bed. The CNA answered the call light and told the resident they would be right back they were going to get another staff member to assist with transfer. When staff returned, the resident was on floor beside the wheelchair laying on the left arm. The resident stated he fell asleep and fell forward out of chair. Record review revealed there was not any evidence that R#10 was assessed, or that the Physician or Responsible Party were notified of the fall on [DATE]. Review of R#10's Change in Condition Form, dated [DATE], revealed R#10 fell on [DATE] at night. R#10 complained of left antecubital pain, pain was rated at a nine (9). The resident had a fall on [DATE] at 6:00 p.m. He stated he fell asleep sitting in wheelchair, waiting on CNA to return with help to transfer him back to bed. The Physician was notified on [DATE] at 2:00 a.m. with an order to send to the ER for left arm pain. Review of R#10's Nurse's Progress Notes, dated [DATE] at 10:44 a.m., revealed the resident complained of elbow pain. R#10 was seen by the Physician and a new order was obtained to send the resident out to the hospital for evaluation and treatment. Review of R#10's Nurse's Progress Notes, dated [DATE] at 8:00 p.m., revealed the resident returned to the facility via stretcher. The resident had a splint and ace bandage to the left arm. A telephone interview was attempted with the Certified Nursing Assistant (CNA), who was assigned to R#10 when he fell , on [DATE] at 1:30 p.m. without success. A telephone interview with the Unit Manager, who investigated R#10's fall, was attempted on [DATE] at 2:30 p.m., without success. Interview with the Director of Nursing (DON) on [DATE] at 12:30 p.m., revealed she expected nursing staff to do the following after an unwitnessed fall per the falls policy: Head to toe assessment, obtain vital signs, completed a pain assessment, document injuries, interview the resident about what happened and any witnesses, call the Physician and RP, and if the resident had a major injury, send to the ER, complete an incident report and change in condition form, monitor the resident based on physician's orders [REDACTED]. The DON said that the LPN HH failed to assess R#10 after the fall. Interview with the Assistant Administrator (AA) on [DATE] at 4:55 p.m., revealed the former Unit Manager reported R#10's fall to him on [DATE]. Continued interview revealed LPN HH should have assessed R#10 for injuries after the fall and performed neurological checks for 72 hours. He also stated the nurse should have completed an incident report and change of condition form. AA stated the nurse should have contacted the MD and notified the RP of the fall. Interview the Medical Director (MD) on [DATE] at 5:56 p.m., revealed when a patient fell , he expected nursing staff to call him to report the assessment findings immediately. The MD further stated that he wasn't notified of R#10's fall until [DATE], when the resident complained of left elbow pain. The MD stated he ordered an x-ray of the elbow; the x-ray revealed a left distal humerus fracture. The facility implemented the following actions to remove the Immediate Jeopardy: 1. RI was admitted on [DATE] to Rivertowne Center. On [DATE], the resident had an unwitnessed fall. On [DATE] the patient became unresponsive and expired in the facility on [DATE]. 2. On [DATE], the policy for neglect was reviewed by the Administrator, Assistant Administrator, Director of Nursing, and Assistant Director of Nursing with no revisions made. 3. On [DATE] the nurse educator provided an in-service education on the resident's right to be free from neglect to include, what is neglect including not responding to a change in condition, how to report neglect, who to report neglect to, the Elder Justice Act (copies of a summary of the Elder Justice Act are also posted at both nursing station), and signs of neglect. The nurse educator also provided education on when a resident is found unresponsive to call for emergency services and call the medical director and responsible party. 4. As of [DATE] 29 of 34 which include full-time, part-time, pm, and one agency nurse (14 RN's of 14, 15 LPN's of 20 for a total of 85%) were educated the resident's right to be free from neglect to include what is neglect including not responding to a change in condition, how to report neglect, who to report neglect to, the Elder Justice Act (copies of a summary of the Elder Justice Act are also posted at both nursing station), and signs of neglect. The nurse educator also provided education on when a resident is found unresponsive to call for emergency services and call the medical director and responsible party. All remaining staff will be required to complete the in-services before they can care for a resident. 5. As of [DATE] 36 of 42 CNA's which include full-time, part-time, and pm staff, there are no agency cna's at this time (for a total of86%) were educated the resident's right to be free from neglect to include how to report neglect, who to report neglect to, and signs of neglect. The nurse educator also provided education on when a resident is found unresponsive to call for emergency services and call the medical director and responsible party. All remaining staff will be required to complete the in-services before they can care for a resident. 6. The director of nursing has created a neglect audit tool which includes residents with a change in condition and did they receive nursing or medical care and will conduct audits Monday through Friday for 1 week starting [DATE] and then weekly for 3 months. 7. The director of nursing created an auditing tool for change of condition status on a unwitnessed fall to include checking vital signs every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours, and complete a head to toe assessment immediately following a fall, neurological checks every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours, and updating person centered care plan and will conduct audits Monday through Friday for 1 week starting [DATE] and then weekly for 3 months. 8. The audits will be turned over to the QAA committee monthly for review and recommendations with the administrator evaluating for compliance. 9. All corrective action was completed on [DATE] 10. The IJ was removed on [DATE] The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. RI was admitted on [DATE]. On [DATE], the resident had an unwitnessed fall. On [DATE] the patient became unresponsive and expired in the facility on [DATE]. 2. An interview with the Administrator on [DATE] at 11:59 a.m. revealed the facility policy for Neglect was reviewed and no changes were made. An interview with the Assistant Administrator on [DATE] at 12:00 p.m. revealed the facility policy for Neglect was reviewed and no changes were made. An interview with the Director of Nursing on ,[DATE]//2020 at 12:01 p.m. revealed the facility policy for Neglect was reviewed and no changes were made. An interview with the Assistant Director of Nursing on [DATE] at 12:02 p.m. revealed the facility policy for Neglect was reviewed and no changes were made. 3. Inservice record was reviewed and verified on [DATE] 20 at 10:30 a.m. 4. Record Review dated [DATE] and [DATE] revealed documentation of in-service facilitated by the RN Nurse Educator on Neglect and at least 85% of the facility Registered Nurses and License Practical Nurses were educated. Further review revealed 29 of 34 Licensed Nursing staff was educated. Nursing Licensed Nursing Staff members were interviewed. All staff stated they have attended in-services related neglect on [DATE] and [DATE]. The staff were able define the definition of neglect, responding to change in condition, reporting neglect, who to report neglect, the location of the Elder Justice Act, and the signs of neglect. The neglect in-services were provided by the Nurse Educator. The following staff were interviewed: 7 a.m. to 7 p.m. shift: On [DATE] at 11:05 a.m. with RN Nurse Educator, at 11:10 a.m. with LPN CCC, at 11:15 a.m. with LPN DDD, at 11:20 a.m. with LPN EEE, at 11:25 a.m. with RN-ADON, at 11:30 a.m. with RN FFF. Phone interviews was conducted with the 7 p.m. t0 7 a.m. shift: The following staff were interviewed: On [DATE] at 11:00 a.m. with LPN AAA, at 11:56 a.m. with LPN GGG, at 12:00 p.m. with LPN HHH, at 12:05 p.m. with LPN III, at 12:10 p.m. with LPN JJJ and at 12:15 p.m. with KKK. 5. Record Review dated [DATE] and [DATE] revealed documentation of in-service facilitated by the RN Nurse Educator on Neglect and at least 86% of the facility's Certified Nursing Assistants (CNAs) were educated. Further review revealed 36 of 42 CNAs were educated. Certified Nursing Assistants were interviewed. All staff stated they have attended in-services related to neglect on [DATE] and [DATE]. The staff were able define the definition of neglect, responding to change in condition, reporting neglect, who to report neglect, the location of the Elder Justice Act, and the signs of neglect. The neglect in-services were provided by the Nurse Educator. The following staff were interviewed: 7 a.m. to 7 p.m. shift: On [DATE] at 10:40 a.m. with CNA AAA at 10:30 a.m., with CNA BBB at 10:35 a.m., with CNA CCC at 10:50 a.m., with CNA DDD at 11:05 a.m., with CNA EEE; at 11:10 a.m. with CNA FFF; at 11: 15 a.m. with CNA GGG, at 11:20 with CNA HHH, at 11:27 a.m. with CNA/Restorative III, at 11:29 a.m. with CNA JJJ, at 11:31 a.m. with CNA KKK, at 11:33 a.m. with CNA/Shower Tech LLL Phone interviews were conducted with the 7 p.m. to 7 p.m. shift: The following staff was interviewed: On [DATE] at 11:35 a.m. with CNA MMM, at 11:40 a.m. with CNA NNN, at 11:45 a.m. with CNA OOO, at 11:50 a.m. with CNA PPP and at 11:55 a.m. with CNA QQQ. 6. The neglect audit tool was reviewed and verified on [DATE] at 10:37 a.m. 7. The change of condition status audit tool was reviewed and verified on ,[DATE] at 10:40 a.m. 8. The audits will be turned over to the QAA committee monthly for review and recommendations with the administrator evaluating for compliance. 9. All corrective action was completed on [DATE] 10. The IJ was removed on [DATE]

Based on record review, interview, and review of the facility's policy titled, Person-Centered Comprehensive, Care Plan the facility failed to implement interventions for monitoring and assessing a resident after a fall for two of 51 residents, the facility failed to develop comprehensive person-centered care plans for anticoagulant use for one of 51 residents, and the facility failed to develop comprehensive care plan for cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status for one of 51 residents (R#10). On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Assistant Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 12:00 p.m. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The Immediate Jeopardy is outlined as follows: R#1 was identified on admission as having a history of falls and being at high risk for future falls. R#1 was admitted with orders for [MEDICATION NAME] (an anticoagulant/blood thinner). R#1 had an unwitnessed fall and was found under his bed on [DATE] at 9:00 p.m. R#1's vital signs were obtained and revealed a blood pressure of ,[DATE], oxygen saturation at 90%, and a new irregular pulse rate of 100. The Physician was called, and orders were received to monitor R#1. On [DATE] at 1:22 a.m., R#1's blood pressure dropped to ,[DATE]. At this time, R#1 was unresponsive and required a sternal rub. The Physician was notified with orders given for oxygen to be started and for staff to continue to monitor R#1. However, there was not any evidence that R#1 was monitored and at 3:44 a.m. R#1 was found to be in cardiac and respiratory arrest (he was not breathing and did not have a pulse). R#1 also was observed to have a brown substance coming from his mouth. CPR was performed, however, R#1 died . The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.21 (b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: J); 42 C.F.R. 483.25 (F684, Scope/Severity: J); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: J). Substandard Quality of Care was identified with the requirements 42 C.F.R. 483.12 (a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.25 (F684, Scope/Severity: J). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents at that have fallen to ensure the continuity of the residents' safety. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate identification of residents at risk for falls, monitoring of residents including checking vital signs, neurochecks, monitoring for signs and symptoms of bleeding, identifying change in conditions, and following Physician orders. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing falls and fall risks. In-service materials were reviewed to ensure appropriate training was giving to the staff regarding falls and anticoagulant use which included monitoring, neurochecks and identifying changes in a resident's condition. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions and to ensure monitoring was being conducted for residents' receiving anticoagulant therapy. At the time of exit, on [DATE], the Immediate Jeopardy was removed. Additionally, actual harm was identified when R#10 had an unwitnessed fall on [DATE] at 6:00 p.m. when he fell asleep and fell out of a wheelchair. The Physician was not notified of the fall until [DATE] at 2:00 p.m. The ordered an x-ray of the elbow revealed that R#10 had a left distal humerus fracture. Findings include: Review of the facility's policy titled Person-Centered Comprehensive, Care Plan revised [DATE], revealed the facility utilized protocols which adhered to the overall guidelines of the Resident Assessment Instrument (RAI) Process. Regarding care plan development, the policy documented the comprehensive, person-centered care plan would be completed within seven (7) days after the comprehensive Minimum Data Set (MDS) was completed and would be reviewed quarterly thereafter. If revisions were necessary, changes should be made at the time of the occurrence. Interventions would be derived from thorough information gathered from the resident's family, Attending Physician, professional staff, and nurse aides. Review of the facility's Person-Centered Comprehensive, Care Plan policy revised [DATE] revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident. The care planned interventions would be derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive care plan, in pertinent part, would: -Include measurable objectives and time frames; -Describe the services that would be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being -Include the resident's stated goals upon admission and desired outcomes; -Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; -Incorporate identified problem areas; -Incorporate risk factors associated with the identified problems; -Build on the resident's strengths; -Reflect the resident's expressed wishes regarding care and treatment goals; -Reflect treatment goals, timetables, and objectives in measurable outcomes; -Aid in preventing or reducing decline in the resident's functional status and/or functional levels; -Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and -Reflect currently recognized standards of practice for problem areas and conditions. 1. Closed record review for R#1 revealed the resident was admitted into the facility on [DATE] with the following Diagnoses: [REDACTED]. Due to the resident's [DIAGNOSES REDACTED]. Review of R#1's admission Morse Fall Scale score dated [DATE] revealed score of 75 indicating high risk for falls (>51 indicated high fall risk). The fall scale revealed R#1 had a history of [REDACTED]. R#1 overestimated or forgot his limits when assessing his own ability. Review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven (7) indicating severely impaired cognition. The MDS indicated R#1 experienced a fall with fracture prior to admission. Review of Resident #1's Cognition Care Area Summary (CAA) associated with the [DATE] Admission MDS revealed the resident had impaired ability to make himself-understood. Cognitive loss risk factors included self-care deficits, falls and injuries. Review of activities of daily living (ADL) CAA revealed the resident required assistance with ADLs due to impaired balance and required assistance with transfers. The Care Plan dated [DATE] for R#1 revealed a focus that the resident was at risk for falls related to confusion, deconditioning, and gait/balance problems. The goal was for the resident not to sustain serious injury. The documented interventions were as follows: -Anticipate and meet the resident's needs. -Educate the resident/family/caregiver about safety reminders and what to do if a fall occurs. -Physical Therapy (PT) to evaluate and treat as ordered or as needed (PRN). The fall care plan did not address the resident's overestimating his ability to move that was identified in the Morse Fall Assessment. The care plan also failed to identify the level of assistance needed with ADLS due to impaired balance that was identified on the ADL CAA. Furthermore, preventive individualized interventions (i.e. low bed, mat on floor, non-skid socks, checking resident for incontinence etc.) were lacking. Further record review revealed that there was not a care plan developed to address the resident's anticoagulant medication therapy present at the time of admission on [DATE]. Review of Change in Condition Evaluation report dated [DATE] at 9:06 p.m., revealed R#1 was found lying under bed. R#1 indicated he was attempting to sit up and fell out of bed. The facility failed to determine whether the resident hit his head and failed to implement standard nursing practice to evaluate neuro checks following the initial assessment. Review of R#1's progress note dated [DATE] at 9:21 p.m., revealed R#1's final progress note dated [DATE] at 3:44 a.m. revealed the facility performed an assessment. The assessment revealed the resident was found to have a brown liquid substance coming his mouth (no vital signs were documented). The progress note indicated the Physician was notified, an order was given to send the resident to the hospital, CPR was started, the Emergency Medical Technician (EMT) arrived and stopped CPR. The resident expired. Interview was conducted in the hallway on 300 unit on [DATE] at 11:05 a.m. with Registered Nurse (RN) GG. RN GG was an agency nurse (provided relief staffing due to coronavirus (COVID)) and revealed being employed since [DATE]. RN GG indicated the MDS Coordinators were responsible for initiating and updating the care plan. RN GG stated the care plan was designed to give an individualized snapshot of a resident's care needs and services. Interview was conducted in the conference room on [DATE] at 10:00 a.m. with the Assistant Administrator. The Assistant Administrator stated he knew the resident had fallen at home and was admitted for rehabilitation. He revealed the care plan did not reflect the resident being on anticoagulant medication. Therefore, interventions for anticoagulant monitoring were not implemented. He further stated the fall care plan did not provide interventions to address the resident's overestimation of his ability to move unassisted. Interview was conducted in the conference room on [DATE] at 2:15 p.m. with the MDS Coordinator who revealed being responsible for initiating and updating the care plans. She revealed generic care plans were initiated upon admission. However, care plan updates were updated during morning meeting. She stated interventions were implemented during morning meeting with input from the Interdisciplinary Team (IDT). She revealed a care plan for R#1's anticoagulant medication was not initiated. However, she did reveal an anticoagulant care plan should have been initiated. The MDS Coordinator stated, by not implementing an individualized care plan, staff would not be able to provide the required resident care. 2. Review of R#10's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home with Home Health care on [DATE]. Review of the Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed R#10 had a Brief Interview for Mental Status (BIMS) score of ten out of 15 which indicated the resident was moderately cognitively intact. R#10 was assessed as requiring limited assistance of one (1) person with bed mobility, extensive assistance of two (2) persons with transfers, limited assistance with one (1) person with dressing, supervision of one (1) person with eating, limited assistance with toilet use and personal hygiene, physical assistance of one (1) person with bathing. The resident had bilateral lower extremity impairment in range of motion (ROM) and used a wheelchair for mobility. Review of Section V revealed the care areas that triggered for care planning were cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence, and indwelling catheter, falls, nutritional status, and pressure ulcer. Review of R#10's Care Area Assessment (CAA) Summary, dated [DATE], revealed the following problem areas would be care planned: cognitive loss due to [DIAGNOSES REDACTED]. Record review revealed that although R#10 had triggered for the following care plans: cognitive loss/dementia, activities of daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, and pressure ulcer the only care plan that was developed for R#10 was dated [DATE] was for skin integrity. Interview with MDS Coordinator on [DATE] at 10:00 a.m. revealed she was responsible for completing the comprehensive care plans for residents. The MDS Coordinator also stated she completed the comprehensive care plan by viewing the MDS triggered care areas on the admission assessment and it should be developed before day 21 after admission. Continued interview revealed she was the only MDS Coordinator at this time, but the facility was in the process of hiring another MDS Coordinator to assist her with that responsibility. Interview was conducted in the conference room on [DATE] at 2:15 p.m. with the MDS Coordinator by not implementing an individualized care plan, staff would not be able to provide the required resident care. Interview with the Assistant Administrator (AA) and Director of Nursing (DON) on [DATE] at 4:55 p.m., revealed person-centered care plans should be developed so that staff would know what care to provide to the residents. They also stated that the MDS Coordinator was responsible for developing the comprehensive care plans after completion of the admission MDS and this should have been done for R#10. The facility implemented the following actions to remove the Immediate Jeopardy: F656-Facility will develop a comprehensive person-centered care plan addressing falls and anti-coagulant use. 1. Rl was admitted on [DATE] to Rivertowne Center. On [DATE], the resident had an unwitnessed fall. On [DATE] the patient became unresponsive and expired in the facility on [DATE]. 2. On [DATE], the policy for comprehensive care plans was reviewed by the Administrator, Assistant Administrator, Director of Nursing, and Assistant Director of Nursing and it was determined that no revisions were necessary. 3. On [DATE], the care plans of all residents with falls in the last 3 months (14 total residents) care plans have been reviewed by the Assistant Administrator and Unit Managers, and it was confirmed that all residents have had appropriate person-centered care plans in place addressing falls. All care plans reviewed had interventions in place to address the risk of fall of the residents. On [DATE], all residents in the facility on anticoagulation therapy care plans (32 total residents) were reviewed by the assistant administrator and Unit Managers and all residents had appropriate person-centered care plans in place addressing anticoagulation use and potential side effects and risks. All residents had interventions in place for anticoagulation therapy to include nurse monitoring for signs and symptoms of bleeding to include bloody urine, blood in the stool, bleeding gums during oral care, abnormal bruising, and skin tears or wounds that will not stop bleeding. 4. On [DATE] the nurse educator provided an in-service education on the development and documentation of person-centered care plans and interventions for residents with falls and anti-coagulation therapy. 5. As of [DATE] 29 of 32 nurses which include full-time, part-time, prn, and one agency nurse (14 RN' s out of 14, 15 LPN's out of 20 for a total of 85 %) were educated on the development and documentation of person-centered care plans and care interventions for falls and anticoagulation therapy. No nurse will be allowed to provide resident care until he/she completes the in-services. 6. On [DATE] the director of nursing implemented an auditing tool for care plans and interventions to audit falls and anticoagulation care plans. The fall audit includes witnessed or unwitnessed, if RP and MD were notified, care plan updated, risk management tool complete, change of condition form complete, if any injury occurred and will be done Monday through Friday for 1 week starting [DATE] followed by weekly audits for 3 months. 7. On [DATE] the director of nursing implemented an auditing tool for anticoagulation therapy which includes type of medication, reason for anticoagulation therapy, care plan updated, monitoring for signs and symptoms for bleeding including a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness and will be done Monday through Friday for 1 week starting [DATE] followed by weekly audits for 3 months. 8. The assistant administrator will review the results of the audits weekly every Monday for 3 months. If the assistant administrator is unavailable the Director of Nursing will review the results of the audits. 9. The audits will be turned over to the QAA committee monthly for review and recommendations with the administrator evaluating for compliance. 10. All corrective action was completed on [DATE] 11. The Immediacy of the IJ was removed on [DATE] The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Rl was admitted on [DATE] to Rivertowne Center. On [DATE], the resident had an unwitnessed fall. On [DATE] the patient became unresponsive and expired in the facility on [DATE]. 2. An interview with the Administrator on [DATE] at 11:59 a.m. revealed the facility policy for Comprehensive Care Plans was reviewed and no changes were made. An interview with the Assistant Administrator on [DATE] at 12:00 p.m. revealed the facility policy for Comprehensive Care Plans was reviewed and no changes were made. An interview with the Director of Nursing on ,[DATE]//2020 at 12:01 p.m. revealed the facility policy for Comprehensive Care Plans was reviewed and no changes were made. An interview with the Assistant Director of Nursing on [DATE] at 12:02 p.m. revealed the facility policy for Comprehensive Care Plans was reviewed and no changes were made. 3. An interview with the Assistant Administrator on [DATE] at 12:00 p.m. revealed 14 residents with falls/fall risk care plans were reviewed and it was confirmed al residents have had appropriate person-centered care plans in place addressing falls. All care plans reviewed had interventions in place to address the risk for fall of the residents. An interview with the Unit Manger AAA on [DATE] at 12:05 p.m. revealed 14 residents with falls/fall risk care plans were reviewed and it was confirmed all residents have had appropriate person-centered care plans in place addressing falls. All care plans reviewed had interventions in place to address the risk for fall of the residents. An interview with the Unit Manager BBB on [DATE] at 12:10 p.m. revealed 14 residents with falls/fall risk care plans were reviewed and it was confirmed all residents have had appropriate person-centered care plans in place addressing falls. All care plans reviewed had interventions in place to address the risk for fall of the residents. An interview with the Assistant Administrator on [DATE] at 12:00 p.m. revealed 32 residents were reviewed and all residents had appropriate person-centered care plans in place addressing anticoagulation use and potential side effects and risks. All residents had interventions in place for anticoagulation therapy to include nurse monitoring for signs and symptoms of bleeding to include bloody urine, blood in the stool, bleeding gums during oral care, abnormal bruising, and skin tears or wounds that will not stop bleeding. An interview with the Unit Manager on [DATE] at 12:05 p.m. revealed 32 residents were reviewed and all residents had appropriate person-centered care plans in place addressing anticoagulation use and potential side effects and risks. All residents had interventions in place for anticoagulation therapy to include nurse monitoring for signs and symptoms of bleeding to include bloody urine, blood in the stool, bleeding gums during oral care, abnormal bruising, and skin tears or wounds that will not stop bleeding. An interview with the Unit Manager on [DATE] at 12:00 p.m. revealed 32 residents were reviewed and all residents had appropriate person-centered care plans in place addressing anticoagulation use and potential side effects and risks. All residents had interventions in place for anticoagulation therapy to include nurse monitoring for signs and symptoms of bleeding to include bloody urine, blood in the stool, bleeding gums during oral care, abnormal bruising, and skin tears or wounds that will not stop bleeding. 4. Nursing Staff Members were interviewed. All staff were received in-service education on the development and documentation of person-centered care plans and interventions for residents with falls and anti-coagulation therapy. The following staff were interviewed: 7 a.m. to 7 p.m. shift: On [DATE] at 10:40 a.m. with CNA AAA, at 10:30 a.m., with CNA BBB at 10:35 a.m., with CNA CCC at 10:50 a.m., with CNA DDD at 11:05 a.m., with CNA EEE; at 11:10 a.m. with CNA FFF; at 11: 15 a.m. with CNA GGG, at 11:20 with CNA HHH, at 11:27 a.m. with CNA/Restorative III, at 11:29 a.m. with CNA JJJ, at 11:31 a.m. with CNA KKK, at 11:33 a.m. with CNA/Shower Tech LLL, at 11:05 a.m. with RN Nurse Educator, at 11:10 a.m. with LPN CCC, at 11:15 a.m. with LPN DDD, at 11:20 a.m. with LPN EEE, at 11:25 a.m. with RN-ADON, at 11:30 a.m. with RN FFF. 7 p.m. t0 7 a.m. shift: at 11:00 a.m. with LPN AAA, at 11:35 a.m. with CNA MMM, at 11:40 a.m. with CNA NNN, at 11:45 a.m. with CNA OOO, at 11:50 a.m. with CNA PPP and at 11:55 a.m. with CNA QQQ, at 11:56 a.m. with LPN GGG, at 12:00 p.m. with LPN HHH, at 12:05 p.m. with LPN III, at 12:10 p.m. with LPN JJJ and at 12:15 p.m. with KKK. 5. Record Review dated [DATE] and [DATE] revealed documentation of in-service facilitated by the RN Nurse Educator on the development and documentation of person-centered care plans and care interventions for falls and anticoagulation therapy and at least 85% of the facility Registered Nurses and License Practical Nurses were educated. Further review revealed 29 of 32 Licensed Nursing staff was educated. The following staff were interviewed: 7 a.m. to 7 p.m. shift: On [DATE] at 11:05 a.m. with RN Nurse Educator, at 11:10 a.m. with LPN CCC, at 11:15 a.m. with LPN DDD, at 11:20 a.m. with LPN EEE, at 11:25 a.m. with RN-ADON, at 11:30 a.m. with RN FFF. 7 p.m. t0 7 a.m. shift: at 11:00 a.m. with LPN AAA, at 11:56 a.m. with LPN GGG, at 12:00 p.m. with LPN HHH, at 12:05 p.m. with LPN III, at 12:10 p.m. with LPN JJJ and at 12:15 p.m. with KKK. 6. Audit tool for falls and anticoagulation care plans were reviewed and verified on [DATE] at 11:45 a.m. 7. Audit tool for anticoagulation therapy reviewed and verified on [DATE] at 11:50 a.m. 8. The assistant administrator will review the results of the audits weekly every Monday for 3 months. If the assistant administrator is unavailable the Director of Nursing will review the results of the audits. 9. The audits will be turned over to the QAA committee monthly for review and recommendations with the administrator evaluating for compliance. 10. All corrective action was completed on [DATE] 11. The Immediacy of the IJ was removed on [DATE]

Based on observations, record review, staff interviews, and review of the facility's policy titled, Assessing Falls and Their Causes the facility failed to identify a change in condition and failed to follow the Physicians orders to provide ongoing monitoring, and failed to send the resident out to the emergency room when he was found to have a change in condition after a fall for one (R#1) of 51 sampled residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Assistant Administrator and Director of Nursing were informed of the Immediate Jeopardy on [DATE] at 12:00 p.m. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The Immediate Jeopardy is outlined as follows: R#1 was identified on admission as having a history of falls and being at high risk for future falls. R#1 was admitted with orders for [MEDICATION NAME] (an anticoagulant/blood thinner). R#1 had an unwitnessed fall and was found under his bed on [DATE] at 9:00 p.m. R#1's vital signs were obtained and revealed a blood pressure of ,[DATE], oxygen saturation at 90%, and a new irregular pulse rate of 100. The Physician was called, and orders were received to monitor R#1. On [DATE] at 1:22 a.m., R#1's blood pressure dropped to ,[DATE]. At this time, R#1 was unresponsive and required a sternal rub. The Physician was notified with orders given for oxygen to be started and for staff to continue to monitor R#1. However, there was not any evidence that R#1 was monitored and at 3:44 a.m. R#1 was found to be in cardiac and respiratory arrest (he was not breathing and did not have a pulse). R#1 also was observed to have a brown substance coming from his mouth. CPR was performed, however, R#1 died . The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.21 (b)(1) Develop/Implement Comprehensive Care Plan (F656, Scope/Severity: J); 42 C.F.R. 483.25 (F684, Scope/Severity: J); 42 C.F.R. 483.70 Administration (F835, Scope/Severity: J). Substandard Quality of Care was identified with the requirements 42 C.F.R. 483.12 (a)(1), Free from Abuse and Neglect (F600, Scope/Severity: J); 42 C.F.R. 483.25 (F684, Scope/Severity: J). A Removal Plan (A Credible Allegation of Compliance) was received on [DATE]. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight of residents at that have fallen to ensure the continuity of the residents' safety. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate identification of residents at risk for falls, monitoring of residents including checking vital signs, neurochecks, monitoring for signs and symptoms of bleeding, identifying change in conditions, and following Physician orders. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policy and procedures governing falls and fall risks. In-service materials were reviewed to ensure appropriate training was giving to the staff regarding falls and anticoagulant use which included monitoring, neurochecks and identifying changes in a resident's condition. Resident records were reviewed to ensure care plans were developed and implemented with appropriate interventions and to ensure monitoring was being conducted for residents' receiving anticoagulant therapy. At the time of exit, on [DATE], the Immediate Jeopardy was removed. Findings include: Review of the facility's Assessing Falls and Their Causes policy revised on [DATE] revealed the purpose was to utilize previous evaluation and current data, to identify interventions related to the resident's specific risks to prevent future falls and to minimize fall complications. The policy identified fall complications management intervention as: Staff and Attending Physicians will define the complications of a fall such as bleeding, fracture, and increase fear of walking. Staff and Physician will identify significant potential complications of falling for each resident at risk for falling (e.g., facture in someone with [MEDICAL CONDITION] or bleeding in someone receiving anticoagulants). The facility utilized Nursing Standard of Practice for Neuro Checks. This is utilized to establish a base line of the resident's condition for later comparisons if there would be a change in level of consciousness. 1. Closed record review for R#1 revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#1's admission Morse Fall Scale score dated [DATE] revealed score of 75 indicating high risk for falls (> 51 indicated high risk). The fall scale revealed R#1 had a history of [REDACTED]. The fall assessment indicated R#1 would overestimate or forget his limits when assessing his own ability. Review of Resident #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven (7) indicating severely impaired cognition. Review of the Functional Status section revealed the resident did not ambulate in or out of his room. R#1 required extensive assistance of one (1) person with bed mobility (how resident moved to and from lying position, turning side to side and positions body while in bed), transfers, and personal hygiene. R#1's range of motion was assessed as having no impairment to the upper extremities and having impairment on one (1) side of the lower extremities. The MDS indicated R#1 experienced a fall with fracture prior to admission. Record review revealed that the fall on [DATE] was the first fall R#1 had since admission. Review of Change in Condition Evaluation report dated [DATE] at 9:06 p.m., revealed R#1 was found lying under bed. Review of R#1's progress note dated [DATE] at 9:21p.m., revealed the The Medical Director was notified and instructed nursing to administer oxygen and to monitor the resident. Record review revealed there was not any evidence that R#1 was provided any monitoring and on [DATE] at 3:44 a.m. R#1 was found to have a brown liquid substance coming his mouth. The resident did not have a heartrate and was not breathing. The progress note documented the Physician was notified, an order was given to send the resident to the hospital, CPR was started, but was unsuccessful and R#1 died . Interview was conducted in the hallway on 300 unit on [DATE] at 11:05 a.m. with Registered Nurse (RN) GG. RN GG was an agency nurse (provided relief staffing due to coronavirus (COVID)) and revealed being employed since [DATE]. RN GG indicated an unwitnessed fall intervention included not moving the resident, completion of a head to toe assessment, and if no obvious signs of symptoms of head trauma, monitoring for change in condition. She further indicated the Physician and family would be notified. RN GG stated monitoring interventions included assessment for change in orientation and the ability to move all extremities. Interview was conducted in the conference room on [DATE] at 10:00 a.m. with the Assistant Administrator revealed a hire date [DATE], at which time he inherited the facility with an unsafe atmosphere, inadequate documentation, with inadequate care being provided. The Assistant Administrator revealed when R#1 exhibited a change in vital signs, level of consciousness and required a sternal rub on [DATE], Licensed Practical Nurse (LPN)HH should have utilized nursing judgement to have R#1 resident transferred to hospital. Telephone interview with LPN HH on [DATE] at 10:45 a.m. revealed being employed approximately two years (prior to termination on [DATE]). LPN HH verbalized if a resident sustained [REDACTED]. If there was no obvious head injury, the resident was assisted to bed, and notification was made to the Physician and family. LPN HH stated she cared for R#1 the night of his death. She stated she had not been aware of R#1's fall (was not given this information during the hand off report). She stated when R#1 was difficult to arouse, she notified the Physician. LPN HH did not provide answer to what frequent monitoring would entail per the physician's orders [REDACTED].>Interview was conducted in the conference room, on [DATE] at 12:30 p.m. with the Medical Director. The Medical Director revealed R#1 was admitted to the facility for rehabilitation. He recalled the resident being a professional wrestler and always trying to gain his independence. He revealed R#1 had a history of [REDACTED]. The Medical Director revealed his expectations would be the same for either a witnessed or an unwitnessed fall. He expected the nurse to assess the resident's vital signs extremities, and to monitor orientation. He concluded when a person had a lowering of B/P, heart rate and required a sternal rub for arousal, it may indicate a change in the level of consciousness. The Medical Director acknowledged being notified of the resident's fall. However, he revealed at 1:22 a.m. when the nurse informed him of the resident's vital signs, he stated he was unsure if he was informed that the resident required a sternal rub. He stated he would have ordered the resident to be transferred to the hospital. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Rl was admitted on [DATE] to Rivertowne Center. On [DATE], the resident had an unwitnessed fall. On [DATE] the patient became unresponsive and expired in the facility on [DATE]. 2. On [DATE], the Administrator, Assistant Administrator, Director of Nursing, and Medical Director reviewed the current policies and procedures for the falls and concluded that no revision was needed. 3. On [DATE], the Administrator, Assistant Administrator, Director of Nursing, and Medical Director reviewed the current policy and procedures dealing with Standards of Nursing related to falls which includes performing adequate supervision and monitoring after a fall which includes s/s of bleeding which includes bloody urine, blood in the stool, and a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, to ensure neurological checks are done every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours. Also, ensuring that a person-centered care plan is developed and ensuring that residents receive timely medical care when a resident experience a change of condition. 4. Administrator and Director of Nursing will review the 24-hour nursing summary which includes but not limited to falls, change of conditions, abnormal vital signs and transfers to hospitals in EMR Monday through Friday stating [DATE] and report to Clinical Stand Up any updates or concerns. The Director of Nursing will utilize QAPI monthly meetings to identify and manage any increase or decrease of falls and ensure that it is in the PIP to improve monitoring of quality measures. 5. On [DATE], the Nurse educator conducted an in service with staff. The in-service covered the following information: neglect which included how to report neglect, who to report neglect to, and signs of neglect. Education also included fall prevention which included evaluate and monitor the resident for 72 hours after the fall, investigate fall circumstances, record circumstances, call RP and MD, implement immediate interventions, complete fall assessment, develop plan of care, and monitor staff compliance and resident response. Education also included neurological checks after an unwitnessed fall or fall with head injury to be done every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours. Education also included monitoring sis of bleeding which includes bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness. Education also included ensuring a person-centered care plan is developed which included updating the person-centered care plan when a resident has a fall to include person specific interventions being put in place. Education also included ensuring that residents receive timely medical care when a resident experience a change of condition which includes calling emergency services and the medical director when a resident is unresponsive. 6. As of [DATE] 29 of 34 nurse including full-time, part-time, prn, and one agency nurse (14 RN's of 14, 15 LPN's of 20 for a total of 85%) were educated on neglect which included what is neglect (not responding to a change in condition), how to report neglect, who to report neglect to, the Elder Justice Act (copies of a summary of the Elder Justice Act are also posted at both nursing station), fall prevention, performing neurological checks after a fall every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours, monitoring sis of bleeding which included bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring a person centered care plan is developed, and ensuring that residents receive timely medical care when a resident experiences a change of condition. All remaining staff will be required to complete the in-services before they can care for a resident. 7. As of [DATE] 36 of 42 CNA's which include full-time, part-time, and prn staff, there are no agency cna's at this time (for a total of 86%) were educated on neglect which included what is neglect (not responding to a change in condition), how to report neglect, who to report neglect to, the Elder Justice Act (copies of a summary of the Elder Justice Act are also posted at both nursing station), and signs of neglect, fall prevention, performing neurological checks after an unwitnessed fall or fall with head injury which included change in level of consciousness, monitoring sis of bleeding which included bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, and ensuring that residents receive timely medical care when a resident experiences a change of condition. All remaining staff will be required to complete the in-services before they can care for a resident. 8. On [DATE], an audit tool has been created to address neglect to include was there a change of condition and did that resident receive nursing or medical care, fall prevention which includes when the resident fail, was it witnessed or unwitnessed, was the MD and RP notified, any new orders, care plan, risk management, and change of condition assessment done, performing neurological checks after an unwitnessed fall or fall with head injury which includes performing neurological checks after a fall every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours, monitoring sis of bleeding which includes bloody urine, blood in the stool, a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, ensuring a person-centered care plan is developed, and ensuring that residents receive timely medical care when a resident experience a change of condition. The director of nursing will conduct the audits Monday through Friday starting [DATE] for 1 week followed by weekly audits for 3 months. The administrator will review audits weekly on Wednesdays. All audits will be turned in to the QAA committee for monthly review of compliance and recommendations for changes, if necessary. 9. On [DATE], two unwitnessed falls took place. Immediate action was taken to ensure patient safety. Both residents were immediately assessed and transferred safely back in bed. Head to toe assessments were completed and neurological check flowsheets were initiated and completed. No injuries occurred for both residents. Nurse notified the Responsible Parties and the Medical Director. Person-centered care plans were developed for the unwitnessed falls and risk management assessments were completed. All steps were completed to ensure patient safety for both cases. 10. All corrective action was completed on [DATE] 11. The Immediacy of the IJ was removed on [DATE]. The State Survey Agency (SSA) validated the facility's written Immediate Jeopardy Removal Plan as follows: 1. Rl was admitted on [DATE] to Rivertowne Center. On [DATE], the resident had an unwitnessed fall. On [DATE] the patient became unresponsive and expired in the facility on [DATE]. 2. An interview with the Administrator on [DATE] at 11:59 a.m. revealed the facility policy for Falls was reviewed and no changes were made. An interview with the Assistant Administrator on [DATE] at 12:00 p.m. revealed the facility policy for Falls was reviewed and no changes were made. An interview with the Director of Nursing on ,[DATE]//2020 at 12:01 p.m. revealed the facility policy for Falls was reviewed and no changes were made. An interview with the Medical Director on [DATE] at 12:02 p.m. revealed the facility policy for Falls was reviewed and no changes were made. 3. An interview with the Administrator on [DATE] at 11:59 a.m. revealed the facility policy for dealing with Standards of Nursing related to falls which includes performing adequate supervision and monitoring after a fall which include s/s of bleeding which includes bloody urine, blood in the stool, and a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, to ensure neurological checks are done every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours. Also, ensuring that a person-centered care plan is developed and ensuring that residents receive timely medical care when a resident experience a change of condition was reviewed. An interview with the Assistant Administrator on [DATE] at 12:00 p.m. revealed the facility policy for dealing with Standards of Nursing related to falls which includes performing adequate supervision and monitoring after a fall which include s/s of bleeding which includes bloody urine, blood in the stool, and a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, to ensure neurological checks are done every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours. Also, ensuring that a person-centered care plan is developed and ensuring that residents receive timely medical care when a resident experience a change of condition was reviewed. An interview with the Director of Nursing on ,[DATE]//2020 at 12:01 p.m. revealed the facility policy for dealing with Standards of Nursing related to falls which includes performing adequate supervision and monitoring after a fall which include s/s of bleeding which includes bloody urine, blood in the stool, and a change in vital signs (decrease in blood pressure/increase in heart rate) or a change in level of consciousness, to ensure neurological checks are done every 15 minutes for one hour, then every 30 minutes for 1 hour, then every hour for four hours, and then every shift for the remaining 72 hours. Also, ensuring that a person-centered care plan is developed and ensuring that residents receive timely medical care when a resident experience a change of condition was reviewed. An interview with the Medical Director on [DATE] at 12:02 p.m. revealed the facility policy for Comprehensive Care Plans was reviewed and no changes were made. 4. An interview with the Administrator on ,[DATE].2020 at 12:54 p.m. revealed the 24-hour nursing summary will be reviewed and the Director of Nursing (DON) will utilize QAPI monthly meetings to identify and manage any increase or decrease of falls and ensure that it is in the PIP to improve monitoring of quality measures. An interview with the DON on ,[DATE].2020 at 12:54 p.m. revealed the 24-hour nursing summary will be reviewed and she will utilize QAPI monthly meetings to identify and manage any increase or decrease of falls and ensure that it is in the PIP to improve monitoring of quality measures. 5. Multidisciplinary Staff Members were interviewed. All staff stated they have attended in-services related neglect on [DATE] and [DATE]. The staff were able to tell how to report neglect, who to report neglect to and signs of neglect. Staff was also able to give information regarding fall prevention. Staff was able to give information on neurological checks use after a fall. The following staff was interviewed. 7 a.m. to 7 p.m. shift: On [DATE] at 10:40 a.m. with CNA AAA, at 10:30 a.m., with CNA BBB at 10:35 a.m., with CNA CCC at 10:50 a.m., with CNA DDD at 11:05 a.m., with CNA EEE; at 11:10 a.m. with CNA FFF; at 11: 15 a.m. with CNA GGG, at 11:20 with CNA HHH, at 11:27 a.m. with CNA/Restorative III, at 11:29 a.m. with CNA JJJ, at 11:31 a.m. with CNA KKK, at 11:33 a.m. with CNA/Shower Tech LLL, at 11:05 a.m. with RN Nurse Educator, at 11:10 a.m. with LPN CCC, at 11:15 a.m. with LPN DDD, at 11:20 a.m. with LPN EEE, at 11:25 a.m. with RN-ADON, at 11:30 a.m. with RN FFF, at 2:00 p.m. with Maintenance Supervisor, at 2:05 p.m. with the Activity Director, at 2:10 p.m. with the Receptionist, at 2:20 p.m. with Respiratory Director. 7 p.m. t0 7 a.m. shift: at 11:00 a.m. with LPN AAA, at 11:35 a.m. with CNA MMM, at 11:40 a.m. with CNA NNN, at 11:45 a.m. with CNA OOO, at 11:50 a.m. with CNA PPP and at 11:55 a.m. with CNA QQQ, at 11:56 a.m. with LPN GGG, at 12:00 p.m. with LPN HHH, at 12:05 p.m. with LPN III, at 12:10 p.m. with LPN JJJ and at 12:15 p.m. with KKK. 6. Nursing Licensed Nursing Staff members were interviewed. All staff stated they have attended in-services related to neglect on [DATE] and [DATE]. The staff were able define the definition of neglect, responding to change in condition, reporting neglect, who to report neglect, the location of the Elder Justice Act, and the signs of neglect. The neglect in-services were provided by the Nurse Educator. The following staff were interviewed: 7 a.m. to 7 p.m. shift: On [DATE] at 11:05 a.m. with RN Nurse Educator, at 11:10 a.m. with LPN CCC, at 11:15 a.m. with LPN DDD, at 11:20 a.m. with LPN EEE, at 11:25 a.m. with RN-ADON, at 11:30 a.m. with RN FFF. Phone interviews was conducted with the 7 p.m. t0 7 a.m. shift: The following staff was interviewed: On [DATE] at 11:00 a.m. with LPN AAA, at 11:56 a.m. with LPN GGG, at 12:00 p.m. with LPN HHH, at 12:05 p.m. with LPN III, at 12:10 p.m. with LPN JJJ and at 12:15 p.m. with KKK. 7. Record Review dated [DATE] and [DATE] revealed documentation of in-service facilitated by the RN Nurse Educator on Neglect and at least 86% of the facility's Certified Nursing Assistants (CNAs) were educated. Further review revealed 36 of 42 CNAs was educated. Certified Nursing Assistants were interviewed. All staff stated they have attended in-services related to neglect on [DATE] and [DATE]. The staff were able define the definition of neglect, responding to change in condition, reporting neglect, who to report neglect, the location of the Elder Justice Act, and the signs of neglect. The neglect in-services were provided by the Nurse Educator. The following staff were interviewed: 7 a.m. to 7 p.m. shift: On [DATE] at 10:40 a.m. with CNA AAA at 10:30 a.m., with CNA BBB at 10:35 a.m., with CNA CCC at 10:50 a.m., with CNA DDD at 11:05 a.m., with CNA EEE; at 11:10 a.m. with CNA FFF; at 11: 15 a.m. with CNA GGG, at 11:20 with CNA HHH, at 11:27 a.m. with CNA/Restorative III, at 11:29 a.m. with CNA JJJ, at 11:31 a.m. with CNA KKK, at 11:33 a.m. with CNA/Shower Tech LLL Phone Interviews were conducted with the 7 p.m. to 7 p.m. shift: The following staff was interviewed: On [DATE] at 11:35 a.m. with CNA MMM, at 11:40 a.m. with CNA NNN, at 11:45 a.m. with CNA OOO, at 11:50 a.m. with CNA PPP and at 11:55 a.m. with CNA QQQ. 8. The neglect audit tool was reviewed and verified on [DATE] at 10:37 a.m. 9. Chart reviews were conducted on [DATE] of the unwitnessed falls which took place on [DATE]. No concerns were identified. All measures were in place. 10.All corrective action was completed on [DATE] 11.The Immediacy of the IJ was removed on [DATE].

Based on interviews, record review, review of the facility's policy titled, Change in a Resident's Condition or Status the facility failed to notify the Attending Physician, and the Responsible Party (RP) of a fall for one of 51 sampled residents (Resident (R) #10). Actual harm was identified when R#10 had an unwitnessed fall on 12/28/19 at 6:00 p.m. when he fell asleep and fell out of a wheelchair. The Physician was not notified of the fall until 12/29/19 at 2:00 p.m. The ordered an x-ray of the elbow revealed that R#10 had a left distal humerus fracture. Findings include: Review of the facility's policy, Change in a Resident's Condition or Status, revised May 2017, revealed the facility should promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. Accident or incident involving the resident; b. Discovery of injuries of an unknown source; c. Adverse reaction to medication; d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications two (2) or more consecutive times; g. Need to transfer the resident to a hospital/treatment center; h. Discharge without proper medical authority; and/or i. Specific instruction to notify the Physician of changes in the resident's condition. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change in the resident's physical, mental, or psychosocial status; c. There is a need to change the resident's room assignment; d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/treatment center. Review of R#10's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home with Home Health on 1/2/2020. Review of the Admission Minimum Data Set (MDS) Assessment, dated 12/19/19, revealed R#10 had a Brief Interview for Mental Status (BIMS) score of ten out of 15 indicating the resident was moderately impaired in cognition. R#10 was assessed as requiring limited assistance of one (1) person with bed mobility, extensive assistance of two (2) persons with transfers, limited assistance with one (1) person with dressing, R#10 had bilateral lower extremity impairment in range of motion (ROM) and used a wheelchair for mobility. R#10 had no history of falls. Review of R#10's Morse Fall Scale dated 12/14/19, revealed he scored a 15 which indicated he was at low risk for falling. Review of R#10's Nurse's Progress Notes, dated 12/30/19 at 3:46 p.m., revealed the Unit Manager was informed the resident had a fall on 12/28/19. No fall was documented. Upon investigation and staff interviews, it was determined the resident activated the call light to be put back to bed. The CNA answered the call light and told the resident they would be right back they were going to get another staff member to assist with transfer. When staff returned, the resident was on floor beside the wheelchair laying on the left arm. The resident stated he fell asleep and fell forward out of chair. Review of R#10's Nurse's Progress Notes, dated 12/29/19 at 10:44 a.m., revealed the resident complained of elbow pain. R#10 was seen by the Physician and a new order was obtained to send the resident out to the hospital for evaluation and treatment. Review of R#10's Nurse's Progress Notes, dated 12/29/19 at 8:00 p.m., revealed the resident returned to the facility via stretcher. The resident had a splint and ace bandage to the left arm. Review of R#10's Change in Condition Form, dated 12/30/19, revealed R#10 fell on [DATE] at night. R#10 complained of left antecubital pain, pain was rated at a nine (9). The resident had a fall on 12/28/19 at 6:00 p.m. He (R#10) stated he fell asleep sitting in wheelchair, waiting on a CNA to return with help to transfer him back to bed. The Physician was notified on 12/29/19 at 2:00 a.m. with an order to send to the ER for left arm pain. Interview with R#10's Responsible Party (RP) on 10/27/2020 at 8:45 a.m., revealed she was not notified when R#10 fell on [DATE]. She was first notified when the resident was sent to theER on [DATE]. The RP further stated R#10 sustained a fractured elbow as result of the fall that occurred on 12/28/19. A telephone interview was attempted with the Certified Nursing Assistant (CNA), who was assigned to R#10 when he fell , on 10/27/2020 at 1:30 p.m. without success. A telephone interview with the Unit Manager, who investigated R#10's fall, was attempted on 10/28/2020 at 2:30 p.m., without success. Interview with the Director of Nursing (DON) on 10/27/2020 at 12:30 p.m., revealed LPN HH didn't notify the MD or R#10's RP timely after R#10's fall on 12/28/2020. Interview with the Assistant Administrator (AA) on 10/28/2020 at 4:55 p.m., revealed the former Unit Manager reported R#10's fall to him on 12/30/19. Continued interview revealed the nurse should have contacted the MD after R#10 fell and should have notified the RP of the fall. Interview the Medical Director (MD) on 10/27/2020 at 5:56 p.m., revealed when a patient fell , he expected nursing staff to call him to report the assessment findings immediately. The MD further stated that he wasn't notified of R#10's fall until 12/29/19, when the resident complained of left elbow pain. The MD stated he ordered an x-ray of the elbow; the x-ray revealed a left distal humerus fracture. Cross refer F600

Based on interviews, record reviews and review of the facility policy titled, Orientation Program for Newly Hired Employees, Transfers, and Volunteers policy, it was determined that the facility failed to ensure that the competencies of a newly hired Certified Nursing Assistant (CNA) staff were adequately assessed prior to them providing resident care independently for one of six newly hired CNA's reviewed. On 4/13/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on 4/13/18 at 6:40 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/9/18. The Immediate Jeopardy continued through 4/18/18, and was removed on 4/19/18. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on 4/18/18. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was identified with first and second [MEDICAL CONDITION] the lower extremities, buttocks and groin on the morning of 4/10/18 and was sent to an acute care hospital where she was admitted . Through the facility's investigation, it was determined that the resident had received a shower the evening prior, on 4/9/18. The facility monitored water temperatures in the residents' rooms and the common shower rooms on 4/10/18 and 4/11/18, all water temperatures were found to be less than 120 degrees Fahrenheit (F) at that time. A plumbing company was also contacted and provided onsite services on 4/10/18 and 4/12/18, which included adjusting the water mixing valves. However, unsafe water temperatures were identified on 4/13/18, after surveyor entrance. These unsafe water temperatures were found in five bathrooms, shared by nine resident rooms, with 14 residents occupying those nine rooms, and included water temperatures that ranged from 120.5 degree F to 126.5 degrees F. In addition to the elevated hot water temperatures, on 4/13/18, there was no system in place to monitor the temperature of the water flowing through the mixing valve, as the previous thermometer for monitoring the water temperatures had been removed. Further investigation revealed that the facility had failed to routinely monitor and log water temperatures, with the last documented water temperatures obtained on 2/23/18. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 CFR 483.25 Quality of Care, F689; 42 CFR 483.35 Nursing Services, F726; CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F689. A Credible Allegation of Compliance was received on 4/18/18. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/19/18. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of water temperature monitoring. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility' Policies and Procedures. Findings include: The facility had an Orientation Program for Newly Hired Employees, Transfers, and Volunteers policy. The policy included that a written record would be maintained for each employee's individual orientation program and that completed copies of Employee Orientation Checklists were to be filed in the employee's personnel file. A review of the personnel file for Certified Nursing Assistant (CNA) AA revealed a hire date of 3/24/18. The file also included a CNA job description form. The signature section of the form was blank for the employee and manager signatures. The position description on the form included that the CNA would provide assistance with resident care, including giving baths. The form also documented that the CNA would operate all equipment in a safe manner, and only use equipment for which training had been received. Further review of the personnel file revealed Clinical Competency Validation forms for perineal care, indwelling urinary catheter care, applying non-sterile gloves, gowning, hand hygiene, measuring blood pressure, obstructed airway for non-licensed personnel, removing a gown, removing gloves, weighing the patient, and turn and reposition the patient. All of the forms were blank on whether CNA AA had been assessed for the skills and either met or not met the competencies. During an interview and review of CNA AA's personnel file on 4/17/18 at 12:00 p.m. with the Director of Nursing (DON), she confirmed that the CNA position description in the personnel file was the job description provided to CNA's. The DON stated that the facility's Staff Development Coordinator oversaw the newly hired staff and their training. However, the Staff Development Coordinator had quit without notice last week. The DON stated that the Clinical Competency Validation forms usually should have been completed within the first week of training by either the CNA's preceptor or the Staff Development Coordinator. The DON stated that the facility was in the process of revising the competency forms but those were the forms in place when CNA AA was hired and should have been completed. Record review revealed that Resident (R) #1 had a [DIAGNOSES REDACTED]. On the morning of 4/10/18, R#1 was identified with first and second [MEDICAL CONDITION] the lower extremities, buttocks and groin and hospitalized . Through the facility's investigation, which was initiated on 4/10/18, it was determined that the resident had received a shower from CNA AA, in the West female shower room, on the evening prior, on 4/9/18. The Medical Director examined R#1 on 4/10/18, prior to her being sent to the hospital. The physician's note documented second degree burn like blisters to the left inner groin, left leg and left foot; first degree burn-like changes to the skin of the thigh. During an interview on 4/17/18 at 10:20 a.m. the Medical Director stated that he had received a call on 4/10/18 about the resident having blisters and nursing staff had mentioned she had had a shower the night before. He stated that the areas initially looked like some type of a scald/burn injury. He stated that he did think about bullous impetigo but the [DIAGNOSES REDACTED] made him think about a scalding. He stated that he had been taking care of R#1 since (YEAR) and had not witnessed any of these skin issues on her before 4/10/18. He agreed to send her to the hospital at the family's request. R#1 was transferred to the hospital on [DATE] and admitted . A review of the hospital physicians' notes revealed documentation of first and second [MEDICAL CONDITION] the left leg, right ankle and buttocks, with some blisters broken and some fluid filled. During interviews on 4/13/18 at 6:06 p.m. and on 4/17/18 at 2:07 p.m., and review of written statement, CNA AA (7 p.m. to 7 a.m. shift) she confirmed that she had been paired with another CNA for five days when she first started working at the facility, prior to having an assignment on her own. CNA AA stated that 4/9/18 7:00 p.m. to 4/10/18 7:00 a.m. was the first time she had been assigned to care for R#1. She confirmed that she had given the resident a shower in the West female shower room on 4/9/18 around 11:00 p.m. or 11:30 p.m. She stated that she knew to check the water before putting it on a resident and had checked the water with her hands and was in the shower with the resident, so the water splashed on her too. CNA AA stated that the water did not feel too hot, that it was lukewarm, and the resident did not show any signs of pain or discomfort. CNA AA stated that she checked on the resident routinely, about every two hours during the rest of the shift and there was no noted redness or blisters until the last time she checked her on 4/10/18 around 6:30 a.m., at which time she notified the nurse. There was no evidence that the resident was exposed to a potential source to [MEDICAL CONDITION] prior to or after the shower on the night of 4/9/18. A review of skin assessments completed earlier on 4/9/18 and on 4/2/18 for R#1 documented no new areas of skin impairment. During an interview on 4/17/18 at 1:38 p.m., CNA CC stated that she assisted CNA AA with transferring R#1 onto the shower stretcher and taking her into the shower room. CNA CC also stated that she removed the resident's gown and brief, while CNA AA obtained the resident's personal soap out of her room. CNA CC stated that the resident had no skin issues at that time. CNA CC was not present for the shower. CNA CC stated that she saw the resident again the next morning (4/10/18) around 5:30 a.m. or 6:00 a.m., when assisting CNA AA with turning R#1. She stated that at that time, she saw a large blister on her leg and blisters on the top of the vaginal area and buttocks and told CNA AA to let the nurse know. Further interview with CNA CC revealed that she had not had any issues with the water in the shower feeling too hot, and would always check it on her own arm before using on a resident. Cross refer F689 The facility implemented the following actions to remove the Immediate Jeopardy 1. On 4/13/18, the Director of Nursing reviewed and accepted the existing policies and procedures related to Staff Development/Orientation Program. 2. On 4/13/18 the facility initiated in-service training for all staff, this includes Registered Nurse (RN)'s, Licensed Practical Nurse (LPN)'s, CNA's, Respiratory Staff, Agency Staff, Contract Therapy Staff, Contract Housekeeping Staff, Contract Dietary Staff, Department Head Staff. The in-service information included; when providing resident care, the water temperature shall be measured by feel to the touch, (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water). Staff shall report this finding to the immediate supervisor. In common areas, any water temperature shall be measured by feel to the touch and shall be reported to an immediate supervisor of any negative findings. o First-[MEDICAL CONDITION] to the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. o Second-[MEDICAL CONDITION] the two first layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. o Third-[MEDICAL CONDITION] the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain maybe caused by patches of first and second-[MEDICAL CONDITION] third [MEDICAL CONDITION] dry leathery skin. Skin may appear charred or have patches that appear white, brown, or black. As of 4/16/18, the Director of Nursing, Performance Improvement Coordinator, and Administrator have in-serviced 23 of 29 Licensed Staff 79%, 44 of 51 CNA's 86%, 2 of 2 Minimum Data Set (MDS) 100%, 10 of 10 Respiratory Therapists 100%, 8 of 11 Contract Therapy Staff 72%, 16 of 17 Contract Housekeeping Staff 94%, 11 of 13 Contract Dietary Staff 85%, and 22 of 23 Department Head Staff members 96%. A total of 87% of staff have been in-serviced thus far. The remainder of the staff will be in-serviced by the Performance Improvement Coordinator prior to working their first scheduled shift. Newly hired staff will be in-serviced during orientation. As of 4/17/18, and to be completed 4/18/18, the Performance Improvement Coordinator, Director of Nursing and/or Social Services staff began in-servicing all staff, this includes RN's LPN's CNA's, Respiratory Staff, Agency Staff, Contract Therapy Staff, Contract Housekeeping Staff, Contract Dietary Staff, Department Head Staff on identifying and recognizing signs of pain. Behavioral signs of pain: o verbal expressions such as groaning, crying screaming o facial expressions such as grimacing, frowning, clenching of the jaw o changes in gait, skin color and vital signs o behaviors of resisting care, irritability o limitations in his or her level of activity due to the presence of pain o guarding, rubbing, favoring a particular part of the body Physiological signs of pain: o increased blood pressure o [MEDICAL CONDITION]/>o increased respirations o diaphoresis As of 4/18/18, the Director of Nursing, Performance Improvement Coordinator, and/or Social Services staff have in-serviced 22 of 27 Licensed Staff 81 %, 29 of 37 CNA's 78%, 2 of 2 MDS 100%, 9 of 9 Respiratory Therapists 100%, 6 of 6 Contract Therapy Staff 100%, 16 of 17 Contract Housekeeping Staff 94%, 8 of 9 Contract Dietary Staff 89%, 18 of 18 Administrative Staff 100%. A total of 95% of staff have been in¿-serviced thus far. The remainder of the staff will be in-serviced by the Performance Improvement Coordinator prior to working their first scheduled shift. Newly hired staff will be in-serviced during orientation. 3. On 4/14/18, the facility implemented a new audit tool by which the Director of Nursing and the Performance Improvement Coordinator will ask clinical staff members the following questions: What is the max water temp? Who would you report a high¿ water temperature to? Demonstrate how you would physically assess the water temperature prior to resident care. Describe to me a first, second, and third-degree burns. If a potential burn is identified who would you report to? What is the time frame you must report incidents? This process is to allow nursing management to conduct weekly audits to monitor for competent nursing staff. The Director of Nursing and the Performance Improvement Coordinator will complete 10 audits per week x 3 weeks, then 10 monthly x 2 months. 4. The Wound Nurse will complete 5 skin assessment chart audits per week x 3 weeks, then monthly x 2 months. The assigned Licensed Charge Nurse for each shift will complete a minimum of 2 skin assessments per day. If any skin assessments are identified not being completed will be completed by the on-duty Charge Nurse assigned for the resident. 5. The Director of Nursing will report during the Quality Assurance (QA) meeting the results of the audits completed. The number of audits completed, the number of negative responses requiring re-education will be reported x 2 months to the QA Committee. The QA Committee meets the 3rd Thursday of each month, the next meeting is scheduled for 4/19/18. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. During an interview on 4/19/18 at 11:15 a.m., the DON confirmed that she reviewed and accepted the existing policies and procedures related to staff development/orientation program. A copy of the Orientation Program for Newly Hired Employees, Transfers, Volunteers was provided and reviewed and was signed by the DON and Administrator on 4/13/18. 2. During an interview on 4/19/18 at 11:15 a.m., the DON confirmed that she participated in in-service training of staff to include checking water temperatures by feel to touch, reporting negative findings to the immediate supervisor and descriptions of types of burns. She also confirmed that she was included in the in-service education provided on recognizing signs of pain. Copy of information provided to staff was provided and reviewed. The DON stated that this information has also been added to the new hire packets. During an interview on 4/19/18 at 12:10 p.m., the Maintenance Director confirmed that he attended the in-service with additional department heads on water temperatures, burns, and received written information on signs of pain. In-service records, including sign in sheets was provided and reviewed and confirmed that staff had received in-services as stated in the Allegation of Compliance (A[NAME]). During an interview with the Administrator on 4/19/18 at 3:11 p.m., she confirmed that the new hire employee checklist was being revised to include the water temperature protocol. The Administrator stated that a new checklist had already been revised with an implementation date of this past Monday, but with the identification of the high water temperatures, it was revised again. The Administrator stated that a check off form has been created for the new member file and designates who is responsible for each task. For CNA's- a preceptor will check off the forms except for some items that the nurse will check off- with the competency forms to be completed within 48 hours and will be reviewed and signed off for verification by the Administrator. Record review revealed that on 4/13/18 in-service training was provided for providing resident care, the water temperature shall be measured by feel to the touch, report negative findings immediately for a total of 87% of staff. With remainder of staff to be in-serviced prior to working their first scheduled shift. Record review revealed that as of 4/18/18, that a total of 95% of the staff had been in-serviced and educated on identifying and recognizing signs of pain. During the following interviews, the staff were able to verbalize how to check the hot water temperatures using touch and immediately reporting to the immediate supervisor if it is abnormal before giving a resident a shower or a bed bath. They all knew the water should not exceed 110 degrees F. They were also able to describe first, second and third-degree burns. They showed the surveyor a small quick reference card pertaining to hot water procedures. Staff were also able to describe signs or symptoms of pain a resident could display. The nurses verbalized a new process that would be taking place regarding skin assessments. They would be doing two skin assessments every shift as prompted in the computer program, Blue Strata. They had been to in-service given by the DON which was started yesterday. They knew how document in Blue Strata any incidents and reporting incidents to the Administrator or Director of Nursing. 4/19/18 at 10:30 a.m.- LPN II 100/300 Halls, CNA JJ 300 Hall at 10:32 a.m., CNA KK 300 Hall at 10:40 a.m., CNA LL 400 Hall at 10:45 a.m., CNA MM 400 Hall at 10:50 a.m., CNA NN 200 Hall at 10:55 a.m., CNA OO in orientation on the 200 Hall at 11:00 a.m., CNA PP 300 Hall at 11:05 a.m., CNA QQ Respiratory Unit at 11:10 a.m., CNA RR 400/100 Halls at 11:15 a.m., RN SS 400 Hall at 11:25 a.m., Housekeeper TT at 11:35 a.m., Housekeeper UU at 11:45 a.m., Housekeeper VV at 11:52 a.m., CNA WW 600 Hall at 11:58 a.m., RN agency staff XX 800 Hall at 12:10 p.m., LPN YY 600 Hall at 12:23 p.m., CNA AAA 600 Hall at 12:30 p.m., CNA in orientation ZZ at 12:37 p.m. CNA, shower team BBB at 12:44 p.m., the Wound Treatment Nurse at 1:30 p.m., 700 Hall LPN CCC at 2:11 p.m., Respiratory Unit LPN DDD at 2:20 p.m., Respiratory Therapist EEE at 2:30 p.m. Interview on 4/19/18 at 1:30 p.m. with the Wound Treatment Nurse revealed she has attended the mandatory in-service training on how to check the hot water temperature against her own skin. She stated the temperature should not exceed 110F. She confirmed the shower rooms are closed and they are to give bed bath until the hot water is below 110. The Wound Nurse discussed first, second and third [MEDICAL CONDITION] immediately reporting the hot water to the supervisor and document any incidents in the electronic record. She stated the DON started in-service 4/18/18 for the nurses for them to start doing two skin assessments on their shift and if they are not done, then the next shift will have to do them. She will be monitoring the skin assessment reports every day to see if any assessments had been missed. She is responsible for doing five skin assessment audits every week and it changes in increments. Interviews on 4/19/18 at 1:50 p.m. with Resident J and Resident K, roommates, Resident L and Resident M, roommates at 2:06 p.m., 3:10 p.m. with Resident N, Resident O at 3:25 p.m., Resident P at 3:34 p.m. and Resident Q at 3:45 p.m., revealed that the residents stated that they were informed the hot water was too hot and the shower rooms were closed. They were informed they would be receiving bed baths until the hot water situation was fixed. They knew about the risk of getting burned from water that was too hot. They stated that they knew how to adjust the water to keep it from getting too hot. 3. During an interview on 4/19/18 at 11:15 a.m., the DON confirmed that a new audit tool had been implemented to ask clinical staff questions to assess their knowledge of maximum water temperatures, procedure for reporting abnormal water temperatures, demonstrating how to test for hot water and describing types [MEDICAL CONDITION] the process for reporting incidents. Per DON, they had been completing more than the 10 audits per week. Completed Nursing Competency audit tool questions provided and reviewed as well as staff answers on forms verify knowledge of information regarding burns, maximum water temperature, and how to physically assess water temperatures and reporting incidents, including time frame (immediately). 4. East Wing and West Wing weekly skin assessment calendars provided and reviewed. During an interview on 4/19/18 at 1:30 p.m., the Wound Treatment Nurse confirmed that she would be completing 5 skin assessment chart audits per week x 3 weeks, then monthly x 2 months. She stated that a skin assessment schedule for the nurses had been made but was being revised and the nurses were being in-serviced on completion of the skin assessments. The treatment nurse will be auditing for completion of the skin assessments as scheduled and for any abnormal findings. Skin assessment audit form to be used to audit the skin assessments to ensure completed, was also provided and reviewed. 5. During an interview on 4/19/18 at 11:15 a.m., the DON confirmed that she will be reporting the results of the audits and any negative findings during the QA meetings

Based on staff interview, record review, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program the facility failed to ensure reporting, during Quality Assurance and Performance Improvement (QAPI) committee meetings, of inconsistent monitoring and documentation of water temperatures in order to address and resolve the issue and to prevent the occurrence of unsafe hot water temperatures. The facility census was 122 residents. On 4/13/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on 4/13/18 at 6:40 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/9/18. The Immediate Jeopardy continued through 4/18/18, and was removed on 4/19/18. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on 4/18/18. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was identified with first and second [MEDICAL CONDITION] the lower extremities, buttocks and groin on the morning of 4/10/18 and was sent to an acute care hospital where she was admitted . Through the facility's investigation, it was determined that the resident had received a shower the evening prior, on 4/9/18. The facility monitored water temperatures in the residents' rooms and the common shower rooms on 4/10/18 and 4/11/18, all water temperatures were found to be less than 120 degrees Fahrenheit (F) at that time. A plumbing company was also contacted and provided onsite services on 4/10/18 and 4/12/18, which included adjusting the water mixing valves. However, unsafe water temperatures were identified on 4/13/18, after surveyor entrance. These unsafe water temperatures were found in five bathrooms, shared by nine resident rooms, with 14 residents occupying those nine rooms, and included water temperatures that ranged from 120.5 degree F to 126.5 degrees F. In addition to the elevated hot water temperatures, on 4/13/18, there was no system in place to monitor the temperature of the water flowing through the mixing valve, as the previous thermometer for monitoring the water temperatures had been removed. Further investigation revealed that the facility had failed to routinely monitor and log water temperatures, with the last documented water temperatures obtained on 2/23/18. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 CFR 483.25 Quality of Care, F689; 42 CFR 483.35 Nursing Services, F726; CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F689. A Credible Allegation of Compliance was received on 4/18/18. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/19/18. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of water temperature monitoring. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of facility' Policies and Procedures. Findings include: The facility had a Quality Assurance and Performance Improvement (QAPI) Program policy. The policy documented that the primary purpose of the QAPI program was to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of the residents. The policy also documented that the program was ongoing and comprehensive and that it involved the full range of services and departments in the facility. The facility's QAPI committee included the Administrator, Medical Director, Director of Nursing (DON), Admissions Director, Social Services, Dietician, Interim Dietary Manager, Activities Director, Medical Records, Therapy Director, Environmental Manager, Clinical Case Manager, Central Supply, and Maintenance Director. The QAPI committee met monthly on the third Thursday of each month. The facility utilized the TELS system, a computerized software system to help the maintenance department track and manage services and repairs. A review of the schedule set up in TELS revealed that testing and logging of hot water temperatures was set up to be completed weekly. During an interview on 4/13/18 at 10:30 a.m., the Maintenance Director stated that hot water temperatures were checked monthly in the TELS system but that he had not been checking as often as he was supposed to because of being pulled to do other things. During a subsequent interview on 4/18/18 at 12:10 p.m., the Maintenance Director stated maintenance staff utilized the mobile TELS system on their phones, which had a schedule of what was to be completed. He stated that he checked the TELS system daily as did maintenance staff person DD and that DD would record water temperatures on paper and he would review them but not log them into the TELS system because he was locked out of the login section (on the mobile TELS on his phone) and did not have access to a computer. During an interview on 4/17/18 at 2:07 p.m., maintenance staff DD stated that he had been working at the facility since (MONTH) (YEAR) and had been checking water temperatures once a week since he started. He stated that each week he would check one room at the front and one room at the rear of each hall, checking different rooms each week. He stated he would write the temperatures down and give them to the maintenance director to review. Maintenance staff DD also stated that he had been also checking the common shower rooms for the past month, but not when he first started, because he did not know he was supposed to. However, the Maintenance Director was only able to provide documentation of hot water temperatures for 10/6/17, 10/12/17, 10/19/17, 10/26/17, 11/2/17, 11/7/17 and 2/23/18, until 4/10/18. Resident (R) #1 was identified with first and second [MEDICAL CONDITION] the lower extremities, buttocks and groin on the morning of 4/10/18 and hospitalized . Through the facility's investigation, it was determined that the resident had received a shower the evening prior, on 4/9/18. The facility monitored water temperatures in the residents' rooms and the common shower rooms on 4/10/18 and 4/11/18, all water temperatures were found to be less than 120 degress F at that time. A plumbing company was also contacted and provided onsite services on 4/10/18 and 4/12/18, adjusting the water mixing valves. However, unsafe water temperatures above 120 degrees Fahrenheit (F) were identified on 4/13/18, after surveyor entrance, in five bathrooms, shared by nine resident rooms, with 14 residents occupying those nine rooms and water temperatures that ranged from 120.5 degrees F to 126.5 degrees F. In addition, on 4/13/18, there was no system in place to monitor the temperature of the water flowing through the mixing valve, as the previous mechanism for monitoring (thermometers taped to the water pipes) had been removed. Despite the Maintenance Director being included in the QAPI committee meetings, there was no evidence that the inconsistent monitoring and documentation of water temperatures and limited access to the TELS tracking system had been reported during the monthly QAPI committee meetings. Cross refer F689 The facility implemented the following actions to remove the Immediate Jeopardy On 4/14/18, a reviewed and accepted the Quality Assurance and Performance Improvement (QAPI) Committee Policy and Procedure. 1. On 4/10/18 the assigned Charge Nurse for the resident completed skin assessments on all residents who had received showers on 4/9/18 then a 100% skin assessment began on 4/13/18 and completed on 4/15/18. The results of the audit concluded no resident experienced any injuries resulting from water temperatures exceeding 110 degrees. This audit was completed by the Unit Manager, and Registered Nurse (RN)/Licensed Practical Nurse (LPN) Charge Nurses. The Wound Nurse will complete 5 skin assessment chart audits per week x 3 weeks, then monthly x 2 months. The assigned Licensed Charge Nurse for each shift will complete a minimum of 2 skin assessments per day. If any skin assessments are identified not being completed will be completed by the on-duty Charge Nurse assigned for the resident. 2. On 4/16/18, the Administrator and Director of Nursing conducted in-service training for Department Heads, Medical Director, Administration and Nursing Administration regarding the duties and responsibilities of the Quality Assurance and Performance Improvement Program to include water temperature safety for resident care including temperature monitoring for goal of less than 110 (F) and facility standards to include incident/accident prevention related to injury of resident skin. As of 4/16/18, the Administrator conducted the in-service with 10 of 10 Department Heads 100%, 1 of 1 Medical Director 100%, 1 of 1 Administration 100%, 1 of 1 Nursing Administration 100% completed QAPI in-service education. Newly hired staff will complete same QAPI education upon new hire orientation, annual, and when needed. 3. On 4/19/18, the QAPI Committee who consist of the Administrator, DON, Medical Director, Dietary Representative, Social Services Representative, Wound Care Representative, Clinical Care Coordinator/Minimum Data Set (MDS), Infection Control Representative, Restorative/Rehab Representative, Staff Development Representative, Environmental, Maintenance Representative, and Medical Records Representative, will be responsible for monitoring the outcomes of the information submitted during the monthly Quality Assurance (QA) meeting and during incidents requiring immediate QAPI process attention. The QA Committee will review the plan of correction and target dates from the immediate processes that were implemented during the water exceeding 110 degrees incident to assure quality resident care. 4. The Committee Chairperson/Administrator will be responsible for auditing the results of the monthly QA Committee Meeting. The Monthly QA Committee meets the 3rd Thursday of each month, the next scheduled meeting will be held 4/19/18. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. The Quality Assurance and Performance Improvement Program policy provided and reviewed and existing policy reviewed and was noted to be signed by Administrator on 4/14/18. During an interview on 4/19/18 at 11:15 a.m., the DON confirmed that 100% of skin audits had been completed on residents with no additional skin concerns identified. The facility's investigation of the incident regarding R#1 on 4/10/18 was provided and reviewed during the survey, including the skin audits that were conducted. No further concerns identified. During an interview on 4/19/18 at 12:10 p.m., the Maintenance Director confirmed that he had attended the QA meeting and the QAPI policy and procedure were reviewed and accepted on 4/14/18. During an interview on 4/19/18 at 3:11 p.m., the Administrator confirmed that the current QA and Performance Improvement (PI) policy was reviewed and accepted with no revisions. 2. During an interview on 4/19/18 at 11:15 a.m., the DON confirmed that she participated in conducting an in-service regarding duties and responsibilities of the QA and PI program, including water temperature safety and reporting concerns. During an interview on 4/19/18 at 12:10 p.m., the Maintenance Director confirmed that he received the in-service training regarding the duties and responsibilities of the QAPI program for water temperature safety. During an interview on 4/19/18 at 3:11 p.m., the Administrator confirmed she provided the in-service education to the department heads regarding duties and responsibilities of the QAPI committee, including the information regarding safe water temperatures. Interviews on 4/19/18 at 4:55 p.m. with Department Heads: Activity Director, MDS Coordinator, Social Services Director, BOM (Business Office Manager), Housekeeping Supervisor, Assistant Director of Social Services: confirmed that they were in-serviced regarding the TELS system, descriptions of burns, maximum water temperature, and notification of any unsafe water temperatures. All stated that they participate in the Partners Rounds and were now aware of the new addition of checking of water temperatures by touch with the daily rounds. All were knowledgeable of the system for maintenance notification and work orders to TELS- all with access now to submit work order requests, in addition to verbal notification. All participate in the QAPI meetings, monthly and more often is something comes up. Confirmed that all of QA has been involved and has input in the Immediate Jeopardy issue since 4/10/18 of R#1 and the water temperature issues- have been discussed. The Social Service Director and MDS coordinator confirmed that they had participated in the notification of residents and families of water temperatures, use of bed baths, and education on burns. 3. During an interview on 4/19/18 at 11:15 a.m., the DON confirmed that she will continue to be responsible for monitoring of outcomes of information submitted during the monthly QA meetings. During an interview on 4/19/18 at 12:10 p.m., the Maintenance Director confirmed that he will continue be responsible for monitoring of outcomes of information submitted during the QA meetings, including abnormal water temperatures. During an interview on 4/19/18 at 3:11 p.m., the Administrator confirmed that she would continue to be responsible for monitoring of outcomes of the information submitted during monthly QA meetings and during incidents that require immediate QAPI attention. 4. During an interview on 4/19/18 at 3:11 p.m., the Administrator confirmed that she would be responsible and would continue to audit the results of the monthly QA committee meeting.

Based on observation, interviews, record reviews and review of the facility's policy titled, Water Temperatures, Safety of. it was determined that the facility failed to routinely monitor for safe hot water temperatures in resident rooms on eight halls (100, 200, 300, 400, 500, 600, 700, 800) and in the four common shower rooms (East male, East female, West male, and West female), and failed to ensure safe hot water temperatures of less than 120 degrees Fahrenheit (F), in five bathrooms, shared by nine resident rooms, occupied by 14 residents. The sample size was six residents. On 4/13/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on 4/13/18 at 6:40 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/9/18. The Immediate Jeopardy continued through 4/18/18, and was removed on 4/19/18. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on 4/18/18. The Immediate Jeopardy is outlined as follows: Resident (R) #1 was identified with first and second [MEDICAL CONDITION] the lower extremities, buttocks and groin on the morning of 4/10/18 and was sent to an acute care hospital where she was admitted . Through the facility's investigation, it was determined that the resident had received a shower the evening prior, on 4/9/18. The facility monitored water temperatures in the residents' rooms and the common shower rooms on 4/10/18 and 4/11/18, all water temperatures were found to be less than 120 degrees Fahrenheit (F) at that time. A plumbing company was also contacted and provided onsite services on 4/10/18 and 4/12/18, which included adjusting the water mixing valves. However, unsafe water temperatures were identified on 4/13/18, after surveyor entrance. These unsafe water temperatures were found in five bathrooms, shared by nine resident rooms, with 14 residents occupying those nine rooms, and included water temperatures that ranged from 120.5 degree F to 126.5 degrees F. In addition to the elevated hot water temperatures, on 4/13/18, there was no system in place to monitor the temperature of the water flowing through the mixing valve, as the previous thermometer for monitoring the water temperatures had been removed. Further investigation revealed that the facility had failed to routinely monitor and log water temperatures, with the last documented water temperatures obtained on 2/23/18. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 CFR 483.25 Quality of Care, F689; 42 CFR 483.35 Nursing Services, F726; CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F689. A Credible Allegation of Compliance was received on 4/18/18. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/19/18. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of water temperature monitoring. This oversight process included the analysis of facility staff's conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility' Policies and Procedures. Findings include: The facility had a policy Water Temperatures, Safety of. The policy documented that water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees Fahrenheit (F), or the maximum allowable temperature per state regulation. (Per State Regulations water temperatures may not exceed 110 degrees Fahrenheit) The policy also documented that maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. The facility utilized the TELS system, a computerized software system to help the maintenance department track and manage services and repairs. A review of the schedule set up in TELS revealed that testing and logging of hot water temperatures was set up to be completed weekly. During an interview on 4/13/18 at 10:30 a.m., the Maintenance Director stated that hot water temperatures were checked monthly in the TELS system but that he had not been checking as often as he was supposed to because of being pulled to do other things. During a subsequent interview on 4/18/18 at 12:10 p.m., the Maintenance Director stated maintenance staff utilized the mobile TELS system on their phones, which had a schedule of what was to be completed. He stated that he checked the TELS system daily as did maintenance staff person DD and that DD would record water temperatures on paper and he would review them but not log them into the TELS system because he was locked out of the login section (on the mobile TELS on his phone) and did not have access to a computer. During an interview on 4/17/18 at 2:07 p.m., Maintenance Staff DD stated that he had been working at the facility since (MONTH) (YEAR) and had been checking water temperatures once a week since he started. He stated that each week he would check one room at the front and one room at the rear of each hall, checking different rooms each week. He stated he would write the temperatures down and give them to the Maintenance Director to review. Maintenance Staff DD also stated that he had been also checking the common shower rooms for the past month, but not when he first started, because he did not know he was supposed to. However, the Maintenance Director was only able to provide documentation of hot water temperatures for 10/6/17, 10/12/17, 10/19/17, 10/26/17, 11/2/17, 11/7/17 and 2/23/18, until 4/10/18, which did not reveal any water temperatures greater than 120 degrees. On the morning of 4/10/18 Resident (R) #1 who resided in room [ROOM NUMBER], had a [DIAGNOSES REDACTED]. The Residents most recent Minimum Data Set Annual assessment dated [DATE], documented that R#1 required extensie assistance for bed mobility requiring one person physical assistance and was totally dependent for hygiene requiring one person physical assistance and was identified with first and second [MEDICAL CONDITION] the lower extremities, buttocks and groin and hospitalized . Through the facility's investigation, it was determined that the resident had received a shower from Certified Nursing Assistant (CNA) AA, in the West female shower room, on the evening prior, on 4/9/18. Record review revealed on 4/10/18 at 9:12 a.m. Nursing Progress Note that documented blister like wounds that were noted on the resident's lower extremities, buttocks area and redness of skin noted on lower abdominal skin folds. The Physician ordered for the resident to be sent to the hospital for further evaluation and treatment. Vital signs were stable with no distress noted. The Medical Director examined R#1 on 4/10/18, prior to the resident being sent to the hospital. The Physician's note documented second degree burn like blisters to the left inner groin, left leg and left foot; first degree burn-like changes to the skin of the thigh. There is a questionable deeper degree of burn-like changes on the inferior edge of the blistered area of the leg, etiology very likely liquid. The only other possibility may be bullous impetigo, but not as likely considering the [DIAGNOSES REDACTED] of the thigh as described. The progress note also provided the additional detailed information: on the anterior surface of the left thigh there is a large flat [DIAGNOSES REDACTED]tous area. On the anteromedial surface of the left leg is a longitudinal blister approximately 12 inches by 3 inches with the inferior edge of the skin darkened to black in color. On the inner surface of the left foot is an area 4 by 4 centimeters (cm) that appears to be a broken blister with underlying [DIAGNOSES REDACTED]tous skin. On the inner surface of the left groin there is an [DIAGNOSES REDACTED]tous skin and a few unbroken blistered areas. The progress note documented that the areas could be treated with [MEDICATION NAME] cream and Foley catheter inserted to prevent contamination. However, the family requested, and the Physician agreed to transfer the resident to the hospital for further evaluation and treatment. During an interview on 4/17/18 at 10:20 a.m. the Medical Director revealed that he had received a call on 4/10/18 about the resident having blisters and nursing staff had mentioned she had a shower the night before. He stated that the areas initially looked like some type of a scald/burn injury. He stated that he did think about bullous impetigo but the [DIAGNOSES REDACTED] made him think about a scalding. He stated that he had been taking care of R#1 since (YEAR) and had not witnessed any of these skin issues on her before 4/10/18. He agreed to send the resident to the hospital at the family's request. R#1 was transferred to the hospital on [DATE] and was admitted . A review of the hospital Physicians' notes revealed documentation of first and second [MEDICAL CONDITION] the left leg, right ankle and buttocks, with some blisters broken and some fluid filled. During interviews on 4/13/18 at 6:06 p.m. and on 4/17/18 at 2:07 p.m., and review of written statement, Certified Nursing Assistant (CNA) AA (7 p.m. to 7 a.m. shift) confirmed that she had given the resident a shower in the West female shower room on 4/9/18 around 11:00 p.m. or 11:30 p.m. She stated that she checked the water with her hands and was in the shower with the resident, so the water splashed on her too. CNA AA stated that the water did not feel too hot, that it was lukewarm, and the resident did not show any signs of pain or discomfort. CNA AA stated that she checked on the resident routinely, about every two hours during the rest of the shift and there was no noted redness or blisters until the last time she checked her on 4/10/18 around 6:30 a.m., at which time she notified the nurse. There is no evidence that the resident was exposed to a potential source to [MEDICAL CONDITION] prior to or after the shower on 4/9/18. The facility monitored water temperatures in the residents' rooms and the common shower rooms on 4/10/18 and 4/11/18, all water temperatures were found to be less than 120 degrees F. A plumbing company was also contacted and provided onsite services on 4/10/18 and 4/12/18, adjusting the water mixing valves. However, unsafe water temperatures were identified on 4/13/18, after surveyor entrance, and during an observation on 4/13/18, starting at 10:30 a.m. with the Maintenance Director, revealed that water temperatures were greater than 120 degrees F, with the facility's thermometer, in the following rooms: On 4/13/18 at 1:12 p.m., the hot water temperature in the shared bathroom sink between rooms [ROOM NUMBERS] was 126.2 degrees F. On 4/13/18 at 1:16 p.m. the hot water temperature in the shared bathroom sink between rooms [ROOM NUMBERS] was 124.5 degrees F. On 4/13/18 at 1:20 p.m. The hot water temperature in the shared bathroom sink between rooms [ROOM NUMBERS] was 120.5 degrees F. On 4/13/18 at 1:45 p.m. the hot water temperature in the shared bathroom sink between rooms [ROOM NUMBERS] was 120.5 degrees F. On 4/13/18 at 1:57 p.m. the hot water temperature in the bathroom sink for room [ROOM NUMBER] was 121.4 degrees F. These five bathrooms accommodated nine resident rooms with 14 residents occupying the rooms. Of the 14 residents residing in the rooms, nine were capable of accessing the water, with four of those nine residents being cognitively impaired. During an observation on 4/13/18 at 12:48 p.m. of the boiler room, where the water tanks were located, there was no device in place to monitor or measure the temperature of the mixture of the hot and cold water passing through the mixing valve, that serviced the resident rooms and common shower rooms. During an interview on 4/18/18 at 12:10 p.m. the Maintenance Director stated that there were thermometer probes taped to the pipes to monitor the water temperatures but that they had been removed sometime the week prior, because they need the extra thermometers to keep checking the water temperatures because the ones they had were being misplaced and/or dropped. The facility implemented the following actions to remove the Immediate Jeopardy 1. The facility began hourly water temperature checks on Friday, 4/13/18 at 10:30 p.m. The hourly water checks consisted of eight rooms per hallway plus 1 stall per shower room to be completed until a 24-hour consecutive period of water temperatures not exceeding 110 degrees was met. The facility has continued to record these hourly water temperatures up to 7:00 a.m. on 4/18/18. The last water temperature reading above 110 degrees was on 4/16/18 at approximately 3:00 p.m. with the surveyor and Maintenance Director, the recorded temperature reading was 110.4. On 4/17/18 the plumbing company shut the hot water off at 11:00 a.m. and was turned back on at 8:35 p.m. with the water temperature reading 80 degrees. The facility began hourly water temperature checks again at 10:00 p.m. with the water temperature reading being 95 degrees and continued until 7:00 a.m. the next morning with a water temperature reading of 105 degrees. 2. As of 4/18/18 at 8:00 a.m. the facility began a hot water check schedule as follows: 4x's a day, x48 hours, then l x daily x2 weeks to assure water temperatures do not exceed 110 degrees. 3. The Wound Nurse will complete 5 skin assessment chart audits per week x 3 weeks, then monthly x 2 months. The assigned Licensed Charge Nurse for each shift will complete a minimum of 2 skin assessments per day. If any skin assessments are identified not being completed will be completed by the on-duty Charge Nurse assigned for the resident. 4. On 4/14/18, the Director of Nursing reviewed and accepted the existing policy & procedure, related to Incidents & Accidents/Investigating & Reporting relating Water Temperature Safety with the goal of water temperature to be below 110 (F). 5. As of 4/16/18, the Director of Nursing will audit daily 100% of Incident/Accident Reports. The audit will assure accuracy of documentation, such as Care Plans updated, physician and family notification, new orders carried out, new medications ordered and received timely, incident report documentation complete in the system, nursing note complete in the system, CNA documentation complete in the system, therapy notified, if any/to all applicable. The weekend Registered Nurse (RN) Supervisor will review all incident/accident reports occurring over the weekend and address issues as necessary. The RN Weekend Supervisor will notify the DON and/or Administrator of any incident/accident requiring Administrative notification. The Director of Nursing will audit 100% of Incident/Accident Reports daily x 2 months. On 4/14/18 the Director of Nursing reviewed orientation/competencies checklist and revised. The orientation information was revised to include the following information: o The Maintenance Department is responsible for checking thermostats and temperature controls in the facility and recording these checks in the TEL's system weekly. o During the weekly checks, a minimum of 2 rooms per hallway and 1 stall per shower room will be check and recorded, each week the room selection of temperature recording will change. o Any temps exceeding 110 degrees the Maintenance Department will notify the Administrator immediately. o The Maintenance Department will shut off the hot water supply to the area of the water exceeding 110 degrees and begin identifying and correcting the problem area. o If affected area includes 5 rooms or more: o The Nursing Department will be notified and the Shower Rooms will be closed immediately and bed baths implemented immediately. o Bed baths will continue until water temps maintain a temp of 110 degrees or below o Shower rooms will remain closed until water temperatures are maintained at 110 degrees or below o If the affected area is 4 rooms or less: o The hot water source (sink) in the resident room will be shut off until the water temperatures are maintained at 110 degrees or below o Water temperatures (a minimum of 2 rooms per hallway and 1 stall per shower room) will be recorded hourly until the water temperatures are maintained at 110 degrees or below o Water temperatures will continue to be monitored and recorded daily x 2 weeks to assure that water temperatures have stabilized to maintain at 110 degrees or less All Other Staff o When providing resident care, the water temperature shall be measured by warm water to the touch, (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water). Staff shall report this finding to the immediate supervisor. o In common areas, any water temperature shall be measured by warm water to the touch and shall be reported to an immediate supervisor of any negative findings. o First-[MEDICAL CONDITION] to the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. o Second-[MEDICAL CONDITION] the two first layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. o Third-[MEDICAL CONDITION] the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain maybe caused by patches of first and second-[MEDICAL CONDITION] third [MEDICAL CONDITION] dry leathery skin. Skin may appear charred or have patches that appear white, brown, or black. 6. On 4/13/18, the facility began conducting in-service training, for RN's, Licensed Practical Nurse (LPN)'s, CNA's. This in-service training was conducted by the Director of Nursing, Performance Improvement Coordinator, and Nurse Supervisor. The in-service information included: When providing resident care, the water temperature shall be measured by warm water to the touch, (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water). Staff shall report this finding to the immediate supervisor. In common areas, any water temperature shall be measured by warm water to the touch and shall be reported to an immediate supervisor of any negative findings. a. First-[MEDICAL CONDITION] to the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. b. Second-[MEDICAL CONDITION] the two first layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. c. Third-[MEDICAL CONDITION] the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain maybe caused by patches of first and second-[MEDICAL CONDITION] third [MEDICAL CONDITION] dry leathery skin. Skin may appear charred or have patches that appear white, brown, or black. This in-service training was conducted by the Performance Improvement Coordinator, DON, and/or Nurse Supervisor. Staff unavailable to attend training will not be allowed to perform resident care until completion of the in-service training. 23 of 29 Licensed Staff, 79% and 44 of 51 CNA's, 86% have completed the Water Temperature Protocol education. Newly hired staff will complete education related to safe water temperatures and Incident & Accident/Investigating & Reporting upon new hire orientation, annual, and when needed. On 4/15/18 the facility began conducting Incident & Accident/Investigating & Reporting EMR Documentation in-service training for RN's, LPN's. The in-service covered the following information: accuracy of documentation, such as Care Plans updated, physician and family notification, new orders carried out, new medications ordered and received timely, incident report documentation complete in system, nursing note complete in system, CNA documentation complete in system, therapy notified, if any/to all applicable. This in-service training was conducted by the Performance Improvement Coordinator, DON, and/or Nurse Supervisor. Staff unavailable to attend training will not be allowed to perform resident care until completion of the in-service training. 23 of 32 Licensed Staff 72%. Newly hired staff will complete education related to safe water temperatures and Incident & Accident/Investigating & Reporting upon new hire orientation, annual, and when needed. 7. As of 4/14/18, the Incident/Accident Log will be monitored weekly by DON x 4 weeks, and then by Unit Manager(s) weekly of their assigned wings, for benchmark trending. The Incident/Accident Log will be monitored specifically of incidents related to hot water temperature incidents. 8. The DON will utilize the incident tracking/trending for Quality Assurance/Performance Improvement (QAPI) monthly to assist with identifying and managing any increase in Incidents & Accidents and the types of Incidents/Accidents. The Monthly Quality Assurance (QA) Committee meets the 3rd Thursday of each month, the next scheduled meeting will be held 4/19/18. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Timeline of events, starting on 4/10/18 provided and reviewed during the course of the survey through record review and staff interview and water temperature checks. Review of the temperature logs revealed that temperatures were monitored on 4/13/18, starting at 3 p.m. and continued hourly until 6:30 p.m. 6:30 p.m. checks revealed water temperatures >110 degrees, up to 120 degrees, but not exceeding 120 degrees. Per continued review of logs- water temperature checks started again at 10:30 p.m. Per review of 10:30 p.m. temperature logs- no reading exceeded 120 degrees but did exceed 110 degrees. Out of order signs were observed posted on the 4 shower room door entrances during observations A plumbing service technician was observed in the building on 4/13/18 at 10:30 p.m. to service the hot water equipment and the water was shut off. Invoices from the previous plumber visits on 4/10/18 and 4/12/18 were provided for review. An invoice dated 4/10/18 documented the following: rooms with water temps over 110 degrees, but not in the shower room. Customer will trace lines in ceiling to see if they are untampered. An invoice dated 4/12/18 documented water temperatures fluctuating- shut off valves in boiler room and traced lines to label pipes in boiler room. Need to continue tracing lines in ceiling to look for potential source of mixing. On 4/13/18, water was shut off from 11 p.m. to 4/14/18 12 a.m. while plumber provided service. Per review of the water temperature logs, hourly water temperature checks resumed at 12 a.m. on 4/14/18 and are logged hourly per review of water temperature log forms through 4/16/18 at 10:00 a.m. Hot water was shut off at 10:15 a.m. on 4/16/18. Hourly checks resumed on 4/16/18 at 11 a.m. and continued through 4/17/18 at 1 p.m., after which the water was turned off while Plumbers worked on the water system. The hourly checks resumed on 4/17/18 at 10 p.m. and continued through 4/18/18 at 7 a.m. with all readings remaining below 110 degrees. During an interview on 4/19/18 at 12:10 p.m., with the Maintenance Director confirmed that the chain of events regarding water temperature monitoring since 4/10/18, closing of the shower rooms, and servicing provided by the plumbing company. The maintenance director also confirmed that he received in-service training regarding checking water temperatures, water checks on skin, and descriptions of burns. He provided a small quick reference sheet he kept on himself to refer back to. He confirmed that he has been checking the boiler room for temperatures daily as the first thing he does when he gets out of his truck. Per Maintenance Director, the plumbers finished their work on 4/18/18 and as of 4/19/18 at 8:00 a.m. water temperature checks, all water temperatures were less than 110 degrees. The plumbers installed one new mixing valve and two new thermostats. Further interview revealed that the Maintenance Director confirmed that the water temperatures will continue to be checked and monitored four times a day x 48 hour, then one time daily for two weeks. 2. Review of the water temperature logs revealed that water temperature monitoring continued four times daily starting on 4/18/18 at 8 a.m. with all temperatures remaining below 110 degrees. During an interview on 4/19/18 at 3:11 p.m., the Administrator confirmed her knowledge of the incident on 4/10/18 with resident #1 and her involvement in the investigation into the possible cause of the blisters, including monitoring of the water temperatures and identification of elevated water temperatures, development of a plan to address and implementation of that plan and in-servicing of staff. Timeline of events provided and reviewed. She confirmed that she helped develop and participate in the in-servicing of staff (especially the department heads) on water temperature testing, burns, signs of pain, incident reporting, and Quality Assurance (QA). 3. During an interview on 4/19/18 at 1:30 p.m., the Wound Treatment Nurse confirmed that she would be completing 5 skin assessment chart audits per week x 3 weeks, then monthly x 2 months. She stated that a skin assessment schedule for the nurses had been made but was being revised and the nurses were being in-serviced on completion of the skin assessments. The treatment nurse will be auditing for completion of the skin assessments as scheduled. 4. During an interview on 4/19/18 at 11:15 a.m., the DON confirmed that she had reviewed and accepted the existing policy and procedure related to Incidents and Accidents/Investigating and Reporting relating Water Temperature Safety. The policy was provided for review and included the DON's signature, dated 4/14/18. 5. During an interview on 4/19/18 at 11:15 a.m., the DON confirmed that she has been completing a 100% audit of Incident/Accident Reports. The audit logs were provided for review. The DON also verified that she has reviewed the revised orientation/competencies checklist. She stated that since the previous staff development nurse is no longer here, she (the DON) and the Performance Improvement (PI) nurse will oversee the skills competency forms and check offs to ensure are completed by the preceptor and reviewed. She confirmed that she participated during the in-servicing of staff and educating staff on correct water temperatures, how to check for water temperature prior to care and descriptions [MEDICAL CONDITION] reporting of incidents. During an interview on 4/19/18 at 12:10 p.m., the Maintenance Director reviewed the process of reporting abnormal water temperatures. Staff on duty, even at night, are to notify him (he is on-call 24 hours a day) and then he is to notify the Administrator. He was able to correctly state the procedure regarding what to do, depending on the number of rooms involved. Per Maintenance Director, if he is not on call, then another maintenance staff person will be. For example, after today (4/19/18), maintenance staff person GG will be on call, due to the Maintenance Director being out of town. Review of the midnight census form for 4/13/18 and in-service logs of residents' and their responsible party's notifications revealed that residents and/or their responsible parties were notified on 4/14/18 of bed baths being provided instead of showers, staff were aware of proper procedure/technique of assuring proper water temperatures prior to resident use and risk factors for scalding/burns. All responsible parties notified via phone except for 6 that were identified with nonworking numbers or a number that would not accept the call. Those responsible parties were notified via mail per review of copy of letter sent out. 6. Review of in-service records revealed an in-service was conducted on 4/13/18 to notify and educate staff on monitoring of water temperatures during direct care at all times, staff were provided with copy of the water temperature policy and descriptions of first, second, and third [MEDICAL CONDITION] reporting any negative findings to the supervisor with a total of 22 of 23 Administrative staff, 23 of 29 Licensed Nursing staff, 44 of 51 Certified Nursing Assistants, 2 of 2 Minimum Data Set (MDS) Coordinators, 10 of 10 Respiratory Therapists, 16 of 17 Housekeeping staff, 8 of 11 Physical Therapists and 11 of 13 Dietary Staff educated. Nursing staff were observed being in-serviced at the East side nursing station that bed baths would be given and no showers were to be provided. Staff not in-serviced will be provided in-service before working their first shift. Observed information [MEDICAL CONDITION] on the computer kiosk on the 600 hall during an observation on 4/13/18 at 8:30 p.m. The DON verified through interview on 4/19/18 at 11:15 a.m. that she provided and participated in the in-servicing of staff on 4/13/18. Record review revealed that on 4/15/18 the facility provided in-service training for RN's, LPN's for accuracy of care plans, Physician and family notification with 23 of 32 Licensed Staff in-serviced. Staff not in-serviced will be provided the in-service before working their first shift. Review of in-services sign in sheets and in-service information confirmed staff had received education on accident and incident reporting and investigation involving resident safety related to safe water temperatures and all other accidents and incidents. Any staff that was not able to attend in-service training will not be allowed to perform resident care until completion of the in-service. The following interviews revealed that the staff were able to verbalize how to check the hot water temp using touch and immediately reporting to the immediate supervisor if it is abnormal before giving a resident a shower or a bed bath. They all knew the water should not exceed 110 degrees F. They were also to describe first, second and third-degree burns. They showed the surveyor a small quick reference card pertaining to hot water procedures. Staff were also able to describe signs and symptoms of pain a resident could display. The nurses verbalized a new process that would be taking place regarding skin assessments. They would be doing two skin assessments every shift as prompted in the computer program, Blue Strata. They had been to in-service given by the DON which was started yesterday. They knew how document in Blue Strata any incidents and reporting incidents to the Administrator or Director of Nursing: On 4/19/18 at 10:30 a.m.- LPN II 100/300 Halls, CNA JJ 300 Hall at 10:32 a.m., CNA KK 300 Hall at 10:40 a.m., CNA LL 400 Hall at 10:45 a.m., CNA MM 400 Hall at 10:50 a.m., CNA NN 200 Hall at 10:55 a.m., CNA OO in orientation on 200 Hall at 11:00 a.m., CNA PP 300 Hall at 11:05 a.m., CNA QQ Respiratory Unit at 11:10 a.m., CNA RR 400/100 Halls at 11:15 a.m., RN SS 400 Hall at 11:25 a.m., Housekeeper TT at 11:35 a.m., Housekeeper UU at 11:45 a.m., Housekeeper VV at 11:52 a.m., CNA WW 600 Hall at 11:58 a.m., RN agency staff XX 800 Hall at 12:10 p.m., LPN YY 600 Hall at 12:23 p.m., CNA AAA 600 Hall at 12:30 p.m., CNA in orientation ZZ at 12:37 p.m. CNA, shower team BBB at 12:44 p.m., the Wound Treatment Nurse at 1:30 p.m., 700 Hall LPN CCC at 2:11 p.m., Respiratory Unit LPN DDD at 2:20 p.m., Respiratory Therapist EEE at 2:30 p.m.<B

Based on review of facility records, review of resident medical records, observations, and staff interviews, the facility failed to ensure that menus for residents having physicians ' orders for ground consistency specified the amount and consistency of meat to be served, and failed to ensure that staff were knowledgeable about proper procedures for food preparation and service regarding food form, for five (5) residents (#s 2, 3, 4, 6 and 7), who had physicians ' orders for ground meat diets or house ground diets, of thirteen (13) sampled residents. This failure resulted in a high potential for serious harm for these five (5) sampled residents. Further, residents were identified at risk based on review of the Centers for Medicare and Medicaid Services Form 672, which denoted that sixty-five (65) residents required mechanically altered diets, either pureed or all-chopped food. According to review of the facility ' s Diet Listing, fifty-two (52) of these sixty-five (65) residents required ground meat and/or foods, thus placing all fifty-two (52) residents at potential risk for serious harm. It was therefore determined that an immediate and serious threat to resident health and safety existed as of 10/30/2010, and was removed on 12/09/2010, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. Findings include: A review of the facility's Saturday Week #3 Fall-Winter Menus revealed that on October 30, 2010, the planned supper menu for residents receiving regular diets listed the meat being served as beef tips over noodles. For the ground diets, the meat was to be three ounces of ground beef tips. On December 7, 2010, the Tuesday Week #1 Fall-Winter Menus had a planned supper menu of homemade beef stew listed as the meat for regular diets. The menu for "ground" consistency read 6 ounces (soft veggies) and did not denote the amount nor the consistency of meat to be served. Interview with dietary staff "AA" on 12/8/10 at 4:35 p.m. revealed that she had prepared the evening meal on 12/7/10. She stated that when she saw the breakdown of the "ground" diet menu for this meal on this date, she was not sure how to prepare the meat for this diet, since the menu did not specify what consistency the meat should be. She said she asked the Dietary Manager if the meat should be ground since the menu just said soft vegetables and he told her he was not sure either, and just to serve the meat in the stew whole. She stated that she had never heard of a dietetic manual or was not aware of how to utilize this manual till today. The Registered Dietician stated on 12/8/10 at 4:10 p.m., that for any resident with a ground meat diet order, all meat should be in ground consistency. The facility's New England Diet Manual for Extended care documented that whole pieces of meat should be avoided for "ground" diets. The Registered Dietician stated during an interview on 12/10/10 at 2:30 p.m., that since 12/8/10, she had revised the menu for homemade beef stew, for ground diets, to read 6 ounces ground meat with soft veggies. She stated that a typographical error had been made on the original menu, in that the ground meat had been left off of the menu for homemade beef stew for the ground diets. Resident #2 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet of beef stew which contained whole pieces of beef; however, the diet order for this resident was for regular/ground. Resident #3 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet with whole pieces of beef in the stew; however, the diet order for this resident was for a house/ground diet. Resident #4 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet with whole pieces of beef in the stew; however, the resident's diet order was for house/ground diet with large portions. Resident #6 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet with whole pieces of beef in the stew; however, the resident's diet order was for house/ ground meat. Resident #7 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet with whole pieces of beef in the stew; however, the resident's diet order was for house/ground meat. Refer to additional information at F365. An immediate and serious threat to resident health and safety was determined to be removed on December 9, 2010, when the facility completed the following steps: With respect to all residents who may be affected: a. On 12/08/10, the Regional Director for Nutritional Services re-educated the center's Dietary Manager and Registered Dietician on proper food form and menu consistency. b. On 12/08/10, training was begun for dietary employees who were on duty regarding re-education on how to prepare and serve resident meals with the emphasis on meat food form based upon the The New England Diet Manual for Extended Care. c. On 12/08/10, training was begun regarding any dietary employee not on duty regarding re-education over the telephone by the center's Registered Dietitian. No employee in dietary who was initially trained by telephone will be allowed to report to duty until also re-educated in person on proper food form and following menus by the Registered Dietician. d. On 12/08/10, training was begun for all nursing staff, to include licensed nursing staff and certified nursing staff, regarding re-education on proper food form and following tray cards. No nursing employee will be allowed to return to duty until re-educated on proper food form, and a manager will be stationed at the employee time clock to ensure that no nursing employee reports to duty until re-educated. e. On 12/08/10, the Regional Director of Nutritional Services reviewed the center's menus with the Dietary Manager and Registered Dietician to ensure that proper food form was prepared as indicated by the menus, and any menu that was confusing was revised and/or eliminated immediately to ensure the proper food form. f. On 12/08/10, the Registered Dietician has reviewed the diet orders of all residents in the center for the appropriate food form. g. On 12/08/10, the Dietary Manager validated the resident diet orders against the residents' tray cards for the proper food form. With respect to ongoing systemic measures: a. On 12/08/10, the dietary manager or a cook began the process of checking each tray on the tray line to ensure each diet food form is prepared correctly per the menu and will document the findings in the tray line audit tool. b. On 12/08/10, a licensed nurse or certified aide began the process of checking each tray before it is served for the proper food form and will document the findings on the audit tool. c. On 12/08/10, the Regional Director of Nutritional Services will review, on a quarterly basis, the center's menus with the Dietary Manager and Registered Dietician to ensure the proper food form and menu are prepared as indicated by the menus. d. On 12/08/10, any menu that is confusing will be revised or eliminated immediately to ensure the proper food form. e. On 12/08/10, upon admission and readmission of a resident at the center, the Licensed Nurse will validate with the admitting physician the proper food form for the resident on the diet order. With respect to quality assurance measures: a. On 12/08/10, an Ad hoc Performance Improvement Meeting was held with the Medical Director to discuss and further develop the plan related to proper food form and education of the staff. This will be presented at the next Performance Improvement Committee meeting scheduled for Wednesday, December 15, 2010. b. On 12/08/10, the center's administrator will begin reviewing the audit tools three times per week for four weeks, then as determined by the Performance Improvement Committee. Even though the facility had implemented the interventions referenced above, a determination could not be made that the facility had implemented an ongoing plan to ensure that the facility's system for providing the correct food form, and for the monitoring of residents' ordered diets, was effective. Therefore, the non-compliance continues, but the scope and severity is reduced to an "E" level.

Based on review of facility records, resident medical records review, interviews with family, emergency medical technicians, and staff, it was determined the facility failed to provide food in a form that met the individual needs of six (6) sampled residents ("A", #2, #3, #4, #6 and #7) of 13 sampled residents. This failure resulted in serious harm (death) for Resident "A" and had a high potential for serious harm for the five sampled residents who had orders for ground meat diets or house ground diets that were reviewed. Additionally, further residents were identified at risk based on review of the Centers for Medicare and Medicaid Services (CMS), Form 672, that denoted 65 residents in the facility required mechanically altered diets, either pureed or all chopped food. Of these 65, according to review of the facility's Diet Listing, 52 residents required gound meat and/or foods, thus all 52 of these residents would be at potential risk for serious harm. It was determined that an immediate and serious threat to resident health and safety existed as of 10/30/10 and was removed on 12/09/10, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. Findings include: A review of the facility's Saturday Week #3 Fall-Winter Menus revealed that on October 30, 2010, the planned supper menu for residents receiving regular diets listed the meat being served as beef tips over noodles. For the ground diets, the meat was to be three ounces of ground beef tips. On December 7, 2010, the Tuesday Week #1 Fall-Winter Menus had a planned supper menu of homemade beef stew listed as the meat for regular diets. The menu for "ground" consistency read 6 ounces (soft veggies) and did not denote the amount nor the consistency of meat to be served. The Registered Dietician stated during an interview on 12/10/10 at 3:00 p.m., that since 12/8/10, she had revised the menu for homemade beef stew, for ground diets, to read 6 ounces of ground meat with soft veggies. She stated that a typographical error had been made on the original menu, in that the ground meat had been left off of the menu for homemade beef stew, for the ground diets. A record review was conducted and revealed Resident "A" was admitted to the facility on [DATE]. The speech therapist's notes of 10/9/10 documented that the resident had poor safety awareness, poor attention to task and poor orientation. The resident was on a regular diet on the initial admission to the facility. The resident was admitted to the hospital on [DATE], with a [DIAGNOSES REDACTED]. An interview with the family of the resident on 11/10/10 at 4:10 p.m. revealed that while the resident was in the hospital he had received a diet of ground consistency. He was readmitted to the facility on [DATE] with a physician's orders [REDACTED]. Despite the physician's orders [REDACTED]. The facility served beef tips and noodles, that had chunks of meat that were not ground served to residents. The facility failed to provide the form of meat that was ordered. A review of documentation in Resident "A's" nursing notes, dated 10/30/10 at 6:40 p.m., revealed the licensed staff person documented that she had been called to the resident's room at that time by a certified nursing assistant (CNA). The resident was found unresponsive in bed. Cardiopulmonary Resuscitation was initiated. The nurse documented that 911 was called at 6:42 p.m.. According to the emergency trip report of 10/30/10, emergency medical technicians arrived to the facility at 6:45 p.m. to transport the resident to the hospital and provide emergency care. The trip report documentation revealed that the resident's airway was obstructed and large chunks of food were suctioned out of the airway. On 12/7/10 at 2:45 p.m., interview with an emergency medical technician revealed that the resident's airway was blocked by what looked like chunks of beef. Interview with the family member of Resident "A" on 11/10/10 at 4:10 p.m. revealed the following information. When the family member got to the hospital on the night of 10/30/10, she was told by the physician that the resident had aspirated food and that the food had been packed in his esophagus. She stated that she was told that the emergency medical technicians had suctioned food out of the resident's airway en route to the hospital. The resident later expired on 10/31/10 at 12:56 p.m. in the hospital with a [DIAGNOSES REDACTED]. 2. Resident #2 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet of beef stew which contained whole pieces of beef; however, the diet order for this resident was for regular/ground. The resident had a 11/10/10 plan of care for dysphasia with an intervention to provide the resident with the appropriate diet and consistency. 3. Resident #3 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet with whole pieces of beef in the stew; however, the diet order for this resident was for a house/ground diet. The resident was observed at that time and date to have missing front teeth. 4. Resident #4 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet with whole pieces of beef in the stew; however, the resident's diet order was for house/ground diet with large portions. The resident had a [DIAGNOSES REDACTED]. 5. Resident #6 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet with whole pieces of beef in the stew; however, the resident's diet order was for house/ ground meat. 6. Resident #7 was observed on 12/07/10 during supper between 5:52 p.m. and 6:20 p.m. to have been served a diet with whole pieces of beef in the stew; however, the resident's diet order was for house/ground meat. The resident had a 10/07/10 plan of care related to difficulty swallowing with an intervention to provide the therapeutic diet plan as ordered per the physician. During an interview with the Registered Dietician on 12/8/10 at 4:10 p.m., said that for any residents with a ground meat diet, all meat should be in ground consistency. She further stated that a typographical error had been made on the original menu, in that the ground meat had been left off of the menu for homemade beef stew, for the ground diets. Cross refer to F361. Based on the above, Resident "A" had a physician's orders [REDACTED]. On 10/30/2010, Resident "A" was served beef tips with chunks of meat which were not ground, was later found unresponsive, and required the initiation of Cardiopulmonary Resuscitation and notication of EMS. The resident's airway was found to be obstructed with large chunks of food, which were described as having the appearance of beef chunks, suctioned out of the airway. The resident later expired. Despite this fact, during the survey, five (5) residents who had physicians' orders specifying food of a ground consistency were served whole pieces of beef in beef stew. An immediate and serious threat to resident health and safety was determined to be removed on December 9, 2010, when the facility completed the following steps: With respect to all residents who may be affected: a. On 12/08/10, the Regional Director for Nutritional Services re-educated the center's Dietary Manager and Registered Dietician on proper food form and menu consistency. b. On 12/08/10, training was begun for dietary employees who were on duty regarding re-education on how to prepare and serve resident meals with the emphasis on meat food form based upon the The New England Diet Manual for Extended Care. c. On 12/08/10, training was begun regarding any dietary employee not on duty regarding re-education over the telephone by the center's Registered Dietitian. No employee in dietary who was initially trained by telephone will be allowed to report to duty until also re-educated in person on proper food form and following menus by the Registered Dietician. d. On 12/08/10, training was begun for all nursing staff, to include licensed nursing staff and certified nursing staff, regarding re-education on proper food form and following tray cards. No nursing employee will be allowed to return to duty until re-educated on proper food form, and a manager will be stationed at the employee time clock to ensure that no nursing employee reports to duty until re-educated. e. On 12/08/10, the Regional Director of Nutritional Services reviewed the center's menus with the Dietary Manager and Registered Dietician to ensure that proper food form was prepared as indicated by the menus, and any menu that was confusing was revised and/or eliminated immediately to ensure the proper food form. f. On 12/08/10, the Registered Dietician has reviewed the diet orders of all residents in the center for the appropriate food form. g. On 12/08/10, the Dietary Manager validated the resident diet orders against the residents' tray cards for the proper food form. With respect to ongoing systemic measures: a. On 12/08/10, the dietary manager or a cook began the process of checking each tray on the tray line to ensure each diet food form is prepared correctly per the menu and will document the findings in the tray line audit tool. b. On 12/08/10, a licensed nurse or certified aide began the process of checking each tray before it is served for the proper food form and will document the findings on the audit tool. c. On 12/08/10, the Regional Director of Nutritional Services will review, on a quarterly basis, the center's menus with the Dietary Manager and Registered Dietician to ensure the proper food form and menu is prepared as indicated by the menus. d. On 12/08/10, any menu that is confusing will be revised or eliminated immediately to ensure the proper food form. e. On 12/08/10, upon admission and readmission of a resident at the center the Licensed Nurse will validate with the admitting physician the proper food form for the resident on the diet order. With respect to quality assurance measures: a. On 12/08/10, an Ad hoc Performance Improvement Meeting was held with the Medical Director to discuss and further develop the plan related to proper food form and education of the staff. This will be presented at the next Performance Improvement Committee meeting scheduled for Wednesday, December 15, 2010. b. On 12/08/10, the center's administrator will begin reviewing the audit tools three times per week for four weeks, then as determined by the Performance Improvement Committee. Even though the facility had implemented the interventions referenced above, a determination could not be made that the facility had implemented an ongoing plan to ensure that the facility's system for providing the correct food form, and for the monitoring of residents' ordered diets, was effective. Therefore, the non-compliance continues, but the scope and severity level is reduced to an "E" level.