Every finding on record at Salyersville Nursing and Rehabilitation Center

Based on interview, record review, and review of the facility's documentation and policy, the facility failed to ensure professional standards of nursing practice were maintained regarding the storage, tracking, and reconciliation of scheduled controlled substances for 1 of 1 residents sampled for narcotic medication out of the total sample of 10 (Resident (R)43). The findings include: Review of the facility's policy titled, Medication Administration Standards of Practice, last revised 03/2026, revealed the policy did not specifically address new narcotic medication security after delivery from the pharmacy. Review of the admission Face Sheet for R43 revealed the facility admitted the resident on 07/07/2026. According to review of the admission Face Sheet, the resident's medical history included diagnoses of left femoral neck fracture, muscle wasting and atrophy, and unspecified pain. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/30/2026, revealed the facility assessed R43 to have a Brief Interview for Mental Status (BIMS) of nine out of 15, which indicated moderate cognitive impairment. Review of the facility's final investigation dated 07/26/2026, revealed on 07/25/2026, Registered Nurse (RN) 1 checked to ensure R43 had his narcotic pain medication available if he should need it for breakthrough pain, and found there were not any available. Per review, RN 1 phoned the pharmacy to check for an order to refill R43's narcotic medication. Continued review revealed the pharmacy notified RN 1 that R43's medication had been filled and delivered to the facility on [DATE] (two days previously) with the 6:30 AM delivery that day. According to the investigation review, the facility performed interviews and drug screens of all nursing staff who had access to the medication cart from 07/23/2026 at 6:30AM to 07/25/2026 at 5:00 PM, when the medication was discovered missing. Further review of the investigation revealed one of the nurses interviewed, RN 2, had suspicious behavior such as, at times discouraging other staff from counting the narcotics on the medication carts. Per review, RN 2 also had accidentally taken home a resident's medication on 07/23/2026; however, returned the medication the same evening at 11:30 PM. In addition, review revealed RN 2 failed to sign R43's narcotic pain medication (Norco 7.5 mg) into the medication cart as requested by KMA 1 and the missing narcotic medication was never located. Review further revealed the facility suspendered RN 2, with termination pending. During an interview, on 07/31/2026 at 8:54 AM, Pharmacy Consultant 1 stated R43's Norco (narcotic pain medication used to treat moderate to severe pain) 7.5 milligrams (mg) 30 count blister pack had been delivered to the facility on [DATE]. During an interview, on 07/31/2026 at 12:50 PM, Licensed Practical Nurse (LPN) 2 stated she had received the narcotic pain medication for R43 in the pharmacy delivery on 07/23/2026. She stated she asked Kentucky Medication Aide (KMA) 1 to assist her with logging in the narcotic medication. During an interview, on 07/31/2026 at 11:12AM, KMA 1 stated she had been asked by LPN 2 to put the narcotic medication in the medication cart and sign them in. She stated she placed the narcotic medication in the cart as requested. KMA 1 stated a blue sheet came with the narcotic medication from the pharmacy which the receiving facility staff person and pharmacy staff person signed and each got a copy of it. KMA 1 stated the procedure for signing in narcotics medications included the white sheet (used for tracking the narcotic count on the medication cart), which was the log for the number of blister packs of the narcotic medication. The KMA stated when a new narcotic medication was received from pharmacy, facility staff added the new blister pack to the total of the medication on the back side of the white sheet. She stated (on 07/23/2026) she told the oncoming nurse, RN 2 she (the RN) would need to fill out a blue sheet and a white sheet for R43's Norco 7.5 mg medication. She stated however, she should have done that herself. During an interview, on 07/31/2026 at 2:00 PM, RN 1 stated, on 07/25/2026, R43 requested as needed (PRN) pain medication. RN 1 stated she went to pull the PRN pain medication; however, the medication was unavailable. She stated she contacted the pharmacy to ensure R43 had a prescription on file. RN 1 stated the pharmacy told her 30 pills had been sent and received by LPN 2 on 07/23/2026 at 6:30 AM. During an interview on 07/31/2026 at 9:06 AM, the Director of Nursing (DON) stated the facility did not have a policy for checking in narcotic medications or a drug diversion policy. The DON stated the Unit Managers (UM) audited a couple of times per week on the narcotic medications. The DON further stated, however, the UM for Blue Unit failed to follow the auditing process and had been suspended. During an interview, on 07/31/2026 at 8:54 AM, Pharmacy Consultant 1 stated R43's Norco (narcotic pain medication used to treat moderate to severe pain) 7.5 milligrams (mg) 30 count blister pack had been delivered to the facility on [DATE].

Based on interview, record review, and review of facility policy, the facility failed to immediately inform the resident's physician and/or Responsible Party (RP) as required for one (Resident (R) 1) of nine residents reviewed for medication administration. R1's Vimpat (an anti-convulsant medication used to treat seizures) was unavailable and not administered from 01/29/2026 until 02/01/2026. When the evening dose of Vimpat was administered on 02/01/2026, R1 received twice the ordered dose. The facility failed to immediately notify the resident's physician and representative of these medication errors. In addition, the facility failed to immediately notify the resident's RP when the resident was transferred to the hospital for evaluation after the 02/01/2026 medication overdose resulted in a change of condition.The findings include:Review of the facility's protocol, Medication Error Standard of Practice, dated 04/2025, revealed the purpose was to provide a timely response to identified medication administration errors. Further review revealed it was the facility's protocol upon suspected/identified resident medication administration error; the administering nurse or medication aide should immediately alert the Director of Nursing (DON) and/or charge nurse for physician notification. Review of R1's Care Plan Report revealed the facility admitted R1 on 01/29/2026 with diagnoses which included acute and chronic respiratory failure with hypoxia, anoxic brain damage, and severe intellectual disabilities. Review of R1 s admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 01/31/2026, also revealed the resident had a diagnosis of seizure disorder. a. Review of physician orders, dated 01/29/2026, revealed an order for Vimpat 100 milligrams (mg) twice daily. R1 also had orders for an additional anti-seizure medication, Zonisamide 200mg, on a daily basis. However, review of R1 s Medication Administration Record (MAR) for 01/2026 and 02/2026 revealed R1's Vimpat was marked as not available/not administered on 01/29/2026, 01/30/2026, and 01/31/2026 for either morning or evening dose. Further review revealed R1 s Vimpat was also not given on the 02/01/2026 morning dose. (Refer to F760.) There was no evidence that the facility notified the physician that the anti-seizure medication was not available and not being administered during this time. b. Review of an 02/02/2026 Medication Variance Form, (used to document medication errors) and the facility's investigation report revealed that Licensed Practical Nurse (LPN) 1 administered R1 200mg of Vimpat, rather than the 100mg ordered. Per a late entry Progress Note for 02/01/2026, the facility investigation, and a review of a hospital report, dated 02/02/2026, R1 was transferred to the hospital for evaluation of a medication overdose, after showing a significant change in condition. (Refer to F760.) Further review of the 02/02/2026 Medication Variance Form revealed documentation that the physician was notified of this error on 02/01/2026 with no new orders, and the responsible party was notified on 02/02/2026. Although LPN1 documented physician notification of the medication error occurred on 02/01/2026 and RP notification on 02/02/2026, interviews with the physician and RP revealed that this was not accurate.During an interview on 02/11/2026 at 11:51 AM, R1's responsible party (RP1) stated she received a phone call from the hospital on [DATE] at 1:56 AM, informing her that R1 was sent to the hospital for a med error. She confirmed that, prior to the hospital's notification, no one from the facility called her to inform her that R1 was being transferred to the hospital for a change in condition. Further interview with RP1 revealed no one from the facility had ever notified her of R1 missing medications for multiple days or the medication error in which the resident received twice the ordered amount of Vimpat .During an interview, on 02/11/2026 at 12:10 PM, the Medical Director stated he would expect to be notified of every time a resident missed a dose of their seizure medication. He further stated he was never notified of R1 missing any medication. During an interview, on 02/12/2026 at 9:30 AM, Physician Assistant (PA) 1 stated she was not informed of R1 missing anti-seizure medication from 01/292/2026 - 02/01/2026. In addition, PA1 stated she was not immediately informed of the medication error which occurred at approximately 6:00 PM on 02/01/2026. PA1 stated she was unaware of any concerns with R1 until the 02/01/2026 call from the nurse around midnight stating she had trouble keeping R1's oxygen level up and R1 was drowsy with increased secretions. Interview on 02/10/2026 at 1:30 PM with LPN1 revealed conflicting information about the required notification. LPN1 stated she was called on 02/02/2026 and asked to come into the facility to complete a report on a medication error that occurred on 02/01/2026 when she accidentally popped two pills out instead of one, because I thought she got two. During this interview, LPN1 stated she was unaware she had made an error until she was called on 02/02/2026. LPN1 provided no explanation as to why she had documented MD/RP notification on 02/01/2026 (if she was not aware of the error until 02/02/2026.) Although LPN1 alleged she was unaware of the medication error until 02/02/2026, interviews with additional staff revealed that the facility was aware of the error on 02/01/2026 and indicated that the physician should have been immediately contacted. For example, during an interview on 02/12/2026 at 12:17 PM, LPN2 (the night nurse on 02/01/2026) stated LPN1 realized during shift change at 7PM on 02/01/2026 that she gave the wrong medication to R1. LPN2 stated she thought LPN1 would call the doctor and responsible party since she made the error and knew what occurred. During an interview on 02/12/2026 at 12:52 PM, the weekend supervisor stated he worked 7:00 AM to 7:00 PM on 02/01/2026 and was notified at the end of the shift by LPN1 that a medication error was made for R1 that was caught when LPN1 counted the narcotic cart with the oncoming nurse. He stated he expected LPN1 to call the provider and responsible party as she made the error. However, he stated he did not follow up to ensure that was done. During an interview on 02/12/2026 at 2:30 PM, the DON stated it was her expectation that any nurse who identified a medication error would immediately notify the physician and responsible party immediately.

Based on interview, record review, and review of facility policy, the facility failed to ensure one (Resident (R) 1) of nine residents reviewed for medication administration was free from significant medication errors. The facility failed to administer Vimpat (an anti-convulsant medication used to treat seizures) from 01/29/2026 until 02/01/2026, due to unavailability. When Licensed Practical Nurse (LPN) 1 administered the first (evening) dose of Vimpat on 02/01/2026, the resident received 200 milligrams (mg), rather than the 100 mg which was ordered. These errors are considered significant, as Vimpat has a narrow therapeutic window for safety, with high doses or incorrect administration having the potential to lead to increased seizures and/or severe, life-threatening events. After receiving twice the ordered dose, the resident became lethargic, displayed a change in condition, and required transfer to the hospital for evaluation in response to medication overdose. The findings include:Review of the facility's protocol, Medication Administration Standard of Practice, dated 04/2025, revealed Medications must be administered in accordance with the orders, including required time frame. Review of the facility's protocol, Medication Error Standard of Practice, dated 04/2025, revealed it was the facility's protocol upon suspected/identified resident medication administration that the administering nurse or medication aide should immediately alert the Director of Nursing and/or charge nurse for physician notification. Per the policy, the resident should be assessed for potential adverse reaction, with any change of condition reported to the physician. Additionally, the nurse should complete a Medication Variance Form to document the event detail, interventions, and notifications.Review of R1's Care Plan Report revealed the facility admitted R1 on 01/29/2026 with diagnoses which included acute and chronic respiratory failure with hypoxia, anoxic brain damage, and severe intellectual disabilities. Review of R1's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 01/31/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0/15, indicating R1 had severe cognitive impairment. Further review of the MDS revealed the resident had a diagnosis of seizure disorder. a. Review of physician orders, dated 01/29/2026, revealed an order for Vimpat 100 milligrams (mg) twice daily. R1 also had orders for an additional anti-seizure medication, Zonisamide 200mg, on a daily basis. Review of R1's Medication Administration Record (MAR) for 01/2026 and 02/2026 revealed R1's Vimpat was marked as not available and was not administered on 01/29/2026, 01/30/2026, and 01/31/2026 for either morning or evening dose. Further review revealed R1 s Vimpat was also not available/administered for the 02/01/2026 morning dose. There was no evidence that the facility notified the physician that the anti-seizure medication was not available and not being administered as ordered during this time frame. (Refer to F580). 0n 02/01/2026, the Weekend Supervisor contacted the pharmacy for a Stat (immediate) delivery, and the medication was provided in time for the evening administration on 02/01/2026. b. Review of a Medication Variance Form (used to document medication errors) revealed that on 02/02/2026 at 12:35 PM, Licensed Practical Nurse (LPN) 1 documented an error which occurred on 02/01/2026 at 6:00 PM. Per the report, R1 was ordered 100 mg of an unidentified medication; however, the resident was administered a 200 mg dose. Investigation revealed that the unidentified medication error was administration of 200 mg of Vimpat, rather than 100mg (twice the prescribed dose.) Review of R1's Progress Notes revealed that on 02/04/2026, LPN2 made a late entry for 02/01/2026. Per the note, LPN2 sent R1 out to the hospital around 11:50 PM on 02/01/2026, as respiratory staff were concerned regarding R1's oxygen level at 88%-92%. Per notes, R1 was not herself, in an almost sedated state after the medication error at approximately 6:00 PM, when 200 mg of Vimpat was given, instead of R1's normal order of 100 mg. Review of R1's Investigation Interview Form, dated 02/02/2026 at 12:00 PM, and signed by Unit Manager (UM) 1, revealed UM1 was working 11:00 PM to 7:00 AM (02/01 - 02/02/2026) shift, when a nurse (night shift) approached UM1 and informed her that the day shift nurse (LPN1) gave R1 a medication from a different blister pack of the same medication but a different dose. Further review revealed the night shift nurse said R1 seemed lethargic and had an increased amount of mucous with respiratory confirming an increased need for suctioning. Continued review revealed UM1 advised the nurse to contact the on-call provider and Director of Nursing (DON). Additionally, the on-call provider instructed the nurse to send R1 to the ED for evaluation. Review of R1's hospital Emergency Department (ED) Note, dated 02/02/2026 at 1:53 AM, revealed R1 was seen for a chief complaint of overdose and a stated complaint of overmedicated. Further review revealed R1 was transferred to the ED from the facility for an overdose of antiseizure medication. The resident was assessed, treated, and returned to the facility on [DATE] with no new orders.Further review of R1's Investigation Interview Form, dated 02/02/2026 at 12:00 PM, and signed by Registered Nurse (RN) 1, revealed RN1 spoke with LPN1 about the medication error and asked LPN1 (who was off shift) to return to the facility to complete an incident report on medication error. The form noted that LPN1 stated that meds were delivered from pharmacy and she was in a hurry and pulled meds from wrong blister pack. During an interview on 02/10/2026 at 1:30 PM, LPN1 stated she was called on 02/02/2026 and asked to come into the facility to complete a report on a medication error that occurred on 02/01/2026. LPN1 stated the error occurred when she accidentally popped two pills out instead of one, because I thought she got two. During this interview, LPN1 stated she was unaware she had made a medication error until she was called on 02/02/2026. Although LPN1 alleged she was unaware of the medication error until 02/02/2026, interviews with additional staff revealed that the facility was aware of the error on 02/01/2026. For example, during an interview, on 02/12/2026 at 12:17 PM, LPN2 (the night nurse on 02/01/2026) stated LPN1 realized during shift change at 7PM on 02/01/2026 that she gave the wrong medication to R1. LPN2 stated that the weekend supervisor was notified at the time the med error was discovered on 02/01/2026. Interview with LPN2 revealed that after the medication error occurred, R1 became more lethargic during the night and, in response, she called the on-call provider and sent the resident to the ED.During an interview on 02/12/2026 at 12:52 PM, the weekend supervisor stated he worked from 7:00 AM to 7:00 PM on 02/01/2026. He confirmed that LPN1 notified him at the end of the shift that a medication error was made for R1, and the error was caught when LPN1 counted the narcotic cart with the oncoming nurse. During an interview, on 02/11/2026 at 12:10 PM, the Medical Director stated he would expect the staff administering medications to verify they gave the correct medication. During an interview, on 02/12/2026 at 9:30 AM, Physician Assistant (PA) 1 stated she was on call the night of 02/01/2026 and received a call from the nurse around midnight. PA1 stated the nurse related she had trouble keeping R1's oxygen level up and R1 was drowsy with increased secretions, and, in response, she ordered the nurse to send R1 to the ED.During an interview, on 02/12/2026 at 2:30 PM, the DON stated it was her expectation that any nurse would follow physician orders. Although LPN1 described the error as occurring because she accidentally gave R1 two of her Vimpat tablets, interview with the DON revealed that this was not accurate. The DON provided narcotic count sheets and explained that the significant medication error occurred when LPN1 pulled a 200 mg Vimpat tablet from the supply belonging to R7 (a different resident) and administered it to R1, instead.

Based on observation, interview, record review and facility policy, the facility failed to notify the Responsible Party (RP) when) a decision was made to transfer or discharge the resident from the facility to the hospital for one of 14 sampled residents. (Resident (R) 3). The findings include:Review of the facility policy titled Admission, Discharge, and Transfer Standard of Practice dated 10/2020 revealed before the facility transfers a resident, the facility shall notify the resident and resident's representative to include the reason in a language and manner they understand.On 06/18/2025, R3 was transferred to the hospital from the facility. The RP was not informed of the transfer by the facility. Review of R3's admission Face Sheet revealed R3 was admitted to the facility on [DATE] with diagnoses of Diastolic Heart Failure; Vascular Dementia, severe; and Diabetes.Review of R3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/01/2025 revealed a Brief Interview for Mental Status (BIMS) score of three of 15 which indicated severe cognitive impairments.During an interview on 07/31/2025 at 8:55 PM with R3's RP, she stated R3 was transferred to the hospital on [DATE] and she was not notified of the transfer. The RP further stated she was made aware of the transfer when the hospital called and made her aware.During an interview on 08/01/2025 at 4:11 PM with RN3, she stated she was assigned to R3 on 06/18/2025. She stated R3 was having breathing issues that day. RN3 had contacted in house respiratory to assist. RN3 further stated Unit Manager (UM) 1 was also assisting. RN3 stated while she was caring for other residents, R3 was noted to be out of her room. RN3 further stated she was informed by the UM1, R3 was transferred via ambulance to the hospital. UM1 further told her that the physician had been contacted, and all paperwork was completed and there was nothing further she needed to do. RN3 stated she started at the facility in May 2025 and was still learning the facility processes. RN3 further stated it was common for the UM to take care of the calls and forms required for resident transfers to the hospital.UM 1 is no longer employed by the facility. There were no answer to phone calls to UM1.During an interview on 08/01/2025 at 11:30 AM with the Interim Director of Nursing (DON), she stated her expectation was the staff follow the policy and always contact the RP with any transfer.During an interview on 08/01/2025 at 5:57 PM with the Administrator he stated his expectation was that staff follow the policy with transfers and notify accordingly.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a care plan was developed and implemented for four of 14 sampled residents (Resident #1 (R1), R3, #6, and R8. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 04/06/2015 and revised 02/09/2024, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Closed record review of R1's face sheet revealed the facility admitted the resident on 04/22/2024. R1 was readmitted to the facility on [DATE] included diagnoses of: subsequent encounter for closed fracture with routine healing; personal history of Transient Ischemic Attack (TIA/stroke); and cerebral infarction without residual deficits, and difficulty in walking, not elsewhere classified. Review of the admission Minimum Data Set (MDS) Assessment, dated 04/25/2024, revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of zero out of 15. This score indicated the resident was not cognitively intact. Record review revealed no documented evidence the facility developed a Comprehensive Care Plan for R1 that was resident specific. R1’s care plan had unachievable interventions in place such as “Encourage resident to not yell at other residents”. Record review revealed that R1’s care plan was not updated quarterly. During an interview with the Minimum Data Set (MDS) Coordinator on 07/31/2025 at 11:12 AM, she stated R1 should have had a Comprehensive Care Plan implemented when he was admitted to the facility on [DATE]. During an interview with the Director of Nursing (DON) on 07/31/2025 at 10:06 AM, she stated each resident should have a person-centered Comprehensive Care Plan and the MDS Coordinator was responsible for implementing the care plans. The DON stated her expectations were for each resident to have the appropriate care plan implemented. During an interview with the Administrator on 07/31/2025 at 10:41 AM, he stated he expected all residents to have a comprehensive care plan and for staff to follow the facility's policies. He also stated that all care plans should be revised and reviewed quarterly, at minimum. Review of Resident (R) 3’s face sheet revealed the resident was admitted on [DATE] with diagnoses of Dementia and Delirium. Review of R3’s Minimum Data Set (MDS), assessment reference date (ARD) 06/01/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of three of 15, indicating severe mental impairment. Review of R3’s Behavior Care Plan, established 07/01/2025, identified problems of smearing feces on self and walls (07/01/2024) and a resident-to-resident incident (07/23/2025). The interventions included, “resident separated immediately,” “psychiatrist to visit PRN,” and “psychologist to visit as needed,” were reactive and failed to address the resident’s cognitive limitations or provide individualized strategies to prevent recurrence. Review of R6’s face sheet revealed the resident was admitted on [DATE] with diagnoses of Depression and Anxiety. Review of R6’s MDS, dated [DATE], revealed the resident had a BIMS score of five of 15, indicating severe mental impairment. Review of R6’s Behavior Care Plan, established 12/08/2022, revealed the care plan listed multiple behavioral concerns, including depression, anxiety, fabrication, sexual inappropriateness, verbalizing a desire to die, hitting/biting/exit seeking, and repeated resident-to-resident contacts/altercations between 07/15/2025 and 07/28/2025. Interventions such as “resident separated immediately,” “Q 15-minute checks,” and “1:1 related to resident-to-resident altercation” were reactive, and implemented after incidents occurred. Review of R8’s face sheet revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's Disease, dementia, and anxiety. Review of R8’s MDS, dated [DATE], revealed the resident had a BIMS score of one of 15, indicating severe mental impairment. Review of R8’s Behavior Care Plan, established 11/05/2021, revealed documented behaviors including elopement attempts, increased agitation, exit-seeking, and physical altercations with other residents. Interventions listed included redirection, one-on-one visits, encouraging activity participation, monitoring for increased agitation, and providing reassurance. While the interventions addressed behaviors after they occurred, there was no evidence of proactive, individualized interventions designed to prevent recurrence of these behaviors. In an interview on 08/01/2025 at 5:50 PM, the Director of Nursing (DON) stated she was unaware the residents were having recurring behaviors. The DON continued to state care plans were not resident-specific and required work to ensure residents received the care they deserved. The DON continued to state that she had not looked at any resident care plans since 07/17/2025. In an interview on 08/01/2025 at 6:16 PM, the Social Services Director (SSD) stated that behaviors were overlooked in the past and “tossed to the side and not addressed.” The SSD continued to state that it never “clicked with her” to be proactive with resident care planning and look at patterns of behaviors residents were having, to try to prevent future incidents. In continued interview, the SSD stated that it was her responsibility to ensure resident care plans were updated, but she could not answer why interventions to prevent additional incidents were not placed on care plans.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents. On 07/28/2025, Resident (R)8 was in the dining room and hit R6; only one staff member, out of three scheduled, was present during the altercation.The findings include:Review of facility policy titled, Resident Rights Standard of Practice, review date 04/2025, revealed residents have the right to have a safe, clean, comfortable, and homelike environment.Review of facility policy titled, Abuse Prohibition Standard of Practice, review date 04/2025, revealed neglect was the failure of the center, its team members or service providers to provide services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect included cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could result in physical harm, pain, mental anguish, or emotional distress.Review of a mealtime staffing sheet, undated, revealed three staff members were required to be present for each mealtime. Additional review revealed staff must stay in the dining room for the entire meal.In an interview on 08/01/2025 at 2:09 PM, Kentucky Medication Aide (KMA)1 stated she was working alone in the dining room for dinner service on 07/28/2025. KMA1 stated that Resident (R)8 was walking around the dining room and started a verbal altercation with R6. KMA1 stated she separated the two residents and placed them on opposite sides of the dining room, but was unable to leave to get additional staff to ensure the residents stayed separated, as she was the only staff member in the dining room. KMA1 continued to state she was getting drinks for residents when she turned around and saw R8 walk to R6 and hit her on the arm and then hit her with a bologna sandwich. KMA1 stated she never witnessed R6 hit R8, but R6 did start crying. KMA1 then walked R8 to the door and asked the resident to leave the dining room. KMA1 stated she waited until dinner service was over to report the incidents because she didn't want to leave the residents unsupervised. KMA1 continued to state that there should have been three staff members present during the meal service but she was not sure why no one else was where they were scheduled to be. In an interview on 08/01/2025 at 3:05 PM, Activities Assistant 2 stated that he was scheduled to leave at noon on 07/28/2025 for an appointment and was unsure if anyone covered his shift in the dining room. Activities Assistant 2 stated it was important to have an adequate number of staff in the dining room to ensure residents were safe and taken care of.In an interview on 08/01/2025 at 3:14 PM, Activities Assistant 1 stated that Activities Assistant 2 was scheduled to be in the dining room for dinner on 07/28/2025, but he left early, and she was not sure if anyone from the activities department was present for that meal. In an interview on 08/01/2025 at 3:25 PM, the Activities Director stated he was responsible for ensuring activities staff were present during each meal service in the dining room, but he forgot Activities Assistant 2 had an appointment on 07/28/2025 and did not schedule anyone to replace him. The Activities Director stated it is important to have staff present at mealtimes for resident safety.In an interview on 08/01/2025 at 3:34 PM, Registered Nurse (RN) 3 stated it was too difficult for only one staff member to be in the dining room and you can't keep your eyes on everyone. RN3 stated that the facility trained staff to separate residents if there was an incident and immediately report the incident; however, it was impossible to separate residents and report the incident if only one staff member was present. RN3 continued to state there should have been more staff in the dining room for the safety of residents.In an interview on 08/01/2025 at 4:00 PM, Licensed Practical Nurse (LPN)1 stated that she did not know she was scheduled to be in the dining room during dinner. LPN1 continued to state that no one told her she was responsible for being in the dining room. LPN1 additionally stated that having staff present during mealtimes was important for resident safety and to prevent verbal altercations from becoming physical. LPN1 continued to state that she was aware there was a schedule for staff being present in the dining room, but she was not aware it was her day to be there, as she was passing medications. In an interview on 08/01/2025 at 5:50 PM, the Director of Nursing (DON) stated the facility did not have any staff members who were responsible for ensuring staff members were going to the scheduled shift in the dining room for meal services and continued to state, we assume that staff go. The DON stated she expected that staff follow the posted staffing schedule for resident safety and to prevent resident altercations. The DON continued to state that she created the staffing schedule for meal times and distributed them to the nursing staff on the floor.In an interview on 08/01/2025 at 5:57 PM, the Administrator stated one staff member being present during a meal service was not sufficient to prevent resident altercations or ensure resident safety. The Administrator stated that he expected staff to follow their posted schedules.

Based on record review, interview, and review of state law, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Review of employee medical records revealed facility staff had not received tuberculosis (TB) testing within the required timeframe.Review of 902 [NAME] 20:205 revealed the administrative regulation established requirements for TB testing of healthcare workers in healthcare facilities or settings. The procedures were necessary to minimize the transmission of infectious TB disease among staff, patients, and residents of health facilities. Continued review revealed healthcare workers consisted of physicians, nurses, nurse aides, therapists, housekeeping, laundry, maintenance, and billing. Healthcare workers were required to have annual TB screening risk assessments and annual education about the signs and symptoms of active TB disease.The facility did not provide facility-specific policies for TB testing when requested.Review of a facility staffing sheet, undated, revealed the facility has 131 active employees. The facility provided TB testing records for 70 of the 131 active employees but failed to provide TB records for 61 active employees. Further review of the 70 TB records revealed 23 active employees who were in compliance with state and local TB testing guidelines. The remaining employee files revealed that 47 active employees had either lapsed TB testing or their medical records did not show consistent annual testing. Additional review revealed the Infection Preventionist, who was responsible for ensuring staff had TB tests completed on time, was hired on 09/22/2021 and only had records for TB test being completed on 09/03/2024.During an interview on 08/01/2025 at 11:22 AM, a Registered Nurse (RN) representing the local health department stated the county expected TB testing to be completed annually in the same month as the employee was hired.The Director of Nursing (DON) stated in interview, on 08/01/2025 at 11:30 AM, that the facility did not have an acting Infection Preventionist (IP) as the current IP was on medical leave, and the facility did not have any way to ensure that current staff were getting their TB testing on time. The DON stated that staff should be current on all TB testing for the safety of residents, visitors, and staff.During an interview on 08/01/2025 at 5:57 PM, the Administrator stated it was his expectation for all facility staff to follow all federal, state, and local regulations for the safety of staff and residents.Multiple calls to the IP on 07/31/2025 and 08/01/2025 were unanswered and unreturned.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to protect residents from abuse for 2 of 84 sampled residents, (Residents (R)11 and R43). The findings include: Review of the facility's policy titled Abuse Prohibition Standard of Practice, last revised 07/2022, revealed the facility's definition of sexual abuse was, Non-consensual sexual contact of ANY type with a resident/patient. Per review, prevention of abuse included an ongoing assessment of resident behaviors was to be performed with care planning to include appropriate interventions. Continued review revealed for the reporting of abuse, the policy stated, alleged violations shall be reported to the state survey agency, adult protective services, and all other required agencies within specified time frames, and appropriate steps shall be taken to prevent recurrence of the incident.Review of the facility's internal Grievance/Concern Form, completed by the Social Services Director (SSD) on 06/24/2025, revealed that R11 reported to the SSD that another resident was making inappropriate comments to her. Continued review revealed the SSD noted the Certified Nursing Assistant (CNA) (Nursing Assistant [NA]) Instructor, from an outside CNA [NA] educational resource, reported to her that R11 said another resident was making inappropriate comments to her. Further review revealed the SSD noted going to talk to R11, and the resident was not upset. Review revealed the SSD documented R11 told her she did not like the words that R12 used but did not feel harmed in any way. In addition, review revealed the resolution of the grievance was dated 06/24/2025 and noted R11 was advised to report any further concerns to staff. During the interview on 06/30/2025 at 2:00 PM, with the Interim Administrator, the SSA Surveyor requested a copy of any documentation the facility had of reporting of the incident to the appropriate state agencies, and a list of grievances. The Interim Administrator stated the facility had no documentation of a report filed. Review of R11's face sheet revealed the facility admitted the resident on 03/07/2025, with diagnoses of chronic obstructive pulmonary disease (COPD), and depression. Review of the quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 06/11/2025, revealed the facility assessed R11 to have a BIMS score of 5 out of 15, indicating severe cognitive impairment.During the interview on 06/30/2025 at 3:07 PM, the SSA Surveyor asked R11 if someone said something to her last week that bothered her. R11 said yes and identified R12 by his first name. The resident proceeded to tell the SSA Surveyor R12 had been following her around and he came up to her and said, I bet you have a pretty pussy. She said she was pissed and stated, I wondered what I did that made him feel that was okay to say to me. R11 stated that when asked if she felt unsafe around R12, she said, Not now. She reported, however, At the time, I didn't know what he would do; I am in this wheelchair. Observation on 06/30/2025 at 3:10 PM revealed R11 was independently mobile in a wheelchair.Review of R12's Face Sheet revealed the facility initially admitted the resident on 05/21/2021, with diagnoses of malignant neoplasm of unspecified bronchus, or lung; anxiety; and a history of nicotine dependence.Review of the quarterly MDS Assessment for R12, with an ARD of 06/06/2025, revealed the facility assessed R12 to have a BIMS score of 9 out of 15, indicating moderate cognitive impairment.During the interview on 07/01/2025 at 11:15 AM, R12 stated he did not recall saying anything to R11 last week and denied knowing that resident. R12 further denied speaking with the SSD about saying anything inappropriate to the resident. Observation on 07/01/2025 at 1:35 PM revealed R12 was independently mobile in his wheelchair. During the interview on 06/30/2025 at 1:36 PM, Nursing Assistant (NA) 1 approached the SSA Surveyor and reported R11 told her R12 had been following her around and had made a sexual comment to her. She said even though R12 did not smoke, R11 told her he (R12) had followed her outside to the smoking area before. The resident reported that the Nursing Assistant (NA) Instructor overheard her conversation with R11 as well, and they reported the information to the Administrator. She further stated she was aware the Administrator told the NA Instructor to take the incident information to the Social Services Director (SSD). During the interview on 06/30/2025 at 2:10 PM, the SSD stated it had was reported to her that R12 told R11 he thought she had a nice ass. She stated that when she spoke to R11, the resident told her she didn't like the words he used.During the interview on 07/01/2025 at 5:12 PM, the Regional Nurse Consultant (RNC) stated, We didn't feel it was reportable. During the interview on 07/01/2025 at 5:35 PM, the Interim Administrator stated he was surprised R11 was offended by being told she had a nice ass. since the language she used was as bad or worse. The SSA Surveyor reviewed the facility's abuse policy with the Interim Administrator, and after the review, he stated, In retrospect, it should have been reported. Review of the facility policy, Abuse Prohibition Standard of Practice, dated 04/2025, revealed the facility was to prohibit and prevent abuse and neglect. Per review, the facility defined neglect as failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. Continued review revealed the facility further defined neglect as including cases where the facility's indifference or disregard for resident care resulted in mental anguish or emotional distress. Review of the facility form and attachments, Grievance/Concern Form, dated 06/10/2025, revealed R43 wrote to the Social Services Director (SSD) that at 2:11 AM, she pressed her call light because she absolutely flooded her bed with urine and needed to be changed. Continued review revealed R43 noted she waited over two hours for staff to come change her while she smelled like an [NAME]. Per review of R43's written statement, she wrote she was 100% being neglected and that she should not have to suffer with that type of care until she could be transferred to another facility.Review of R43's admission Face Sheet revealed the facility admitted the resident on 09/09/2022, with diagnoses including respiratory failure, anxiety disorder, and peripheral vascular disease. Review of R43's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident had intact cognition. Review of R43's Comprehensive Care Plan (CCP) dated 09/09/2022, revealed the facility identified the resident as requiring assistance with Activities of Daily Living (ADLs), including incontinence. Continued review revealed the interventions included the facility staff to provide incontinence care as needed. Further review revealed no documented evidence the CCP specified how many staff members were needed to assist R43 with care. In interview on 07/16/2025 at 9:16 AM, R43 stated she had filed a grievance about being left wet for hours on night shift. She stated that had made her feel angry to not receive the care she needed. In interview on 07/16/2025 at 5:09 PM, SRNA 12 stated she was the aide responsible for R43 on the night of 06/09/2025. She reported she saw R43 had pressed her call light and looked into the resident's room to make sure the resident had not fallen onto the floor before continuing down the hallway. SRNA 12 said she had to wait on someone else to help her provide R43's care due to the resident's weight. She stated R43 had requested the other aide on the hall, (SRNA 11) not provide care for her. SRNA 12 explained the other aides working that night would not come help her until they were finished with the care rounds on the residents they were assigned to. She said she did not know how long it took the other aides to become available to help her. SRNA 12 further stated the Administrator reprimanded her and told her it was not acceptable to not provide incontinence care for a prolonged period of time after a resident requested care be provided. In interview on 07/16/2025 at 5:15 PM, SRNA 11 stated she had fallen asleep at the nurse's station on 06/09/2025, due to her health problems. She said R43 previously requested not to have her provide care of her (R43), so SRNA 12 had not awakened her to help with R43's care. SRNA 11 further stated she did not know why the other aides had not awakened her to switch places with them so she could assist with their routine care rounds while the other staff assisted with R43's incontinence care. In interview on 07/16/2025 at 4:10 PM, Licensed Practical Nurse (LPN) 6 stated she was working the night of 06/09/2025, and into the early morning of 06/10/2025. She said she had been busy with her medication pass and charting and had not noticed SRNA 11 was sleeping, nor that R43's call light was on for an extended period of time. LPN 6 reported the Administrator told her after the fact that she was responsible for the aides on her shift; however, said she did not know how to do that as she was busy with her own tasks. In interview on 07/17/2025 at 1:03 PM, the Unit Manager (UM) stated it was her expectation residents' call lights were answered within a reasonable period of time. She said all staff were responsible for answering call lights, not just the SRNAs. The UM stated she also expected staff to change a resident who had called out for help before providing care to other residents who might be sleeping at that time. She reported the facility did not have a night shift supervisor, so it was up to the nurse on the floor to manage the residents' care at night. The UM further stated nurses had not received training on what the expectations were for managing other employees on night shift. In interview on 07/16/2025 at 2:59 PM, the Social Services Director (SSD) stated she filed the grievance on 06/10/2025 after receiving R43's email about her care the night before. She stated she then reported to the facility management team and watched the surveillance footage from that night and confirmed R43's allegations of staff not answering her call light for over two hours. The SSD further stated the surveillance footage also showed SRNA 11 asleep at the nurse's station for approximately two and a half hours during the time R43's call light was on. In interview on 07/17/2025 at 10:15 AM, the Director of Nursing (DON) stated she was aware of R43's grievance and that the facility confirmed the resident's allegations in their investigation. She said she saw clips from the surveillance footage that showed SRNA 11 asleep at the nurse's station. The DON reported she provided education to staff regarding all staff being responsible for answering call lights. She further stated she also provided education that nurses were responsible for supervising SRNAs during their shift to ensure no SRNAs were sleeping at the nurse's station and SRNAs were answering call lights timely and providing care.In interview on 07/17/2025 at 3:35 PM, the Administrator stated the facility's investigation into R43's grievance confirmed her allegations of neglect. He said he focused on resolving her concerns and checked in with her daily with no further concerns identified. The Administrator further stated he issued official disciplinary action to the staff involved and provided staff re-education to all staff on the importance of meeting residents' needs.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to implement the facility's abuse policy for 2 of 84 sampled residents. (Residents (R)11 and R43).The findings include:Review of the facility's policy titled, Abuse Prohibition Standard of Practice, last revised 07/2022, revealed the facility's definition of sexual abuse was, Non-consensual sexual contact of ANY type with a resident/patient. Per review, prevention of abuse included an ongoing assessment of resident behaviors was to be performed with care planning to include appropriate interventions, Continued review revealed for the reporting of abuse, the policy stated, alleged violations shall be reported to the state survey agency, adult protective services, and all other required agencies within specified time frames, and appropriate steps shall be taken to prevent recurrence of the incident.Review of the facility's internal Grievance/Concern Form, completed by the SSD on 06/24/2025, revealed R11 reported to the SSD that another resident was making inappropriate comments to her. Continued review revealed the SSD noted the CNA (Nursing Assistant [NA]) Instructor, from an outside CNA [NA] educational resource, reported to her that R11 said another resident was making inappropriate comments to her. Review revealed the SSD documented R11 told her she did not like the words that R12 used. In addition, review revealed the resolution of the grievance was dated 06/24/2025 and noted R11 was advised to report any further concerns to staff. During an interview on 06/30/2025 at 2:00 PM, with the Interim Administrator, the SSA Surveyor requested a copy of any documentation the facility had related to the reporting of the incident to the appropriate state agencies, and a list of grievances. The Interim Administrator stated the facility had no documentation of a report filed. Review of R11's face sheet revealed the facility admitted the resident on 03/07/2025, with diagnoses of chronic obstructive pulmonary disease (COPD), and depression. Review of the quarterly MDS Assessment, with an ARD of 06/11/2025, revealed the facility assessed R11 to have a BIMS score of 5 out of 15, indicating severe cognitive impairment.During the interview on 06/30/2025 at 3:07 PM, the SSA Surveyor asked R11 if someone said something to her last week that bothered her. R11 said yes and identified R12 by his first name. The resident proceeded to tell the SSA Surveyor R12 had been following her around and he came up to her and said, I bet you have a pretty pussy. She said she was pissed and stated, I wondered what I did that made him feel that was okay to say to me. R11 stated when asked if she felt unsafe around R12, she said, Not now. She reported, however, At the time, I didn't know what he would do; I am in this wheelchair. Review of R12's Face Sheet revealed the facility initially admitted the resident on 05/21/2021, with diagnoses of malignant neoplasm of unspecified bronchus, or lung; anxiety; and a history of nicotine dependence.Review of the quarterly MDS Assessment for R12, with an ARD of 06/06/2025, revealed the facility assessed R12 to have a BIMS score of 9 out of 15, indicating moderate cognitive impairment.During the interview on 07/01/2025 at 11:15 AM, R12 stated he did not recall saying anything to R11 last week and denied knowing that resident. R12 further denied speaking with the SSD about saying anything inappropriate to the resident. During interview on 06/30/2025 at 1:36 PM, the Nursing Assistant (NA) 1 approached the SSA Surveyor and reported R11 told her R12 had been following her around and had made a sexual comment to her. She stated the resident reported to the Nursing Assistant (NA) Instructor her concerns and she overheard R11's conversation with her instructor. She stated the NA Instructor reported the information to the Administrator, however, the Administrator advised the NA instructor to report the incident to the Social Service Director (SSD). During the interview on 06/30/2025 at 2:10 PM, the SSD stated it was brought to her attention that R12 told R11 he thought she had a nice ass. She stated that when she spoke to R11 the resident told her she didn't like the words he used.During the interview on 07/01/2025 at 5:12 PM, the Regional Nurse Consultant (RNC) stated, We didn't feel it was reportable. During the interview on 07/01/2025 at 5:35 PM, the Interim Administrator stated he was surprised R11 was offended from being told she had a nice ass since the language she used was as bad or worse. The SSA Surveyor reviewed the facility's abuse policy with the Interim Administrator and after the review, he stated, In retrospect, it should have been reported. Review of the facility policy, Abuse Prohibition Standard of Practice, dated 04/2025, revealed the facility was to prohibit and prevent abuse and neglect. Further review revealed the facility defined neglect as failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain mental anguish or emotional distress. Continued review revealed the facility further defined neglect as including cases where the facility's indifference or disregard for resident care resulted in mental anguish or emotional distress. Additional review revealed the Administrator was to conduct an internal investigation into allegations of abuse and neglect and report the results of the investigation to the state survey agency (SSA).Review of the facility form and attachments, Grievance/Concern Form, dated 06/10/2025, revealed R43 wrote to the Social Services Director (SSD) that at 2:11 AM, she pressed her call light because she needed her briefs changed. Per review, the facility confirmed R43's allegation of staff working night shift on 06/09/2025 into 06/10/2025 failing to respond to her call light and provide the care she needed. Continued review of the facility grievance file revealed no documented evidence the facility reported R43's neglect allegation to the State Survey Agency (SSA).In interview on 07/16/2025 at 9:16 AM, R43 stated she had filed a grievance about being left wet for hours on night shift. She stated that had made her feel angry to not receive the care she needed. In interview on 07/16/2025 at 5:09 PM, State Registered Nurse Aide (SRNA) 12 stated she was the aide responsible for R43 on the night of 06/09/2025. She stated she saw R43 had pressed her call light and looked into the resident's room to make sure the resident had not fallen onto the floor before continuing down the hallway. SRNA 12 said she had to wait on someone else to help her provide R43's care due to the resident's weight. She stated R43 had requested the other aide on the hall, (SRNA 11) not provide care for her. SRNA 12 explained the other aides working that night would not come help her until they were finished with the care rounds on the residents they were assigned to. She said she did not know how long it took the other aides to become available to help her. SRNA 12 further stated the Administrator reprimanded her and told her it was not acceptable to not provide incontinence care for a prolonged period of time after a resident requested care be provided. In interview on 07/16/2025 at 5:15 PM, SRNA 11 stated she had fallen asleep at the nurse's station on 06/09/2025, due to her health problems. She said R43 previously requested not to have her provide care of her (R43), so SRNA 12 had not awakened her to help with R43's care. SRNA 11 further stated she did not know why the other aides had not awakened her to switch places with them so she could assist with their routine care rounds while the other staff assisted with R43's incontinence care. In interview on 07/16/2025 at 4:10 PM, Licensed Practical Nurse (LPN) 6 stated she was working the night of 06/09/2025, and into the early morning of 06/10/2025. She said she had been busy with her medication pass and charting and had not noticed SRNA 11 was sleeping, nor that R43's call light was on for an extended period of time. In interview on 07/17/2025 at 1:03 PM, the Unit Manager (UM) stated it was her expectation residents' call lights were answered within a reasonable period of time. She said all staff were responsible for answering call lights, not just the SRNAs. In interview on 07/16/2025 at 2:59 PM, the Social Services Director (SSD) stated she filed the grievance on 06/10/2025 after receiving R43's email about her care the night before. She reported the facility management team watched surveillance footage from that night and confirmed R43's allegations of staff not answering her call light for over two hours was true. Further, she stated she turned her findings over to the Administrator and he decided if the allegations and findings needed to be reported to the SSA.In interview on 07/17/2025 at 10:15 AM, the Director of Nursing (DON) stated her responsibilities did not include reporting allegations of abuse and neglect. The DON additional said she believed the Administrator or SSD should have reported R43's allegations and did not know why they had not done that.In interview on 07/17/2025 at 3:35 PM, the Administrator stated the facility's investigation into R43's grievance confirmed her allegations of neglect. The Administrator reported he should have reported R43's grievance as a neglect allegation, as the resident called what had happened neglect. He stated he had not thought the situation was reportable, but admitted he made a mistake. The Administrator said his focus had been on resolving R43's concern and making sure she got the care she needed. In continued interview, the Administrator stated he needed to discuss the facility's reporting practices because it was a whole new mindset from previous facility practice.

Based on interviews, record reviews, and review of the facility's policy, the facility failed to implement its policies and procedures to ensure 2 of 84 sampled residents (R11) and (R12) were thoroughly investigated for abuse. The findings include:Review of the facility's policy titled Abuse Prohibition Standard of Practice, last revised 07/2022, revealed that in the event an alleged or actual violation occurs, the resident would be immediately assessed and removed from any potential harm. Continued review revealed the Administrator, or designee, would conduct an internal investigation regarding any allegation of abuse, neglect, exploitation, injury of unknown source, or misappropriation of resident property, and report the results of the investigation to the enforcement agency in accordance with state law, including the state survey agency within five working days of the incident. Continued review of the abuse policy revealed the facility's definition of sexual abuse was Non-consensual sexual contact of ANY type with a resident/patient. Additionally, the facility's policy, last revised on 07/2022, clarified mental abuse as the use of verbal or nonverbal conduct that causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. The prevention of abuse included an ongoing assessment of resident behaviors is assessed with care planning to include appropriate interventions. In the reporting of abuse, the policy stated, alleged violations shall be reported to the state survey agency, adult protective services, and all other required agencies within specified time frames, and appropriate steps shall be taken to prevent recurrence of the incident.Review of the Abuse Education Post Test, undated, and administered on 06/02/2025, revealed that question number five (5) asked which of the following constitutes abuse? The selection included a) inappropriate touch, b) voicing unwanted sexual comments, c) sharing unwanted sexually implicit photos or materials, or d) all the above. The correct answer was listed as d) all the above. The Social Services Director and the Administrator had signatures affixed to their tests. 1.Record review of an internal Grievance / Concern Form, completed by the SSD on 06/24/2025, revealed that Resident (R)11 reported to the SSD that another resident was making inappropriate comments to her. Further, it stated that the Certified Nursing Assistant (CNA) (Nursing Assistant [NA]) instructor, from an outside CNA [NA] educational resource, reported that R11 had reported another resident was making inappropriate comments to her. a. Record review of R11's face sheet revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease and multiple comorbidities.Review of the quarterly Minimum Data Set (MDS) of 06/11/2025 revealed a Brief Interview of Mental Status of 5, indicating severe cognitive impairment.Record review of R11's Comprehensive Care plan (CCP), dated 03/07/2025, related to the diagnosis of depression, revealed a concern dated 06/24/2025 of increased agitation related to inappropriate comments made by another resident. An intervention, dated 06/24/2025, revealed that the intervention was a social services visit. Further review, however, revealed no documentation to support the facility monitored the resident to protect her from further abuse or to assess her for any psychosocial outcomes. b. Record review of R12's face sheet revealed the facility admitted the resident on 05/21/2021 and most recently on 05/29/2025 with a principal diagnosis of malignant neoplasm of unspecified bronchus, or lung, anxiety, history of nicotine dependence, and multiple chronic co-morbidities.Review of the quarterly MDS with an ARD of 06/06/2025 revealed a Brief Interview of Mental Status of 9, indicating a moderate cognitive impairment.Record review of R12's CCP, dated 05/21/2024 and updated 06/24/2025, revealed a problem related to the resident making inappropriate comments at times and an intervention, also dated 06/24/2025, of a social services visit to discuss behaviors/inappropriate comments to others. Further review revealed no documentation to support that the facility monitored the resident's behaviors to protect R12 and other resident(s) from abuse. During an interview on 06/30/2025 at 1:36 PM, Nursing Assistant (NA)1 approached the SSA surveyor, stating that R11 reported to her that R12 had been following her around and had made a sexual comment to her. She added that even though R12 did not smoke, R11 stated he had followed her outside. She stated that the instructor for the NA class overheard this conversation as well, and they reported to the Administrator. During an interview on 06/30/2025 at 2:00 PM with the Administrator, the SSA surveyor requested a copy of any documentation of reporting of this incident, and a list of grievances. Per the interview, the Administrator stated the facility did not report the incident. He stated the SSD would be able to answer questions regarding investigating the incident. When asked to clarify, he stated that he did not feel this situation warranted reporting, however, the SSD followed up with the resident by filling out a grievance and by speaking with the residents involved.During an interview on 06/30/2025 at 2:10 PM with the SSD, she stated that it was brought to her attention that R12 said to R11 that he thought she had a nice ass. She stated that when she spoke to R11, she said, she didn't like the words he used. During an interview with the NA instructor on 07/01/2025 at 08:00 AM the instructor confirmed what had been reported, and she stated she took it immediately to the Administrator, adding, We teach our staff to take any allegations seriously. She then stated that the Administrator advised her to relay the allegation/incident to the SSD. Per the interview, the NA instructor stated she then notified the SSD of the verbal abuse allegation.During an interview on 07/01/2025 at 5:12 PM with the RCC, she stated she provided the Abuse Education to the Department Heads, such as the Director of Nurses, Minimum Data Set (MDS) nurses and Staff Development Coordinator (SDC) as part of the most recent Plan of Correction. She stated examples of abuse were sexual, verbal, physical, seclusion and misappropriation. She added that allegations should be reported, and an investigation should have been initiated. During an interview on 07/01/2025 at 5:35 PM with the Interim Administrator, he stated that he was surprised that R11 was offended by being told she had a nice ass since the language she used was as bad or worse. In a further interview, he stated that, however, the facility policy should have been followed.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 87 sampled residents (Residents (R) 45, and 81). The findings include:Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that were responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional levels. Further review revealed that residents' assessments were to be ongoing, and care plans were required to be revised as information about the residents and their conditions changed. Review of the Facility Investigation dated 05/17/2025 around 7:25 PM revealed Registered Nurse (RN) 2 observed R45 throw an ashtray at R81, during smoke break outside the facility.(a) Review of R45's Face Sheet revealed the facility admitted the resident on 07/08/2024. R45's diagnoses included aphasia following cerebral infarction, unspecified.Review of the Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 05/07/2025, revealed the facility assessed R45 to have a Brief Interview for Mental Status (BIMS) score of 00 of 15, which indicated severe cognitive impairments. Further review revealed the facility assessed R45 to have no behaviors exhibited. Review of R45's comprehensive care plan revealed the facility developed a behavior care plan which was updated on 05/24/2025, for behavior/emotional outbursts; on 05/27/2025, for an altercation; and on 06/06/2025, for behaviors of throwing a coffee cup in the hallway. Per review of the care plan, the interventions included R45 being sent out for psychiatric evaluation on 05/25/2025; and from 05/27/2025 through 05/30/2025, 1:1 supervision of the resident. However, record review revealed no interventions for increased supervision between R45 and R81.1(b) Review of R81's admission Face Sheet revealed the facility admitted the resident on 06/06/2024. The resident's diagnoses included Epilepsy and Cerebral Palsy. Review of R81's MDS with an ARD of 03/12/2025, revealed the facility assessed the resident to have a BIMS score of 3 out of 15, indicating severe cognitive impairments. Continued review revealed the facility assessed R81 to have no behaviors such as, yelling, screaming or cursing. Further review revealed the facility updated R81's BIMS score on 07/12/2025, with the resident scoring 12 out of 15, indicating moderately impaired cognition.Review of R81's comprehensive care plan revealed the facility developed a behavior care plan which was updated on 07/14/2025, related to the resident making statements he did not like black people, being verbally abusive to staff, and for a resident-to-resident altercation. Continued review revealed the interventions included on 07/12/2025, to encourage R81 to be respective of others; on 07/13/2025, to place R81 on every 15-minute checks while in bed; and on 07/14/2025,1:1 supervision and allowing the resident space to calm down. However, there were no interventions to closely monitor interactions with R45.In interview on 07/15/2025 at 2:56 PM, R81 stated there was a black woman in the facility who had called him a mother fucker. He stated he told the resident he would rather be a mother fucker than a nigger. R81 further stated he had no further incidents with her.In interview on 07/16/2025 at 9:47 AM, Family Member 7 stated when visiting his spouse, he overheard R81 calling R45 a nigger several times in the past.In interview on 07/18/2025 at 11:40 AM, Registered Nurse (RN) 2 stated on 05/17/2025 around 7:30 PM, she had been standing in the lounge area of the facility looking at the smoke break area, and saw an ashtray go flying into the air toward a resident. She stated R45 had thrown the ashtray at R81. RN 2 stated she separated the residents and asked R45 why she had thrown the ashtray. She stated R45 told her that R81 had called her a nigger. However, RN 2 stated R45 could not talk, but other residents in the smoke break area reported hearing R81 call R45 the derogatory name. She stated there had been no staff outside with the residents on smoke break when the incident occurred as staff were assisting other residents outside.In interview on 07/18/2025 at 3:45 PM, the Social Services Director (SSD) stated when a resident displayed behaviors and she was not in the building, she was made aware. She stated the incident was documented in the progress notes by the nurse and discussed during the Interdisciplinary Team (IDT) meetings. The SDC stated she followed up for 72 hours with the residents involved in those types of incidents to ensure no psycho-social harm or distress had incurred. She stated she did not normally create a progress note regarding her follow-up with the residents. The SSD stated as of today a new process had been put in place for her to do a progress note in the resident's chart for her follow-up visits.In interview on 07/18/2025 at 5:05 PM, the Administrator stated his expectation was for residents' care plans to be updated with any changes in order to guide staff to provide appropriate care.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received care to prevent pressure ulcers from developing and promote healing consistent with professional standards of practice for two of 37 sampled residents Resident (R) 26 and R110. Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR §483.25(b)(1) Pressure ulcers (F686) at the scope and severity (S/S) of a K. Substandard Quality of Care (SQC) was identified at 42 CFR §483.25(b)(1) Pressure ulcers (F686). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional levels. Further review revealed that residents' assessments were ongoing, and care plans were required to be revised as information about the residents and their conditions changed Review of the facility's policy, Skin Care Standard of Practice, dated 07/2020, revealed the facility was required to assess the resident on admission, readmission, and with each change of condition that may compromise the skin. The nurse was required to perform staging and measuring to maintain continuity in documenting the progression of wound healing. Staff were also required to perform weekly documentation of the wound status and response to healing, including the potential need to alter treatment. Wound documentation was to include location of the wound, staging of the wound, size of the wound (length x width x depth), exudate (if present), wound bed description, description of wound edges and surrounding tissue, and pain (if present). Further review revealed that all assessments/evaluations relating to skin/wound care would be documented in the EMR (Electronic Medical Record) System. 1. Review of R26's admission Face Sheet revealed the facility admitted the resident on 12/17/2024 with diagnoses that included Alzheimer's Disease, chronic kidney disease, chronic obstructive pulmonary disease with (acute) exacerbation, delusional disorders, dementia, diffuse large B-cell lymphoma, unspecified site, and malignant neoplasm of brain, unspecified. Review of R26's current Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 0/15, indicating the resident had severe cognitive impairment. Further review revealed R26 required total assistance with turning side to side in the bed, showering/bathing, and personal hygiene. Review of R26's care plan, related to Impaired Skin Integrity, dated 02/10/2025 revealed the goal was for R26 to be free from additional skin breakdown. Further review revealed that a weekly skin assessment was one of the interventions of the care plan. Review of the Bath/Shower Sheet completed from 02/27/2025 until 05/08/2025 revealed that each time R26 received a shower or bed bath from the State Registered Nurse Aide (SRNA), no new skin areas were identified. Review of R26's progress note, dated 03/04/2025 revealed an order for preventative measures for bilateral heels by painting heels with betadine and apply dry dressing daily, and as needed due to the resident scooting his heels on the bed. Review of R26's Progress Note, dated 03/17/2025 revealed R26's skin assessment was completed with no new areas noted. Review of R26's Progress Note dated 03/17/2025 revealed that the Wound Care Physician Assistant (PA) saw R26 for a pressure wound to the head. However, there was no documented evidence the PA assessed any other areas. Interview with the PA on 05/16/2025 at 12:34 PM revealed that the PA assessed the wound to the resident's head; however, did not assess any other wounds. According to the PA, the DON provided instructions to the PA on which residents were to be evaluated. The PA stated that when evaluating residents for skin breakdown she assessed the high-pressure areas, such as the heels, elbows and bottom, for wounds. The PA stated R26 did not have any other wounds but the wound to the head when she assessed the resident on 03/17/2025. During an interview on 05/14/2025 at 12:10 PM with License Practical Nurse (LPN) 3, she stated her skin assessment was when she looked at a resident's skin that was exposed during her medication pass. LPN3 stated she did not conduct a head-to-toe skin assessment. Interview with Registered Nurse (RN)1 on 05/24/2025 at 12:23 PM revealed that she had never conducted skin assessments during her shift. According to RN1, the DON had instructed facility staff that the wound care staff were responsible to conduct all skin assessments, wound assessments to include surgical wounds and provide any physician ordered wound care. During an interview on 05/14/2025 at 9:38 PM with Registered Nurse (RN) 2, she stated that she did not complete resident head -to-toe assessments weekly. RN2 stated this was a task delegated to the wound nurse by the Director of Nursing (DON). According to RN2, the DON had instructed all the nursing staff that wound care and skin assessment were to be conducted by the wound care staff. Review of R26's Treatment Administration Record (TAR) dated 03/2025 revealed no documentation that the preventive treatment to bilateral heels was provided on 03/19/2025 or 03/20/2025. Record review revealed, on 03/20/2025, R26 was admitted to a local hospital with the following diagnosis: sepsis, acute kidney injury, UTI, and pneumonia. The hospital physician documented multiple areas of skin breakdown that the nursing facility had failed to identify including eschar to bilateral heels, a stage III to the left buttock, a stage III to the right buttock, non-pressure chronic ulcer of the heel and midfoot, and unstageable pressure ulcer of the sacral area. R26 required surgical debridement of his bilateral heels on 03/21/2025 at the hospital. R26 was discharged back to the nursing facility on 03/26/2025. During an interview on 05/15/2025 at 8:40 AM with the Director of Nursing (DON), she stated that the staff had failed to identify the wounds on R26 heels, and that the facility was currently working on improving their skin program after results from a mock survey in 04/2025. The DON stated that she expected a weekly head-to-toe assessment to be completed on residents to identify and prevent pressure ulcers. During an interview on 05/16/2025, the Administrator stated he expected skin assessments to be done weekly and all physician orders to be followed to keep residents safe and healthy. 2. Review of R110's admission Face Sheet revealed the facility admitted the resident on 02/18/2025 with diagnoses that included unspecified dementia, Parkinson's Disease, neurocognitive disorder with Lewy bodies, anxiety, depression, bowel incontinence, generalized weakness, anemia, urinary retention, hypertension, history of dehydration, and a history of malignant neoplasm of large intestine. The resident was also admitted with a Stage II pressure ulcer to the right buttock. Review of R110's current Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 3/15, indicating the resident had severe cognitive impairment. Further review revealed R110 required total assistance with turning side to side in the bed, showering/bathing, transfers, and personal hygiene. Review of R110's care plan, related to Impaired Skin Integrity, dated 02/20/2025 revealed the resident was identified as high risk for impaired skin integrity due to incontinence, immobility, and multiple comorbidities including dementia, Parkinsonism, and a history of skin breakdown. The interventions included repositioning every two hours, a weekly skin assessment, and to promote adequate nutrition. Review of R110's Turn and Repositioning Log, dated May 2025 revealed the facility had multiple missed repositioning intervals, particularly during critical overnight hours (May 2-5 had missing entries at 3 AM and 5 AM; May 7-10 had missing entries at 1 AM and 3 AM; May 13-15 had missing entries from 3 PM- 9PM; and May 17-18 had missing entries from 1 AM until 7 AM). The facility failed to ensure consistent implementation of repositioning interventions for R110 as outlined in the care plan to prevent skin breakdown. Review of the Skin Committee Progress Notes dated 02/18/2025 through 05/18/2025, revealed the facility did not complete weekly skin assessments as required per the facility policy Skin Care Standards of Practice. The note lacked documentation of the resident's wound status and healing progress, including the need to modify treatment as appropriate. The required documentation such as wound location, stage, size (length x width x depth), presence of exudate, wound bed description, condition of surrounding tissue and, and pain was not consistently recorded. Further review revealed the facility's policy required all skin and wound assessments to be documented in the EMR (Electronic Medical Record) System. Review of R110's Progress Note, dated 02/21/2025 revealed R110's skin assessment was completed and identified one stage two pressure ulcer on the right buttock. Further review revealed the facility initiated a treatment to cleanse the right buttock wound with NS (normal saline) or wound cleanser, dry, and apply zinc, leaving open to air daily and as needed. This treatment remained in place through early March. Review of a Progress Note, dated 04/11/2025, revealed the wound was described as unstageable, measuring 4.0 x 3.4 x 0.3 cm. The wound continued to drain moderate amounts of exudate and eventually required enzymatic debridement and sharp debridement by a wound care provider on 04/21/2025 at the facility. Review of Physician's Orders and the Skin Committee Progress notes revealed no change in the resident's pressure treatments. Continued review revealed the facility failed to conduct weekly skin assessments. Review of Progress Note dated 04/24/2025, revealed the unstageable wound to the right buttock remained open and draining, with only 5% granulation tissue and 95% necrotic tissue. A sharp debridement was performed at the facility. Review of Progress notes from 05/04/2025 and 05/09/2025 revealed continued orders for Santyl, calcium alginate, and super absorbent adhesive dressings with daily application and PRN (as needed). The skin committee noted no changes to the treatment plan despite documented wound deterioration. Review of the Progress Notes revealed a deep tissue injury (DTI) to the right heel was identified on the Progress Note dated, 03/14/2025. Treatment was initiated with Betadine, ABD pads (abdominal pads used to collect drainage), and a tubular bandage. Review of the Skin Committee Progress Notes revealed over time, this DTI progressed to dried necrotic tissue, requiring ongoing management through March and April. Review of the body map dated 05/16/2025 identified extensive breakdown, including multiple wounds on the sacrum, buttocks, heels, and upper back, indicating R110 had widespread deterioration. Review of progress notes, skin assessments, and interviews revealed a lack of shift-to-shift monitoring, failure to reassess and escalate care when wounds worsened, and delays in response following the wound care nurse's departure. Review of the Hospital Discharge summary, dated [DATE], revealed the facility transferred R110 to the hospital due to altered mental status on 05/18/2025. R110 expired at the hospital on [DATE] due to Anemia. During an interview with the Unit Manager on 05/28/2025 at 10:58 AM, she stated that she completed the skin assessment on the Body Map dated 05/16/2025 that identified new areas of skin breakdown. However, the physician was not notified until 05/18/2025 due to miscommunication with the Director of Nursing (DON). During interview with the Interim Director of Nursing (IDON) on 05/29/2025 at 10:04 AM, she stated that upon arrival, she was informed the wound care nurse was on FMLA (Family and Medical Leave Act) leave. The IDON stated the facility had not designated another nurse to monitor, assess, or treat residents' wounds during the wound care nurse's absence for the last few weeks. Review of the resident's nutritional care plan, initiated 02/17/2025, revealed the facility identified the resident was at risk for weight loss with increased protein needs due to wound presence. Interventions included fortified foods, protein supplements, multivitamins, and a dysphagia-pureed diet. Review of a dietary progress note dated 05/01/2025, revealed the resident was generally accepting of oral supplements with an average meal intake of 77%. However, review of the daily meal and fluid intake records from May 11-17, 2025, revealed multiple days of refused or poor intake (0-25%), and fluid intake below 500 mL on at least two days. There was no documented evidence of staff reassessment, physician notification, or additional dietary interventions related to the low intake trends. During an interview conducted on 05/29/2025 at 2:33 PM, State Registered Nurse Aide 7 (SRNA7) stated that R110 had experienced a significant decline the last week at the facility before going to the hospital on [DATE]. SRNA 7 stated R110 just slept all the time and had become difficult to awake for meals. The SRNA stated that R110 just stopped eating and drinking and had very limited fluid output that was dark orange in color. She stated she reported the changes to LPN 2 but did not recall any formal change in dietary interventions or additional monitoring being implemented at that time. During an interview with Licensed Practical Nurse (LPN) 2 on 05/28/2025 at 10 AM, she stated that approximately one week prior to the resident's decline, she noticed the resident was not eating very much. LPN 2 stated the SRNAs mentioned that the resident had reduced intake, and she had gone into R110's room to try and encourage the resident to eat. She stated she notified the unit manager of R110's decline. However, she was unsure if she followed up on her concern. LPN 2 stated she assumed the Unit Manager would notify the physician and did not initiate or observe any changes to the nutritional care plan, or increased monitoring during this period. During an interview with the Unit Manager on 05/28/2025 at 10:58 AM, she stated that staff had reported R110's decline in eating, drinking, and output. However, she acknowledged that she did not notify the physician, stating she believed it was the DON's responsibility to do so. During an interview conducted on 5/29/2025 at 9:55 AM, the Interim Administrator stated there had been a lack of appropriate assessments and absence of a consistent Quality Assurance process. He stated that wound care concerns were not routinely discussed in the morning meetings and were only added to the meeting agenda after the most recent issues were identified. The Intern Administrator stated that failures in the turning, repositioning and wound care processes and lack of rounds had contributed to the problem. He stated, When you have an issue with wounds, it's because of processes mostly. He further explained that it was evident there had been a breakdown in systems and oversight, and that wounds were not included in daily discussions until he intervened. The Intern Administrator stated the failure ultimately rested, in the administrator's chair. He stated that strong morning meetings and clinical leadership could have prevented the breakdown in skin, nutrition, and care coordination systems. During an interview on 05/28/2025 at 7:15 PM the newly appointed Wound Care Physician (WCP) stated after her review of the previous resident wound/skin documentation on 05/28/2025, the WCP felt there were multiple discrepancies and inaccuracies in comparison to her assessment. For example, the WCP explained that every wound had been documented and treated as unstageable; however, there were no weekly skin assessment sheets, minimal to no documentation regarding the wounds and no measurements and/or appropriate treatments in place to support healing of the wounds. The WCP stated that due to the lack of documentation, she became very concerned for the overall health and safety of the residents. The WCP stated after she arrived at the facility, she immediately realized the lack of preventative measures such as off-loading and special support devices for at-risk residents with apparent high-risk areas along with the lack of staff knowledge, education, communication and in-sufficient staffing. Therefore, according to the WCP most of the wounds she assessed were facility acquired and a facility wide failure was identified. During an interview on 05/29/2025 at 9:58 PM with the newly appointed Wound Care Nurse (WCN), the WCN stated during her initial skin sweep assessment of all residents she identified staff were not following up or taking appropriate measures to identify new areas such to include implementing skin assessment sheets, as they were non-existent. In addition, the WCN stated the documentation was not supportive and/or accurate due to a lack of leadership, communication, education and training. The WCN stated wounds were never discussed or part of the clinical meetings. On 05/20/2025 the WCN stated she attended the morning clinical meeting with all other departmental leadership to discuss concerns; however, nothing was discussed about the wounds and/or resident conditions. The WCN stated from her continued observation of resident wrinkles, redness on pressure areas, uncleanliness of digits and poor condition of resident's heels, it was apparent that skin assessments were not being performed nor was the appropriate repositioning or offloading being implemented. In interview, with the Regional Quality Manager (RQM) on 05/29/2025 at 10: 50 AM, she stated she was part of the Governing body and was present during the quarterly calls, as well as onsite at the facility, on a regular basis to audit and monitor any concerns the facility had identified. She stated for example, in March 2025 they performed and assisted with a MOCK survey at the facility. The RQM stated they treated and performed the MOCK survey just as the State performed their surveys. She stated all care areas were reviewed and investigated. During the interview, she stated their survey also identified deficiencies with wounds and that the wound nurse was not assessing and documenting correctly. The RQM stated a plan of correction was provided; however, we were not getting results. She stated she felt the lack of communication, notification and education was the root cause of the problem. In addition, she stated the facility failed to replace the wound care nurse when she went on medical leave and unfortunately residents were not being assessed and/or provided treatment appropriately. Attempts were made to contact the Medical Director on 05/28/2025 at 1:54 PM,1:56 PM and 4:00 PM. There was no response from the Medical Director.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received care to prevent pressure ulcers from developing and promote healing consistent with professional standards of practice for one of 37 sampled residents (Resident (R) 26). Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR 483.25(b)(1) Pressure ulcers (F686) at the scope and severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25(b)(1) Pressure ulcers (F686). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional levels. Further review revealed that residents' assessments were ongoing, and care plans were required to be revised as information about the residents and their conditions changed. Review of the facility's policy, Skin Care Standard of Practice, dated 07/2020, revealed the facility was required to assess the resident on admission, readmission, and with each change of condition that may compromise the skin. The nurse was required to perform staging and measuring to maintain continuity in documenting the progression of wound healing. Staff were also required to perform weekly documentation of the wound status and response to healing, including the potential need to alter treatment. Wound documentation was to include location of the wound, staging of the wound, size of the wound (length x width x depth), exudate (if present), wound bed description, description of wound edges and surrounding tissue, and pain (if present). Further review revealed that all assessments/evaluations relating to skin/wound care would be documented in the EMR (Electronic Medical Record) System. Review of R26's admission Face Sheet revealed the facility admitted the resident on 12/17/2024 with diagnoses that included Alzheimer's Disease, chronic kidney disease, chronic obstructive pulmonary disease with (acute) exacerbation, delusional disorders, dementia, diffuse large B-cell lymphoma, unspecified site, and malignant neoplasm of brain, unspecified. Review of R26's current Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 0/15, indicating the resident had severe cognitive impairment. Further review revealed R26 required total assistance with turning side to side in the bed, showering/bathing, and personal hygiene. Review of R26's care plan, related to Impaired Skin Integrity, dated 02/10/2025 revealed the goal was for R26 to be free from additional skin breakdown. Further review revealed that a weekly skin assessment was one of the interventions of the care plan. Review of the Bath/Shower Sheet completed from 02/27/2025 until 05/08/2025 revealed that each time R26 received a shower or bed bath from the State Registered Nurse Aide (SRNA), no new skin areas were identified. Review of R26's progress note, dated 03/04/2025 revealed an order for preventative measures for bilateral heels by painting heels with betadine and apply dry dressing daily, and as needed due to the resident scooting his heels on the bed. Review of R26's Progress Note, dated 03/17/2025 revealed R26's skin assessment was completed with no new areas noted. Review of R26's Progress Note dated 03/17/2025 revealed that the Wound Care Physician Assistant (PA) saw R26 for a pressure wound to the head. However, there was no documented evidence the PA assessed any other areas. Interview with the PA on 05/16/2025 at 12:34 PM revealed that the PA assessed the wound to the resident's head; however, did not assess any other wounds. According to the PA, the DON provided instructions to the PA on which residents were to be evaluated. The PA stated that when evaluating residents for skin breakdown she assessed the high pressure areas, such as the heels, elbows and bottom, for wounds. The PA stated R26 did not have any other wounds but the wound to the head when she assessed the resident on 03/17/2025. During an interview on 05/14/2025 at 12:10 PM with License Practical Nurse (LPN) 3, she stated her skin assessment was when she looked at a resident's skin that was exposed during her medication pass. LPN3 stated she did not conduct a head-to-toe skin assessment. Interview with Registered Nurse (RN)1 on 05/24/2025 at 12:23 PM revealed that she had never conducted skin assessments during her shift. According to RN1, the DON had instructed facility staff that the wound care staff were responsible to conduct all skin assessments, wound assessments to include surgical wounds and provide any physician ordered wound care. During an interview on 05/14/2025 at 9:38 PM with Registered Nurse (RN) 2, she stated that she did not complete resident head -to-toe assessments weekly. RN2 stated this was a task delegated to the wound nurse by the Director of Nursing (DON). According to RN2, the DON had instructed all of the nursing staff that wound care and skin assessment were to be conducted by the wound care staff. Review of R26's Treatment Administration Record (TAR) dated 03/2025 revealed no documentation that the preventive treatment to bilateral heels was provided on 03/19/2025 or 03/20/2025. Record review revealed, on 03/20/2025, R26 was admitted to a local hospital with the following diagnosis; sepsis, acute kidney injury, UTI, and pneumonia. The hospital physician documented multiple areas of skin breakdown that the nursing facility had failed to identify including eschar to bilateral heels, a stage III to the left buttock, a stage III to the right buttock, non-pressure chronic ulcer of the heel and midfoot, and unstageable pressure ulcer of the sacral area. R26 required surgical debridement of his bilateral heels on 03/21/2025 at the hospital. R26 was discharged back to the nursing facility on 03/26/2025. During an interview on 05/15/2025 at 8:40 AM with the Director of Nursing (DON), she stated that the staff had failed to identify the wounds on R26 heels, and that the facility was currently working on improving their skin program after results from a mock survey in 04/2025. The DON stated that she expected a weekly head-to-toe assessment to be completed on residents to identify and prevent pressure ulcers. During an interview on 05/16/2025, the Administrator stated he expected skin assessments to be done weekly and all physician orders to be followed to keep residents safe and healthy.

Based on interview, record review, and review of the facility's policies, the facility failed to utilize its resources effectively to ensure that its policies related to nutrition/hydration were implemented and failed to ensure that an effective system was in place to obtain accurate weights for each resident. In addition, the facility did not identify significant/severe weight changes and failed to implement interventions to ensure adequate nutrition/hydration and prevent serious adverse outcomes for 79 of 87 sampled residents (R1-R79).Immediate Jeopardy (IJ) was identified on 07/14/2025. It was determined to exist on 06/11/2025 in the areas of 42 CFR 483.25, Nutrition/Hydration Status Maintenance (F692) at the highest scope and severity (S/S) of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F692). The facility was notified of the Immediate Jeopardy on 07/14/2025.The facility presented an acceptable plan for removal of the IJ on 07/18/2025 at 1:00 PM. The survey team validated the IJ was removed on 07/19/2023 at 4:40 PM following the facility's plan implementation. Based on interview, record review, and review of the facility's policies, the facility failed to utilize its resources effectively to ensure that its policies related to nutrition/hydration were implemented and failed to ensure that an effective system was in place to obtain accurate weights for each resident. In addition, the facility did not identify significant/severe weight changes and failed to implement interventions to ensure adequate nutrition/hydration and prevent serious adverse outcomes for 79 of 87 sampled residents (R1-R79).Immediate Jeopardy (IJ) was identified on 07/14/2025. It was determined to exist on 06/11/2025 in the areas of 42 CFR 483.25, Nutrition/Hydration Status Maintenance (F692) at the highest scope and severity (S/S) of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F692). The facility was notified of the Immediate Jeopardy on 07/14/2025.The facility presented an acceptable plan for removal of the IJ on 07/18/2025 at 1:00 PM. The survey team validated the IJ was removed on 07/19/2023 at 4:40 PM following the facility's plan implementation.The findings include:Review of the facility's policy titled Nutrition / Hydration Status Maintenance, dated 04/2025, revealed that the facility was to provide nutrition/hydration status maintenance according to State and Federal regulations.Review of the facility's policy titled, Weight Process Standard of Practice, dated 04/2025, revealed the policy's purpose was to recognize, evaluate, and address the needs of every resident, including but not limited to the resident at risk or already experiencing impaired nutrition and hydration. Per review, the Director of Nursing (DON) was responsible for obtaining and recording residents' weights in the medical records. Continued review revealed that staff were required to obtain resident weights on admission or readmission, weekly for the first four weeks after admission, and at least monthly thereafter to identify and document trends such as insidious (gradual and harmful) weight loss. Further review revealed that residents with a weight change of 3% in 1 month, 5% in 3 months, or 7.5% in 6 months were to be reviewed by the Interdisciplinary Team (IDT) and addressed through care planning.Review of the facility's policy titled Nutrition/Hydration Status Maintenance, dated 04/2025, revealed that the facility was to provide nutrition/hydration status maintenance according to State and Federal regulations.1.Review of R79's admission Face Sheet revealed the facility admitted the resident on 05/25/2022, with the following diagnoses: Alzheimer's disease, dementia, gastritis, and major depressive disorder. Review of R79's medical record revealed the resident was placed on a dysphagia pureed diet on 03/02/2025 due to choking and aspiration risk.Review of R79's current Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of 15. This score indicated severe cognitive impairment.Review of R79's care plan established on 05/24/2022 and updated through 07/2025, revealed that the facility identified problems related to dehydration risk. Per review, the care plan included goals to maintain adequate nutrition and hydration and to adhere to the prescribed diet regimen. The continued review revealed that the interventions listed included monitoring R79's weights per order, honoring the resident's food preferences, and offering alternatives if PO (by mouth) intake was suboptimal or refused. However, further review of the care plan revealed no documented evidence that it addressed R79's known aspiration risk or included interventions related to aspiration precautions, even though the resident had a diagnosis of dysphagia and there were recurrent episodes of R79 getting choked during her meals.Review of R79's Weight Logs from 05/07/2025 through 06/05/2025 revealed the facility documented the resident's weight as 99 pounds on 05/07/2025, 05/13/2025, 05/14/2025, 05/15/2025, and as 98 pounds on 05/22/2025, 05/29/2025, and 06/05/2025. However, review of R79's medical record revealed R79 was admitted to the hospital on [DATE] for sepsis, acute renal failure, aspiration pneumonia, cachexia, hypoproteinemia, and adult failure to thrive.Review of R79's hospital medical record revealed the resident's weight was recorded as 83 pounds, a 16-pound weight loss the facility neither recognized nor addressed. Further review revealed R79's weight loss was a 16.2% weight loss from the facility's last documented weight for the resident.Review of the facility's Progress Note for R79 revealed the resident returned to the facility on [DATE], with a new order for end-of-life care. Continued record review revealed R79 expired on 06/21/2025.During the interview on 06/30/2025 at 7:00 PM, Hospitality Aide 3 stated she worked daily with the restorative aide responsible for obtaining resident weights. She stated she had observed the restorative aide documenting residents' weights without weighing the residents.In an interview on 07/09/2025 at 1:30 PM, SRNA 7 stated that residents' weights were often fabricated before the unit nurses documented them in the residents' records. She reported that residents' weights frequently remained documented as the same for multiple months, even when residents' conditions had changed. SRNA 7 further stated she had not seen residents' weights obtained consistently for the past two or three years.During interview on 07/09/2025 at 11:00 AM, Family Member (FM) 7 stated R79 had lost significant weight. FM7 stated R79 had not appeared to weigh 80 pounds at her death.2. Review of R62's admission Face Sheet revealed the facility admitted the resident on 05/21/2019. R62's diagnoses included failure to thrive, depression, dementia, and history of a feeding tube.Review of the current MDS, with an ARD of 07/06/2025, revealed the facility assessed the resident with a BIMS' score of 11 out of 15, indicating moderate cognitive impairment. Continued review of the MDS revealed the facility assessed R62 to require setup or clean-up assistance with eating.Review of the Nutritional Services care plan for R62, dated 06/29/2025, revealed the facility identified the resident as being at risk for weight loss or gain. Per review, the facility care planned R62 with a goal to maintain adequate nutrition and hydration and to sustain a stable weight without significant weight changes. Continued review revealed one of the interventions listed was for staff to monitor R62's weight following the facility's policy.Review of the facility's weight log for R62 revealed the resident's weight was documented on 04/10/2025, 05/17/2025, and 06/05/2025 as 170 pounds. However, review of R62's medical record revealed on 06/24/2025, the resident was admitted to the hospital for shortness of breath, aspiration pneumonia, and malnutrition. Review of the hospital medical record for R62 revealed an admission weight of 139.8 pounds, which was a 30.2 pounds weight loss (17.8%) from the facility's last documented weight for R62.Review of the hospital's Registered Dietician's (RD) Note, dated 06/26/2025, revealed R62's nutritional status was noted as underweight, with contributing factors of swallowing difficulty, chronic illness, decreased appetite, poor intake, and muscle wasting. Further review of the RD's Note revealed R62's hospital discharge weight was 137 pounds.Further review of R62's hospital medical record revealed the resident required total assistance with feeding and had poor oral intake (38% of meals). Per review, the hospital's RD recommended a supplement twice daily and tube feeding, if needed. However, further review of the facility's medical record for R62 revealed no documented evidence the facility recognized or addressed R62's weight loss prior to the resident's hospitalization.During interview on 07/10/2025 at 3:23 PM, R62 stated facility staff had not weighed him in months. R62 stated he was sure he had lost weight. The resident stated the weight loss was from the food being too hard and him not being able to chew it.During interview on 07/10/2025 at 10:40 AM, Registered Nurse (RN) 2 stated the facility had access to R62's hospital's electronic medical records. However, review of R62's medical record revealed the facility failed to obtain and review the hospital's dietary recommendations upon the resident's readmission.3. Review of the admission Face Sheet for R37 revealed the facility admitted the resident on 10/03/2024. R37's diagnoses included abnormal weight loss, cachexia, anorexia, severe protein-calorie malnutrition, and dehydration.Review of the current MDS, with an ARD of 07/07/2025, revealed the facility assessed R37 with a BIMS' score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed the facility assessed R37 to require setup or clean-up assistance with eating.Review of the facility's documentation for R37 revealed in less than one month, the resident's weight went from 111 pounds to 204 pounds (83.8% increase).Review of the Nutrition Services care plan, initiated on 10/08/2024 (R37's weight at this date was 111 pounds) and updated through 05/2025, revealed the facility identified the resident as nutritionally at risk due to a low body mass index (BMI) and unplanned weight loss. Per review, interventions included weekly weight monitoring, documentation of meal intake percentages, and routine lab monitoring. Continued review revealed the facility placed R37 on a high-calorie nutritional regimen, including physician-ordered nutritional supplements and scheduled snacks twice daily.However, further review of the facility's documentation revealed the facility failed to weigh R37 or recognize she had gained a significant amount of weight. In addition, there was no documented evidence of care plan adjustments on the part of the facility, nor of a facility investigation despite the severity of the change in the resident's weight.4. Review of R53's admission Face Sheet revealed the facility admitted the resident on 10/25/2023. The resident's diagnoses included hypokalemia, hypomagnesemia, encephalopathy, and morbid obesity.A review of the current MDS, with an ARD of 07/07/2025, revealed that the facility assessed R53 to have a BIMS score of 15 out of 15, indicating that the resident was cognitively intact. The review further revealed that the facility assessed R53 as requiring setup or clean-up assistance with eating.Review of R53's Nutritional Services care plan, initiated on 11/01/2023, revealed that the facility identified her as having an increased nutritional need related to severe obesity and abnormal electrolyte levels. Per review the interventions included monitoring R53's weight.A review of the facility's weight logs for R53 revealed that the resident had lost 152 pounds in one month, dropping from 350 pounds to 198 pounds (43.4%). R53 stated she had gone from wearing a size 3X brief to a 1X and expressed concerns her weight checks were infrequent and that her decline was not being addressed.During Interview with R53 on 07/03/2025 at 3:00 PM, the resident stated she had only been weighed twice since her admission to the facility. She expressed concern, stating, I use to be under weight and now I'm overweight. Staff not weighing us is dangerous because the doctor prescribes certain medications based on our weight. She further stated she asked staff to weigh her; however, she had been told, We don't have time.Additional review of the facility's weight records revealed 50 residents (R1, R2, R3, R4, R5, R6, R13, R14, R16, R17, R18, R19, R20, R22, R24, R25, R26, R27, R30, R31, R32, R33, R34, R35, R36, R38, R39, R42, R43, R45, R46, R49, R50, R53, R54, R57, R58, R59, R60, R61, R62, R64, R65, R67, R72, R74, R76, R78, and R79) experienced significant weight loss. Further review of the weight records revealed 29 residents (R7, R8, R9, R10, R11, R12, R15, R21, R23, R28, R29, R37, R40, R41, R44, R47, R48, R51, R52, R55, R56, R63, R66, R68, R69, R70, R71, R73, R75, and R77) experienced significant weight gain over the reviewed period, indicating widespread fluctuations in the residents' nutritional status which the facility failed to address. All 79 residents (R1-R79) were added to the facility's NAR (Nutrition at Risk) program after the State Survey Agency (SSA) identified that staff had failed to weigh residents as required by facility policy and had failed to identify and address the residents' weight losses/gains.Interviews on 07/02/2025 at 2:30 PM, with the DON, the Regional Nurse, the Speech Therapist, and the Unit Manager, revealed that entering false information into the residents' weight records and failure to act on residents' weight changes could cause significant weight loss, malnourishment, skin deterioration/open wounds, and death to a resident.During an interview on 07/01/2025 at 2:00 PM, the Administrator stated that staff failed to implement the facility's nutrition policy and identify and take the necessary actions to prevent significant weight changes for the residents.

Based on interview, record review, review of the facility's Administrator and Director of Nursing's Position Descriptions, review of the facility's policies and procedures, and review of the facility's abuse investigations, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's failure to have an effective system in place to ensure it was 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 has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F610) at the highest scope and severity (S/S) of a J; 42 CFR 483.25 Quality of Care (F684) at the highest S/S of a J: 42 CFR 483.25 Quality of Care (F686) at the highest S/S of a J; and, 42 CFR 483.25 Quality of Care (F697); and, 42 CFR 483.70 Administration (F835) at the highest Scope and Severity (S/S) of a J. The facility was notified of the IJ on [DATE]. The IJ is ongoing. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600 and F610), and 42 CFR 483.25 Quality of Care (F684, F686, and F697). The facility was notified of the SQC on [DATE]. Refer to F600, F610, F684, F686, and F697 The findings include: Review of the facility's document, titled Position Description-Administrator, revealed the Administrator's purpose was to direct the day-to-day functions of the facility by current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality care could be provided to residents at all times. Further review revealed under essential functions of position, the Administrator would ensure excellent care for residents was maintained by overseeing and monitoring patient care services delivered. Review of the facility's document, titled Position Description-Director of Nursing (DON), revealed the DON's purpose was to plan, organize, develop, and direct the overall operation of the facility's nursing department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, as may be directed by the Administrator, to ensure the highest degree of quality care was maintained at all times. Further review revealed under essential functions of position, the DON was responsible for the planning, organizing, direction, supervision, and evaluation of all nursing services provided in the facility. Further review revealed the DON would ensure nursing department compliance with federal, state, and local regulations and implementation of nursing services. 1. Review of the facility's abuse policy, Abuse Prohibition Standard of Practice, revised 07/2022, revealed the purpose of the policy was to protect and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigating of alleged violations in accordance with Federal and State laws. In the event an alleged or actual violation occurred, the resident would be immediately assessed and removed from any potential harm. The alleged violation would be reported to the Administrator and/or designee immediately. Alleged violations would be reported to the state survey agency, adult protective services, and all other required agencies within specified time frames. The Administrator, or designee would oversee the center in conducting an internal investigation against any violation/alleged violation of abuse, neglect, exploitation, injury of unknown origin, misappropriation of resident property, or involuntary seclusion and report the results of the investigation to the enforcement agency in accordance with state law, including the state survey agency (SSA) within five working days of the incident. On [DATE], R73 notified State Registered Nurse Aide (SRNA)9, the Medical Director (MD) had shown her a pornographic image on his personal mobile device. R73 stated the alleged incident was unwanted and left her feeling shook up. The Administrator was notified of the allegation on the same date; however, administration failed to identify the allegation as an allegation of abuse and failed to notify the State Agencies or law enforcement. The facility failed to complete a thorough abuse investigation related to the incident and allowed the Medical Director to continue working as scheduled. Additionally, administration failed to ensure residents were free from abuse related to R12. Moreover, administration failed to ensure a thorough investigation was conducted timely, failed to protect the safety of the residents, and failed to report to State Agencies and local law authorities immediately, but no later than two hours after an allegation of verbal abuse related to R98. During an interview, on [DATE] at 11:05 AM, the Director of Nursing (DON) stated it was her expectation all nursing staff followed the facility's abuse policies and procedures including notifying her of abuse allegations. In further interview, the DON stated if she had been made aware of the allegation related to R73, she would have ensured the State Agencies were notified. The DON further stated if she became aware of any abuse allegation, she would immediately notify the Administrator who was to notify the State Agencies. During an interview, on [DATE] at 8:50 AM, the Administrator stated he defined abuse as the resident feeling abused or for residents with cognitive impairment, showing any signs or symptoms of abuse. He stated he was informed of R73's allegation that the Medical Director had shown her a pornographic picture on [DATE]. He further stated after discussion with the Chief Nursing Officer (CNO), they determined the allegation was a grievance, not an abuse allegation because it would be the same imaging as if they had shown her a movie with nudity. In continued interview, the Administrator stated he was responsible for investigating abuse allegations and R73's allegation did not rise to the level of abuse, but was investigated as a grievance. The Administrator further stated since the facility did not consider R73's allegation as abuse, they felt it did not need to be reported. Further, he stated there was no need to ensure R73's safety in this situation. The Administrator provided statements from the Medical Director, Registered Nurse (RN)1 and State Registered Nurse Aide (SRNA)2 related to the allegation of abuse by R73. However, interview with the Medical Director on [DATE] at 2:53 PM, confirmed the facility had never contacted him for a statement after R73's allegation, nor was he asked by the facility to stay off the premises or not to provide physician services to R73. The Medical Director stated after the allegation, he continued to be R73's primary physician. During interview with RN1 on [DATE] at 10:30 AM, she stated she did not give a statement regarding R73's allegation and had only called/notified the Unit Manager of the allegation on [DATE]. During an interview with SRNA2, on [DATE] at 12:45 PM, she stated the Administrator asked her in passing what was going on related to R73, on [DATE], and she did not give a formal statement. 2. Review of R320's closed record, revealed the admission Face Sheet, which noted the facility admitted the resident on [DATE] for short-term rehabilitation and the resident was noted to have a status-post surgical incision measuring 27 centimeters (cm) (length) x 0.3 cm (width) to her mid back. R320's Physician's order, dated [DATE], revealed orders for staff to monitor the resident's surgical incision to the spine area for signs/symptoms of worsening and/or improvement every twelve hours. However, there was no documented evidence staff monitored the resident's wound as per physician's orders, nor was there documented evidence skin assessments were completed weekly to include location, staging, size of the wound (length x width x depth), exudate (if present), wound bed description, description of wound edges and surrounding tissue, and pain (if present). R320's most recent skin assessment noted in the Progress Notes, dated [DATE] at 4:15 PM, revealed the resident's midback wound had large amounts of serosanguinous exudate (a thin light pink, odorless wound drainage) and measured 27 cm (length) x 6.4 cm (width) x 5.8 cm (depth). Review of the Progress Notes dated [DATE] at 6:32 PM, revealed R320 was transferred to the hospital. Review of the hospital admission record, dated [DATE], revealed R320 had a large open wound on her back with hardware exposed and a foul-smelling odor; and was diagnosed with sepsis and acute renal failure. Interviews with the facility's nursing staff revealed they had not assessed the resident's wound; and had just checked to ensure the dressing was intact to the surgical wound. Interview with RN1 on [DATE] at 7:39 PM, revealed nobody had removed the surgical bandage from the hospital until ten days after the resident's admission, and by this time the wound was a big hole with purulent drainage. Furthermore, there was no documented evidence staff provided effective pain management related to the large wound on R320's back. Although R320's Physician's orders, dated [DATE], revealed an admission order for Norco (a narcotic pain medication) five milligrams every six hours as needed for pain management and Tylenol (a pain medication) 325 milligrams every four hours as needed for pain management, there was no documented evidence staff consistently documented the location and rate of pain prior to and after administering pain medication. Staff interviews revealed R320 frequently refused wound care, resisted turning in bed, and refused to be changed or showered due to pain from the wound on her back. Per the hospital Emergency Room records dated [DATE] at 7:22 PM, R320's pain could not be controlled even with Morphine administered intravenously in the ER. R320 was transferred and admitted to Hospice for pain control and expired on [DATE] due to sepsis and acute kidney injury while at the Hospice facility. During interview, on [DATE] at 8:40 AM, the DON stated R320's midback dressing should have been removed, and the nurses should have looked at the incision every twelve hours to assess for signs and symptoms of the wound improving or worsening. The DON further stated she expected a weekly head-to-toe assessment to be completed on residents to prevent pressure ulcers and infections. In further interview, the DON stated R320 was not non-complaint but experienced such significant pain that she could not tolerate care consistently. However, the DON further stated she had never contacted the physician regarding the resident's refusal of care or reports of pain. During an interview, on [DATE] at 4:42 PM, the Administrator stated the facility should always prioritize what was best for the resident. He further stated staff was expected to notify the physician if a resident was experiencing uncontrolled pain. 3. Review of R26's Progress Note, dated [DATE], revealed an order for preventative measures for bilateral heels by painting heels with betadine and apply a dry dressing daily, and as needed due to the resident scooting his heels on the bed. R26's Progress Note, dated [DATE], revealed R26's skin assessment was completed with no new areas noted. R26's Progress Note revealed the resident was admitted on [DATE] to a local hospital. Review of R26's Hospital Discharge Summary revealed the hospital physician documented multiple areas of skin breakdown that the facility had failed to identify including including eschar to bilateral heels, a stage III to the left buttock, a stage III to the right buttock, non-pressure chronic ulcer of the heel and midfoot, and unstageable pressure ulcer of the sacral area. R26 required surgical debridement of his bilateral heels on [DATE] at the hospital. During an interview, on [DATE] at 8:40 AM, the DON stated the staff had failed to identify the wounds on R26 heels, and the facility was currently working on improving their skin program after results from a mock survey in [DATE]. The DON further stated she expected a weekly head-to-toe assessment to be completed on residents to identify and prevent pressure ulcers. During an interview, on [DATE] at 4:42 PM, the Administrator stated he expected skin assessments to be completed weekly and staff to follow physician's orders. He further stated it was the DON's job to determine who performed skin assessments and how they were performed. In continued interview, the Administrator stated he left the DON in charge of the day-to-day nursing tasks and was unaware wounds were not being monitored and treated per physician's orders and per policy.

Based upon interview, review of medical records, review of the facility's policy/procedures, the facility failed to ensure that its Quality Assurance and Performance Improvement Plan (QAPI) provided overall guidance to the facility; to provide excellence in quality of care and support quality of life through patient-centered care. The facility failed to implement an effective QAPI program to guide its operations and ensure the appropriate allocation of resources. As a result, the facility did not operate effectively or efficiently to achieve the highest practicable level of physical, mental, and psychosocial well-being for residents. This systemic failure caused or was likely to cause serious injury, impairment, or death to the resident. Immediate Jeopardy (IJ) was identified on 07/14/2005. IJ was determined to exist on 06/11/2025 at 9:30 PM in the areas of 42 CFR S483.75 Quality Assurance and Performance Improvement (F865) at the highest S/S of J. 42 CFR S483.25 Nutrition/Hydration Status Maintenance (F692) at the highest S/S of K and 42 CFR S483.70 Administration (F835) at the highest S/S of J. The facility presented an acceptable plan for removal of the immediate jeopardy on 07/18/2025 at 1:00 PM. The survey team validated that the immediate jeopardy was removed on 07/19/2025 at 4:40 PM following the facility's implementation of the plan for removal of the immediate jeopardy.Refer to F600, F610, F865, F842, F692 and F835The findings include:Review of the facility's policy, titled QAPI Plan Standard of practice, revised 04/2025, revealed the facility's Quality Assurance Performance Improvement QAPI program reflected its commitment to continuous quality improvement.Review of the facility's records and staff interviews revealed 79 of 87 sampled residents experienced significant unrecognized weight gain or loss. Interviews with staff responsible for obtaining residents' weights revealed they made up weights and had not actually weighed residents for the past two years. When residents had changes in weight these changes were not identified, documented or investigated. The QAPI committee failed to identify these as indicators of clinical decline requiring intervention.Review of facility and hospital medical records revealed Resident (R) 62 lost 33 pounds over 24 days, dropping from 170 to 137 pounds. However, there was no evidence of any QAPI analysis into the cause of R62's significant weight decline.Review of the facility's weight records revealed R37 gained 93 pounds in less than one month, increasing from 111 lbs. to 204 lbs. However, there was no documented evidence of a QAPI investigation to determine the accuracy of the weight despite the clinical severity of the change.Review of the facility's weight records revealed R53 lost 152 pounds in one month, dropping from 350 pounds to 198 pounds. R53's roommate stated R53 had gone from wearing a size 3X brief to a 1X and expressed concerns that her weight checks were infrequent, and her decline was not addressed. However, R53's weight loss was not taken to the QAPI team for review.Review of the weight loss logs revealed 79 of the facility's 116 residents were identified to have potential weight loss or gain.Review of the facility's policy, QAPI Plan Standard of Practice, revised 04/2025 revealed the facility's Administrator was required to ensure that performance improvement plans were in place for areas that required improvement. The Administrator was responsible to ensure QA initiatives were available to the Governing Body for review as the Governing Body was responsible for overseeing the development and enforcement of resident care standards.During an interview with the Administrator on 07/10/2025 at 2:00 PM, he stated that the purpose of QAPI was to review systems and identify areas of needed improvement. He stated that the weight discrepancies occurred because staff did not follow the facility's policy and procedures for obtaining weights. During an interview with the Director of Nursing (DON) on 07/10/2025 at 2:04 PM, she acknowledged that the facility failed to identify the weight discrepancies, stating they were not discovered until brought to their attention by the State Survey Agency (SSA). Record review revealed no documented evidence of root cause analyses, interdisciplinary meetings, or performance improvement plans targeting weight management concerns. Despite the severity and frequency of residents' weight changes, the QAPI committee failed to recognize or address systemic problems with weight accuracy, documentation practices, and clinical follow-up.

Based on observation, interview, record review, and review of the facility's documentation and policy, it was determined the facility failed to protect residents from abuse for three (3) of thirty-seven sampled residents (Residents (R) R12, R73, and R98.) Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at the highest scope and severity S/S of a J and (F610), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600, and F610). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025. The findings include: Review of the facility's policy titled, Abuse Prohibition Standard of Practice, last revised 07/2022 revealed in the event an alleged or actual violation occurs, the resident would be immediately assessed and removed from any potential harm. Continued review revealed the Administrator, or designee, would conduct an internal investigation regarding any allegation of abuse, neglect, exploitation, injury of unknown source, or misappropriation of resident property, and report the results of the investigation to the enforcement agency in accordance with state law including the state survey agency within five working days of the incident. Continued review of the abuse policy revealed the facility's definition of abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Additionally, the facility's policy clarified mental abuse as the use of verbal or nonverbal conduct which caused or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. 1. Review of R73's admission Face Sheet revealed the resident was diagnosed with a cognitive communication deficit, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominate side, with voice and resonance disorders (voice and resonance disorders refer to problems with how sounds are produced and resonated in the vocal tract, affecting speech and voice quality). Review of R73's Quarterly Minimum Data Set (MDS) assessment, dated 02/12/2025, revealed the facility assessed R73 to have a Brief Interview for Mental Status (BIMS) score of 15. A BIMS' score of 15 indicated the resident had intact cognition (meaning their cognitive abilities, including memory, orientation, and other mental functions, were functioning normally.) Review of R73's Care plan revealed the resident utilized a facility iPad (computer/mobile device used for communication). In interview on, 05/12/2025 at 12:20 PM, R73 stated the Medical Director was doing monthly rounds and when he got his personal mobile device, she initially thought he was going to write a message to communicate with her. However, she was shown an image of a topless woman kneeling in front of a penis. R73 stated the Medical Director then worked his eyebrows up and down and winked as he was leaving her room. R73 stated she notified the Ombudsman and shortly after, she notified State Registered Nurse Aide (SRNA) 9. R73 stated being shown the pornographic image by the Medical Director made her feel very vulnerable and she did not feel safe receiving care from him. R73 stated the Medical Director was still providing physician care services to her. In interview, on 05/15/2025 at 12:45 PM, SRNA 9 stated facility staff never go into residents' rooms with the Medical Director. She stated she entered R73's room to answer her call light and R73 appeared to be upset. SRNA 9 stated R73 started to type on her iPad and she stopped her when she saw the allegation and immediately got Registered Nurse (RN)1. In interview, on 05/15/2025 at 10:30 AM, RN 1 stated SRNA 9 notified her she was needed in R73's room. When she entered the room, she read the allegation that was made and immediately notified the Unit Manger on duty. RN1 stated it was not common practice to follow the Medical Director into residents' rooms. She stated the Medical Director did not want staff to be in the room while he was with residents. RN1 stated it was never communicated to staff they needed to be present in R73s room while the Medical Director was with her. In interview, on 05/12/2025 at 10:50 AM, Unit Manager 12 stated that she was notified of the allegation R73 had made against the Medical Director and she proceeded to notify the Director of Nursing (DON). In interview, on 05/12/2025 at 11:05 AM, the DON stated she could not recall being notified of the allegation made by R73. In interview, on 05/13/2025 at 2:18 PM, Family Member (FM) 5 stated that R73 had contacted her and asked her to call Adult Protective Services (APS) because the Medical Director had shown her an inappropriate image and she did not feel safe receiving medical care from him. FM5 stated she was angry and concerned for her family member's care. During interview, on 05/15/2025 at 8:50 AM, the Administrator stated the facility did not feel R73's allegation was anything more than a grievance; therefore, the facility did not need to provide any additional safety measures for her. The Administrator stated the facility had not offered R73 access to another medical provider/physician nor had R73's care plan been updated to include any protections for her. In interview, on 05/13/2025 at 2:53 PM, the Medical Director stated he was still providing physician services to R73. He stated no one at the facility had ever asked him to have staff present when he was with residents and he did not have staff accompany him into residents' rooms. 2. Review of R98's admission Face Sheet revealed the facility admitted the resident on 10/03/2024 with diagnoses that included Failure to Thrive, Major Depressive Disorder and anxiety disorder. Review of R98's Quarterly MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During interview with R98 on 05/11/2025, she stated she had pushed her call light on 05/09/2025 at approximately 7:30 PM due to needing to have her adult brief changed. She stated staff did not enter her room until approximately 9:00 PM to respond to her needs. After the resident informed staff about her care needs, Licensed Practical Nurse (LPN)3 stated to her, If you don't like the care here your mom can take you to your fucking house. Interview with R98 on 05/11/2025, revealed she laid in her soiled brief and bed for three hours before being changed on 05/09/2025. R98 reported the allegation to LPN2 on 05/10/2025 at 7:00 AM. In interview, on 03/12/2025 at 9:30 AM, R98's FM1 stated that she was on the phone with R98 on 05/09/2025 at approximately 9:00 PM when LPN3 was in the room and overheard the conversation. FM1 heard LPN3 tell R98, If you don't like the care here your mom can take you to your fucking house. In interview, on 05/13/2025 at 3:00 PM, LPN2 stated R98 informed her that LPN3 stated to her, If you don't like the care here your mom can take you to your fucking house. LPN2 stated R98 reported that she had laid in her soiled brief and bed for three hours before being changed on 05/09/2025. LPN2 stated that she did not report the incident. During interview with the Administrator on 05/15/2025 at 9:00 AM, the Administrator stated the allegation of alleged abuse was not reported to him until 05/11/2025 and an investigation was conducted regarding the incident Review of the facility's Five (5) Day Follow Up Investigation revealed R 98 was offended by the statements that LPN3 made to her. However, the facility could not validate that abuse occurred. The incident occurred on 05/09/2025, and LPN3 continued to work and provide direct care to residents including R 98 until 05/11/2025. In a follow-up interview, on 05/12/2025 at 3:30 PM, R 98 stated that LPN3 talked to other residents with foul language as well. R 98 stated that LPN3 demonstrated an attitude and used foul language such as damn and shift often in front of residents. R 98 stated this was her home, and LPN3 talking to her that way made her feel like she was not wanted, like an intruder in her own home. R 98 stated she was supposed to be at peace in her home, but she was not at peace. R 98 stated, This nurse is the one that gives me my medicine and she could kill me with it. 3. Review of 12's admission Face Sheet revealed the facility admitted the resident on 02/27/2025 with diagnoses that included major depressive disorder, anxiety disorder, autonomic neuropathy (control of automatic body functions that include urinary issues and control), chenille and empress affecting left non-dominant side, muscle wasting and atrophy. Review of R12's admission MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of thirteen out of fifteen (15), indicating the resident was cognitively intact. Review of R12's admission MDS, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of thirteen out of fifteen (15), indicating the resident was cognitively intact. During interview on 05/09/2025, at approximately 7:00 PM, R12 stated that she had activated the call light to request incontinent care. She stated that SRNA5 stated to her, You are pissing and shitting too much, and you will have to wait your turn. During an interview on 05/11/2025, R12 stated she was left in a soiled brief from 7:00 PM until 10:00 PM on 05/09/2025. This incident was reported to the Administrator by the family member on 05/11/2025. Review of the facility's Five (5) Day Follow Up Investigation revealed the facility could not validate abuse occurred in this instance only that the resident was offended by the statements that were made to her. In interview, on 05/15/2025 at 1:15 PM, the Director of Nursing (DON) stated she was unaware of the incident with R12. The DON stated that the Administrator had mentioned it to her, but she did not know any details. In interview, on 05/15/2025 at 1:45 PM, the Administrator stated he was made aware of the situation on 05/11/2025 at approximately 5:45 PM by R12's daughter. The Administrator stated that SRNA5 was previously suspended on 05/10/2025 pending another investigation. In a follow-up interview, on 05/16/2025 at 3:40 PM, the Administrator stated that the facility's investigation determined that the allegation regarding the alleged abuse of R12 was unsubstantiated. The Administrator stated that he had spoken with R12 on Sunday, 05/11/2025, and that R12 did not mention that SRNA5 had cursed at her. The Administrator stated that it was important for staff to be educated on dignity and respect because residents need to feel like people.

Based on interview, record review and review of the facility's investigation and policy, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated to prevent further potential abuse for 2 of 37 sampled residents, (Residents (R)73 and R98). The facility's failure to ensure allegations of sexual and verbal abuse were thoroughly investigated to protect residents has caused or is likely to cause serious injury, impairment, or death to a resident if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 05/16/2025 and was determined to exist on 10/04/2024 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600) at the highest scope and severity S/S of a J and ( F610), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, Free from Abuse and Neglect (F600 and F610). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on 05/16/2025. (Refer to F600) The findings include: Review of the facility's policy titled, Abuse Prohibition Standard of Practice, last revised 07/2022 revealed in the event an alleged or actual violation occurred, the resident would be immediately assessed and removed from any potential harm. Continued review revealed the Administrator, or designee, would conduct an internal investigation regarding any allegation of abuse, neglect, exploitation, injury of unknown source, or misappropriation of resident property, and report the results of the investigation to the enforcement agency in accordance with state law including the state survey agency within five working days of the incident. Continued review of the facility's policy revealed the facility's definition of abuse included verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled using technology. Further review of the policy revealed that if the suspected perpetrator of abuse against a resident was a team member/employee, the Administrator/ Director of Nursing (DON) or designee would place the employee on immediate investigatory suspension while completing the investigation. Further review of the Abuse Policy, last revised 07/2022, revealed the policy defined mental abuse as the use of verbal or nonverbal conduct which caused or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Review of the facility's policy titled, Grievances Standard of Practice, last revised 05/2020, revealed residents and their family may voice grievances in writing or verbally to the facility or other entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The facility will make prompt efforts to resolve grievances. The Grievance Official is responsible for coordinating with state and federal agencies as required. Further review revealed that evidence demonstrating the results of all grievances will be maintained for a period of no less than three years from the issuance of the grievance decision. The Administrator was the acting Grievance Official. Review of the grievance investigation, dated 03/01/2025, revealed the Administrator completed the investigation. Further review revealed the investigation did not confirm the allegation that was made by R73. The grievance investigation revealed the Grievance Official [The Administrator] reviewed the security footage from the hall outside the resident's room and had statements regarding the alleged incident from the Medical Director, Registered Nurse (RN)1, and State Registered Nurse Aide (SRNA)9. Further review of the investigation revealed three unsigned statements. Interviews with staff and the Medical Director [the alleged perpetrator], however, revealed they were not asked to give a statement to assist with the investigation and they were not notified of the results of the investigation. Review of R73's admission Face Sheet revealed the resident had diagnoses that included a cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting the right dominate side, and voice and resonance disorders. (Voice and resonance disorders refer to problems with how sounds are produced and resonated in the vocal tract, affecting speech and voice quality). Review of R73's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 02/12/2025, revealed the facility assessed R73 to have a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of R73's Comprehensive Care Plan, dated 08/02/2024, revealed the resident used a facility tablet (electronic device/computer) for communication. In an interview, on 05/12/2025 at 12:20 PM, R73 stated the Medical Director was doing monthly rounds, on the morning of 03/01/2025, and when he got his personal mobile device, she initially thought he was going to write a message to communicate with her; however, she was shown an image of a topless woman kneeling in front of a penis. She stated the Medical Director then worked his eyebrows up and down and winked as he was leaving her room. R73 stated being shown the pornographic image by the Medical Director made her feel very vulnerable and she did not feel safe receiving care from the Medical Director. R73 stated that the Medical Director was still providing medical care services to her. She stated she notified the Ombudsman, immediately after the Medical Director left her room and shortly after she notified State Registered Nurse Aide (SRNA) 9. In an interview, on 05/12/2025 at 4:15 PM, with the Ombudsman, she stated she had been contacted by R73 about an alleged incident regarding the Medical Director. The Ombudsman stated she had contacted Adult Protective Services (APS) but had not received any updates on their investigation. She further stated that R73 was seeking a transfer to a different long term care facility because of how she had been treated at the current facility. The Ombudsman further stated that R73 expressed feelings of being shocked, degraded, disappointed, and like the staff at the facility have disregarded what she had to say. In an interview with SRNA9, on 05/15/2025 at 12:45 PM, she stated she entered R73's room to answer her call light and R73 was upset. SRNA 9 stated R73 started to type a description of the alleged image on her tablet and she stopped her when she saw the allegation [of abuse] and immediately got Registered Nurse (RN) 1. SRNA 9 stated that she was not aware if the facility had investigated the allegation, but believed it should have been investigated. She further stated she was never asked to give an official statement or sign anything regarding an investigation about the alleged incident. In interview with RN1, on 05/15/2025 at 10:30 AM, she stated SRNA 9 notified her she was needed in R73's room and when she entered, she read the allegation, that the medical director had shown R73 an image of a woman kneeling affront of a penis, and immediately notified the Unit Manger on duty. RN1 stated that when an abuse allegation was made, it was very serious and not something to be played with. RN1 stated that facility staff were never advised to accompany the Medical Director into R73's room, however, she felt it would have been best practice for the Medical Director to have staff accompany him into resident's rooms, for his protection and the protection of the residents. RN1 stated that she was not sure if the facility investigated the allegation, but she never gave her statement regarding the alleged incident. She stated she only followed the chain of command by notifying the Unit Manager 12. In an interview, on 05/12/2025 at 10:50 AM, with Unit Manager 12, she stated RN1 notified her that R73 had told staff that the Medical Director had shown her a picture of a topless female in front of a penis. She stated she notified the Director of Nursing (DON), the same day it was reported to her[on the morning of 03/01/2025]. The Unit Manager further stated that she was never asked to give any type of statement regarding the alleged incident and was not sure if it was investigated. The Unit Manager 12 stated that she could not say if the allegation was true or not the facility should have looked into it to ensure the safety of the residents. In an interview, on 05/12/2025 at 11:05 AM, with the Director of Nursing (DON), she stated she could not recall being notified of the alleged report made by R73. The DON stated that she expected all nursing staff to follow facility policies and procedures, including following the chain of command and notifying her of abuse claims. The DON stated that if she had been made aware of the situation she would have notified the Administrator and ensured the Office of Inspector General (OIG) [State Survey Agency (SSA] was also notified. The DON stated that the allegation was investigated as a grievance and the facility did not need to take additional action. In interview with the Medical Director, on 05/13/2025 at 2:53 PM, he stated he was the primary care provider for R73 and did provide routine services on 03/01/2025. The Medical Directed stated that he performs most services in resident rooms and provided a routine exam for R73. The Medical Director stated that he was aware R73 alleged he showed her an inappropriate image on his personal mobile device, but had never received any report or notices from the facility, so he was unsure of the status of the facility's investigation. He stated he assumed the facility had completed its investigation. The Medical Director stated that he was not included in the investigation and was not sure what the process included, or the findings of the investigation. In continued interview with the Medical Director, on 05/13/2025 at 2:53 PM, he stated he revised the abuse policy to include instructions on how to handle employees during an employee to resident abuse allegation. He stated he was not asked to remove himself from the premises during the investigation because the facility completed a grievance investigation instead of an abuse investigation. Further, he stated he was never contacted to give any type of statement regarding the alleged incident. The Medical Director stated that he should have been asked to give a statement regarding the incident so both sides could have told their stories. The Medical Director stated that he had not been contacted with the results of the grievance investigation and continued to provide medical care for R73. In interview, on 05/15/2025 at 8:50 AM, the Administrator stated he did not feel like R73's allegation was anything more than a grievance; therefore, the facility did not need to report the alleged incident or provide any additional safety measures for R73. The Administrator stated his investigation consisted of reviewing security footage, interviewing two staff members, the Medical Director, and the resident. The Administrator stated the facility had not interviewed other staff or residents to ask if they have had similar incidents with the Medical Director. The Administrator stated that he should have handled the alleged incident differently and investigated more thoroughly. 2. Review of the facility's Five (5) Day Follow-Up Investigation, dated 05/15/2025, revealed R98 was offended by the statements that Licensed Practical Nurse (LPN)3 made to her. The facility could not validate that abuse occurred and unsubstantiated the allegation. Review of R98's admission Face Sheet revealed the facility admitted the resident on 10/03/2024 with diagnoses that included failure to thrive, major depressive disorder, and anxiety disorder. Review of R98's quarterly MDS with an Assessment Reference Date (ARD) of 04/07/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Interview with R98, on 05/11/2025 at 5:00PM, she stated the resident had pushed her call light on 05/09/2025 at approximately 7:30 PM to get assistance with incontinence care. She stated Licensed Practical Nurse (LPN)3 entered her room at approximately 9:00 PM, to respond to her needs. After the resident informed staff about her care needs, LPN3 stated to R98 if you don't like the care here your mom can take you to your fucking house. In a follow-up interview, on 05/12/2025 at 3:30 PM, with R98, she stated LPN3 had an attitude and used foul language such as damn and shit often in front of the residents. Further, she stated this was her home and LPN3 talking to her that way made her feel like she was not wanted, like an intruder in her own home. R98 added, she was supposed to be at peace in her home, but she was not at peace. In interview with Family Member (FM)1, on 05/12/2025 at 9:30 AM, she stated that she was on the phone with the resident on 05/09/2025 at approximately 9:00 PM when LPN3 was in the resident's room and overheard the conversation. FM1 stated she heard LPN3 tell R98, if you don't like the care here your mom can take you to your fucking house. In interview, on 05/13/2025 at 3:00 PM, with LPN2, she stated R98 informed her that LPN3 stated to the resident, If you don't like the care here your mom can take you to your fucking house. LPN2 stated that she did not report the incident. In interview on 05/13/2025 at 08:39 AM, LPN3, stated that on 05/09/2025 at 8:50 PM, R98's family member called the nursing station and spoke to her about R98. LPN3 stated that the resident's family member was upset and cursing at her over the resident needing to be changed and reported the resident had not been changed in over three hours. At 9:00 PM that evening, LPN3 stated she went into R98's room and informed the resident that the aides were busy but would attend to her needs when they were available. LPN3 denied using profanity or being verbally abusive towards the resident. In interview, on 05/13/2025 at 12:00 PM, the Ombudsman, stated she had received several complaints from residents related to LPN3's bad attitude. She stated residents reported to her the LPN was disrespectful, and rough with the residents when she provided care to them. The Ombudsman stated in March of this year, she had brought residents' complaints to the attention of the Administrator, specifically about LPN3's attitude and he informed her he would investigate the Ombudsman's concerns; however, she stated she never heard anything back from the Administrator. In interview with the Administrator, on 05/14/2025 at 4:21 PM, he stated he expected his staff to report all abuse to him immediately. He stated residents had the right to be free from abuse and verbal abuse was considered abuse.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of thirty-seven sampled residents (R) R26. Review of R26's Care Plan for Impaired Skin Integrity, dated 02/10/2025, indicated that R26 would have a weekly skin assessment performed. However, the facility failed to provide evidence of weekly skin assessments. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated, 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that were responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional levels. Further review revealed that residents' assessments were to be ongoing, and care plans were required to be revised as information about the residents and their conditions changed. Review of R26's admission Face Sheet revealed the facility admitted the resident on 12/17/2024 with diagnoses that included Alzheimer's disease, chronic kidney disease, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, delusional disorders, dementia, diffuse large B-cell lymphoma, unspecified site, and malignant neoplasm of the brain, unspecified. Review of R26's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2025, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 0/15. This score indicated the resident had severe cognitive impairment. Further review revealed R26 required total assistance with turning side to side in the bed, showering/bathing, and personal hygiene. Review of R26's care plan, related to Impaired Skin Integrity, dated 02/10/2025 revealed the goal was for R26 to be free from additional skin breakdown. Further review revealed that a weekly skin assessment was one of the interventions of the care plan. Review of the Bath/Shower Sheet completed from 02/27/2025 through 05/08/2025 revealed that each time R26 received a shower or bed bath from the State Registered Nurse Aide (SRNA), no new skin areas were identified. Review of R26's progress note, dated 03/04/2025 revealed an order for preventative measures for bilateral heels by painting the heels with Betadine and applying a dry dressing daily, and as needed due to the resident scooting his heels on the bed. Review of R26's Progress Note, dated 03/17/2025 revealed R26's skin assessment was completed with no new areas noted. Review of R26's Progress Note dated 03/17/2025 revealed that the Wound Care Physician Assistant (PA) saw R26 for a pressure wound to the head. However, there was no documented evidence the PA assessed any other areas. Interview with the PA on 05/16/2025 at 12:34 PM revealed she assessed the wound to the resident's head. However, she did not assess any other wounds. According to the PA, the Director of Nursing (DON) provided her with instructions on which residents were to be evaluated. The PA stated that when evaluating residents for skin breakdown she assessed the high-pressure areas, such as the heels, elbows and bottom, for wounds. The PA stated R26 did not have any other wounds but the wound to the head when she assessed the resident on 03/17/2025. During an interview on 05/14/2025 at 12:10 PM with License Practical Nurse (LPN) 3, she stated she conducted a skin assessment when she looked at a resident's skin that was exposed during the medication pass. LPN3 stated she did not conduct a head-to-toe skin assessment of R26's skin. Interview with Registered Nurse (RN)1 on 05/14/2025 at 12:23 PM revealed that she had never conducted skin assessments during her shift. According to RN1, the Director of Nursing (DON) had instructed facility staff that the wound care staff were responsible to conduct all skin assessments, wound assessments to include surgical wounds and provide any physician ordered wound care. During an interview on 05/14/2025 at 9:38 PM with RN 2, she stated that she did not complete resident head -to-toe assessments weekly. RN2 stated this was a task delegated to the wound nurse by the DON. According to RN2, the DON had instructed all of the nursing staff that wound care and skin assessments were to be conducted by the wound care staff. Review of R26's Treatment Administration Record (TAR) dated 03/2025 revealed no documentation that the preventive treatment to bilateral heels was provided on 03/19/2025 or 03/20/2025. Record review revealed, on 03/20/2025, R26 was admitted to a local hospital with the following diagnoses: sepsis, acute kidney injury, UTI (Urinary Tract Infection), and pneumonia. The hospital physician documented multiple areas of skin breakdown that the nursing facility had failed to identify including eschar to bilateral heels, a stage III to the left buttock, a stage III to the right buttock, a non-pressure chronic ulcer of the heel and midfoot, and an unstageable pressure ulcer of the sacral area. R26 required surgical debridement of his bilateral heels on 03/21/2025 at the hospital. R26 was discharged back to the nursing facility on 03/26/2025. During an interview on 05/15/2025 at 8:40 AM with the DON, she stated that the staff had failed to identify the wounds on R26 heels, and that the facility was currently working on improving their skin program after results from a mock survey in 04/2025. The DON stated that she expected a weekly head-to-toe assessment to be completed on residents to identify and prevent pressure ulcers. During an interview on 05/16/2025, the Administrator stated he expected skin assessments to be done weekly and all physician orders to be followed to keep residents safe and healthy.

Based on interview, record review, and review of the facility's policies, the facility failed to ensure its residents received the necessary care and treatment by professional standards of practice and as required by the comprehensive person-centered care plan for one (Resident (R) 320) of 37 sampled residents. Immediate Jeopardy (IJ) was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.25 Quality of Care (F684) at the highest scope and severity S/S of a J and (F697), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F684, and F697). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. The findings include: Review of the facility's policy, Skin Care Standard of Practice, dated 07/2020, revealed the facility was required to assess the resident on admission, readmission, and with each change of condition that may compromise the skin. The facility's nurse was required to perform staging and measuring to maintain continuity in documenting the progression of wound healing. The staff were required to perform weekly documentation of the wound status and response to healing, including the potential need to alter treatment. Wound documentation was to include location of the wound, staging of the wound, size of the wound (length x width x depth), exudate (if present), wound bed description, description of wound edges and surrounding tissue, and pain (if present). Further review revealed that all assessments/evaluations relating to skin/wound care would be documented in the EMR (Electronic Medical Record) System. Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated 10/2020 revealed that each resident's comprehensive care plan was designed to: identify problem areas, incorporate risk factors associated with identified problems, identify the professional services that are responsible for each element of care, and aid in preventing or reducing declines in the resident's functional status or functional levels. Further review revealed that assessments of the residents were ongoing, and care plans were required to be revised as information about the residents and their conditions changed. Review of R320's closed record revealed the admission Face Sheet that noted the facility admitted the resident on [DATE] with diagnoses that included unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, and major depressive disorder. Review of R320's EMR revealed the facility admitted R320 on [DATE], for short-term rehabilitation, with a status-post surgical incision measuring 27 cm (length) x 0.3 cm (width), located on her mid back. Further review revealed R320's physician had ordered for staff to monitor the resident's surgical incision to the spine area for signs/symptoms of worsening and/or improvement every 12 hours. Review of R320's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed R320 to have a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. Further review revealed the facility admitted R320 with one surgical wound, and no pressure ulcers. The facility assessed R320 to be dependent on staff for Activities of Daily Living (ADL). Review of R320's Care Plan, related to Impaired Skin Integrity, dated [DATE], revealed that the surgical incision to the spine would be free from signs and symptoms of infection, uncontrolled bleeding, or complications. Further review revealed that a weekly skin assessment was one of the interventions of the care plan. Review of R320's Braden Scale completed on [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that R320 had a mild risk of developing a pressure ulcer. Review of the Bath/Shower Sheet completed from [DATE] until [DATE] revealed that each time the State Registered Nurse Aide (SRNA) provided R320 a shower or bed bath no new skin areas were identified. Review of R320's Weekly Skin Committee Meetings Progress Notes, dated [DATE], [DATE], [DATE], [DATE], and [DATE]. revealed facility staff failed to perform weekly skin assessments and failed to monitor and assess the status of the resident's surgical wound. Review of the Weekly Skin Committee Progress Notes, dated [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that all of R320's wounds were listed on the document at the time of admission. However, there was no evidence that facility staff monitored and assessed the status of the resident's surgical wound, including the potential need to alter treatment. In addition, staff failed to assess and document the staging of the wound, size of the wound (length x width x depth), exudate (if present), wound bed description, description of wound edges and surrounding tissue, and pain (if present). Interview with the DON (Director of Nursing Services) on [DATE] at 4:42 PM, revealed that the information documented in the Weekly Skin Committee Meeting Progress Notes represented the facility's weekly skin assessment. When asked to clarify, the DON stated the Weekly Skin Committee Meeting Progress Notes themselves were considered the formal skin assessments. Review of the Interdisciplinary Discipline Team (IDT) meeting note on [DATE] revealed the facility should monitor R320's surgical incision to the spine area, schedule follow-up appointments with orthopedic trauma in two weeks, a follow-up appointment with the wound care services in the facility, and to see the wound care Physician Assistant (PA) as needed. Review of the Progress Notes dated [DATE] revealed that a follow-up appointment with orthopedic trauma was scheduled for [DATE]. Review of the Progress Notes dated [DATE] at 11:15 AM revealed that the facility wound nurse assessed R320's surgical site to the midback with black necrotic (dead) tissue and a moderate amount of serosanguinous (a thin, light pink, and odorless wound drainage) exudate. According to the progress note the resident's wound measured 27 cm (length) x 4.7 cm (width) x 0.3 cm (depth). Further review revealed this Progress Note was the first documented assessment of R320's wound since admission on [DATE] (13 days). The Note stated the physician was notified of the changes in the resident's surgical wound on [DATE] and orders were received to apply betadine to the wound and cover the wound with a dressing. A review of the Progress Note dated [DATE] at 1:54 PM revealed the Medical Director assessed Resident #320's surgical wound and ordered an evaluation of the wound at the local wound center, scheduled for [DATE]. The Medical Director also ordered Doxycycline, a broad-spectrum antibiotic, to be administered daily. Documentation on the Medication Administration Record (MAR) showed the first dose of Doxycycline was given on [DATE] at 9:00 PM, prior to the documented assessment by the Medical Director. The order was not recorded in the medical record until [DATE]. Review of the local wound center notes dated [DATE] at 2:00 PM revealed that R320 was transferred to and from the wound center by the facility's van. Review of the documentation from the wound center revealed R320 was assessed to have an open, non-healing surgical wound to the back, an underlying deep tissue injury with eschar, cellulitis, and drainage. The note further revealed that the surgery was three weeks ago, and R320 had not had a follow-up appointment with the surgeon. R320 was transferred back to the facility from the wound center. Clinical record review revealed there was no further documentation regarding R320's wound until [DATE] at 4:15 PM when a Progress Note revealed R320's midback wound had large amounts of serosanguinous exudate (a thin, light pink, odorless wound drainage) and measured 27 cm (length) x 6.4 cm (width) x 5.8 cm (depth). There was no evidence facility staff had assessed the wound after the resident was seen at the wound center until [DATE] (8 days later). Review of R320's Skin Committee Notes dated [DATE] at 4:09 PM revealed that the in-house wound care PA had seen R320 on [DATE] for a new identified Stage III to the sacrum. However, the PA did not assess the resident's surgical wound to the midback. Review of the Emergency Medical Service (EMS) run sheet and 911 recording, dated [DATE] at 7:04 AM, revealed R320 had called 911 and asked for the EMS to come get her as she was sickand really bad. When EMS called the facility to inquire about the resident, Registered Nurse (RN)1 stated the resident was stable, without assessing or identifying the resident's condition. EMS did not go to the facility. Review of Progress Notes dated [DATE] at 6:32 PM revealed RN1 failed to assess R320 until 6:32 PM. At this time, RN1 notified the Medical Director(MD) of the resident's deteriorating wound condition. According to the Progress Notes, the Medical Director went to the facility, assessed the wound and orders were obtained to send R320, as a direct admit to the hospital, for further evaluation and treatment. According to the Progress Notes, EMS transported R320 to the local hospital at 6:43 PM on [DATE], immediately after the MD assessed the wound. Review of the emergency room (ER) record revealed R320 presented with a large open wound along the thoracic spine starting at T4 and tracking to L1 with foul-smelling drainage and hardware exposed. Further review of the emergency room records revealed that R320's pain was hard to control with pain medications, even though Morphine was administered intravenously in the Emergency Room. Continued review of the ER record revealed the hospital also diagnosed R320 with sepsis and acute kidney failure. The hospital transferred and admitted R320 to an in-patient hospice for pain control. R320 expired on [DATE] while at the hospice facility. Review of R320's death certificate revealed the cause of death was acute kidney failure and sepsis. During an interview on [DATE] at 12:00 PM with State Registered Nurse Aide (SRNA) 10, he stated R320's wound to her midback on [DATE] was so bad with large amounts of green drainage and a strong foul-smelling odor. In interview with RN2 on [DATE] at 5:21 PM, she stated she observed R320's wound and described it as the the worst wound she had ever seen and stated, it looked so bad. During an interview on [DATE] at 12:10 PM with Registered Nurse (RN)1 she stated that she had never looked at R320's incision but instead looked at R320's midback dressing to ensure it was intact. However, RN1 signed the Treatment Administration Record (TAR) 9 times, indicating that she had monitored and assessed the resident's surgical incision to the spine area for signs/symptoms of worsening and/or improvement every 12 hours. During the interview RN1 stated that she did not conduct a weekly head-to-toe skin assessment. During an interview on [DATE] at 7:38 PM with Registered Nurse (RN) 3, she stated that no one had removed the surgical bandage on Resident 320's back until 10 days after the resident's admission. RN3 stated that by this time, the wound was a big hole with purulent green drainage. RN3 further stated she had never contacted the physician concerning the wound. During an interview on [DATE] at 8:40 AM with the Director of Nursing (DON), she stated that R320's midback dressing should have been removed. She stated the nurses should have looked at the incision every 12 hours to assess for signs and symptoms of the wound improving or worsening. The DON stated that she expected a weekly head-to-toe assessment to be completed on residents to prevent pressure ulcers and infections. During an interview on [DATE], the Administrator stated he expected skin assessments to be done weekly and all physician orders to be followed to keep residents safe and healthy.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure that pain management was provided to residents who required services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.25(k), Pain Management (F697) at the highest scope and severity S/S of a J and (F684), at the highest scope and severity S/S of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 42 CFR 483.25(k), (F697, and F684). The IJ is ongoing. The facility was notified of the Immediate Jeopardy on [DATE]. (Refer to F684) The findings include: Review of the facility's policy titled, Pain Management, dated 07/2020, revealed the facility must ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Further review revealed strategies for pain management included the staff were to perform a comprehensive pain assessment to identify circumstances of when pain may be anticipated on admission, readmission, and as needed, or with a significant change in conjunction with the resident's physician to prevent/manage pain consistent with the care plan, and the resident's goals and preferences. The facility, in conjunction with the resident's physician, was required to address/treat the underlying cause of the pain, and monitor the effectiveness of the interventions utilized for pain management. Closed record review of R320's Electronic Medical Record (EMR) revealed the facility admitted R320 on [DATE], for short-term rehabilitation, with a status-post surgical incision measuring 27 cm (length) x 0.3 cm (width), located on her mid back. Review of R320's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed the resident was taking, and had a documented indication, for opioid medication. Further review revealed the resident was not receiving a scheduled pain medication regimen. Further review revealed the pain assessment interview would be conducted. Review of R320's Comprehensive Care Plan for Pain, dated [DATE], revealed R320 was at risk for alteration in comfort related to the fracture of the lumbar and thoracic vertebrae. The projected goal for the resident was for her pain to be at an acceptable level, and not interfere with her daily routine. Further review revealed interventions included to adjust her daily routine as necessary, identify the location and rate of pain prior to and after any interventions, pain assessment as ordered, and to report unrelieved or unacceptable levels of pain to the physician as needed. Review of the [DATE] Physician's Orders, revealed an admission order for Norco (a narcotic pain medication) five milligrams every six hours as needed for pain management and Tylenol (a pain medication) 325 milligrams every four hours as needed for pain management. Review of the Controlled Drug Records and the MARS for [DATE] revealed Oxycodone HCL oral capsule 5 gm by mouth was administered as follows: on [DATE] three times;[DATE] two times; [DATE] three times; [DATE] at two times, the facility assessed R320's pain level as a 3. On [DATE] R320 received the medication three times. On [DATE] two times the medication was given, and the pain was assessed as level 1. On [DATE] two times; [DATE] three times; [DATE] four times (pain level 1); [DATE] three times; [DATE] two times pain level 1; [DATE] three times; [DATE] two times; [DATE] one time; [DATE] four times (pain level 3); [DATE] three times; [DATE] three times; [DATE] two times; [DATE] three times (pain level 1); [DATE] four times (pain level 1); and on [DATE] three times. Further review of the October MAR revealed during this month, there was no documented evidence the facility had administered the resident's medication from [DATE] to [DATE]. There was no documentation of the resident's level of pain prior to and after the administration of the resident's pain medication. On [DATE], [DATE], [DATE], and [DATE], the facility documented the resident was administered the medication between 2:00 AM to 3:30 AM, the facility documented the resident's Pain Level was between 1 to 3, however,there was no documentation to support the facility identified the location of the pain prior to administering the resident's medication. Review of the Controlled Drug Records and the MARS for [DATE] revealed Oxycodone HCL oral capsule 5 gm by mouth was administered as follows: [DATE] at 9:20 AM, 3:40 PM, and 9:38 PM; [DATE] at 3:00 AM, 12:39 PM, and 9:44 PM; [DATE] at 3:00 AM, 9:00 AM, and 3:02 PM. During this month, there was no documented evidence to support the facility had identified the location and rate of the resident's pain prior to and after administering the pain medication and no documentation to support the medication was effective. Review of the Medication Administration Record (MAR) for R320 revealed staff had administered Acetaminophen Oral Tablet 325 mg on the following dates:[DATE] at 9:48 PM; [DATE] at 4:30 PM; [DATE] at 10:44 PM; [DATE] at 3:04 AM, and 10:02 PM; [DATE] at 4:57 PM, [DATE] at 1:33 PM, [DATE] at 11:38 PM; [DATE] at 8:13 PM; [DATE] at 9:54 PM; [DATE] at 9:20 AM; and on [DATE] at 12:03 PM. However, the facility :failed to identify the location and rate of pain prior to and after administering pain medication. Further, record review revealed staff had not administered any form of pain medication to the resident to include Tylenol nor Oxycodone on [DATE] and [DATE], to address the resident's pain. Review of the Pain Assessment Interview, dated [DATE] and completed by Licensed Practical Nurse (LPN)3, revealed R320 experienced frequent and nearly constant pain. The pain interferred with her ability to perform activities of daily living,and prevented her from sleeping or participating in therapy due to back pain. Further review revealed the resident received as needed pain medication including Norco (a narcotic pain medication) five milligrams every six hours as needed for pain management and Tylenol (a pain medication) 325 milligrams every four hours as needed. The documentation indicated this regimen was effective. However, the facility failed to complete the Evaluation Summary of the Pain Assessment, dated [DATE], which required assessment input from other disciplines, including the physician,to determine the nature and extent of the resident's pain. The record lacked documentation to show whether the physician had been notified of the pain or whether staff evaluated the pain's onset or duration. Review of the local wound center note dated [DATE] at 2:00 PM, revealed R320 reported ongoing constant pain at the surgical wound site on her back. The documentation indicated that her current pain management was inadequate. Review of the Pain Scale Log, dated [DATE] at 7:00 AM, revealed Registered Nurse (RN)2 recorded that R 320 had no pain; however, R320 called 911 at 7:04 AM requesting that the Emergency Medical Services (EMS) send an ambulance and I'm really bad. Review of the hospital emergency room records, dated [DATE] at 7:22 PM revealed that R320's pain was hard to control with pain medications even though Morphine was administered intravenously in the Emergency Room. Further review revealed R320 had a large open wound along the thoracic spine (located in the center of the upper and middle back. It begins at the base of the neck [cervical spine] and ends around the bottom of the rib cage, just above the lower back [lumbar spine] ) starting at the T4 and tracking to T1 with foul smelling drainage and hardware exposed. R320 was transferred and admitted to Hospice for pain control. R320 expired on [DATE] due to sepsis and acute kidney injury while at the hospice facility. During an interview, on [DATE] at 11:30 AM, R320's family member stated R320 was having severe pain, and she was notified by R320 that she called 911 on [DATE] because she couldn't take the pain anymore and just wanted something for the pain. During an interview conducted on [DATE] at 12:35 PM, Kentucky Medication Aide (MA)1 stated R320 requested pain medication every hour. However, the MA stated she failed to inform the nurse of the resident's pain. She stated R320's pain was not effectively assessed, and the Medical Director was not notified of the resident's continued and increased pain. During an interview conducted on [DATE] at 12:35 PM, State Registered Nurse Aide (RNA)10 stated R320 refused to be changed or showered because she was so uncomfortable, and it hurt her so bad to be moved. During an interview conducted on [DATE] at 5:21 PM, Registered Nurse (RN)2 stated that R320 was difficult to care for because she only wanted to take pain pills and refused to allow staff to touch or assist her due to generalized pain all over. RN 2 stated she had discussed concerns with the resident's family member multiple times regarding R320's repeated requests for narcotic pain medication. Further, RN2 acknowledged that she did not notify the physician about the resident's frequent pain complaints. During an interview conducted on [DATE] at 8:40 AM, the Director of Nursing (DON) stated there was no issue with R320 being non-complaint with care. She stated the resident experienced such significant pain that she could not tolerate care consistently. The DON further stated she had never contacted the physician regarding the resident's refusal of care or reports of pain. During an interview conducted on [DATE] at 4:42 PM with the Administrator, he stated that the facility always prioritizes what was best for the resident. He further stated that the staff were expected to notify the physician if a resident was experiencing uncontrolled pain.

Based upon interview, review of medical records, and review of the facility's policy/procedures, the facility failed to maintain complete and accurately documented clinical records. The facility failed to maintain complete and accurately documented clinical records for 79 of 116 residents (R1 - R79). Staff documented weights that had been falsified (made up). The fabricated and inaccurate weight records were used in clinical assessments related to residents' nutritional status, monitoring of weight changes, and care planning. These inaccurate records compromised the facility's ability to appropriately monitor residents' nutritional status and respond to weight changes. Documentation inconsistencies were found between recorded weights and residents' actual physical condition and intake records.This widespread and systemic failure to ensure reliable clinical documentation created an Immediate Jeopardy to resident health and safety, as the falsified data directly impacted critical clinical decisions.Immediate Jeopardy (IJ) was identified on 07/14/2005 and was determined to exist on 06/11/2025. Immediate Jeopardy was identified in the areas of 42 CFR S483.75 Quality Assurance and Performance Improvement (F865) at the highest S/S of K. 42 CFR S483.70 Administration (F842) at the highest S/S of J. 42 CFR S483.25 Nutrition/Hydration Status Maintenance (F692) at the highest S/S of K and 42 CFR S483.70 Administration (F835) at the highest S/S of J.The facility presented an acceptable plan for removal of the immediate jeopardy on 07/18/2025 at 1:00 PM. The survey team validated that the immediate jeopardy was removed on 07/19/2025 at 4:40 PM following the facility's implementation of the plan for removal of the immediate jeopardy.The Finding Include:Staff interview and record review revealed the facility failed to maintain complete and accurately documented clinical records for 79 of 116 residents (R1 - R79). Staff documented weights that had been falsified (made up). The fabricated and inaccurate weight records were used in clinical assessments related to residents' nutritional status, monitoring of weight changes, and care planning. Records reflected weight data that did not match the residents' intake documentation or physical condition. Review of R79's admission Face Sheet revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease, anxiety, chronic obstructive pulmonary disease (COPD), dementia. hypothyroidism and major depressive disorder. R79 was placed on a dysphagia pureed diet on 03/02/2025 due to choking and aspiration risk. Review of the weight record log revealed R79's weights document included: On 05/15/2025 R79's weight was 99 pounds (lbs.); on 05/23/2025 was 98.8 lbs.; on 05/29/2025 was 99.2 lbs.; and on 06/05/2025 was 98.8 lbs. Despite these stable weights, facility progress notes documented R79 was experiencing frequent choking incidents after meal consumption. Additionally, review of the facility's weight record log revealed that 79 residents' weights were documented as unchanged over consecutive weeks or with fluctuations not supported by clinical observations or intake records. On 06/11/2025, R79 was transferred to the hospital for treatment for diagnoses that included sepsis and aspiration pneumonia. R79's hospital records documented her admission weight as 83 lbs. Record review revealed R62 had a facility documented weight of 170 pounds on 06/05/2025, with no noted weight changes in the prior month or six months. However, the hospital records dated 06/24/2025 showed a weight of 139.8 lbs. R62's hospital discharge weight on 06/29/2025 was 137 lbs. Despite this significant loss of 30.2 lbs., (a 17.8% weight loss), the facility's records did not reflect corresponding changes or interventions during that period. A nutrition assessment performed at the hospital on [DATE] described R62 as underweight and noted that he had lost quite a bit of weight. The nutritional assessment from the hospital recommended that within the next 7 days, the facility modify R62's food texture, increase the resident's caloric intake by 25%, and provide an additional 500cc of fluid daily. An interview with the Administrator on 07/02/2025 at 5:45 PM revealed that RA2 is an honest employee and that when she reported weights had been fabricated, it was probably true. The Administrator further stated that recording weights incorrectly was inappropriate. During interview with the facility's Director of Nursing (DON), on 07/02/2025 at 2:30 PM, she stated that the facility failed to implement the hospital's dietary recommendations because the information was unavailable when the resident returned to the facility on [DATE].However, during an interview with Registered Nurse (RN) 2 on 07/10/2025 at 3:23 PM, RN2 stated the facility had access to the hospital's electronic records. Continued interview revealed the facility failed to obtain and review the dietary recommendations for R62 upon readmission to the facility. During an interview on 06/30/2025 at 7:00 PM with Hospitality Aide 3 stated she worked daily with the restorative aide responsible for obtaining resident weights and observed the restorative aide documenting weights without weighing the residents. During an interview on 07/09/2025 at 1:30 PM, SRNA 7 stated residents' weights were often fabricated before unit nurses documented them in the resident's record. SRNA7 stated weights frequently remained the same for multiple months, even when residents' conditions had changed. SRNA 7 stated she had not seen resident weights being obtained consistently for two or three years.Interviews with Restorative Aide (RA) 2 on 07/01/2025 at 10:04 AM and RA3 on 06/30/2025 at 7:00 PM revealed that staff did not consistently weigh residents but recorded past weights or documented weights without performing actual measurements.During an interview with R53 on 07/03/2025 at 3:00 PM, the resident stated she had only been weighed twice since her admission to the facility. R53 expressed concern, stating, I use to be under weight and now I'm overweight. Staff not weighing us is dangerous because the doctor prescribes certain medications based on our weight. R53 further stated she asked staff to weigh her; however, she had been told, We don't have time.An interview with the Pharmacist on 07/10/2025 at 11:17 AM, noted that having inaccurate weights on residents could have a negative health effect. Continued interview revealed that certain medications were dosed on having an accurate weight. He stated if you dose medications based on inaccurate weights, you could underdose or overdose residents. Interviews and record reviews revealed residents were not added to the facility's' Nutritional at Risk (NAR) program due to inaccurate documentation of residents' weights. A total of 79 residents (R1-R79) that were affected by the facility's failure to ensure that accurate weights were obtained and recorded were not added to the NAR program until after the State Survey Agency (SSA) surveyors identified the problem and brought this problem to the attention of facility staff.

Based on interviews, review of the facility's documents, and policy, it was determined the facility failed to ensure allegations of sexual and verbal abuse were reported to State Agencies and local law authorities immediately, but no later than two hours after the allegations were made for two of 37 sampled residents. (Resident (R) R73, and R98). The findings include: Review of the facility's policy titled, Abuse Prohibition Standard of Practice, last revision date 07/2022 revealed in the event an alleged or actual violation occurs, the resident would be immediately assessed and removed from any potential harm. Continued review revealed the Administrator, or designee, would conduct an internal investigation regarding any allegation of abuse, neglect, exploitation, injury of unknown source, or misappropriation of resident property, and report the results of the investigation to the enforcement agency in accordance with state law including the state survey agency within five working days of the incident. Continued review of the facility's policy revealed the policy did not cover the timeframe for reporting abuse to the State Survey Agency (SSA) or Law Enforcement. Interview with the Administrator, on 05/15/2025 at 8:50 AM, revealed the facility's policy did not address the timeframe for reporting; however, his expectation would be that abuse allegations would be reported to the SSA and Law Enforcement no later than two hours after the allegations were made known. Review of R73's admission Face Sheet revealed the resident was diagnosed with a cognitive communication deficit, voice, and resonance disorders. (Voice and resonance disorders refer to problems with how sounds are produced and resonated in the vocal tract, affecting speech and voice quality). Review of R73's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/12/2025, revealed R73 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of R73's Comprehensive Care Plan, dated 08/02/2024 , revealed the resident used a tablet for communication and social interaction with family and friends. In an interview, on 05/12/2025 at 12:20 PM, R73 stated the Medical Director was doing monthly rounds and when he got his personal mobile device, she initially thought he was going to write a message to communicate with her, however, she was shown an image of a topless woman kneeling in front of a penis. She stated the Medical Director then worked his eyebrows up and down and winked as he was leaving her room. R73 stated being shown the pornographic image by the Medical Director made her feel very vulnerable and she did not feel safe receiving care from the Medical Director. The resident stated she notified the Ombudsman and shortly after notified the State Registered Nurse Aide (SRNA) 9, the same day. R73 stated the Medical Director was still providing medical care services to her. Interview with SRNA9, on 05/15/2025 at 12:45 PM, she stated she entered R73's room to answer her call light and R73 was upset. SRNA 9 stated R73 started to type on her tablet [the abuse allegation] and she stopped her when she saw the allegation. She stated she immediately got Registered Nurse (RN) 1. In an interview, on 05/15/2025 at 10:30 AM, with Registered Nurse (RN)1, she stated SRNA 9 notified her she was needed in R73's room and when she entered, she read the allegation that was made and immediately notified the Unit Manger on duty. RN1 stated she followed the chain of command by notifying the Unit Manager. Interview with the Unit Manager 12, on 05/12/2025 at 10:50 AM, revealed she was notified of the allegation R73 had made against the Medical Director. She stated she notified the Director of Nursing (DON). Interview with the Director of Nursing (DON), on 05/12/2025 at 11:05 AM, she stated she could not recall being notified of the allegation of abuse related to R73. The DON stated that she expected all nursing staff to follow facility policies and procedures, including following the chain of command and notifying her of abuse claims. The DON stated that if she had been made aware of the situation, she would have notified the Administrator and ensured the Office of Inspector General (OIG)/State Survey Agency (SSA) was also notified. In an interview with the Medical Director, on 05/13/2025 at 2:53 PM, he stated that he was not asked to stay off the facility premises during the investigation and he was never contacted to give any type of statement regarding the alleged incident. The Medical Director further stated he continued to provide medical care to R73. In an interview with the Administrator, on 05/15/2025 at 8:50 AM, he stated he had been notified of the allegation related to R73 and the Medical Director on the morning of 03/01/2025 at approximately 11:00 AM, by either the Registered Nurse (RN)1 or the DON. He stated he was unsure of who called him. The Administrator stated that he was told that the resident had been shown a picture and it was his understanding that it had just been a topless woman, and the Medical Director could have been using the image as a reference for the resident. In continued interview, the Administrator stated that he would only investigate abuse when the resident reports to him that they had been abused. According to the Administrator, the resident stated she did not feel as though she was abused. The Administrator stated that the allegation was only a grievance and did not rise to a level that required reporting to the police or other agencies. 2. Review of the facility's Five (5) Day Follow-Up Investigation, dated 05/15/2025, revealed Resident (R)98 was offended by the statements that Licensed Practical Nurse (LPN)3 made to her; however, the facility could not validate that abuse occurred and unsubstantiated the allegation. Continued review of the facility's investigation revealed the facility failed to report the allegation of abuse to the State Survey Agency (SSA) and Law Enforcement. Review of R98's admission Face Sheet revealed the facility admitted the resident on 10/03/2024 with diagnosis to include major depressive disorder and anxiety disorder. Review of R98's quarterly MDS, with an ARD, dated 04/07/2025, revealed the facility had assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Interview with R98, on 05/11/2025 at 2:40 PM, revealed the resident had pushed her call light on 05/09/2025 at approximately 7:30 PM due to needing to have her adult brief changed. According to the resident, staff did not enter the resident's room until 9:00 PM to respond to the resident's needs. After the resident informed staff about her care needs, Licensed Practical Nurse (LPN)3 stated to R98 if you don't like the care here your mom can take you to your fucking house. In a follow-up interview, on 05/12/2025 at 3:30 PM, with R98, she stated LPN3 demonstrated an attitude and used foul language such as damn and shit, often in front of residents. Further, R98 stated this was her home, and LPN3 talking to her that way made her feel like she was not wanted, like an intruder in her own home. R98 added, she was supposed to be at peace in her home, but she was not at peace. In addition, she stated, this nurse is the one that gives me my medicine and she could kill me with it. In interview, on 05/12/2025 at 9:30 AM, with Family Member (FM)1, she stated that she was on the phone with the resident on 05/09/2025 at approximately 9:00 PM when she overheard LPN3 say to R98, if you don't like the care here, your mom can take you to your fucking house. In an interview, on 05/13/2025 at 3:00 PM, with LPN2, she stated R98 informed her that LPN3 stated to the resident, If you don't like the care here, your mom can take you to your fucking house. LPN2 stated she did not report the incident to anyone at the facility. Interview with LPN3, on 05/13/2025 at 8:39 AM, revealed she did not verbally abuse R98. She stated that the night of the alleged incident, she responded to the resident's call light and informed the resident that an SRNA would take care of the resident as soon as they could. In an interview, on 05/13/2025 at 12:00 PM, with the Ombudsman, she stated she had received several complaints from residents on LPN3 related to her bad attitude. According to the Ombudsman, residents stated the LPN was disrespectful and rough with the residents when she provided care to them. The Ombudsman stated in March of this year, she had brought residents' complaints to the attention of the Administrator, specifically about LPN3's attitude and he informed that he would investigate; however, she never heard anything back. In an interview, on 05/14/2025 at 4:21 PM, the Administrator stated he expected his staff to report all abuse allegations to him immediately. He stated residents had the right to be free from any form of abuse. Further, the Administrator stated abuse could be verbal, sexual, and mental. Further, he stated he was not notified of the alleged verbal abuse related to R98 and LPN3 until after the Survey Survey Agency (SSA) were in the building investigating the abuse allegation.

Based on interview, record review, and review of facility policy, it was determined the facility failed to notify the physician of a change in condition and need to alter treatment for one (1) of four (4) sampled residents (Resident #2). The facility readmitted Resident #2 after an inpatient hospitalization on [DATE] with an Aspira Drainage System (a tunneled, long-term catheter used to drain accumulated fluid from the peritoneal {abdominal} cavity to relieve symptoms associated with malignant ascites), without physician orders for the care of the drainage system. The facility failed to notify the resident's physician that there were no orders regarding the resident's drain. Subsequently, on 0[DATE], Resident #2 reported he/she was short of breath and Registered Nurse (RN) #1 wrote orders to drain as much fluid as the resident could tolerate every other day, treatment for the drain insertion site, and parameters for physician notification. The RN removed two (2) liters of fluid from the resident's abdominal drain without contacting the physician of a need to alter treatment. On 0[DATE], Resident #2 was transported to the Emergency Department (ED) with abdominal pain and was diagnosed with [REDACTED].{normal potassium serum levels are 3.5-5.1} and Resident #2's potassium level on 09/20/19 at 12:12 AM was 2.2, which was critically low) and [DIAGNOSES REDACTED] ([DIAGNOSES REDACTED] is an electrolyte disturbance caused when there is a low level of serum magnesium {less than 1.46} in the blood). Continued review of the hospital record revealed Resident #2 was discharged back to the nursing facility on 09/20/19 after receiving electrolyte replacement. Again, there were no physician orders regarding accessing/draining fluid from the resident's Aspira drain. However, on 09/20/19, 09/21/19 (twice), and 09/22/19, Resident #2 was short of breath and staff removed fluid from the resident's Aspira drain (a total of six (6) liters (L) in three (3) days) without notifying the resident's physician that the resident was short of breath and/or to obtain orders to remove fluid from the resident's peritoneal drain. On 09/23/19, Resident #2 was transferred to the Emergency Department and admitted with [DIAGNOSES REDACTED]. According to Physicians #1, #2, and #3, staff should have contacted a physician for orders regarding Resident #2's Aspira drain. Physician #3 stated, You could kill someone if you didn't know what you were doing; it wouldn't take long to kill them. The Physician stated that the maximum amount of fluid that should have been removed via the Aspira drain was one (1) L in a 24-hour period. The facility's failure to ensure the physician was notified of a need to alter treatment and when a change in the resident's condition occurred, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/30/19 and was determined to exist on 09/04/19 at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2). The facility was notified of the Immediate Jeopardy on 09/30/19. An acceptable Allegation of Compliance was received on 10/04/19, which alleged removal of the Immediate Jeopardy on 10/08/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 10/08/19, prior to exit on 10/09/19, which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CRF 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Observation of Resident #2 on 09/23/19 at 1:28 PM revealed the resident was lying in bed positioned on his/her right side. The resident had family visiting at bedside. An observation of Resident #2 was attempted at approximately 3:00 PM, but the resident was not in his/her room. During interview, Unit Manager (UM) #2 stated the resident had been transported to the Emergency Department (ED) due to abnormal laboratory (lab) test results. Review of Resident #2's medical record revealed the facility admitted the resident on 09/05/19, with [DIAGNOSES REDACTED]. Further review of Resident #2's medical record revealed the facility did not complete an Admission Minimum Data Set (MDS) because the resident did not have a 14-day stay prior to being transferred to the Emergency Department on 09/09/19, 0[DATE], and 09/23/19. Review of a Social Services Director (SSD) Progress Note dated 09/17/19 at 12:29 PM, revealed the facility assessed that the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact and interviewable. Review of Resident #2's Nursing Progress Notes revealed on 09/10/19 at 2:37 AM, RN #1 documented that Resident #2 was lethargic and not responding to family. The note stated the resident's physician was notified and an order was received to transfer the resident to the Emergency Department (ED) for evaluation. According to the record, Resident #2 was admitted to the hospital with [REDACTED]. Further review revealed an Aspira Drainage System was surgically placed in the resident's abdomen on 0[DATE] and two (2) L of fluid were removed from the resident's abdomen during the procedure via the Aspira drain. Further review of Resident #2's hospital medical record revealed Physician #2 documented a Progress Note on 0[DATE] that stated the resident would be scheduled for drainage of four (4) L of fluid via the Aspira drain while receiving [MEDICATION NAME] (a protein made by the liver that assists to keep fluid in the bloodstream so it does not leak into other tissues. It is also responsible for carrying substances such as hormones, vitamins, and enzymes throughout the body). Review of the hospital Discharge Summary dated 09/12/19 revealed the resident was discharged with no evidence documented that physician orders were written to address the care of Resident #2's newly placed Aspira Drainage system. Interview with RN #5 on 09/24/19 at 8:27 PM and 10/01/19 at 4:45 PM, revealed she was working when Resident #2 was readmitted to the facility on [DATE]. She stated there were no physician instructions for the Aspira drain; however, she did not contact the physician for orders regarding care of the resident/drain. Continued review of Resident #2's medical record revealed Registered Nurse (RN) #1 entered physician's orders in the facility's computer for the resident on 0[DATE] to drain as much fluid as the resident could tolerate from the Aspira port every other day. Continued review revealed RN #1 wrote an order to change the dressing to the Aspira drain exit site as needed for moistening, cleanse the area with alcohol, and apply a dressing as needed. RN #1 further documented orders on 0[DATE] to notify the resident's physician of the following: less than 25 to 50 milliliters (ml) of fluid drains for three (3) consecutive days as needed; the resident experienced shortness of air that was not relieved after draining 1,000 ml from the Aspira port at one time as needed; the appearance of the fluid changed between drainage as needed; the resident developed a fever above 100.5 Fahrenheit (F), experienced redness, swelling, oozing, or pain at the port site as needed; and the resident experienced ongoing pain with little or no fluid draining from the catheter as needed. Review of Resident #2's Treatment Administration Record (TAR) for September 2019 revealed on 0[DATE] staff documented that fluid was drained from Resident #2's abdomen via the Aspira drain port. The amount drained was not specified. Interview with RN #1 on 09/24/19 at 7:49 PM and 09/27/19 at 3:04 PM, revealed she wrote the physician's orders for Resident #2 on 0[DATE] related to assessing Resident #2's Aspira drain along with dressing changes and when to notify the resident's physician. However, the interview with RN #1 revealed she did not contact Resident #2's Physician to obtain the orders regarding the care of the resident's drain. She stated she wrote the orders/care plan interventions based on the manufacturer's guide that was sent with the resident when he/she was discharged from the hospital on [DATE], along with orders that Resident #4 had in place to access and care for his/her Aspira drain. She stated that although the manufacturer's guide stated not to remove more than 2,000 ml (two liters) from the resident's abdomen in any one drainage, she stated that Resident #4 had orders to drain as much fluid as the resident could tolerate; therefore, she decided to write Resident #2's orders to match Resident #4's physician's orders. RN #1 stated she should have contacted Resident #2's physician to obtain specific orders for the care of Resident #2's drain. According to RN #1, she drained approximately two (2) L of fluid from the resident's Aspira drain on 0[DATE], even though she had not contacted the resident's physician for an order related to how much fluid should be drained nor did she get an order for [REDACTED]. Review of a late entry nursing progress note dated 0[DATE] at 11:03 PM revealed Resident #2 complained of abdominal pain, and was assessed to have a firm, abdominal distention. The resident's physician was notified and the resident was transferred to the ED at 10:15 PM on 0[DATE]. Review of Resident #2's 0[DATE] admission History and Physical (H & P) dated 09/20/19, revealed the resident had significant [DIAGNOSES REDACTED] at 2.2, [DIAGNOSES REDACTED], and [MEDICAL CONDITION] ([MEDICAL CONDITION] refers to a low level of sodium in the blood. [MEDICAL CONDITION] or low sodium blood levels may result from excess fluid in the body relative to a normal amount of sodium, or it may be due to a loss of sodium and body fluid caused by chronic conditions like kidney or [MEDICAL CONDITION]). The resident received potassium replacement along with D5-1/2 normal saline intravenously (IV) during his/her hospital stay and requested to be discharged back to the nursing facility. Further review of the H & P revealed the resident was discharged back to the nursing facility on 09/20/19 and would continue oral potassium replacement and monitoring of his/her potassium and magnesium levels. Review of a discharge medication list dated 09/20/19 revealed the resident was discharged from the hospital with an order for [REDACTED].#2's Aspira drain. However, continued review of Resident #2's TAR revealed on 09/20/19 (the day the resident was discharged from the hospital) and 09/22/19, RN #5 documented that fluid was drained from Resident #2's abdomen via the Aspira drain port. The amount of fluid drained was not specified on the resident's TAR. In addition, review of Resident #2's medical record revealed on 09/21/19 at 7:53 AM, RN #5 documented that she removed two (2) L of fluid from Resident #2's Aspira drain at 1:00 AM on 09/21/19. Further review revealed RN #5 documented that two (2) more liters of fluid were removed on 09/21/19 at 11:56 PM, approximately 22 hours later. Interview with RN #5 on 09/24/19 at 8:27 PM and 10/01/19 at 4:45 PM revealed she did not provide any care related to Resident #2's drain until 09/20/19 because the resident had no physician orders. However, a treatment was documented for accessing and caring for the drain. Further review revealed on 09/20/19 and 09/22/19 she accessed Resident #2's Aspira drain and removed one (1) L of fluid each time. RN #5 stated that on 09/21/19 she removed two (2) L of fluid via the Aspira drain at 1:00 AM and two (2) L during her next shift prior to midnight on 09/22/19. The RN stated she drained the fluid because the resident was short of breath, but she did not contact the resident's physician related to the resident's condition. Continued review of Resident #2's Nursing Progress Notes dated 09/23/19 at 2:26 PM revealed the laboratory facility reported that Resident #2 had critical values. The APRN was notified with orders to transport the resident to the ED for evaluation and treatment. Review of laboratory testing received on 09/23/19 at 12:49 PM revealed the resident had a critical sodium level of 115 (normal range 135-145), potassium level of 2.9 (normal 3.5-5.3), chloride level of [AGE] (normal 96-110), calcium level of 7.9 (normal 8.4-10.2), magnesium level of 1.3 (normal 1.2-2.5), and an [MEDICATION NAME] level of 2.6 (normal 3.5-5.5). Interview with Unit Manager (UM) #1 on 09/27/19 at 5:37 PM and with the Director of Nursing (DON) on 09/27/19 at 7:37 PM revealed they were not aware that RN #1 wrote treatment orders for how often to access Resident #2's Aspira drain without contacting the physician. They stated when Resident #2 was readmitted to the facility on [DATE] with the Aspira drain, staff should have notified the physician to obtain orders for specific orders for the care of the drain. The UM stated staff should not write physician orders based on a user's manual or another resident's physician's orders. UM #1 and the DON stated that although readmission orders [REDACTED] Interview with the Administrator on 09/30/19 at 5:48 PM revealed the DON was responsible for directing the morning IDT meetings, which covered physician orders and readmission orders [REDACTED]. The Administrator stated that staff should not write a treatment order and provide care without notifying the physician and obtaining an order. Interview with Advanced Practice Registered Nurse (APRN) #1 on 09/30/19 at 3:45 PM revealed she had not been notified by staff for orders related to the Aspira drain for Resident #2. She stated she was told by staff that Physician #1 was notified and gave orders for the care of the resident's Aspira drain. She stated she should have been notified that the resident did not have orders in his/her hospital discharge information. The APRN stated Resident #2's electrolytes would have to be monitored closely along with his/her blood pressure during the procedure to ensure that staff were not draining too much fluid at one time. APRN #1 further stated that she expected staff to monitor Resident #2's urine output and fluid intake especially when draining two (2) L of fluid. Furthermore, she stated removing too much fluid without replacement of fluids could cause an electrolyte imbalance if not monitored closely. Interview with Physician #1 (attending facility physician) on 09/25/19 at 11:53 AM and on 09/26/19 at 1:22 PM revealed he did not write orders for the care of Resident #2's Aspira drain. He stated that facility staff should have phoned him or Physician #2 to get orders for the care of the Aspira drain if they did not receive them when Resident #2 was discharged back to the facility on [DATE]. Physician #1 stated facility staff called him at 3:00 AM for Tylenol orders; therefore, he would have expected them to call for orders related to the resident's Aspira drain's care and use. Further interview with Physician #1 revealed that to his knowledge, the Aspira drain was placed to make paracentesis easier at the hospital and was not intended for the facility staff to utilize. Physician #1 stated that the most fluid that could safely be removed outside of a hospital setting was one (1) L at a time. Interview with Physician #2 on 09/25/19 at 12:17 PM revealed he was consulted by Physician #1 during Resident #2's hospital stay from 09/09/19 through 09/12/19 due to the resident's ascites. He stated he did not perform the placement of Resident #2's Aspira drain; Physician #3 placed the drain. Further interview revealed that facility staff should not have accessed the resident's drain without physician orders for the amount of fluid to be removed and how often the drain could be accessed to remove fluids. He further stated that he would expect the resident's blood pressure and heart rate to be monitored during the procedure to ensure too much fluid was not being removed from the resident at one time. Interview with Physician #3 on 09/25/19 at 2:58 PM revealed he performed the procedure for Resident #2 on 0[DATE] to place the Aspira Drainage system. He stated that there should have been orders for care for the Aspira drain sent with the resident when he/she was discharged to the nursing facility on 09/12/19. He stated he was not sure why orders were not sent with the resident when he/she was discharged . Physician #3 stated that a box with supplies and a reference manual were sent with the resident at discharge, which gave a phone number to call with questions. He stated that when a patient received an Aspira drain he typically initiated treatment with draining approximately 200 milliliters (ml) per day to determine if the amount needed to be increased. Continued interview revealed that to ensure homeostasis was maintained, whatever amount of fluid that was removed would have to be replaced to ensure the patient did not experience an electrolyte imbalance, in addition to the patient's daily recommended fluid intake. Furthermore, Physician #3 stated, You could kill someone if you didn't know what you were doing; it wouldn't take long to kill them. He stated that the maximum amount of fluid that should have been removed via the Aspira drain was one (1) L in a twenty-four (24) hour period. **The facility alleged the following was implemented to remove Immediate Jeopardy effective 10/08/19: Resident #1 was discharged from the facility on 09/13/19 and Resident #2 was discharged from the facility on 09/23/19. 1. Beginning on 09/24/19 with completion on 10/07/19, licensed nurses completed and documented a resident assessment utilizing an assessment tool which included vital signs, neurological, cognitive, respiratory, gastrointestinal, vision, pain, hearing, oral, and skin to identify any changes in condition. Any issues that were identified were addressed with the resident's treating physician. 2. On 09/24/19, the physician was notified by a licensed nurse related to current residents with an Aspira Drain to verify physician orders related to the care of the Aspira Drain. 3. As of 10/07/19, all licensed nurses were interviewed by the Chief Nursing Officer (CNO) and the Human Resources Manager to identify any occurrence of a nurse writing physician orders without physician notification. 4. The Director of Nursing (DON) was terminated by the facility on 09/23/19 and an Interim DON was employed on 09/30/19. 5. Unit Manager #1 was terminated by the facility on 09/29/19. 6. On 10/03/19 the Regional Quality Manager re-educated the Interim Director of Nursing, Education and Training Director, and Unit Manager to the Daily Clinical Meeting; the Change in Condition policy which included the care for drains, pressure ulcers, and notifying the physician to obtain physician orders. 7. The Interim DON, Education and Training Director, and/or Unit Manager re-educated all licensed nurses by 10/07/19 regarding the Change in Condition policy, the care of Aspira Drains, and notifying the physician to obtain physician orders. A posttest was completed to verify understanding of the education received. No nurse will work until successfully completing the posttest. 8. All newly hired licensed nurses will receive education regarding the Change in Condition policy and requirement of notifying a physician to obtain physician orders during orientation by the Interim DON and/or Education and Training Director. 9. Licensed nursing staff not educated as of 10/07/19 will receive the education and successfully complete a posttest prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. No agency staff is utilized by the facility. 10. Resident admission assessments, documentation, and physician orders will be reviewed by the Interim DON and Unit Managers during the Daily Clinical Meeting, Monday through Friday, to identify changes in resident condition and documentation to verify MD notification. Designated nurse management will review admission assessments, physician orders, and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 11. Beginning on 0[DATE] the Regional Quality Manager began audits of resident admissions for the last 30 days and completed the audit on 09/23/19. 12. On 0[DATE] the Administrator, Interim DON, and Unit Managers held an internal Quality Assurance (QA) meeting to review initial findings of the audit of admission documentation for admissions over the last 30 days and plan for correction. 13. On 0[DATE] the Administrator notified the Medical Director of the initial admission audit findings and plan for correction. 14. The Regional Quality Manager and the Chief Nursing Officer were onsite at the facility on 09/23/19 and initiated a plan to correct concerns identified in the admission audit. 15. On 10/03/19 the Administrator, Interim DON, Regional Quality Manager, Chief Nursing Officer, Regional Director of Operations, Unit Manager, Education and Training Director, and Medical Director held a QA meeting to review the plan for further review and recommendation. 16. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that physician notification is complete with changes in condition. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 17. A QA meeting was held on 10/07/19 to review audit results by the DON and Unit Manager, no concerns were identified related to the audit findings. 18. QA meetings will continue weekly until the facility obtains substantial compliance and then will occur monthly for three months and then quarterly thereafter. 19. On [DATE] the Regional Quality Manager and Interim DON completed an audit of the Baseline Care Plan of admissions/readmissions for the past 20 days to verify that the base line care plan was complete and reflected the resident's current status including the treatment and care of pressure ulcers and/or drains. Any concerns identified have been addressed and the baseline care plan updated. 20. On 10/03/19 the Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager regarding resident care plans reflecting the residents' current status which included treatment and care of pressure ulcers and/or drains. 21. The Interim DON, Education and Training Director, and Unit Manager re-educated all licensed nurses on 10/07/19 regarding the Baseline Care Plan reflecting on care of pressure ulcers and/or drains. Nursing staff were administered a posttest verifying understanding. Any nurse that has not successfully completed the posttest will not work until completed prior to the beginning of their next scheduled shift. Signs have been posted by the time clock to communicate this requirement to oncoming staff. Newly hired nurses will receive education related to Baseline Care Plans during orientation by the DON and/or Education and Training Director. 22. Baseline Care Plans for residents who are admitted or readmitted will be reviewed by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday to verify that the Baseline Care Plan reflects the resident's status and condition. Designated nurse management will review admissions and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 23. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that the Baseline Care Plan reflects the residents' status and condition to include but not be limited to the care of pressure ulcers and or drains. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 24. Licensed nurses completed an assessment on 09/24/19 of current residents utilizing an assessment tool that included but was not limited to vital signs and a head-to-toe assessment of the residents' skin to identify any change in condition. Any issues identified were addressed at that time. Any concerns identified were reported to the physician and the residents' plan of care was updated to reflect the residents' current status and conditions. 25. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. 26. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Daily Clinical Meeting, Admission/Readmission assessments/checklist, Change in Condition Policy related to notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services. 27. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager to the Admission/Readmission assessments, the admission/readmission checklist, the Change in Condition policy notifying a physician to obtain physician orders and implementing physician orders, and the requirement that residents receive the necessary care and services. Newly hired licensed nurses will receive education to the Admission/Readmission assessments, the admission/readmission checklist, notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 28. Resident admission assessments, physician orders, and documentation will be reviewed to verify that residents are receiving the necessary care and services by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday, to identify changes in resident condition, and documentation to verify MD notification. Designated nurse management will review admissions, physician orders, and documentation on Saturdays and Sundays and then weekend admissions and documentation are completed including the baseline care plan to verify that residents are receiving necessary care and services. 29. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation, physician orders, and assessments to verify that physician notification is complete and that residents are receiving the necessary care and services. In addition, a licensed nurse will review residents with an Aspira drain to determine that physician orders are followed. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 2 months. Any issues identified will be addressed at that time. 30. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. A licensed nurse completed any missing assessments for current residents as of 10/04/19. 31. Licensed nurses completed an audit on 10/04/19 of current residents with pressure ulcers to assess the pressure ulcer, verify that physician orders are in place to care for the pressure ulcer, and update the plan of care. 32. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Skin Care Guideline and obtaining orders to care for pressure ulcers. 33. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager regarding the Admission/Readmission assessments and checklist and the Skin Care Guideline including but not limited to: skin assessments and obtaining order to care for pressure ulcers. A posttest was completed to verify understanding. No nurse will work until successfully completing the posttest. Newly hired licensed nurses will receive education regarding Admission/Readmission assessments and checklist including but not limited to skin assessments, the Skin Care Guideline, and obtaining orders to care for pressure ulcers during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 34. Resident admission assessments, including skin assessments, and treatments will be reviewed to verify that skin assessments are completed and that orders are obtained to care for pressure ulcers by the Interim DON and Unit Managers during the Daily Clinical Meeting, Monday through Friday. Designated nurse management will review admissions, physician orders, and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are complete and orders obtained to care for pressure ulcers identified. 35. The Director of Nursing, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments, including skin assessments, to verify that the assessments are complete and that orders are obtained for the treatment of any pressure ulcers. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 2 months. Any issues identified will be addressed at that time. 36. Licensed nurses completed a MAR/TAR to cart audit on 10/07/19 to verify that all medications and treatments for current residents are available and in the facility as ordered. Any concerns identified were

Based on interview, record review, and review of the facility's policies it was determined the facility failed to develop and implement a Baseline Care Plan that met professional standards of quality care, and included instructions needed to provide an effective and person-centered plan of care for two (2) of four (4) sampled residents (Residents #1 and #2). The facility admitted Resident #1 on 09/04/19. However, the facility failed to develop a baseline care plan for the resident that directed staff on how to meet the resident's basic needs including wound care, fall risks, dietary needs, or how to provide for the resident's activities of daily living (ADL). Subsequently, interviews with staff revealed Resident #1 did not receive wound care or appropriate hygiene care, and the staff was unaware of the resident's dietary needs, and failed to meet the resident's basic needs. On 09/13/19, Resident #1 was transferred to the hospital with multiple areas of skin breakdown, saturated in urine and covered in feces, and appeared unkempt. Resident #1 was admitted to the Intensive Care Unit (ICU) [MEDICAL CONDITION] (a life threatening complication of infection). Resident #2 was discharged from the hospital on [DATE] with a newly placed Aspira Drainage System (a tunneled, long-term catheter used to drain accumulated fluid from the peritoneal {abdominal} cavity to relieve symptoms associated with malignant ascites). The facility failed to identify that the resident returned with the drain and failed to develop a baseline care plan related to the care of the drain. On 0[DATE], Registered Nurse (RN) #1 wrote physician orders [REDACTED]. without a valid physician's orders [REDACTED]. Subsequently, Resident #2 had two (2) Emergency Department (ED) visits on 0[DATE] and 09/23/19 related to significant electrolyte imbalances. The facility's failure to develop and implement a Baseline Care Plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/30/19 and was determined to exist on 09/04/19 at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2). The facility was notified of the Immediate Jeopardy on 09/30/19. An acceptable Allegation of Compliance was received on 10/04/19, which alleged removal of the Immediate Jeopardy on 10/08/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 10/08/19, prior to exit on 10/09/19, which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: 1. Review of the facility's policy, Comprehensive Care Plan, not dated, revealed a Baseline Care Plan would be developed within 24 hours of a resident's admission to the facility to ensure the resident's immediate care needs were met. Further review of the policy revealed the person-centered care plan would be developed to promote communication of the resident's needs, goals, and interventions to promote successful goal attainment. Review of Resident #1's closed medical record revealed the facility admitted the resident on 09/04/19, with [DIAGNOSES REDACTED]. Review of Resident #1's hospital records revealed the resident presented to the Emergency Department (ED) on 08/31/19, after sustaining a fall at home, and remained on the floor five (5) days prior to being found. Resident #1 was admitted to the hospital with [REDACTED]. Record review revealed Resident #1 resided in the facility less than fourteen (14) days, and a Minimum Data Set (MDS) assessment was not completed. However, review of a Social Services note, dated 09/06/19, revealed the resident had no cognitive impairment. Review of a Baseline Care Plan created on 09/04/19 for Resident #1 revealed the only information documented on the care plan for the resident on 09/04/19 was medications ordered upon discharge from the hospital. On 09/05/19, the care plan had an entry that stated snacks as ordered, hydration assessment as needed, liquid protein as ordered, multivitamin, and to monitor for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] (low and high blood sugar). On 09/06/19, an entry was made which stated Physical Therapy, Occupational Therapy, and Speech Therapy, remain free from psychosocial distress, offer comfort/reassurance, Broda Chair (special wheelchair), and mechanical lift. Further review of the care plan revealed no further information was added regarding Resident #1's care needs or interventions/instructions for staff to use to care for the resident and meet his/her needs. The care plan contained no information related to the resident's pain status, assessing the resident for pain, diet, food consistency, swallowing difficulties, adaptive equipment to be used, denture status, safety/fall risks, interventions to prevent falls, mental health needs, bathing schedule, assistance needed for activities of daily living, ambulatory status, weight-bearing status, mobility status, bowel/bladder status, toileting needs, skin status, interventions to treat or prevent skin breakdown, or documentation of the size/location of any wounds. Further review of the care plan revealed none of the information was ever added to the resident's care plan until 09/13/19, nine (9) days after admission to the facility and the day the resident was transferred to the hospital. On 09/13/19, Excoriation to the groin/abdomen, ulcer right ankle, abrasion to left thigh, treatment as ordered was added. Interview with State Registered Nursing Assistant (SRNA) #2 on 09/24/19 at 5:00 PM revealed Resident #1 was placed on her hallway on 09/04/19 when admitted . The SRNA stated she was not told anything from nursing staff about Resident #1 or how to care for the resident. SRNA #2 stated she took care of Resident #1 the next few days. She stated the resident would ring the call light often, was agitated a lot, and had crusty things on his/her skin. SRNA #2 also stated the resident refused to use the urinal and was often found in urine-saturated linens. The SRNA stated she placed briefs on the resident. However, the briefs available at the facility were too small and dug into the resident's skin. The SRNA stated she was never told how to care for Resident #1 even after the resident had been admitted to the facility for several days. She stated the resident did receive food trays and she gave the resident water, but she was never aware of what diet consistency the resident was ordered. The SRNA stated Resident #1 remained in bed, and she did not know if the resident was allowed up or not. Interview with Licensed Practical Nurse (LPN) #2 on 09/25/19 at 11:12 AM, revealed on 09/04/19, her shift began at 7:00 PM, and she was assigned to Unit One, but she did not receive any information regarding a new admission. LPN #2 stated she was walking down the hallway and she opened the door to what she thought was an empty room, and found Resident #1 lying in bed. She stated she talked to the resident, but she did not know anything about the resident. Further interview revealed there was no information documented about the resident that she could find. LPN #2 stated she did not administer the resident's medication, or provide any care to the resident because she did not know anything about the resident. Interview with SRNA #4 on 09/24/19, revealed Resident #1 started having behaviors from day one. The SRNA stated the resident would holler and squeal all the time. However, the SRNA stated nursing staff had never given her any information on how to care for the resident, and she just took care of (him/her) the best way I knew how. SRNA #4 further stated Resident #1 had open areas all over his/her body, but she never observed nursing staff care for the wounds. Review of a Nurse's Note for Resident #1 on 09/13/19, revealed the resident was sent to the hospital for evaluation of his/her mental status. Review of the hospital records and photographs dated 09/13/19, revealed Resident #1 arrived at the Emergency Department (ED) on 09/13/19 at 2:20 PM, for a mental health evaluation. The hospital assessed Resident #1 to have multiple areas of skin breakdown and pressure areas present. The documentation stated the resident rated his/her pain a nine (9) out of ten (10), was saturated in urine/feces, and appeared unkempt. The hospital admitted Resident #1 to the Intensive Care Unit (ICU) on 09/13/19 [MEDICAL CONDITION]. Interview with Unit Manager (UM) #1 on 09/27/19 at 5:37 PM revealed she was responsible for monitoring to ensure baseline care plans were developed for new admissions, and that they contained all the information for staff to initially care for the residents and to meet their needs. The UM stated the resident's skin status, wounds, fall risks, ADL (activities of daily living) needs, and all the information needed to provide care to the resident should have been documented on the baseline care plan. However, the UM stated she did not know how Resident #1 slipped through the cracks. Interview with the Director of Nursing (DON) on 09/27/19 at 7:30 PM revealed she monitored resident admissions to ensure baseline care plans were in place and accurate. The DON stated staff utilized the baseline care plan to know how to care for newly admitted residents, including what the resident's needs were and how to care for the resident. The DON stated she did not know how staff were caring for the resident or meeting the resident's needs since no information was in place to direct staff. Interview with the Administrator on 09/30/19 at 5:40 PM revealed that when another State Agency came to the facility on [DATE] requesting Resident #1's chart, that was when he found nothing was in place to direct staff on how to care for the resident. The Administrator stated the DON and the UMs were responsible for monitoring to ensure staff were providing care to residents in accordance with each resident's plan of care. 2. Continued review of the facility's Comprehensive Care Plan policy, not dated, revealed the care planning/interdisciplinary team (IDT) was responsible for reviewing and updating care plans when there was a significant change in the resident's condition and when the resident was readmitted to the facility from a hospital stay. Review of Resident #2's medical record revealed the facility admitted the resident on 09/05/19 with [DIAGNOSES REDACTED]. Further review of Resident #2's medical record revealed the facility did not complete an Admission Minimum Data Set (MDS) because the resident did not have a 14-day stay due to being transferred to the Emergency Department on 09/09/19, 0[DATE], and 09/23/19. Review of a Social Services Director (SSD) Progress Note dated 09/17/19 at 12:29 PM, revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact and interviewable. Review of Resident #2's baseline care plan revealed the facility created a care plan on 09/09/19 that addressed the resident's medications, cognitive status, communication, vision, hearing, diet, oxygen, shortness of breath while lying flat, etc. There was no documented evidence that the facility developed a care plan that addressed the resident's [MEDICAL CONDITION] or ascites. Continued review of Resident #2's medical record revealed the resident was transferred to the hospital on [DATE] at 2:37 AM, due to lethargy and unresponsiveness, and was admitted with [MEDICAL CONDITION] (low sodium level), [DIAGNOSES REDACTED] (low potassium level), ascites, a pancreatic mass, and [DIAGNOSES REDACTED] (low blood sugar). Review of Resident #2's hospital medical record revealed an Aspira Drainage System was surgically placed in the resident's abdomen on 0[DATE] and he/she was discharged back to the facility on [DATE]. Continued review of the hospital record revealed there was no documented evidence that physician orders [REDACTED].#2's newly placed Aspira Drainage system. Further, continued review revealed Resident #2's baseline care plan revealed no documented evidence that the facility identified that the resident had an abdominal drain nor developed interventions to address the care of the drain. Further review of Resident #2's medical record revealed on 0[DATE], Registered Nurse (RN) #1 documented physician orders [REDACTED]. A review of Resident #2's Treatment Administration Record (TAR) for September 2019 revealed a treatment was also initiated on 0[DATE] to drain the resident's Aspira port every other day, as much as the resident could tolerate (every two (2) days) at 8:00 PM. Staff documented that fluid was drained on 0[DATE], 09/20/19, and 09/22/19 (the amount was not documented). Interview with RN #1 on 09/24/19 at 7:49 PM and 09/27/19 at 3:04 PM revealed she wrote the physician's orders [REDACTED].#2's Aspira drain. However, the interview with RN #1 revealed that she did not contact Resident #2's physician to obtain orders regarding the care of the resident's drain. She stated she wrote the orders based on the manufacturer's guide for the Aspira drain and orders that another resident (Resident #4) had in place to access and care for his/her Aspira drain. According to RN #1, she drained approximately two (2) L of fluid from the resident's Aspira drain on 0[DATE]. Review of a late entry nursing progress note dated 0[DATE] at 11:03 PM revealed Resident #2 complained of abdominal pain; was assessed to have firm, abdominal distention; and was transferred to the ED at 10:15 PM on 0[DATE]. Review of Resident #2's 0[DATE] admission History and Physical (H & P) dated 09/20/19, revealed the resident had significant [DIAGNOSES REDACTED] at 2.2 (normal range 3.5 to 5.3), [DIAGNOSES REDACTED], and [MEDICAL CONDITION] ([MEDICAL CONDITION] refers to a low level of sodium in the blood. [MEDICAL CONDITION] or low sodium blood levels may result from excess fluid in the body relative to a normal amount of sodium, or it may be due to a loss of sodium and body fluid caused by chronic conditions like kidney or [MEDICAL CONDITION]). The resident was discharged from the hospital on [DATE] with an order for [REDACTED]. However, continued review of Resident #2's TAR revealed on 09/20/19 (the day the resident was discharged from the hospital), and 09/22/19 staff RN #5 documented that fluid was drained from Resident #2's abdomen via the Aspira drain port. In addition, review of Nursing Progress Notes revealed staff removed two (2) L of fluid from Resident #2's abdomen at 1:00 AM on 09/21/19 and two (2) more liters of fluid were removed on 09/21/19 at 11:56 PM, approximately 22 hours later. Continued review of Resident #2's Nursing Progress Notes dated 09/23/19 at 2:26 PM revealed the laboratory reported that Resident #2 had critical laboratory values. The APRN was notified and orders were obtained to transport the resident to the ED for evaluation and treatment. Review of laboratory testing received on 09/23/19 at 12:49 PM revealed the resident had a critical sodium level of 115 (normal range 135-145), potassium level of 2.9 (normal 3.5-5.3), chloride level of [AGE] (normal 96-110), calcium level of 7.9 (normal 8.4-10.2), magnesium level of 1.3 (normal 1.2-2.5), and an [MEDICATION NAME] level of 2.6 (normal 3.5-5.5) ([MEDICATION NAME] is a protein made by the liver that assists to keep fluid in the bloodstream so it does not leak into other tissues. It is also responsible for carrying substances such as hormones, vitamins, and enzymes throughout the body). Review of a hospital H & P dated 09/24/19 revealed Resident #2 presented to the hospital on [DATE] at approximately 3:45 PM, after laboratory results revealed the resident had significant [DIAGNOSES REDACTED] and very profound and acute [MEDICAL CONDITION] with sodium levels reported as low as 113 to 114. The record stated Resident #2 was admitted with plans for aggressive electrolyte correction, hypertonic saline administration, and monitoring in the Critical Care Unit (CCU). The resident was discharged home with hospice care on 09/25/19, per the resident's and family's request. Interviews on 09/27/19 with Unit Manager (UM) #1 at 5:37 PM and the Director of Nursing (DON) at 7:37 PM revealed during the daily Interdisciplinary Team (IDT) meetings they reviewed physician orders, nursing notes, and assessments from the previous day. They stated care plans were also updated during the IDT meetings with any new physician orders. However, they stated they did not identify that Resident #2 did not have orders for care of the Aspira drain when the resident was readmitted on [DATE]. They stated they did not identify that the resident did not have a care plan that addressed the care of the resident's drain until 09/23/19, after someone requested the resident's medical record. **The facility alleged the following was implemented to remove Immediate Jeopardy effective 10/08/19: Resident #1 was discharged from the facility on 09/13/19 and Resident #2 was discharged from the facility on 09/23/19. 1. Beginning on 09/24/19 with completion on 10/07/19, licensed nurses completed and documented a resident assessment utilizing an assessment tool which included vital signs, neurological, cognitive, respiratory, gastrointestinal, vision, pain, hearing, oral, and skin to identify any changes in condition. Any issues that were identified were addressed with the resident's treating physician. 2. On 09/24/19, the physician was notified by a licensed nurse related to current residents with an Aspira Drain to verify physician orders [REDACTED]. 3. As of 10/07/19, all licensed nurses were interviewed by the Chief Nursing Officer (CNO) and the Human Resources Manager to identify any occurrence of a nurse writing physician orders [REDACTED]. 4. The Director of Nursing (DON) was terminated by the facility on 09/23/19 and an Interim DON was employed on 09/30/19. 5. Unit Manager #1 was terminated by the facility on 09/29/19. 6. On 10/03/19 the Regional Quality Manager re-educated the Interim Director of Nursing, Education and Training Director, and Unit Manager to the Daily Clinical Meeting; the Change in Condition policy which included the care for drains, pressure ulcers, and notifying the physician to obtain physician orders. 7. The Interim DON, Education and Training Director, and/or Unit Manager re-educated all licensed nurses by 10/07/19 regarding the Change in Condition policy, the care of Aspira Drains, and notifying the physician to obtain physician orders. A posttest was completed to verify understanding of the education received. No nurse will work until successfully completing the posttest. 8. All newly hired licensed nurses will receive education regarding the Change in Condition policy and requirement of notifying a physician to obtain physician orders [REDACTED]. 9. Licensed nursing staff not educated as of 10/07/19 will receive the education and successfully complete a posttest prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. No agency staff is utilized by the facility. 10. Resident admission assessments, documentation, and physician orders [REDACTED]. Designated nurse management will review admission assessments, physician orders, and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 11. Beginning on 0[DATE] the Regional Quality Manager began audits of resident admissions for the last 30 days and completed the audit on 09/23/19. 12. On 0[DATE] the Administrator, Interim DON, and Unit Managers held an internal Quality Assurance (QA) meeting to review initial findings of the audit of admission documentation for admissions over the last 30 days and plan for correction. 13. On 0[DATE] the Administrator notified the Medical Director of the initial admission audit findings and plan for correction. 14. The Regional Quality Manager and the Chief Nursing Officer were onsite at the facility on 09/23/19 and initiated a plan to correct concerns identified in the admission audit. 15. On 10/03/19 the Administrator, Interim DON, Regional Quality Manager, Chief Nursing Officer, Regional Director of Operations, Unit Manager, Education and Training Director, and Medical Director held a QA meeting to review the plan for further review and recommendation. 16. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that physician notification is complete with changes in condition. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 17. A QA meeting was held on 10/07/19 to review audit results by the DON and Unit Manager, no concerns were identified related to the audit findings. 18. QA meetings will continue weekly until the facility obtains substantial compliance and then will occur monthly for three months and then quarterly thereafter. 19. On [DATE] the Regional Quality Manager and Interim DON completed an audit of the Baseline Care Plan of admissions/readmissions for the past 20 days to verify that the base line care plan was complete and reflected the resident's current status including the treatment and care of pressure ulcers and/or drains. Any concerns identified have been addressed and the baseline care plan updated. 20. On 10/03/19 the Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager regarding resident care plans reflecting the residents' current status which included treatment and care of pressure ulcers and/or drains. 21. The Interim DON, Education and Training Director, and Unit Manager re-educated all licensed nurses on 10/07/19 regarding the Baseline Care Plan reflecting on care of pressure ulcers and/or drains. Nursing staff were administered a posttest verifying understanding. Any nurse that has not successfully completed the posttest will not work until completed prior to the beginning of their next scheduled shift. Signs have been posted by the time clock to communicate this requirement to oncoming staff. Newly hired nurses will receive education related to Baseline Care Plans during orientation by the DON and/or Education and Training Director. 22. Baseline Care Plans for residents who are admitted or readmitted will be reviewed by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday to verify that the Baseline Care Plan reflects the resident's status and condition. Designated nurse management will review admissions and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 23. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that the Baseline Care Plan reflects the residents' status and condition to include but not be limited to the care of pressure ulcers and or drains. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 24. Licensed nurses completed an assessment on 09/24/19 of current residents utilizing an assessment tool that included but was not limited to vital signs and a head-to-toe assessment of the residents' skin to identify any change in condition. Any issues identified were addressed at that time. Any concerns identified were reported to the physician and the residents' plan of care was updated to reflect the residents' current status and conditions. 25. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. 26. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Daily Clinical Meeting, Admission/Readmission assessments/checklist, Change in Condition Policy related to notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services. 27. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager to the Admission/Readmission assessments, the admission/readmission checklist, the Change in Condition policy notifying a physician to obtain physician orders [REDACTED]. Newly hired licensed nurses will receive education to the Admission/Readmission assessments, the admission/readmission checklist, notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 28. Resident admission assessments, physician orders, and documentation will be reviewed to verify that residents are receiving the necessary care and services by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday, to identify changes in resident condition, and documentation to verify MD notification. Designated nurse management will review admissions, physician orders, and documentation on Saturdays and Sundays and then weekend admissions and documentation are completed including the baseline care plan to verify that residents are receiving necessary care and services. 29. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation, physician orders, and assessments to verify that physician notification is complete and that residents are receiving the necessary care and services. In addition, a licensed nurse will review residents with an Aspira drain to determine that physician orders [REDACTED]. Any issues identified will be addressed at that time. 30. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. A licensed nurse completed any missing assessments for current residents as of 10/04/19. 31. Licensed nurses completed an audit on 10/04/19 of current residents with pressure ulcers to assess the pressure ulcer, verify that physician orders [REDACTED]. 32. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Skin Care Guideline and obtaining orders to care for pressure ulcers. 33. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager regarding the Admission/Readmission assessments and checklist and the Skin Care Guideline including but not limited to: skin assessments and obtaining order to care for pressure ulcers. A posttest was completed to verify understanding. No nurse will work until successfully completing the posttest. Newly hired licensed nurses will receive education regarding Admission/Readmission assessments and checklist including but not limited to skin assessments, the Skin Care Guideline, and obtaining orders to care for pressure ulcers during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 34. Resident admission assessments, including skin assessments, and treatments will be reviewed to verify that skin assessments are completed and that orders are obtained to care for pressure ulcers by the Interim DON and Unit Managers during the Daily Clinical Meeting, Monday through Friday. Designated nurse management will review admissions, physician orders, and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are complete and orders obtained to care for pressure ulcers identified. 35. The Director of Nursing, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments, including skin assessments, to verify that the assessments are complete and that orders are obtained for the treatment of [REDACTED]. Any issues identified will be addressed at that time. 36. Licensed nurses completed a MAR/TAR to cart audit on 10/07/19 to verify that all medications and treatments for current residents are available and in the facility as ordered. Any concerns identified were resolved at that time. 37. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding ordering and receiving of controlled and non-controlled medication policy and order entry into the electronic health record. 38. Licensed nurses were re-educated as of 10/0

Based on observation, interview, record review, review of the facility's job descriptions for Registered Nurses (RNs), and review of the Kentucky Board of Nursing Advisory Opinion Statements (#14 and #41), it was determined the facility failed to provide care in accordance with professional standards of practice for two (2) of four (4) sampled residents (Residents #1 and #2). Resident #2 was readmitted to the facility after an inpatient hospitalization on [DATE] where an Aspira Drainage System was placed (an Aspira drain is a tunneled, long-term catheter used to drain accumulated fluid from the peritoneal {abdominal} cavity to relieve symptoms associated with malignant ascites {the accumulation of fluid in the peritoneal cavity, causing abdominal swelling}). Upon readmission on 09/12/19, no physician orders were written regarding the care of the drain. However, four (4) days later, on 0[DATE], Registered Nurse (RN) #1 wrote physician orders to drain as much fluid as the resident could tolerate every other day; however, the RN failed to obtain the orders from the resident's physician. RN #1 drained fluid from the resident's abdomen on 0[DATE], after writing physician orders (without conferring/calling the physician) for the removal of fluid and without adequate monitoring of the resident's vital signs and laboratory values. In addition, on 09/20/19, 09/21/19 (twice), and 09/22/19, RN #5 removed fluid from the resident's abdomen via the Aspira drain (a total of six (6) Liters (L) in three days). RN #5 stated she was not familiar with the drain, but referred to a user's manual and a YouTube video for instructions regarding removal of fluid from the drain. Resident #2 was transported to the Emergency Department with abdominal pain and was diagnosed with [REDACTED]. In addition, on 09/23/19, Resident #2 was transferred to the Emergency Department and admitted with [DIAGNOSES REDACTED]. In addition, on 09/04/19, the facility admitted Resident #1 after an acute care hospital stay related to sustaining a fall at home. However, the facility failed to conduct any comprehensive assessments of the resident, including a nursing admission assessment, a skin assessment, or a fall risk assessment, or ensure the resident received basic nursing care. On 09/13/19, Resident #1 was transferred to the hospital and admitted to the Intensive Care Unit (ICU) due [MEDICAL CONDITION] (a life-threatening complication of infection). The facility's failure to provide professional standards of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/30/19 and was determined to exist on 09/04/19 at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2). The facility was notified of the Immediate Jeopardy on 09/30/19. An acceptable Allegation of Compliance was received on 10/04/19, which alleged removal of the Immediate Jeopardy on 10/08/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 10/08/19, prior to exit on 10/09/19, which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and F6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #41 RN/LPN Scope of Practice, Accountability and Responsibility of Nurses, approved February 2018, revealed in accordance with KRS (Kentucky Revised Statute) 314.021(2), nurses are responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing, and requires licensees to practice nursing with reasonable skill and safety. Nursing practice should be consistent with the Kentucky Nursing Laws and established standards of practice, and be evidence based. Review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14 Patient Care Orders, Revised October 2010/Editorial Revision May 2018, revealed nurses are held responsible and accountable for their decisions regarding the receipt and implementation of patient care orders based upon the individual's educational preparation and clinical competence in nursing. The nurse's practice should be consistent with the Kentucky Nursing Laws and established standards of practice, and be evidence based. The AOS stated it is within the scope of nursing practice for registered nurses or licensed practical nurses to accept direct and telephone orders of a qualified prescriber/provider and/or verbal intermediary. However, state and federal regulations governing the operation of various health care facilities have established rules regarding the receipt of verbal orders by nurses. Therefore, nurses should accept verbal orders according to established policy of the health care facility that complies with the applicable state and federal regulations. Review of the facility's Position Description for Registered Nurses (RNs) revealed they were required to collaborate with physicians, implementing orders for medications, treatments, and special testing. Interview with the facility's Administrator on 09/30/19 at 5:48 PM revealed staff were required to obtain treatment orders from a physician and should not write a treatment order and provide care without an order from a physician. 1. Observation of Resident #2 on 09/23/19 at 1:28 PM revealed the resident was in bed and had visitors. An observation of Resident #2 was attempted at approximately 3:00 PM on 09/23/19; however, the resident was not in his/her room. According to Unit Manager (UM) #2, the resident had been transported to the Emergency Department (ED) due to abnormal laboratory (lab) test results. Review of Resident #2's medical record revealed the facility admitted the resident on 09/05/19, with [DIAGNOSES REDACTED]. Further review of Resident #2's medical record revealed the facility did not complete an Admission Minimum Data Set (MDS) because the resident did not have a 14-day stay before he/she was transferred to the Emergency Department (ED) and/or hospital stays on 09/09/19, 0[DATE], and 09/23/19. Review of Resident #2's Nursing Progress Notes revealed on 09/10/19 at 2:37 AM, the resident was transferred to the ED due to lethargy and unresponsiveness. According to the record, Resident #2 was admitted to the hospital with [REDACTED]. Review of Resident #2's hospital medical record revealed an Aspira Drainage System was surgically placed in the resident's abdomen on 0[DATE] and two (2) L of fluid were removed during the procedure. Review of a hospital Progress Note dated 0[DATE] by Physician #2 revealed the resident would be scheduled for drainage of four (4) liters (L) via the Aspira drain while receiving [MEDICATION NAME] (a protein made by the liver that assists to keep fluid in the bloodstream so it does not leak into other tissues. It is also responsible for carrying substances such as hormones, vitamins, and enzymes throughout the body). Further review revealed the resident was discharged back to the facility on [DATE]; however, there was no documented evidence that physician orders were written to address the care of Resident #2's newly placed Aspira Drainage system. Interview with Physician #3 on 09/25/19 at 2:58 PM revealed Resident #2's Aspira Drainage system was placed on 0[DATE]. He stated that there should have been orders for care for the Aspira drain sent with the resident when he/she was discharged to the nursing facility on 09/12/19. Physician #3 stated when a patient received an Aspira drain, he typically initiated treatment with draining approximately 200 milliliters (ml) per day to determine if the amount needed to be increased. He stated that to ensure homeostasis was maintained, the amount of fluid that was removed would have to be replaced to ensure the patient did not experience an electrolyte imbalance. He stated that the maximum amount of fluid that should have been removed via the Aspira drain was one (1) L in a twenty-four (24) hour period. Interview with Physician #2 on 09/25/19 at 12:17 PM revealed he would expect staff to monitor the resident's blood pressure and heart rate while removing fluid to ensure too much fluid was not being removed from the resident at one time. Interview with Advanced Practice Registered Nurse (APRN) #1 on 09/30/19 at 3:45 PM revealed Resident #2's electrolytes and blood pressure would have to be monitored closely when removing fluid from the resident's abdomen to ensure that staff were not draining too much fluid at one time. Furthermore, she stated removing too much fluid without replacement of fluids could cause an electrolyte imbalance if not monitored closely. Continued review of Resident #2's medical record revealed on 0[DATE], four (4) days after readmission to the facility, Registered Nurse (RN) #1 documented physician orders to drain the resident's Aspira port every other day as much as the resident could tolerate. Continued review revealed RN #1 wrote an order to change the dressing to the Aspira drain exit site as needed for moistening, cleanse the area with alcohol, and apply dressing as needed. RN #1 further documented orders on 0[DATE] to notify the resident's physician if the resident had less than twenty-five (25) to fifty (50) milliliters (ml) of fluid from the drain for three (3) consecutive days as needed (PRN); if the resident experienced shortness of air that was not relieved after draining one thousand (1,000) ml from the Aspira port at one time PRN; if the appearance of fluid changes between drainage PRN; if the resident developed a fever above 100.5, experienced redness, swelling, oozing, or pain at the port site PRN; and if the resident experienced ongoing pain with little or no fluid draining from the catheter PRN. Further review of the orders written by RN #1 revealed no documented evidence that RN #1 obtained orders from the physician to assess Resident #2's vital signs prior to, during, or after the resident's Aspira drain was accessed for complications related to providing care to the Aspira drain for a change in condition. Interview with RN #1 on 09/24/19 at 7:49 PM and 09/27/19 at 3:04 PM, revealed she wrote the physician's order for care of Resident #2's Aspira drain on 0[DATE]. However, the interview with RN #1 revealed she did not contact Resident #2's physician to obtain the orders. RN #1 stated she wrote the orders based on a manufacturer's guide that was sent with the resident when he/she was discharged from the hospital on [DATE]; and based on physician orders for another resident with an Aspira drain (Resident #4). She stated that although the manufacturer's guide stated not to remove more than 2,000 ml (two liters) from the resident's abdomen in any one drainage, the orders that she wrote for Resident #2 stated to drain as much fluid as the resident could tolerate, and she decided to write Resident #2's orders to match Resident #4's physician's orders. Review of Resident #2's Treatment Administration Record (TAR) for September 2019 revealed a treatment order was initiated on 0[DATE], related to the resident's drain. The treatment order stated to drain the resident's Aspira port every other day, as much as the resident could tolerate (every two (2) days) at 8:00 PM. Continued review revealed on 0[DATE], 09/20/19, and 09/22/19 staff documented that fluid was drained from Resident #2's abdomen via the Aspira drain. The amount of fluid that was removed was not specified. Further, there was no documented evidence that the facility assessed the resident's vital signs during the procedures. Continued interview with RN #1 on 09/24/19 at 7:49 PM and 09/27/19 at 3:04 PM, revealed that even though she had not contacted the resident's physician for an order related to how much fluid should be drained, nor received an order for [REDACTED].#1 stated vital signs were obtained prior to removing the fluid on 0[DATE]; however, she did not obtain the resident's vital signs during or after the procedure. Further interview with RN #1 revealed she was aware that when fluid was removed, the resident's electrolytes should be monitored closely to ensure the resident did not become dehydrated; however, she did not contact the physician regarding the removal of fluid. Review of a late entry nursing progress note dated 0[DATE] at 11:03 PM revealed Resident #2 complained of abdominal pain, and was assessed to have a firm, distended abdomen. The resident's physician was notified and the resident was transferred to the ED at 10:15 PM on 0[DATE]. Review of Resident #2's 0[DATE] Admission History and Physical (H & P) dated 09/20/19, revealed the resident had significant [DIAGNOSES REDACTED] (low potassium level) at 2.2 (normal 3.5-5.3), [DIAGNOSES REDACTED] (low magnesium), and [MEDICAL CONDITION] ([MEDICAL CONDITION] refers to a low level of sodium in the blood. [MEDICAL CONDITION] or low sodium blood levels may result from excess fluid in the body relative to a normal amount of sodium, or it may be due to a loss of sodium and body fluid caused by chronic conditions like kidney or [MEDICAL CONDITION]). The resident received potassium replacement and intravenous (IV) fluids during his/her hospital stay and was discharged back to the facility on [DATE], with physician orders for oral potassium replacement and monitoring of his/her potassium and magnesium levels. Review of the discharge medication list dated 09/20/19 revealed the resident was discharged from the hospital with an order for [REDACTED].#2's Aspira drain. However, continued review of Resident #2's TAR revealed on 09/20/19 (the day the resident was discharged from the hospital) and 09/22/19, RN #5 documented that fluid was drained from Resident #2's abdomen via the Aspira drain port. The amount of fluid drained was not specified on the resident's TAR. In addition, review of Resident #2's medical record revealed RN #5 documented that she removed two (2) L of fluid from Resident #2's Aspira drain at 1:00 AM on 09/21/19. Further review revealed RN #5 documented that two (2) more liters of fluid were removed on 09/21/19 at 11:56 PM, approximately 22 hours later. However, there was no documented evidence that the resident's vital signs were monitored during the procedures on 09/20/19, 09/21/19, or 09/22/19. Interview with RN #5 on 09/24/19 at 8:27 PM and 10/01/19 at 4:45 PM revealed she had not received training regarding accessing and caring for an Aspira drain. She stated that she worked the night of 09/20/19, 09/21/19, and 09/22/19 with Resident #2 and had RN #1 assist her with draining fluid from Resident #2's abdomen, since she had never received education/training on accessing or providing care for an Aspira drain. She stated that prior to caring for the resident's drain, the RNs referred to an Aspira reference manual and a video on YouTube that provided instructional guidance. RN #5 stated that on 09/20/19 and 09/22/19 she accessed the resident's Aspira drain and removed one (1) L of fluid each time, and on 09/21/19 she removed two (2) L of fluid via the Aspira drain at 1:00 AM and again on the next shift prior to midnight on 09/21/19. RN #5 stated she was not aware of specific monitoring that was required when removing fluid from the resident's abdomen. According to RN #5, she believed that the resident's drain could be accessed and two (2) L of fluid removed daily. Review of nursing progress notes dated 09/23/19 at 2:26 PM revealed the laboratory reported Resident #2 had critical laboratory values. The note stated the resident's APRN was notified and orders were obtained to transfer the resident to the ED for evaluation and treatment. Review of laboratory testing received on 09/23/19 at 12:49 PM revealed the resident had a critical sodium level of 115 (normal range 135-145), potassium level of 2.9 (normal 3.5-5.3), chloride level of [AGE] (normal 96-110), calcium level of 7.9 (normal 8.4-10.2), magnesium level of 1.3 (normal 1.2-2.5), and an [MEDICATION NAME] level of 2.6 (normal 3.5-5.5). Review of a hospital H & P dated 09/24/19 revealed Resident #2 presented to the hospital on [DATE] at approximately 3:45 PM, after laboratory results revealed the resident had significant [DIAGNOSES REDACTED] and very profound and acute [MEDICAL CONDITION] with sodium levels reported as low as 113 to 114. The record stated the resident was brought to the ED and was found to have significant [DIAGNOSES REDACTED] as well as other electrolyte disturbances therefore, Resident #2 was admitted with plans for aggressive electrolyte correction, hypertonic saline administration, and monitoring in the Critical Care Unit (CCU). The resident was discharged home with hospice care on 09/25/19, per the resident's and family's request. Interview with the Staff Development Coordinator (SDC) on 09/27/19 at 7:00 PM revealed she had dealt with the Aspira drains in the past at a previous job. She stated staff should have definitely contacted Resident #2's physician to obtain orders for the Aspira drain. The SDC stated it was not a good idea to write orders and not have parameters for how much fluid to drain, how often fluid could be drained, and monitoring of the resident during the procedure. Continued interview with APRN #1 on 09/30/19 at 3:45 PM revealed she had not been notified by staff for orders related to the Aspira drain for Resident #2. She stated she was told by staff that Physician #1 was notified and gave orders for the care of his/her Aspira drain. She stated she should have been notified that the resident did not have orders in his/her hospital discharge information. Continued interview with Physician #2 on 09/25/19 at 12:17 PM revealed facility staff should not have accessed Resident #2's drain without physician orders for the amount/how often fluid could be removed. Interview with Physician #1 (attending facility physician) on 09/25/19 at 11:53 AM and 09/26/19 at 1:22 PM revealed he did not write orders for the care of Resident #2's Aspira drain, nor did staff contact him for orders to care for the resident's drain. He stated that facility staff should have phoned him or Physician #2 to get orders for the care of the Aspira drain if they did not receive them when Resident #2 was discharged back to the facility on [DATE]. Physician #1 stated facility staff called him at 3:00 AM for Tylenol orders; therefore, he would have expected them to call for orders related to the resident's Aspira drain's care and use. Further interview with Physician #1 revealed that to his knowledge the Aspira drain was placed to make paracentesis easier at the hospital and was not intended for the facility staff to utilize. Further interview with Physician #1 revealed that the most fluid that could safely be removed outside of a hospital setting was one (1) L at a time. Interview with Unit Manager (UM) #1 on 09/27/19 at 5:37 PM and with the Director of Nursing (DON) on 09/27/19 at 7:37 PM revealed they were not aware that RN #1 wrote treatment orders for Resident #2's Aspira drain without contacting the physician. They stated when Resident #2 was readmitted to the facility on [DATE] with the Aspira drain, staff should have notified the physician to obtain specific orders for the care of the drain. The UM stated staff should not write physician orders based on a user's manual or another resident's physician orders. Interview with the Administrator on 09/30/19 at 5:48 PM revealed the DON dealt with clinical areas because he did not have a medical background. However, the Administrator stated that staff should not write a treatment order and provide care without notifying the physician and obtaining orders from the physician. 2. Review of the POS [REDACTED]. The Position Description also stated staff would conduct communication between shifts to ensure the exchange of significant information to provide ongoing comprehensive care to the resident, as well as the resident's response to care. Further Review of the POS [REDACTED]. Review of the POS [REDACTED]. The RN would monitor to ensure documentation was completed daily and ensure accurate documentation was made in the resident's medical record. Review of Resident #1's closed record revealed the facility admitted the resident on 09/04/19 after an acute care hospital stay for a fall sustained at home. The resident had [DIAGNOSES REDACTED]. In addition, review of Resident #1's hospital records revealed the resident had also been diagnosed with [REDACTED]. Due to Resident #1 residing in the facility less than fourteen (14) days, a Minimum Data Set assessment was not completed. However, review of a note made by the Social Services Director (SSD) on 09/06/19, revealed Resident #1 was alert and oriented, and had no cognitive impairment. Interview with Family Member #1 on 09/27/19 at 10:03 AM, revealed the family transported Resident #1 to the facility via private vehicle after discharge from the hospital on [DATE]. The Family Member stated they arrived at the facility at approximately 5:00 PM. Further interview revealed staff wrapped the resident's lower extremities in towels because the resident had multiple open areas on both legs that were draining. Family Member #1 stated they had the discharge instructions from the hospital, but no staff member requested to see the discharge papers from the hospital concerning Resident #1. Review of Resident #1's medical record revealed no documented evidence that the facility assessed the resident upon admission, including conducting a nursing admission assessment to determine what basic care needs the resident required. Although Resident #1 had been hospitalized for [REDACTED].#1 upon admission. Continued review of Resident #1's medical record revealed the only documentation made for Resident #1 when admitted to the facility was on 09/04/19, when a Baseline Care Plan (BCP) for the resident was developed. However, review of the BCP revealed it only listed the resident's hospital discharge medications, and contained no instruction for staff related to caring for the resident including fall precautions, hydration status, pain management wound care, or mobility status. Review of the 24-Hour Report/Change of Condition Reports for Blue Hall, the hall where Resident #1 was admitted , from 09/04/19 through 0[DATE], revealed no documentation concerning Resident #1 on any of the reports until 0[DATE], when the resident's name was listed under the Admissions section of the report, seven (7) days after the resident was admitted to the facility. Review of nursing entries in the Progress Notes for Resident #1 revealed no documentation was made in the notes for Resident #1 on 09/04/19. Continued review revealed the only nursing documentation made for the resident from 09/05/19 through 09/10/19, was on 09/05/19, when a nurse documented acknowledgment that orders had been written for the resident to receive PT, OT, ST, a Broda wheelchair, and utilize a mechanical lift. On 09/10/19, six (6) days after the resident was admitted to the facility, a nurse made an entry stating, resident noted with altered mental status. Although laboratory tests were ordered for the resident, there was no documentation related to the resident's medical status or what altered mental status the resident exhibited. In addition, there was no documentation made related to pain, vital signs, skin condition, or documentation that any care was being provided to the resident. Further review of Resident #1's nursing entries revealed on 0[DATE], seven (7) days after admission to the facility, the first diet order was received for Resident #1 which stated new order received for regular diet with thick liquids. Interview with UM #2 on 09/25/19 at 10:23 AM revealed on 09/04/19 she was informed that Unit One had a new admission. UM #2 stated she called Resident #1's Physician, who was unaware that Resident #1 was being admitted to the facility. The UM stated the physician instructed her to contact the hospital and find out what discharge medications the resident was ordered. UM #2 stated she contacted the hospital and spoke to the House Supervisor, who gave her the resident's medication ordered upon discharge on 09/04/19. However, the UM made no further effort to ensure that the facility nursing staff were made aware of Resident #1's required care needs to ensure the resident's safety and basic care needs were met. UM #2 stated she called the Staff Development Coordinator (SDC), who agreed to come to the facility on [DATE], to assist LPN #2, who was a new nurse at the facility, with Resident #1's admission. The UM stated she also instructed RN #1, who was already in the facility, to assist LPN #2 with Resident #1's admission if LPN #2 needed assistance. Interview with the SDC on 09/25/19 at 10:54 AM confirmed on 09/04/19, UM #2 called her and requested that she come to the facility to assist LPN #2 with Resident #1's admission. However, she stated she had an accident at her home that evening and was unable to go to the facility. Further interview revealed the SDC made no effort to ensure another staff member was assisting LPN #2, who had never admitted a resident to the facility, to ensure all required assessments were conducted to ensure Resident #1's health and safety needs were met. Interview with RN #1 on 09/27/19 at 5:30 PM revealed on 09/04/19, UM #2 told her Unit One had a new admission, and for her to assist LPN #2 with the admission. However, RN #1 stated LPN #2 did not request any assistance with the admission for Resident #1. The UM stated she did not specifically ask LPN #2 if she needed assistance or provide any oversight to ensure the admission was being completed appropriately. Interview with LPN #2 on 09/25/19 at 11:12 AM, revealed on 09/04/19, her shift began at 7:00 PM, and she was assigned to Unit One, but she did not receive any information regarding a new admission or the need to conduct an assessment of the resident during shift report. LPN #2 stated the facility had just initiated a new computer system for documenting. LPN #2 stated, Everybody was running around and I really didn't know what to do. LPN #2 stated she was walking down Unit One Hall, when she opened the door to what she thought was an empty room, and found Resident #1 lying in bed. She stated she talked to the resident, but she did not fill out any admission papers or assess the resident in any way, including performing any resident assessments. Further interview with LPN #2 revealed she made no effort to ensure the resident had medications ordered, or ensure that the resident received medication on 09/04/19. LPN #2 stated she did not ask RN #1 for assistance with admitting the resident, because she did not know anything about the resident or that she was supposed to conduct an admission assessment on the resident. LPN #2 stated she did not know where the resident came from or why he/she was there, so she provided no care to the resident during her shift. During interview with LPN #2, she stated she did tell the on-coming nurse on 09/05/19 during shift report, that Unit One had a new resident. However, she did not know anything about the resident or when the resident came to the facility. Interview with State Registered Nurse Aide (SRNA) #2 on 09/24/19 at 5:00 PM revealed Resident #1 was on her hall on 09/04/19. SRNA #2 stated she did not receive any information from nursing staff about the resident on 09/04/19. SRNA #2 stated the nurses were really stressed because of the new computer system and the facility was short-staffed. In addition, the SRNA stated LPN #2 was new to the facility. Interview with LPN #1 on 09/24/19 at 6:18 PM, revealed she received report on Resident #1 on 09/05/19 at 7:00 AM from LPN #2, and the only information she received was that Resident #1 was a new resident. LPN #1 stated the only information available to her on 09/05/19, regarding Resident #1 was the resident's medications that were to be administered. LPN #1 stated she did not assess the resident in any way on 09/05/19, and made no effort to obtain additional information regarding the resident or how to meet the resident's basic needs including diet, mobility, fall interventions, and pain management. LPN #1 stated she provided no nursing care to Resident #1 on 09/05/19. Interview with RN #4 on 09/25/19 at 11:45 AM revealed she was Resident #1's nurse a couple of times (could not recall exact dates) after the facility admitted the resident on 09/04/19. RN #4 stated she did not assess the resident in any way or provide any nursing care for the resident. In addition, SRNA #2 stated she took care of Resident #1 for the next few days after admission. The SRNA stated Resident #1 would ring the call light often, was agitated a lot, and had crusty things on his/her skin. SRNA #2 stated the resident needed the big depends (adult incontinence briefs) to wear, but she had to use the green depends, which were a smaller size, and definitely too tight for Resident #1. SRNA #2 stated the resident would pull at the incontinence briefs trying to loosen them up. She stated she told the staff member who ordered supplies to order larger briefs for Resident #1. However, when the larger briefs came to the facility, the other unit also needed them, and the staff from that unit hid them for their residents. Continued review of nursing entries for Resident #1 revealed on 09/13/19, the nurse documented that Resident #1 was sent to the hospital for psych. However, review of Resident #1's medical record revealed no physical or medical assessment was conducted of the resident's status or condition prior to the resident being transferred to the hospital. Review of the Behavior Monitoring Form for Resident #1 revealed the fac

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide necessary treatments, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (1) of four (4) sampled residents (Resident #1). On 09/04/19, Resident #1 was discharged from the hospital and admitted to the facility with several areas of skin breakdown and a pressure ulcer to the coccyx. However, the facility failed to conduct an admission assessment or skin assessment, or obtain orders for treatment of [REDACTED]. Although the facility's Advanced Practice Registered Nurse (Nurse Practitioner/NP) identified the resident had skin breakdown on 0[DATE], the facility failed to follow the Nurse Practitioner's orders and provide treatment to Resident #1's wounds. On 09/12/19, the NP ordered additional treatment for [REDACTED]. On 09/13/19, the facility transferred Resident #1 to the hospital with multiple decubitus areas (sites not specified), a Deep Tissue Injury (DTI) on the left posterior calf, severe denuded skin to the inner thighs, and scattered ulcers on the resident's legs. The hospital admitted Resident #1 to the Intensive Care Unit (ICU) on 09/13/19 with a [DIAGNOSES REDACTED]. The facility's failure to provide necessary treatments, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/30/19 and was determined to exist on 09/04/19 at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2). The facility was notified of the Immediate Jeopardy on 09/30/19. An acceptable Allegation of Compliance was received on 10/04/19, which alleged removal of the Immediate Jeopardy on 10/08/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 10/08/19, prior to exit on 10/09/19, which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Skin Care Guidelines, dated April 2019, revealed upon admission a baseline skin assessment would be completed within twenty-four (24) hours and then staff would perform weekly skin assessments and the findings would be documented in the resident's medical record. Further review of the policy revealed staff would perform a Braden Scale assessment (used to determine the resident's risk of pressure ulcers) in order to plan the resident's care as needed. The policy revealed if interruption in skin integrity was noted evaluation of the wound would include location, staging (degree of severity), wound measurements, exudate (wound drainage), wound bed (area of breakdown) appearance, description of wound edges, description of the surrounding tissue, and if pain was present. Review of Resident #1's closed medical record revealed the facility admitted the resident on 09/04/19 with [DIAGNOSES REDACTED]. The resident's family transported the resident to the facility via private vehicle after discharge from the hospital. Review of Resident #1's hospital records revealed the resident was admitted to the hospital on [DATE] after sustaining a fall at home. Continued review of the hospital records revealed the resident was discharged on [DATE], with significant Psoriasis on his/her bilateral upper and lower extremities, face, neck, and ears. The hospital records also stated Resident #1 had weeping from the Psoriasis on his/her bilateral lower extremities, an abrasion on the right cheek, an open wound on the left shin area, an unstageable pressure ulcer on the right buttock, and an abrasion on the right cheek. An interview was conducted on 09/26/19 at 10:45 AM, with the Hospital RN (Registered Nurse) who had discharged Resident #1 from the hospital on [DATE]. The RN stated the resident had an unstageable pressure ulcer with eschar (black dead skin) present to the buttocks, several open areas on the left shin/calf, open areas on the arms, and a lesion on his/her face that was scabbed over on discharge. However, upon admission (to the nursing facility) the facility failed to perform any assessment for Resident #1, including a skin assessment, an assessment for predicting pressure ulcer risk, and failed to assess or document any of the resident's wounds. Due to the resident residing in the facility less than fourteen (14) days, the facility did not complete a Minimum Data Set (MDS) assessment for Resident #1. Review of a Baseline Care Plan created for Resident #1 on 09/04/19, revealed no documented evidence the facility developed a plan of care upon admission to address or treat the resident's skin breakdown, or implement interventions to prevent further skin breakdown for the resident. Further review of the Baseline Care Plan revealed the only documentation made related to the resident's skin status was on 09/13/19, the day the facility transferred the resident back to the hospital, and nine (9) days after the facility admitted the resident. Review of a Bed Mobility Form dated 09/06/19 completed for Resident #1 revealed the facility assessed the resident to require the assistance of two (2) staff members for turning and repositioning. However, there was no documented evidence found to indicate the facility assessed the resident or implemented the required care until 09/06/19, two (2) days after the facility admitted the resident. Review of Nurse's Notes for Resident #1 from the day of admission, 09/04/19, through 09/08/19, four (4) days after admission, revealed no documentation related to the resident's skin condition or wounds. Review of Resident #1's Progress Notes revealed on 09/13/19, at 7:43 AM, the Nurse Practitioner (NP) made a late entry into the progress note for 09/09/19, indicating she assessed the resident on 09/09/19, because she was asked to see for different behaviors. The NP documented Resident #1 was alert and oriented, but conversation wanders. The only documentation made by the NP related to the resident's skin was that the resident had scattered [MEDICAL CONDITION] to the face, chest, both arms, and both legs. On 09/10/19, review of a physician's Telephone Order revealed the NP ordered the staff to obtain several laboratory tests for Resident #1, related to altered mental status. Continued review of Resident #1's Progress Notes revealed on 09/13/19, at 1:40 PM, the NP made a late entry into the progress note for 0[DATE], indicating she assessed the resident on 0[DATE], because she was asked to see to review labs. The NP documented in this entry that Resident #1 had [MEDICAL CONDITION] noted on left inner shin and a pressure ulcer on right ankle. The NP documented under the Care Plan/Assessment portion of the progress note to apply border foam dressing to the right ankle (frequency unspecified). However, review of physician orders [REDACTED].#1's left lower extremity with wound cleanser, apply Triple Antibiotic Ointment daily, and keep the area open to air. Continued review of Resident #1's Progress Notes revealed on 09/17/19, at 9:14 AM, the NP made a late entry in the progress note for 09/12/19, indicating she assessed the resident on 09/12/19, because she was asked to see for [MEDICAL CONDITION]. The NP documented Resident #1 had multiple excoriated [MEDICAL CONDITION] on his/her legs/buttocks and two (2) unstageable pressure ulcers on the right ankle and foot. The NP documented under the Care Plan/Assessment portion of the progress note for Santyl dressing ([MEDICATION NAME] agent) to be applied to the resident's right foot and right ankle daily, [MEDICATION NAME] Powder applied topically to the groin area (frequency unspecified), and Triple Antibiotic Ointment be applied to excoriated skin areas (frequency and exact location unspecified). Review of Physician order [REDACTED]. outer ankle/foot, and [MEDICATION NAME] Powder (topical antifungal agent) to the groin twice daily. However, review of Resident #1's medical record, including the Treatment Administration Record (TAR), from 09/09/19 through 09/13/19, revealed the resident did not receive the treatments as ordered. Resident #1 only received the [MEDICATION NAME] Ointment one (1) time on 0[DATE] at 9:00 AM, two (2) times on 09/12/19 at 9:00 AM and 9:00 PM, and one time on 09/13/19 at 9:00 AM. Resident #1 received the Triple Antibiotic Ointment (location not specified) twice on 09/12/19 at 7:00 AM and 7:00 PM, and once on 09/13/19 at 7:00 AM. Further review revealed Resident #1 received Santyl External Ointment (location not specified) topically one (1) time on 09/12/19 at 7:00 AM and one (1) time on 09/13/19 at 7:00 AM. However, review of Shipping Manifests from the pharmacy utilized by the facility and interview with the Pharmacist on 09/27/19 at 12:40 PM revealed the Santyl Ointment was never delivered to the facility. Furthermore, there was no documented evidence Resident #1 ever received any wound care to the right lower extremity, the Border Foam Dressing to the right ankle, or [MEDICATION NAME] Powder applied to the groin area. Further review revealed there was no documented evidence in Resident #1's medical record to indicate the nursing staff provided direct care to Resident #1 or the facility's wound care nurse ever assessed, measured, or monitored the wounds while Resident #1 resided in the facility. Interview with State Registered Nurse Aide (SRNA) #2 on 09/24/19 at 5:00 PM and SRNA #7 on 10/01/19 at 4:02 PM, revealed they were working on 09/04/19, when Resident #1 arrived at the facility. The SRNAs stated they both assisted other staff members to get Resident #1 out of the vehicle and into the facility. The SRNA stated staff wrapped towels around the resident's pant legs to absorb the excessive draining from the resident's lower extremities. SRNA #2 stated staff placed the resident in a room on her hallway, but she never received any information on the care needs of Resident #1, and never observed a nurse conduct a physical assessment of the resident. Interview with Licensed Practical Nurse (LPN) #2 on 09/25/19 at 11:12 AM, revealed on 09/04/19, she was the nurse for Unit One during the 7PM-7AM shift. However, the LPN stated she did not receive any information concerning a new resident during shift change. LPN #2 stated that while walking down the hallway, she opened a door to a room that she thought was empty and found Resident #1 lying in bed. LPN #2 stated she briefly spoke to the resident, who told her he/she was new at the facility. The nurse stated she did not conduct a skin assessment or provide any treatment to the resident's wounds. The LPN stated the next morning on 09/05/19 during shift report, she reported to the oncoming nurse that Unit One had a new resident; however, she did not know anything about the resident or when the resident came to the facility. Interview with LPN #1 on 09/24/19 at 6:18 PM, revealed she received report from LPN #2 on 09/05/19 at 7:00 AM, but the only information she received from LPN #2 was that Resident #1 was a new resident. LPN #1 stated she did not do a skin assessment on Resident #1, or provide any treatment to the resident's wounds. Interview with Registered Nurse (RN) #4 on 09/25/19 at 11:45 AM, revealed she was Resident #1's nurse a couple of times (unable to recall exact dates) after the resident was admitted on [DATE]. However, RN #4 stated she did not conduct any skin assessments for Resident #1, because the resident did not have any wounds. RN #4 also denied that any staff had reported to her that Resident #1 had any wounds present. Interview with the Wound Care Nurse on 09/26/19 at 4:00 PM, revealed she was out of the facility on 09/04/19 through 09/06/19, when the facility admitted Resident #1. She stated when she returned to the facility on [DATE] she was notified by staff that Unit One had a new resident. However, the Wound Care Nurse stated she never saw or evaluated Resident #1, because UM #1 told her the resident did not have any open areas or wounds present. Interview with Unit Manager (UM) #1 on 09/26/19 at 4:30 PM, revealed she observed Resident #1's arms and legs on 09/04/19, after staff had placed the resident in bed. The UM stated she observed an open area on the resident's right outer ankle and a black area approximately two (2) to three (3) inches above the open area on the right ankle. However, the UM stated her shift was over and she left the facility. The UM stated the second shift nurse should have completed an admission assessment on Resident #1. Further interview with UM #1 on 09/27/19 at 5:37 PM, revealed she was responsible to monitor the 24-Hour Shift Report to ensure any new admissions or new orders were noted on the report. Although the UM stated she reviewed the report daily, it was not until 0[DATE], six (6) days after the resident was admitted to the facility, that she identified that Resident #1 had never been placed on the 24-Hour Shift Report. UM #1 stated a skin assessment and a Braden Scale (used to predict pressure ulcer risk) should have been completed during Resident #1's admission, and further skin assessments conducted as warranted. Continued interview with UM #1 revealed she had not identified that the [MEDICATION NAME] Powder or Border Foam Dressing had not been ordered for the resident and that staff were signing Resident #1's TAR indicating they had applied Santyl Ointment to Resident #1's wound when it had never been delivered to the facility. Interview with the NP on 09/25/19 at 3:53 PM, revealed staff asked her to assess Resident #1 the first time on 09/09/19 for behaviors. The NP stated the resident had really bad Psoriasis, ulcers on both legs, and scattered [MEDICAL CONDITION] on his/her arms, face, chest, and legs. The NP stated the ulcers on Resident #1's legs were open with pink/moist tissue observed. She stated she did not write orders for the resident's wounds on 09/09/19, because she assumed the facility had completed a skin assessment on the resident already, identified the skin breakdown, and was treating the leg ulcers and skin breakdown. The NP stated when she was documenting discussing lab results with the resident on 0[DATE], she also documented the resident's [MEDICAL CONDITION] on the left inner shin, the pressure ulcer on the right ankle, and that the resident had [MEDICAL CONDITION] over his/her entire body. The NP stated she instructed a nurse at the facility to write an order to apply a border foam dressing to the wound on the resident's right ankle. Continued interview with the NP revealed she saw Resident #1 again on 09/12/19, and observed that the resident had multiple excoriated [MEDICAL CONDITION] on both legs and buttocks, and two (2) unstageable pressure ulcers on the right ankle and dorsal side of the right foot. The NP stated she wrote an order for [REDACTED].#1, she would have made a referral for the resident to be seen at the Wound Care Clinic. Further review of Progress Notes for Resident #1 dated 09/13/19, revealed the Social Services Director (SSD) had talked with resident several times this day. The SSD documented that each time (times not documented) she observed the resident he/she was confused and delusional. Further review of the Progress Notes revealed on 09/13/19 at 1:40 PM, the NP observed the resident and documented he/she was having visual hallucinations. The Progress Notes stated on 09/13/19 at 2:26 PM, the facility transferred Resident #1 to the hospital for psych. Review of hospital records for Resident #1 and photographs obtained at the hospital dated 09/13/19 revealed Resident #1 arrived at the Emergency Department (ED) via Emergency Medical Services (EMS) on 09/13/19 at 2:20 PM. The hospital documented that the resident had generalized excoriation on the abdomen with [DIAGNOSES REDACTED] (redness) and oozing, multiple ulcers to the groin area, severe denuded skin to the bilateral inner thighs, an unstageable pressure wound with eschar on the right lateral ankle, an unstageable pressure wound with eschar on the right lateral foot, a deep tissue injury on the left posterior calf, and scattered ulcerations to the anterior right and left shin. Continued review of the note revealed Resident #1 rated his/her pain level a nine (9), using a numeric rating with ten (10) being unbearable, excruciating pain. The hospital diagnosed Resident #1 with [MEDICAL CONDITION], Acute Kidney Injury, Dehydration, and [MEDICAL CONDITION]. Resident #1 was admitted to the Intensive Care Unit (ICU) [MEDICAL CONDITION]. Interview with Resident #1's Physician on 09/26/19 at 1:10 PM, revealed on 09/04/19 he was notified by the facility at approximately 8:45 PM, that the facility (nursing facility) had admitted the resident. Physician #1 stated he instructed the facility to call the hospital to obtain the discharge medication list for Resident #1 and to continue with the same wound care orders that Resident #1 was receiving while in the hospital. The Physician stated he was never contacted regarding Resident #1's wounds after talking with the facility staff on 09/04/19. Interview with the DON (Director of Nursing) on 09/24/19 at 2:05 PM revealed the facility did not do an Admission Assessment, Skin Assessment, or Braden Scale assessment for Resident #1 when admitted to the facility on [DATE]. Further interview with the DON on 09/27/19 at 7:30 PM revealed she monitored admission packets to ensure everything had been completed correctly in the admission packets. However, she stated she had not been aware until 09/18/19, when another state agency arrived at the facility requesting Resident #1's medical record, that the admission packet for Resident #1 was blank. The DON stated staff should have measured, documented, and obtained treatment for [REDACTED]. Interview with the Administrator on 09/30/19 at 5:40 PM revealed he also became aware that the facility had failed to assess, document and treat Resident #1's wounds appropriately on 09/18/19. The Administrator further stated he spoke to the DON and UM #1 concerning the issues with Resident #1, and was told by the DON and UM that they did not have any answers for him. **The facility alleged the following was implemented to remove Immediate Jeopardy effective 10/08/19: Resident #1 was discharged from the facility on 09/13/19 and Resident #2 was discharged from the facility on 09/23/19. 1. Beginning on 09/24/19 with completion on 10/07/19, licensed nurses completed and documented a resident assessment utilizing an assessment tool which included vital signs, neurological, cognitive, respiratory, gastrointestinal, vision, pain, hearing, oral, and skin to identify any changes in condition. Any issues that were identified were addressed with the resident's treating physician. 2. On 09/24/19, the physician was notified by a licensed nurse related to current residents with an Aspira Drain to verify physician orders [REDACTED]. 3. As of 10/07/19, all licensed nurses were interviewed by the Chief Nursing Officer (CNO) and the Human Resources Manager to identify any occurrence of a nurse writing physician orders [REDACTED]. 4. The Director of Nursing (DON) was terminated by the facility on 09/23/19 and an Interim DON was employed on 09/30/19. 5. Unit Manager #1 was terminated by the facility on 09/29/19. 6. On 10/03/19 the Regional Quality Manager re-educated the Interim Director of Nursing, Education and Training Director, and Unit Manager to the Daily Clinical Meeting; the Change in Condition policy which included the care for drains, pressure ulcers, and notifying the physician to obtain physician orders. 7. The Interim DON, Education and Training Director, and/or Unit Manager re-educated all licensed nurses by 10/07/19 regarding the Change in Condition policy, the care of Aspira Drains, and notifying the physician to obtain physician orders. A posttest was completed to verify understanding of the education received. No nurse will work until successfully completing the posttest. 8. All newly hired licensed nurses will receive education regarding the Change in Condition policy and requirement of notifying a physician to obtain physician orders [REDACTED]. 9. Licensed nursing staff not educated as of 10/07/19 will receive the education and successfully complete a posttest prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. No agency staff is utilized by the facility. 10. Resident admission assessments, documentation, and physician orders [REDACTED]. Designated nurse management will review admission assessments, physician orders, and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 11. Beginning on 0[DATE] the Regional Quality Manager began audits of resident admissions for the last 30 days and completed the audit on 09/23/19. 12. On 0[DATE] the Administrator, Interim DON, and Unit Managers held an internal Quality Assurance (QA) meeting to review initial findings of the audit of admission documentation for admissions over the last 30 days and plan for correction. 13. On 0[DATE] the Administrator notified the Medical Director of the initial admission audit findings and plan for correction. 14. The Regional Quality Manager and the Chief Nursing Officer were onsite at the facility on 09/23/19 and initiated a plan to correct concerns identified in the admission audit. 15. On 10/03/19 the Administrator, Interim DON, Regional Quality Manager, Chief Nursing Officer, Regional Director of Operations, Unit Manager, Education and Training Director, and Medical Director held a QA meeting to review the plan for further review and recommendation. 16. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that physician notification is complete with changes in condition. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 17. A QA meeting was held on 10/07/19 to review audit results by the DON and Unit Manager, no concerns were identified related to the audit findings. 18. QA meetings will continue weekly until the facility obtains substantial compliance and then will occur monthly for three months and then quarterly thereafter. 19. On [DATE] the Regional Quality Manager and Interim DON completed an audit of the Baseline Care Plan of admissions/readmissions for the past 20 days to verify that the base line care plan was complete and reflected the resident's current status including the treatment and care of pressure ulcers and/or drains. Any concerns identified have been addressed and the baseline care plan updated. 20. On 10/03/19 the Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager regarding resident care plans reflecting the residents' current status which included treatment and care of pressure ulcers and/or drains. 21. The Interim DON, Education and Training Director, and Unit Manager re-educated all licensed nurses on 10/07/19 regarding the Baseline Care Plan reflecting on care of pressure ulcers and/or drains. Nursing staff were administered a posttest verifying understanding. Any nurse that has not successfully completed the posttest will not work until completed prior to the beginning of their next scheduled shift. Signs have been posted by the time clock to communicate this requirement to oncoming staff. Newly hired nurses will receive education related to Baseline Care Plans during orientation by the DON and/or Education and Training Director. 22. Baseline Care Plans for residents who are admitted or readmitted will be reviewed by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday to verify that the Baseline Care Plan reflects the resident's status and condition. Designated nurse management will review admissions and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 23. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that the Baseline Care Plan reflects the residents' status and condition to include but not be limited to the care of pressure ulcers and or drains. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 24. Licensed nurses completed an assessment on 09/24/19 of current residents utilizing an assessment tool that included but was not limited to vital signs and a head-to-toe assessment of the residents' skin to identify any change in condition. Any issues identified were addressed at that time. Any concerns identified were reported to the physician and the residents' plan of care was updated to reflect the residents' current status and conditions. 25. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. 26. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Daily Clinical Meeting, Admission/Readmission assessments/checklist, Change in Condition Policy related to notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services. 27. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager to the Admission/Readmission assessments, the admission/readmission checklist, the Change in Condition policy notifying a physician to obtain physician orders [REDACTED]. Newly hired licensed nurses will receive education to the Admission/Readmission assessments, the admission/readmission checklist, notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 28. Resident admission assessments, physician orders, and documentation will be reviewed to verify that residents are receiving the necessary care and services by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday, to identify changes in resident condition, and documentation to verify MD notification. Designated nurse management will review admissions, physician orders, and documentation on Saturdays and Sundays and then weekend admissions and documentation are completed including the baseline care plan to verify that residents are receiving necessary care and services. 29. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation, physician orders, and assessments to verify that physician notification is complete and that residents are receiving the necessary care and services. In addition, a licensed nurse will review residents with an Aspira drain to determine that physician orders [REDACTED]. Any issues identified will be addressed at that time. 30. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. A licensed nurse completed any missing assessments for current residents as of 10/04/19. 31. Licensed nurses completed an audit on 10/04/19 of current residents with pressure ulcers to assess the pressure ulcer, verify that physician orders [REDACTED]. 32. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Skin Care Guideline and obtaining orders to care for pressure ulcers. 33. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager regarding the Admission/Readmission assessments and checklist and the Skin Care Guideline including but not limited to: skin assessments and obtaining order to care for pressure ulcers. A posttest was completed to verify understanding. No nurse will work until successfully completing the posttest. Newly hired licensed nurses will receive education regarding Admission/Readmission assessments and checklist including but not limited to skin assessments, the Skin Care Guideline, and obtaining orders to care for pressure ulcers during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 34. Resident admission assessments, including skin assessments, and treatments will be reviewed to verify that skin assessments ar

Based on interview, record review, and facility policy review, it was determined the facility failed to provide pharmaceutical services, which included the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of two (2) of four (4) sampled residents (Residents #1 and #2). Review of a physician order [REDACTED].#1. On 09/13/19, Resident #1 was transferred to the hospital with excoriation on the abdomen, multiple ulcers to the groin area, severe denuded skin to the bilateral inner thighs, an unstageable pressure wound with eschar on the right lateral ankle, an unstageable pressure wound with eschar on the right lateral foot, a deep tissue injury on the left posterior calf, and scattered ulcerations to the right and left shins. Resident #1 was admitted to the Intensive Care Unit (ICU) [MEDICAL CONDITION] (a life-threatening complication of infection). The facility's failure to ensure pharmaceutical services were provided which included the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/30/19 and was determined to exist on 09/04/19 at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2). The facility was notified of the Immediate Jeopardy on 09/30/19. An acceptable Allegation of Compliance was received on 10/04/19, which alleged removal of the Immediate Jeopardy on 10/08/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 10/08/19, prior to exit on 10/09/19, which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2) while the facility monitors the effectiveness of systemic changes and quality assurance activities. In addition, the facility failed to ensure Resident #2's physician-ordered controlled pain medication was ordered from the pharmacy and administered to the resident timely. Resident #2's provider wrote an order on 09/08/19 to discontinue Resident #2's [MEDICATION NAME] 12 mcg patch and begin [MEDICATION NAME] 25 mcg [MEDICATION NAME] on 09/09/19. However, the facility failed to order Resident #2's [MEDICATION NAME] 25 mcg [MEDICATION NAME] from the pharmacy and the resident did not receive the [MEDICATION NAME] 25 mcg [MEDICATION NAME] until 09/13/19. The findings include: 1. Review of the facility's policy, Ordering and Receiving Non-Controlled Medications, dated September 2010, revealed medications and related products would be ordered and received from the provider pharmacy on a timely basis so medication administration was not delayed. In addition, the policy stated the facility would maintain accurate records of the medication orders. Review of Resident #1's closed medical record revealed the facility admitted the resident on 09/04/19 with [DIAGNOSES REDACTED]. Resident #1 had been discharged from the hospital on [DATE], with skin breakdown present. Due to the resident residing in the facility less than fourteen (14) days, the facility did not complete a Minimum Data Set (MDS) assessment for the resident. However, review of a Social Services note, dated 09/06/19, revealed the resident had no cognitive impairment. Review of Resident #1's Progress Notes revealed on 09/13/19, at 1:40 PM, the NP made a late entry into the progress note for encounter date 0[DATE], indicating she assessed the resident on 0[DATE], and documented Resident #1 had [MEDICAL CONDITION] noted on left inner shin and a pressure ulcer on right ankle. The NP documented under the Care Plan/Assessment portion of the progress note to apply border foam dressing to the right ankle. Continued review of Resident #1's Progress Notes revealed on 09/17/19, at 9:14 AM, the NP made a late entry into the progress note for encounter date of 09/12/19, indicating she assessed the resident on 09/12/19, because she was asked to see for [MEDICAL CONDITION]. Further review revealed the NP documented that Resident #1 had multiple excoriated [MEDICAL CONDITION] on his/her legs/buttocks and two (2) unstageable pressure ulcers on the right ankle and foot. Review of physician orders [REDACTED]. outer ankle/foot, and [MEDICATION NAME] Powder (topical antifungal agent) to be applied to the resident's groin area twice daily. However, review of Resident #1's medical record, including the Treatment Administration Record (TAR), from 09/09/19 through 09/13/19, revealed the resident did not receive the treatments as ordered. Review of the resident's TAR revealed Resident #1 received Santyl Ointment topically one (1) time on 09/12/19 and one (1) time on 09/13/19. However, review of the Shipping Manifests from the pharmacy utilized by the facility revealed the Santyl Ointment was never delivered to the facility. Furthermore, there was no documented evidence that Resident #1 ever received the Border Foam Dressing to the right ankle, or [MEDICATION NAME] Powder applied to the groin area. Interview with the Pharmacist on 09/27/19 at 12:40 PM revealed the facility ordered Santyl Ointment for Resident #1 on 09/12/19 but the medication was not delivered to the facility because of insurance issues. The Pharmacist stated he notified a nurse at the facility (name unknown), who stated she would call Resident #1's physician to see if an alternative medication could be ordered for the resident. However, the Pharmacist stated he did not hear back from the facility concerning the Santyl Ointment, and an order was never received from the facility for an alternate medication. Further interview with the Pharmacist revealed the pharmacy never received an order from the facility for [MEDICATION NAME] Powder or Border Foam Dressing for Resident #1. Review of Resident #1's medical record, including the 24-hour report, revealed no documentation that any staff documented an alternative medication needed to be obtained for Resident #1 to substitute for the Santyl Ointment. Interview with the Staff Development Coordinator (SDC) on 09/27/19 at 1:20 PM, revealed she was the nurse who documented on the TAR for 09/13/19, that Santyl Ointment was applied to Resident #1's wounds. However, the SDC stated that was an error, because she did not perform any treatment to Resident #1's wounds at any time. She stated she was unaware the resident had skin breakdown. Interview with Unit Manager (UM) #1 on 09/27/19 at 5:37 PM, revealed she was unaware why the Border Foam Dressing and [MEDICATION NAME] Powder was not ordered for Resident #1. The UM stated she was also unaware that the Santyl Ointment was never delivered to the facility and did not know which nurse the Pharmacist talked to about it. The UM stated she had not been aware that staff were signing the resident's TAR, indicating they had provided treatment to the resident when they had not. Interview with the Director of Nursing (DON) on 09/24/19 at 2:05 PM, revealed if Pharmacy notified a nurse that a medication was not available and would not be delivered, for whatever reason, the nurse should document it on the 24-Hour Shift Report. The DON stated the shift report was used to let the next shift staff know of any new orders or changes in a resident's care. The DON further stated staff should not be documenting on the TAR that they completed a treatment when they had not provided the treatment. The DON could not explain why Resident #1's [MEDICATION NAME] Ointment or Border Foam Dressing was not ordered from Pharmacy. Interview with the Administrator on 09/30/19 at 5:40 PM, revealed the DON and the UMs were responsible for monitoring the TARS and he assumed that was being done. He also stated when a staff member provided a treatment, he expected them to document it on the TAR and if for any reason the treatment was not provided, he expected the staff to document the reason why and to notify the resident's physician. The Administrator further revealed the DON was responsible to monitor the 24-Hour Shift Report and he thought she was doing that. Review of the hospital records dated 09/13/19 revealed Resident #1 was transferred to the hospital on [DATE], at 2:20 PM. The resident was assessed by hospital staff to have excoriation on the abdomen, multiple ulcers to the groin area, severe denuded skin to the bilateral inner thighs, an unstageable pressure wound with eschar on the right lateral ankle, an unstageable pressure wound with eschar on the right lateral foot, a deep tissue injury on the left posterior calf, and scattered ulcerations to the right and left shins. Resident #1 was admitted to the Intensive Care Unit (ICU) [MEDICAL CONDITION]. 2. Review of the facility's Medication Administration Controlled Substances policy, dated 2007, revealed controlled medications were subject to special handling, storage, disposal, and recordkeeping, in accordance with federal and state laws and regulations. The policy stated when a controlled medication was administered, the licensed nurse administering the medication was required to immediately enter the date, time, and amount administered along with the signature of the nurse. Continued review of the policy revealed after the controlled medication was administered it should be also be documented on the resident's MAR. Review of the facility's Medication Order and Receiving from Pharmacy Provider Ordering and Receiving Controlled Medications, dated May /2016, revealed the policy did not address obtaining a medication when the dosage was changed. Interview with the Chief Nursing Officer (CNO) on 09/24/19 at 3:15 PM revealed the facility did not have policies addressing pain management or performing pain assessments. Review of Resident #2's medical record revealed the facility admitted the resident on 09/05/19, with [DIAGNOSES REDACTED]. Observation of Resident #2 on 09/23/19 at 1:28 PM, revealed the resident was lying in bed, with visitors at the bedside. Review of Resident #2' physician's orders [REDACTED]. Review of Resident #2's Medication Administration Record [REDACTED]. However, further review revealed the MAR indicated [REDACTED]. Continued review of Resident #2's medical record revealed the resident was transferred to a hospital prior to midnight on 09/09/19 and returned to the facility on [DATE]. Review of Resident #2's Narcotic Sheet for the [MEDICATION NAME] 25 mcg patch revealed the facility did not administer the increased dosage of [MEDICATION NAME] on 09/09/19 as ordered. The resident did not receive the increased dose of [MEDICATION NAME] until 09/13/19 at 9:45 AM. Interview with Pharmacist #1 on 09/26/19 at 11:25 AM revealed the pharmaceutical company the facility utilized did not receive an order (initially wrote on 09/08/19) to discontinue Resident #2's [MEDICATION NAME] 12 mcg patch and start [MEDICATION NAME] 25 mcg patch until 09/13/19, five (5) days after the order was initially received from Advanced Practice Registered Nurse (APRN) #1. Interview with Unit Manager (UM) #2 on 09/26/19 at 6:04 PM revealed she was responsible for Resident #2's care on 09/08/19 when APRN #1 changed Resident #2's [MEDICATION NAME] order from 12 mcg to 25 mcg. She stated she entered the new order into the facility's computer system and stated it should automatically transmit to the pharmacy in order to receive the new dosage. UM #2 stated she was not aware that the dosage change was not completed until 09/13/19. Continued interview with UM #2 revealed that physician orders [REDACTED]. Interview with UM #1 on 09/27/19 at 5:37 PM revealed she was responsible for overseeing staff on the unit where Resident #2 resided. She stated she assisted the DON with reviewing MARs and nursing notes, as well as physician orders. UM #1 stated that she worked as the floor nurse on 09/09/19 on the unit and should have identified that Resident #2's [MEDICATION NAME] order had been changed and that the new medication had not been received from Pharmacy. UM #1 stated if Resident #2's [MEDICATION NAME] dosage was changed by APRN #1 on 09/08/19, she expected the order to be transmitted to Pharmacy the same day. Interview with the Director of Nursing (DON) on 09/27/19 at 7:37 PM revealed all physician orders [REDACTED]. However, the DON stated she was not working from 09/08/19 through 09/13/19. Further interview with the DON revealed that UM #1 was in the facility during her absence and she should have followed up to ensure Resident #2's 25 mcg [MEDICATION NAME] was ordered and received on 09/08/19. Interview with APRN #1 on 09/24/19 at 5:16 PM and 09/30/19 at 3:45 PM revealed that she wrote an order on 09/08/19 to discontinue Resident #2's 12 mcg [MEDICATION NAME] and begin [MEDICATION NAME] 25 mcg patch. She stated she expected all of her orders to be completed timely and she was not aware that the facility did not complete the order until 09/13/19. **The facility alleged the following was implemented to remove Immediate Jeopardy effective 10/08/19: Resident #1 was discharged from the facility on 09/13/19 and Resident #2 was discharged from the facility on 09/23/19. 1. Beginning on 09/24/19 with completion on 10/07/19, licensed nurses completed and documented a resident assessment utilizing an assessment tool which included vital signs, neurological, cognitive, respiratory, gastrointestinal, vision, pain, hearing, oral, and skin to identify any changes in condition. Any issues that were identified were addressed with the resident's treating physician. 2. On 09/24/19, the physician was notified by a licensed nurse related to current residents with an Aspira Drain to verify physician orders [REDACTED]. 3. As of 10/07/19, all licensed nurses were interviewed by the Chief Nursing Officer (CNO) and the Human Resources Manager to identify any occurrence of a nurse writing physician orders [REDACTED]. 4. The Director of Nursing (DON) was terminated by the facility on 09/23/19 and an Interim DON was employed on 09/30/19. 5. Unit Manager #1 was terminated by the facility on 09/29/19. 6. On 10/03/19 the Regional Quality Manager re-educated the Interim Director of Nursing, Education and Training Director, and Unit Manager to the Daily Clinical Meeting; the Change in Condition policy which included the care for drains, pressure ulcers, and notifying the physician to obtain physician orders. 7. The Interim DON, Education and Training Director, and/or Unit Manager re-educated all licensed nurses by 10/07/19 regarding the Change in Condition policy, the care of Aspira Drains, and notifying the physician to obtain physician orders. A posttest was completed to verify understanding of the education received. No nurse will work until successfully completing the posttest. 8. All newly hired licensed nurses will receive education regarding the Change in Condition policy and requirement of notifying a physician to obtain physician orders [REDACTED]. 9. Licensed nursing staff not educated as of 10/07/19 will receive the education and successfully complete a posttest prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. No agency staff is utilized by the facility. 10. Resident admission assessments, documentation, and physician orders [REDACTED]. Designated nurse management will review admission assessments, physician orders, and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 11. Beginning on 0[DATE] the Regional Quality Manager began audits of resident admissions for the last 30 days and completed the audit on 09/23/19. 12. On 0[DATE] the Administrator, Interim DON, and Unit Managers held an internal Quality Assurance (QA) meeting to review initial findings of the audit of admission documentation for admissions over the last 30 days and plan for correction. 13. On 0[DATE] the Administrator notified the Medical Director of the initial admission audit findings and plan for correction. 14. The Regional Quality Manager and the Chief Nursing Officer were onsite at the facility on 09/23/19 and initiated a plan to correct concerns identified in the admission audit. 15. On 10/03/19 the Administrator, Interim DON, Regional Quality Manager, Chief Nursing Officer, Regional Director of Operations, Unit Manager, Education and Training Director, and Medical Director held a QA meeting to review the plan for further review and recommendation. 16. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that physician notification is complete with changes in condition. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 17. A QA meeting was held on 10/07/19 to review audit results by the DON and Unit Manager, no concerns were identified related to the audit findings. 18. QA meetings will continue weekly until the facility obtains substantial compliance and then will occur monthly for three months and then quarterly thereafter. 19. On [DATE] the Regional Quality Manager and Interim DON completed an audit of the Baseline Care Plan of admissions/readmissions for the past 20 days to verify that the base line care plan was complete and reflected the resident's current status including the treatment and care of pressure ulcers and/or drains. Any concerns identified have been addressed and the baseline care plan updated. 20. On 10/03/19 the Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager regarding resident care plans reflecting the residents' current status which included treatment and care of pressure ulcers and/or drains. 21. The Interim DON, Education and Training Director, and Unit Manager re-educated all licensed nurses on 10/07/19 regarding the Baseline Care Plan reflecting on care of pressure ulcers and/or drains. Nursing staff were administered a posttest verifying understanding. Any nurse that has not successfully completed the posttest will not work until completed prior to the beginning of their next scheduled shift. Signs have been posted by the time clock to communicate this requirement to oncoming staff. Newly hired nurses will receive education related to Baseline Care Plans during orientation by the DON and/or Education and Training Director. 22. Baseline Care Plans for residents who are admitted or readmitted will be reviewed by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday to verify that the Baseline Care Plan reflects the resident's status and condition. Designated nurse management will review admissions and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 23. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that the Baseline Care Plan reflects the residents' status and condition to include but not be limited to the care of pressure ulcers and or drains. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 24. Licensed nurses completed an assessment on 09/24/19 of current residents utilizing an assessment tool that included but was not limited to vital signs and a head-to-toe assessment of the residents' skin to identify any change in condition. Any issues identified were addressed at that time. Any concerns identified were reported to the physician and the residents' plan of care was updated to reflect the residents' current status and conditions. 25. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. 26. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Daily Clinical Meeting, Admission/Readmission assessments/checklist, Change in Condition Policy related to notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services. 27. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager to the Admission/Readmission assessments, the admission/readmission checklist, the Change in Condition policy notifying a physician to obtain physician orders [REDACTED]. Newly hired licensed nurses will receive education to the Admission/Readmission assessments, the admission/readmission checklist, notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 28. Resident admission assessments, physician orders, and documentation will be reviewed to verify that residents are receiving the necessary care and services by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday, to identify changes in resident condition, and documentation to verify MD notification. Designated nurse management will review admissions, physician orders, and documentation on Saturdays and Sundays and then weekend admissions and documentation are completed including the baseline care plan to verify that residents are receiving necessary care and services. 29. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation, physician orders, and assessments to verify that physician notification is complete and that residents are receiving the necessary care and services. In addition, a licensed nurse will review residents with an Aspira drain to determine that physician orders [REDACTED]. Any issues identified will be addressed at that time. 30. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. A licensed nurse completed any missing assessments for current residents as of 10/04/19. 31. Licensed nurses completed an audit on 10/04/19 of current residents with pressure ulcers to assess the pressure ulcer, verify that physician orders [REDACTED]. 32. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Skin Care Guideline and obtaining orders to care for pressure ulcers. 33. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager regarding the Admission/Readmission assessments and checklist and the Skin Care Guideline including but not limited to: skin assessments and obtaining order to care for pressure ulcers. A posttest was completed to verify understanding. No nurse will work until successfully completing the posttest. Newly hired licensed nurses will receive education regarding Admission/Readmission assessments and checklist including but not limited to skin assessments, the Skin Care Guideline, and obtaining orders to care for pressure ulcers during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 34. Resident admission assessments, including skin assessments, and treatments will be reviewed to verify that skin assessments are completed and that orders are obtained to care for pressure ulcers by the Interim DON and Unit Managers during the Daily Clinical Meeting, Monday through Friday. Designated nurse management will review admissions, physician orders, and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are complete and orders obtained to care for pressure ulcers identified. 35. The Director of Nursing, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments, including skin assessments, to verify that the assessments are complete and that orders are obtained for the treatment of [REDACTED]. Any issues identified will be addressed at that time. 36. Licensed nurses completed a MAR/TAR to cart audit on 10/07/19 to verify that all medications and treatments for current residents are available and in the facility as ordered. Any concerns identified were resolved at that time. 37. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding ordering and receiving of controlled and non-controlled medication policy and order entry into the electronic health record. 38. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager regarding ordering and receiving controlled and non-controlled medication policy. A posttest was completed by all licensed nurses to verify understanding. No nurse will work until successfully completing the posttest. Newly hired licensed nurses will receive education regarding Ordering and Receiving of Controlled and Non-controlled medication policy during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 39. The Interim DON and Unit Managers will review Physician order [REDACTED]. Designated nurse management will review physician orders [REDACTED]. 40. The Director of Nursing, Education and Training Director, and/or Unit Manager will complete an audit of new orders to verify that medication and treatments are received from the pharmacy and are available for administration as ordered. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 2 months. Any issues identified will be addressed at that time. 41. Licensed nurses and medication technicians were interviewed by the Regional Director of Operations and Administrator to verify that any resident medication and treatment orders signed as administered were administered as documented on 10/03/19. 42. Licensed nurses completed a MAR/TAR to cart audit to determine that medications and treatments had been ordered and were available from the pharmacy on 10/04/19. Any issues identified have been addressed. 43. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Daily Clinical Meeting, the Admission/Readmission assessments, obtaining and implementing physician orders, as well as verifying medications were received from the pharmacy. 44. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager regarding Admission/Readmission assessments including but not limited to skin assessments, obtaining and implementing physician orders, and verifying medications were available from the pharmacy. A posttest was completed by licensed nurses to verify understanding. No nurse will work until successfully completing the posttest. Newly hired licensed nurses will receive education regarding Admission/Readmission assessments including, but not limited to, skin assessments, obtaining and implementing physician orders, and verifying that medications were received from the pharmacy in new employee orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director,

Based on interview, record review, and review of the facility's policy it was determined the facility failed to maintain complete and accurate medical records for one (1) of four (4) sampled residents (Resident #1). Review of Resident #1's Treatment Administration Records (TARs) revealed staff documented on 09/12/19 and 09/13/19 that physician-ordered Santyl Ointment (ointment used to help heal skin ulcers/wounds) was applied to Resident #1's wounds. However, review of the Pharmaceutical Shipping Manifest and interview with the pharmacist on 09/26/19 at 11:30 AM, revealed the Santyl Ointment was never delivered to the facility or applied to Resident #1. On 09/13/19, the facility transferred Resident #1 to the hospital with multiple areas of skin breakdown and the resident was admitted to the Intensive Care Unit (ICU) [MEDICAL CONDITION] (a life-threatening complication of infection). The facility's failure to complete and ensure accurate medical records were maintained has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/30/19 and was determined to exist on 09/04/19 at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2). The facility was notified of the Immediate Jeopardy on 09/30/19. An acceptable Allegation of Compliance was received on 10/04/19, which alleged removal of the Immediate Jeopardy on 10/08/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 10/08/19, prior to exit on 10/09/19, which lowered the scope and severity to D level at 42 CFR 4[AGE].10 Resident Rights (F5[AGE]), 42 CFR 4[AGE].21 Comprehensive Person-Centered Care Plans (F655), 42 CFR 4[AGE].25 Quality of Care (F6[AGE] and 6[AGE]), 42 CFR 4[AGE].45 Pharmacy Services (F[AGE]5), and 42 CFR 4[AGE].70 Administration (F[AGE]2) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Charting and Documentation, revised April 2008, revealed all services provided to a resident, or any changes in a resident's medical or mental condition, shall be documented in the resident's medical record. Further review of the policy revealed all medications must be documented in the resident's clinical record. Review of Resident #1's closed medical record revealed the facility admitted the resident on 09/04/19, with [DIAGNOSES REDACTED]. Record review revealed because Resident #1 did not reside in the facility fourteen (14) days, a Minimum Data Set (MDS) assessment was not completed. However, review of a Social Services note dated 09/06/19 revealed Resident #1 had no cognitive impairment. Review of the physician's orders [REDACTED]. outer ankle. Further review of physician's orders [REDACTED].#1's Physician ordered the resident to receive [MEDICATION NAME] Insulin 30 units daily. Review of Resident #1's Treatment Administration Record (TAR) revealed Licensed Practical Nurse (LPN) #4 documented she applied Santyl Ointment to Resident #1 (location not specified) on 09/12/19. Further review of Resident #1's TAR revealed the Staff Development Coordinator (SDC) documented she applied Santyl Ointment to Resident #1 on 09/13/19 (location not specified). Review of a Shipping Manifest Pharmaceutical Form dated 09/04/19, and interview with the Pharmacist on 09/26/19 at 11:30 AM, revealed Santyl Ointment was never delivered to the facility for Resident #1. Interview with Registered Nurse (RN) #4 on 09/30/19 at 6:13 PM, revealed she could not remember applying Santyl Ointment to a PU on Resident #1's right ankle/foot on 09/12/19, even though she had documented she had applied it on the resident's TAR. Interview with the SDC on 09/27/19, at 1:20 PM revealed she had documented on the TAR for 09/13/19, that she applied Santyl Ointment to Resident #1. However, the SDC stated that was an error, because she had never performed wound care for Resident #1, because she was not aware the resident had wounds. Interview with Unit Manager (UM) #1 on 09/27/19 at 5:37 PM, revealed she was responsible to monitor the TARs and ensure the treatments were being provided as ordered. However, the UM stated she had not reviewed the Nurse's Notes for Resident #1. She stated the nurses have been trained not to document on the MAR (Medication Administration Record)/TAR until after they administered the medication or provided the treatment as ordered by the physician. UM #1 verbalized that the nurses were responsible for notifying the physician when a medication order was unable to be filled by the pharmacy, and when a medication was not given or refused by a resident. Interview with the Director of Nursing (DON) on 09/27/19 at 7:30 PM revealed the UM was responsible to monitor the TARs to ensure treatments were being provided as ordered. She stated when staff did not administer a medication/treatment, the staff should document why the medication/treatment was not administered and notify the physician. Interview with the Administrator on 09/30/19 at 5:40 PM revealed the DON and the UMs were responsible for monitoring the TARS and Nurse's Notes. The Administrator stated he had assumed the TARS were being monitored. He stated when a staff member failed to provide a treatment, for any reason, staff were expected to document the reason. Review of the hospital records dated 09/13/19, revealed Resident #1 was admitted to the Intensive Care Unit (ICU) [MEDICAL CONDITION], after presenting to the facility with multiple areas of skin breakdown and pressure areas. **The facility alleged the following was implemented to remove Immediate Jeopardy effective 10/08/19: Resident #1 was discharged from the facility on 09/13/19 and Resident #2 was discharged from the facility on 09/23/19. 1. Beginning on 09/24/19 with completion on 10/07/19, licensed nurses completed and documented a resident assessment utilizing an assessment tool which included vital signs, neurological, cognitive, respiratory, gastrointestinal, vision, pain, hearing, oral, and skin to identify any changes in condition. Any issues that were identified were addressed with the resident's treating physician. 2. On 09/24/19, the physician was notified by a licensed nurse related to current residents with an Aspira Drain to verify physician orders [REDACTED]. 3. As of 10/07/19, all licensed nurses were interviewed by the Chief Nursing Officer (CNO) and the Human Resources Manager to identify any occurrence of a nurse writing physician orders [REDACTED]. 4. The Director of Nursing (DON) was terminated by the facility on 09/23/19 and an Interim DON was employed on 09/30/19. 5. Unit Manager #1 was terminated by the facility on 09/29/19. 6. On 10/03/19 the Regional Quality Manager re-educated the Interim Director of Nursing, Education and Training Director, and Unit Manager to the Daily Clinical Meeting; the Change in Condition policy which included the care for drains, pressure ulcers, and notifying the physician to obtain physician orders. 7. The Interim DON, Education and Training Director, and/or Unit Manager re-educated all licensed nurses by 10/07/19 regarding the Change in Condition policy, the care of Aspira Drains, and notifying the physician to obtain physician orders. A posttest was completed to verify understanding of the education received. No nurse will work until successfully completing the posttest. 8. All newly hired licensed nurses will receive education regarding the Change in Condition policy and requirement of notifying a physician to obtain physician orders [REDACTED]. 9. Licensed nursing staff not educated as of 10/07/19 will receive the education and successfully complete a posttest prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. No agency staff is utilized by the facility. 10. Resident admission assessments, documentation, and physician orders [REDACTED]. Designated nurse management will review admission assessments, physician orders, and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 11. Beginning on 0[DATE] the Regional Quality Manager began audits of resident admissions for the last 30 days and completed the audit on 09/23/19. 12. On 0[DATE] the Administrator, Interim DON, and Unit Managers held an internal Quality Assurance (QA) meeting to review initial findings of the audit of admission documentation for admissions over the last 30 days and plan for correction. 13. On 0[DATE] the Administrator notified the Medical Director of the initial admission audit findings and plan for correction. 14. The Regional Quality Manager and the Chief Nursing Officer were onsite at the facility on 09/23/19 and initiated a plan to correct concerns identified in the admission audit. 15. On 10/03/19 the Administrator, Interim DON, Regional Quality Manager, Chief Nursing Officer, Regional Director of Operations, Unit Manager, Education and Training Director, and Medical Director held a QA meeting to review the plan for further review and recommendation. 16. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that physician notification is complete with changes in condition. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 17. A QA meeting was held on 10/07/19 to review audit results by the DON and Unit Manager, no concerns were identified related to the audit findings. 18. QA meetings will continue weekly until the facility obtains substantial compliance and then will occur monthly for three months and then quarterly thereafter. 19. On [DATE] the Regional Quality Manager and Interim DON completed an audit of the Baseline Care Plan of admissions/readmissions for the past 20 days to verify that the base line care plan was complete and reflected the resident's current status including the treatment and care of pressure ulcers and/or drains. Any concerns identified have been addressed and the baseline care plan updated. 20. On 10/03/19 the Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager regarding resident care plans reflecting the residents' current status which included treatment and care of pressure ulcers and/or drains. 21. The Interim DON, Education and Training Director, and Unit Manager re-educated all licensed nurses on 10/07/19 regarding the Baseline Care Plan reflecting on care of pressure ulcers and/or drains. Nursing staff were administered a posttest verifying understanding. Any nurse that has not successfully completed the posttest will not work until completed prior to the beginning of their next scheduled shift. Signs have been posted by the time clock to communicate this requirement to oncoming staff. Newly hired nurses will receive education related to Baseline Care Plans during orientation by the DON and/or Education and Training Director. 22. Baseline Care Plans for residents who are admitted or readmitted will be reviewed by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday to verify that the Baseline Care Plan reflects the resident's status and condition. Designated nurse management will review admissions and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are completed including the baseline care plan. 23. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments to verify that the Baseline Care Plan reflects the residents' status and condition to include but not be limited to the care of pressure ulcers and or drains. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 24. Licensed nurses completed an assessment on 09/24/19 of current residents utilizing an assessment tool that included but was not limited to vital signs and a head-to-toe assessment of the residents' skin to identify any change in condition. Any issues identified were addressed at that time. Any concerns identified were reported to the physician and the residents' plan of care was updated to reflect the residents' current status and conditions. 25. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. 26. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Daily Clinical Meeting, Admission/Readmission assessments/checklist, Change in Condition Policy related to notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services. 27. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager to the Admission/Readmission assessments, the admission/readmission checklist, the Change in Condition policy notifying a physician to obtain physician orders [REDACTED]. Newly hired licensed nurses will receive education to the Admission/Readmission assessments, the admission/readmission checklist, notifying a physician to obtain physician orders, implementing physician orders, and the requirement that residents receive the necessary care and services during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 28. Resident admission assessments, physician orders, and documentation will be reviewed to verify that residents are receiving the necessary care and services by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday, to identify changes in resident condition, and documentation to verify MD notification. Designated nurse management will review admissions, physician orders, and documentation on Saturdays and Sundays and then weekend admissions and documentation are completed including the baseline care plan to verify that residents are receiving necessary care and services. 29. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation, physician orders, and assessments to verify that physician notification is complete and that residents are receiving the necessary care and services. In addition, a licensed nurse will review residents with an Aspira drain to determine that physician orders [REDACTED]. Any issues identified will be addressed at that time. 30. The Regional Quality Manager completed an audit of admissions and readmissions for the past 30 days on 09/23/19 to verify that residents were assessed upon admission. A licensed nurse completed any missing assessments for current residents as of 10/04/19. 31. Licensed nurses completed an audit on 10/04/19 of current residents with pressure ulcers to assess the pressure ulcer, verify that physician orders [REDACTED]. 32. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Skin Care Guideline and obtaining orders to care for pressure ulcers. 33. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager regarding the Admission/Readmission assessments and checklist and the Skin Care Guideline including but not limited to: skin assessments and obtaining order to care for pressure ulcers. A posttest was completed to verify understanding. No nurse will work until successfully completing the posttest. Newly hired licensed nurses will receive education regarding Admission/Readmission assessments and checklist including but not limited to skin assessments, the Skin Care Guideline, and obtaining orders to care for pressure ulcers during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 34. Resident admission assessments, including skin assessments, and treatments will be reviewed to verify that skin assessments are completed and that orders are obtained to care for pressure ulcers by the Interim DON and Unit Managers during the Daily Clinical Meeting, Monday through Friday. Designated nurse management will review admissions, physician orders, and documentation on Saturdays and Sundays to verify that weekend admissions and documentation are complete and orders obtained to care for pressure ulcers identified. 35. The Director of Nursing, Education and Training Director, and/or Unit Manager will complete an audit of residents' admission/readmission documentation and assessments, including skin assessments, to verify that the assessments are complete and that orders are obtained for the treatment of [REDACTED]. Any issues identified will be addressed at that time. 36. Licensed nurses completed a MAR/TAR to cart audit on 10/07/19 to verify that all medications and treatments for current residents are available and in the facility as ordered. Any concerns identified were resolved at that time. 37. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding ordering and receiving of controlled and non-controlled medication policy and order entry into the electronic health record. 38. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager regarding ordering and receiving controlled and non-controlled medication policy. A posttest was completed by all licensed nurses to verify understanding. No nurse will work until successfully completing the posttest. Newly hired licensed nurses will receive education regarding Ordering and Receiving of Controlled and Non-controlled medication policy during orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 39. The Interim DON and Unit Managers will review Physician order [REDACTED]. Designated nurse management will review physician orders [REDACTED]. 40. The Director of Nursing, Education and Training Director, and/or Unit Manager will complete an audit of new orders to verify that medication and treatments are received from the pharmacy and are available for administration as ordered. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 2 months. Any issues identified will be addressed at that time. 41. Licensed nurses and medication technicians were interviewed by the Regional Director of Operations and Administrator to verify that any resident medication and treatment orders signed as administered were administered as documented on 10/03/19. 42. Licensed nurses completed a MAR/TAR to cart audit to determine that medications and treatments had been ordered and were available from the pharmacy on 10/04/19. Any issues identified have been addressed. 43. The Regional Quality Manager re-educated the Interim DON, Education and Training Director, and Unit Manager on 10/03/19 regarding the Daily Clinical Meeting, the Admission/Readmission assessments, obtaining and implementing physician orders, as well as verifying medications were received from the pharmacy. 44. Licensed nurses were re-educated as of 10/07/19 by the Interim DON, Education Director, and/or Unit Manager regarding Admission/Readmission assessments including but not limited to skin assessments, obtaining and implementing physician orders, and verifying medications were available from the pharmacy. A posttest was completed by licensed nurses to verify understanding. No nurse will work until successfully completing the posttest. Newly hired licensed nurses will receive education regarding Admission/Readmission assessments including, but not limited to, skin assessments, obtaining and implementing physician orders, and verifying that medications were received from the pharmacy in new employee orientation by the Interim DON and/or Education and Training Director. Any licensed nursing staff member not educated as of 10/07/19 will receive the education prior to beginning work on their next scheduled shift by the Interim DON, Education and Training Director, or Unit Manager. Signs have been posted at the time clock to communicate this requirement to oncoming staff. The scheduler and Administrator are tracking this to verify that licensed nurses do not work until the education is complete. 45. MAR and TAR documentation will be reviewed to verify completion by the Interim DON and Unit Managers during the Daily Clinical Meeting Monday through Friday. Designated nurse management will review MAR/TAR documentation to verify completion on Saturdays and Sundays. 46. The Interim DON, Education and Training Director, and/or Unit Manager will complete an audit of resident MARs and TARs to verify that medication and treatment administration are documented. They will further interview three licensed nurses to determine if all medications and treatments were administered and signed as documented. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 2 months. Any issues identified will be addressed at that time. ***The State Survey Agency verified that the facility implemented the following action and that Immediate Jeopardy was removed effective 10/08/19 as alleged by the facility: 1. Review of the assessment tools revealed all residents were assessed utilizing the facility's assessment tool to include vital signs, neurological, cognitive, respiratory, gastrointestinal, vision, pain, hearing, oral, and skin to identify any changes in condition. Interview with the Education and Training Director on 10/09/19 at 6:00 PM and the Interim DON on 10/09/19 at 6:30 PM revealed they performed assessments of all residents utilizing the facility's assessment tool. 2. Interview with the Interim DON on 10/09/19 at 6:30 PM revealed she notified Physician #1 about orders for current residents with Aspira Drains. 3. Review of facility documentation and interviews with Licensed Practical Nurse (LPN) #5, LPN #6, and Registered Nurse (RN) #9 on 10/09/19 at 4:00 PM revealed they were interviewed about writing physician orders [REDACTED]. Interviews on 10/09/19 with the CNO at 1:55 PM and the Human Resources Officer at 2:15 PM revealed they completed interviews with all licensed nurses regarding any occurrence of nurses writing physician orders [REDACTED]. 4. Interview with the CNO on 10/09/19 at 1:55 PM revealed the DON was terminated on 09/23/19. The CNO stated that an Interim DON was employed by the facility on 09/30/19. 5. Interview with the CNO on 10/09/19 at 1:55 PM revealed Unit Manager #1 was terminated on 09/23/19. 6. Review of education and interview with the Regional Quality Manager on 10/09/19 at 6:00 PM revealed she performed education with the Interim DON, Education Training Director, and Unit Manager on 10/03/19 regarding the Daily Clinical Meeting, Change in Condition policy, which included the care of drains, pressure ulcers, and physician notification for obtaining physician orders. Interviews with the Interim DON, Education and Training Director, and Unit Manager on 10/09/19 at 5:30 PM revealed they received training from the Regional Quality Manager on 10/03/19 related to the Daily Clinical Meeting, Change in Condition policy that included caring for drains, pressure ulcers, and notifying the physician to obtain physician orders. 7. Review of education and posttest along with an interview with the Education and Training Director on 10/09/19 at 6:15 PM revealed she trained licensed nurses from 10/03/19 through 10/07/19 regarding the Change in Condition policy, the care of Aspira Drains, and notifying the physician to obtain physician orders. She stated a posttest was completed by all licensed nurses to verify understanding of the education received. Interviews with LPN #5, LPN #6, and RN #9 on 10/09/19 at 4:00 PM revealed they received education and completed a posttest regarding Change in Condition policy, the care of Aspira Drains, and notifying the physician to obtain physician orders [REDACTED]. 8. Interview with the Education and Training Director on 10/09/19 at 6:15 PM revealed she would provide education to all newly hired licensed nurses regarding the Change in Condition policy and requirement of notifying a physician to obtain physician orders [REDACTED]. 9. Signage was observed on 10/09/19 at 2:30 PM posted at the time clock for all nursing staff to complete education regarding the Change in Condition policy and requirement of notifying a physician to obtain physician orders. Interview with the Administrator on 10/09/19 at 7:00 PM revealed he monitoring daily to ensure all licensed nurses received the training prior to working their next scheduled shift. 10. Interview with the Interim DON on 10/09/19 at 6:30 PM revealed she was reviewing all resident admission assessments, physician orders, and documentation daily to ensure any change in condition was documented along with evidence of physician notification. Review of audits regarding resident admission assessments revealed they had been completed during the Daily Clinical Meetings and on weekends by the Interim DON. 11. Review of admission audits and interview with the Regional Quality Manager on 10/09/19 at 6:00 PM revealed she had completed audits on 09/23/19 for all admissions for the last 30 days. 12. Review of QA meeting minutes and interviews with the Administrator on 10/09/19 at 7:00 PM, the Education and Training Director on 10/09/19 at 6:15 PM, and the Regional Quality Manager on 10/09/19 at 6:00 PM revealed they attended a QA meeting on 0[DATE] where they reviewed initial findings of an admission documentation audit and discussed plans of correction. 13. Interview with the Administrator on 10/09/19 at 7:00 PM revealed he notified the Medical Director on 0[DATE] regarding the initial findings of the admission audits and plan to correct. 14. Review of the admission audit and interviews with the CNO on 10/09/19 at 1:55 PM and the Regional Quality Manager on 10/09/19 at 6:00 PM revealed they were onsite at the facility on 09/23/19 and initiated a plan to correct concerns identified in the admission audit. 15. Review of QA meeting minutes for 10/03/19 and interviews on 10/09/19 with the Administrator at 7:00 PM, the Interim DON at 6:30 PM, the Regional Quality Manager at 6:00 PM, the CNO at 1:55 PM, the Regional Director of Operations at 5:30 PM, and the Education and Training Director at 6:15 PM revealed they attended a QA meeting on 10/03/19 to review the plan of correction for further review and recommendations. 16. Interviews on 10/09/19 with the Education and Training Director at 6:15 PM and the Interim DON at 6:30 PM revealed they would complete an audit of resident admission/readmission documentation and assessments to verify that physician notification is complete with changes in condition. This audit will be completed daily for 14 days, weekly for 2 weeks, and then monthly for 1 month. Any issues identified will be addressed at that time. 17. Review of the 10/07/19 QA meeting minutes and interviews on 10/09/19 with the Education and Training Director at 6:15 PM, the Interim DON at 6:30 PM, the Regional Quality Manager at 6:00 PM, and the Regional Director of Operations at 5:30 PM revealed they held a QA meeting on 10/07/19 and all audit results were presented and discussed. 18. Interview with the Administrator on 10/09/19 at 7:00 PM revealed QA meetings would continue weekly until the facility obtained substantial compliance and then would occur monthly for three months and quarterly thereafter. 19. Review of the audit of Baseline Care Plans related to admissions/readmissions for the past 20 days and an interview with the Regional Quality Manager on 10/09/19 at 6:00 PM revealed she completed audits on [DATE] of baseline care plans to verify that the baseline care plan was complete and reflected the resident's current status. 20. Review of education and interviews on 10/09/19 with the Interim DON at 6:30 PM and the Education and Training Director at 6:15 PM revealed they received education from the Regional Quality Manager on 10/03/19 regarding resident care plans reflecting the residents' current status, which may include treatment and care of pressure ulcers and/or drains. Interview with the Regional Quality Manager on 10/09/19 at 6:00 PM revealed she educated the Interim DON and the Education and Training Director on 10/03/19 regarding resident care plans reflecting the residents' current status, which included treatment and care of pressure ulcers and/or drains. 21. Review of education an

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an environment free of hazards to prevent accidents for one hundred eighteen (118) residents who resided at the facility during an evacuation of the facility on 02/24/19. Interviews with staff revealed on 02/23/19, floodwater began entering the facility. When staff recognized that electrical cords for portable oxygen machines were in the water, staff began utilizing portable liquid oxygen tanks. Further interviews revealed staff placed the portable liquid oxygen tank on its side in the beds with residents to keep the tank out of the water. The facility failed to store the tank in an upright position, as required by facility policy (Liquid oxygen is stored at negative 300 degrees Fahrenheit. Skin exposed to liquid oxygen will suffer a frostbite thermal injury that is almost identical to a burn). Interview revealed Resident #87 was one of the residents who utilized a portable oxygen tank and was moved to the hallway of the facility for approximately four (4) hours before being transferred to an evacuation site on 02/24/19 at approximately 5:30 AM. After being evacuated, Resident #87's oxygen saturation dropped and he/she was transferred to the Emergency Department (ED) where ED staff discovered the resident had red/blistered linear areas to the inner and back of both legs. The resident was admitted to the hospital with [REDACTED]. In addition, on 02/24/19 at approximately 1:41 AM, an evacuation of the facility was initiated. Interviews with staff revealed the facility failed to ensure oxygen was transported to and utilized at the evacuation site safely. Interviews with staff revealed they transported tanks that contained liquid oxygen to the evacuation site and stored a liquid oxygen supply tank, utilized to refill smaller portable tanks, in the gymnasium with residents. Interviews with the facility's oxygen vendor revealed liquid oxygen could not be transported by the facility safely or stored in an open area in that manner. According to a Transportation Regulatory Specialist with the Federal Motor Safety Administration Hazardous Material Information Center, the facility could not transport liquid oxygen unless a waiver and a local or state escort was obtained. The facility's failure to ensure the environment was free of accident hazards has caused or is likely to cause injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/21/19, and determined to exist on 02/24/19 at 42 CFR 483.25 Quality of Care (F689), 42 CFR 483.70 Administration (F835), and 42 CFR 483.80 Infection Control (F880). The facility was notified of the Immediate Jeopardy on 03/21/19. An acceptable Allegation of Compliance was received on 03/26/19, which alleged removal of the Immediate Jeopardy on 03/30/19. The State Survey Agency determined the Immediate Jeopardy was removed on 03/30/19, prior to exit on 04/03/19, which lowered the scope and severity to F level at 42 CFR 483.25 Quality of Care (F689) and 42 CFR 483.70 Administration (F835), and to [NAME] level at 42 CFR 483.80 Infection Control (F880), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Incident and Accident Process not dated, revealed the facility's environment would be as free from accident hazards over which the facility had control. Review of the facility's policy titled Oxygen Therapy and Devices not dated, revealed liquid portable oxygen tanks should be kept upright at all times to prevent leakage of the liquid oxygen, which could [MEDICAL CONDITION] in contact with the skin. Further review of the policy revealed staff should secure oxygen cylinders tanks so that they remained upright and should never place a liquid portable unit on its side on a person's lap. Review of Resident #87's medical record revealed the facility admitted the resident on 07/01/12, with [DIAGNOSES REDACTED]. Review of Resident #87's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) test could not be conducted on the resident because the resident was severely cognitively impaired. Continued review of Resident #87's MDS revealed the facility assessed the resident to require total assistance of two (2) staff for Activities of Daily Living (ADLs). The MDS also revealed Resident #87 required oxygen therapy. A review of Resident #87's care plan initiated on 12/06/18, revealed the facility identified the resident was bedbound and required total assistance of two (2) staff and a mechanical device for transfers. Review of Resident #87's Skin Assessments for (MONTH) 2019 revealed on 02/04/19, the facility identified a Stage 2 Pressure Ulcer to Resident #87's coccyx area. Review of a skin assessment completed on 02/18/19, prior to an evacuation of the facility on 02/24/19, revealed the resident had no redness or open areas on the resident's legs. Review of the Bath Daily Roster sheet, on 02/23/19, approximately fifteen (15) hours before the facility's evacuation was initiated, revealed Resident #87 received a sponge bath at 9:48 AM and there was no documentation that the resident had any skin concerns, redness, or blistered areas identified to the legs. Interview with the area Emergency Management Director on 03/17/19 at 3:50 PM revealed a city councilman notified him during the early morning of 02/24/19 that water was rising around the facility (unable to recall the time he was notified). The Emergency Management Director stated when he arrived at the facility, sometime after midnight, water had already entered the facility and he instructed the facility to evacuate the residents at 1:41 AM on 02/24/19. Interview with Registered Nurse (RN) #9 on 03/14/19 at 7:00 PM revealed Resident #87 was one of the last residents evacuated and the last resident was evacuated at approximately 5:30 AM on 02/24/19. Review of an audio recording and review of an Incident Form from Emergency Medical Services (EMS) revealed on 02/24/19 at 7:43 AM Dispatch was called to transfer a resident from the evacuation site to the hospital, because the resident's oxygen (O2) saturation was below sixty (normal is 95-100). Further review revealed EMS arrived at the evacuation site at 7:56 AM and Resident #87 was transported to the hospital. Review of Resident #87's Emergency Department (ED) Notes dated 02/24/19 at 11:01 AM, revealed the resident had redness and blisters to the inner and backs of both legs. Further review revealed the ED staff documented, Spoke with (DON) of nursing home and no one was aware of reddened skin to bilateral legs. Review of Photographic Wound Documentation dated 02/24/19 revealed Resident #87 had partial thickness left posterior calf and partial thickness to the right medial thigh and right medial calf. Resident #87 was admitted to the hospital on [DATE] at 12:24 PM with [DIAGNOSES REDACTED]. Review of a Nurse's Note dated 02/24/19 at 12:48 PM, revealed the hospital documented that Resident #87 had bilateral linear redness (with) fluid filled blisters to lower extremities. Review of the Wound Care Consultant Nurse's Note dated 02/25/19 at 6:52 PM, revealed Resident #87 had partial thickness wounds-[MEDICAL CONDITION] the right medial thigh and right medial calf with fluid filled blisters and serous drainage noted. Further, the Note stated the resident had partial thickness wounds to the left posterior calf. Interview with the ED Triage Nurse on 03/14/19 at 10:50 AM, revealed she observed bright red blisters down the inner thighs of Resident #87 on 02/24/19 at 8:40 AM when the resident arrived at the hospital. She also stated the areas looked like something had been sitting on top of the resident. According to the Triage Nurse, when the resident arrived, EMS had the resident's oxygen anchored to the back of the stretcher. Interview with Registered Nurse (RN) #13 on 03/12/19 at 11:15 AM and on 03/13/19 at 10:35 AM, revealed she cared for Resident #87 upon arrival to the ED on 02/24/19. She stated the resident had blisters up and down both inner thighs and calf that looked burns. RN #13 stated she called the facility and spoke with a staff nurse and the DON, who stated they did not know what happened to the resident's legs. Interview with the RN #17 on 03/12/19 at 1:45 PM revealed she cared for Resident #87 upon admission to the hospital. She stated the resident's leg had a huge blistered, fluid filled, angry red. Looked/appeared like a burn, partial thickness. The nurse stated the resident did not have pain on admission, but started having pain later. On 03/12/19 at 3:01 PM, an interview was conducted with RN #18, the hospital Charge Nurse on 03/25/19. RN #18 stated Resident #87 had one big blister to his/her leg and she had never seen a blister that big. The Charge Nurse stated the resident had second degree partial [MEDICAL CONDITION] both legs. She sated the resident was cognitively impaired and it was difficult to communicate with the resident; however, she stated the resident was in pain. Interview with EMS #4 on 03/12/19 at 3:30 PM and 03/15/19 at 5:30 PM; and, EMS #3 at 03/15/19 at 4:12 PM revealed they transferred Resident #87 to the hospital on [DATE], due to a low oxygen saturation. They stated they did not assess the resident's legs, but he stated nothing happened during transport that would have burned the resident's legs. Interview with the Wound Care Specialist, RN #16 on 03/21/19 at 11:38 AM revealed she evaluated Resident #87 on 02/25/19 and the areas to the resident's legs looked like full thickness burns. She stated the areas on the resident's legs were open, blistered, full thickness that extended from the upper medial thighs to below both knees. She further stated she assessed/treated the resident again on 03/07/19 and the areas on Resident #87's legs were responding to treatment like a burn and were progressing like a burn. Continued review of Resident #87's hospital medical record revealed the resident was discharged back to the facility on [DATE] at 2:35 PM with orders for Intravenous (IV) Antibiotics, antibiotic ointment to the legs, and an appointment to return to the Wound Care Center. Review of a skin assessment dated [DATE], completed upon readmission from the hospital revealed Resident #87 had a large open blister to his/her right calf measuring 35 centimeters (cm) in length and 10.2 cm width, and on the left calf a large fluid filled blister measuring 49.40 cm in length and 11.0 cm width. Observation of Resident #87's skin on 03/15/19 at 7:00 PM revealed large open wounds to the resident's legs. The wound to the resident's left leg covered most of the back of the resident's left thigh and another large area to the back of the left calf. Observation of the right leg revealed the resident had a wound that extended from the inner thigh down the back of the knee to the lower leg. The wounds were black and yellow with a red border. Interview with Licensed Practical Nurse (LPN) #1 on 03/14/19 at 9:23 AM revealed on 02/23/19 she assisted a State Registered Nurse Aide (SNRA) with providing incontinent care for Resident #87 on the night of 02/23/19. She stated the resident did not have any skin issues on (his/her) legs at that time. She stated after the resident was transferred to the hospital on [DATE], a nurse from the Emergency Department (ED) called for the DON to ask what caused the red areas on Resident #87's legs. LPN #1 stated the ED Nurse asked if the facility had placed a heating pad between the resident's legs. LPN #1 stated she informed the ED Nurse the facility did not use heating pads. Interview with RN #9 on 03/14/19 at 7:00 PM, revealed she had provided incontinent care for Resident #87 on 02/23/19 at approximately 9:45 PM and the resident did not have any redness or blisters to his/her legs. She further revealed that Resident #87 did have a portable liquid oxygen tank in his/her bed between the resident's legs while waiting to be evacuated from the facility. RN #9 stated that the resident was one of the last residents to be evacuated. The RN stated the last resident that was evacuated from the facility at approximately 5:30 AM on 02/24/19. Interview with LPN #6 on 03/15/19 at 7:30 PM, revealed on the night of 02/23/19 there was water over the oxygen concentrator electrical cords, so staff started utilizing portable liquid oxygen tanks (exact time unknown). She stated it was so chaotic during the evacuation, she did not recall assisting Resident #87, but stated staff placed the oxygen tanks in the beds, between the residents' legs to keep the tank out of the water. Interview with SRNA #23 on 03/25/19 at 12:13 PM revealed all oxygen tanks were placed in bed with residents, but in no particular place. SRNA #23 revealed some of the oxygen tanks were at the resident's feet, some were at the head of the bed, and some were on the resident's lap. She further revealed that the tanks were not kept in an upright position and were positioned on their side in bed with the resident. Interview with SRNA #25 on 03/21/19 at 3:01 PM revealed she was completing other tasks and did not provide direct resident care during the evacuation, but recalled seeing a portable liquid oxygen tank lying on a resident's bed. Interview with Respiratory Therapist (RT) #4 on 03/15/19 at 4:50 PM revealed residents were placed in the hallway while waiting to be evacuated from the facility. RT #4 stated liquid oxygen tanks would often frost over and if they were full, a mist would leak out for about an hour, if the tank was on its side. According to RT #4, she could not remember whether she saw tanks stored in residents' beds during the evacuation Interview with SRNA #20 on 03/13/19 at 4:15 PM revealed on 02/24/19 at approximately 1:00 AM, the residents that were bedbound were moved to the hallways. SRNA #20 revealed the water was ankle deep in the facility and the portable liquid oxygen tanks were placed in the resident's bed to keep the tanks out of the water. SRNA #20 stated she and other SRNAs were going to provide incontinent care for the resident at the evacuation site on 02/24/19 at approximately 6:30 AM, when the resident got bluish colored. SRNA #20 stated she summoned the Respiratory Therapist who checked the resident's oxygen saturation level. According to the SRNA, the resident's oxygen tank was on the floor. The SRNA stated they moved on to the next resident but remembered that EMS took the resident to the hospital. According to the SRNA, oxygen tanks had been known to frost up. Interview with State Registered Nurse Aide (SRNA) #6 on 03/18/19 at 5:45 PM revealed Resident #87 was observed to have a change in condition while at the evacuation site when they attempted to provide incontinent care. SRNA #6 stated the resident was blue in appearance; she notified RN #4. Interview with RT #5 on 03/15/19 at 9:25 AM revealed she was still in training on 02/24/19 when the facility had to evacuate. She stated staff showed her how to fill up portable liquid oxygen tanks that night on 02/23/19, then she started filling up tanks by herself. She stated portable tanks were placed at the head of residents' beds and between residents' legs. RT #5 stated Resident #87 initially utilized an oxygen concentrator at the evacuation site; however, the electricity kept tripping and wouldn't stay on so the resident was switched to a portable tank again. Interview with the Vice President of Operations from the Oxygen Company on 03/15/19 at 6:05 PM, revealed portable oxygen tanks should always be stored upright so liquid oxygen does not leak from the tank. He stated if a portable oxygen tank was placed between a resident's legs, liquid oxygen could leak out and could possibly cause a burn to the resident. Interview with the DON on 03/13/19 at 9:05 AM, revealed she arrived at the facility on 02/24/19, at approximately 1:30 AM to 2:00 AM and made copies of paperwork in her office, then at some point, went to the evacuation site. She stated she did not observe Resident #87's skin prior to leaving for the ED, but thought staff provided incontinent care. She said she observed EMS transfer the resident to the stretcher utilizing the sheet from the cot and EMS stored Resident #87's oxygen tank underneath the stretcher for transport. Further interview revealed an ED Nurse called and asked about the blisters on the resident's legs, but the DON was not aware of any injuries to the resident's legs. Interview with the Administrator on 03/13/19 at 8:55 AM revealed she did not conduct an investigation of the cause of Resident #87's injuries to the legs. She stated she was aware the resident had injuries because the ED called and asked what happened. She stated the DON talked to staff and they told her the resident did not have blisters on his/her legs at the facility, but she did not investigate the cause of the injury. According to the Administrator, she was not aware staff stored oxygen tanks in the beds with residents during the evacuation. 2. Review of the facility's policy titled Disaster and Emergency Planning revised 09/01/18 revealed the Director of Nursing's (DON) responsibilities during an evacuation included supervising the evacuation of facility residents and ensuring residents' medications, and supplies and/or needed equipment was transported and available for the residents when the evacuation occurred. The policy revealed the Administrator was required to give staff direction during the evacuation process and was in full charge of the facility during any threat or emergency. According to the policy, staff was required to notify medical supply and medication vendors to ensure the needs were met for facility residents. The plan did not address transporting oxygen to an evacuation site. Interview with State Registered Nurse Aide (SRNA) #8 on 03/21/19 at 5:00 PM revealed during an emergency evacuation on 02/24/19, he and an unknown Volunteer loaded a liquid oxygen storage tank from the facility onto the back of a bus, and transported the oxygen tank to the evacuation site. He was unable to recall who directed him to place the oxygen cylinder on the bus, and was unaware of guidelines related to oxygen storage or transportation. Interview with the Oxygen Vendor's Vice President (VP) on 03/15/19 at 6:00 PM revealed the facility did not contact him about the evacuation. The VP stated liquid oxygen was hazardous and required specialized transportation and was against Federal and State guidelines for the facility to transport liquid oxygen. He stated the cylinder should not have been transported by anyone except by a member of his company and stated untrained facility staff should not have transported oxygen, in any form, outside of the facility. Further interview revealed that if the facility had contacted him about the evacuation, he would have provided the facility with needed oxygen supplies to ensure the residents' needs were met at the evacuation site while remaining safe and in compliance with regulations. Further, the oxygen vendor VP stated liquid oxygen had to be stored behind a one and one-half inch thick firewall, and in an area free from electrical outlets. Interview with the facility's Respiratory Director on 03/17/19 at 11:20 AM, revealed RT #4 contacted her about the facility's evacuation and she instructed RT #4 to ensure residents who required oxygen, had a portable liquid oxygen tank. She stated she did not contact the facility's oxygen vendor for guidance on how to supply the needed oxygen at the evacuation site, and had not been directed by the Administrator to do so. The Respiratory Director further stated that she provided care to residents at the evacuation site and was aware that portable liquid oxygen tanks had been transported and were in use at the site. In addition, the Director confirmed the liquid oxygen storage tank was stored in the gymnasium with the residents and stated she utilized the storage tank to refill portable liquid oxygen tanks while wearing no personal protective equipment (PPE). She stated she was aware PPE was required; however, PPE was not available at the evacuation site. Interview with the Director of Nursing (DON) on 03/14/19 at 6:37 PM revealed she was also aware that the facility had transported the bigger liquid oxygen storage tank and portable liquid oxygen tanks to the evacuation site. The DON stated she was not aware that staff should not have transported liquid oxygen out of the facility. A post-survey interview on 04/15/19 at 2:08 PM with a Transportation Regulatory Specialist with the Federal Motor Safety Administration Hazardous Material Information Center revealed according to 49 CFR 177.823 all hazardous materials, including liquid oxygen should be properly labeled and stored when transported. He stated there were exceptions for emergencies; however, even in an emergency, transportation of the material required a waiver (permission) from the Department of Transportation, along with an emergency escort from the state or local government. Continued interview revealed that liquid oxygen was defined as a hazardous material under the regulations for specific requirements for transportation. Interview with the Administrator on 03/21/19 at 4:15 PM revealed she did not visit the evacuation site when residents were evacuated and was not aware staff transported liquid oxygen to the evacuation site; or, that the liquid oxygen storage tank was not stored properly at the site. In addition, she stated she was not aware that liquid oxygen could only be transported under special circumstances and that the oxygen vendor should have been contacted for an alternative to liquid oxygen. ***The facility alleged the following actions removed Immediate Jeopardy on 03/30/19: 1. Resident #87 was transferred to theER on [DATE] and returned to the facility on [DATE]. Treatment per physician's orders [REDACTED]. 2. Resident #902 was transferred to theER on [DATE] and returned to the facility on [DATE]. Treatment per physician's orders [REDACTED]. 3. Licensed nurses completed an assessment of all current residents on 03/23/19 to determine any changes in condition. The changes in condition included, but was not limited to respiratory distress, changes in skin condition, and signs and symptoms of infection. No changes in condition were identified. 4. The Oxygen Inspector was at the facility on 03/25/19 and completed an assessment of all oxygen tanks to determine that they were stored and functioning as appropriate. No problems were identified. 5. The Administrator, on record during the evacuation, is no longer employed at the facility as of 03/22/19. 6. The Administrator, Director of Nursing (DON), Maintenance Director, Regional Director of Operations, Chief Nursing Officer, and the Kentucky Education Director reviewed and revised the Emergency Preparedness Plan (EPP) related to flooding and emergency evacuation as of 03/29/19. The EPP changes included, but were not limited to the following: when to initiate an evacuation based on associated environmental conditions (See attachment A); have medical and pharmaceutical supplies (including medical records, medications, blood sugar testing equipment, oxygen, suctioning equipment, and a crash cart) available at the receiving location prior to or in conjunction with the resident's arrival; a tracking tool to document who, when and where residents were transported during an evacuation; and the tracking of and knowledge of volunteers, duties performed and assignment of tasks. 7. The Kentucky Education Director educated the Administrator as of 03/29/19 on implementing the Emergency Preparedness Plan which included tracking resident transports, identifying volunteers and the duties they perform, infection control related to providing transmission-based precautions during an evacuation, oxygen transport, and making sure medical records, medical supplies (including but not limited to oxygen, suction equipment, blood sugar testing supplies and a crash cart) and pharmaceutical supplies were at the alternate site prior to, or in conjunction with the residents' arrival. 8. All facility staff have been re-educated on or before 03/29/19 by the Staff Development Coordinator, Education Director, Director of Nursing, Unit Manager, or Kentucky Education Director on the Emergency Preparedness Plan as related to evacuation, staff duties, including but not limited to: tracking resident transports; identifying volunteers and the duties they perform; infection control related to providing transmission based precautions during an evacuation; oxygen transport; making sure medical records, medical supplies (including but not limited to medical records, oxygen, suction equipment, blood sugar testing supplies, and a crash cart) and pharmaceutical supplies are at the alternate site prior to, or in conjunction with the residents' arrival. 9. All nursing staff were re-educated to the types of oxygen, how to appropriately transport oxygen (to include not laying oxygen cylinders on resident's beds or touching skin) on or before 03/29/19 by the Education Director. 10. The facility held an Ad hoc Performance Improvement Committee meeting on or before 03/29/19 with the Medical Director to review the Emergency Preparedness Plan related to evacuation including when to initiate an evacuation based on associated environmental conditions; having medical and pharmaceutical supplies (including medical records, medications, blood sugar testing equipment, oxygen, suctioning equipment, and a crash care) available at the receiving location prior to, or in conjunction with the resident's arrival; a tracking tool to document who, when and where residents were transported during an evacuation; and the tracking of and knowledge of volunteers, duties performed, and assignment of tasks. 11. An evacuation drill will be completed on or before 03/29/19 at the facility and led by the Administrator, or designee. The evacuation drill will include observations of staff response and verbal discussion to explain specific steps to take during an evacuation to include but not limited to: when to authorize the evacuation; implementing the Emergency Preparedness Plan; provide medical and pharmacological supplies such as resident medical records, medications, blood sugar testing equipment, oxygen, suctioning equipment, and crash cart; tracking of resident transports; volunteer tracking and assignments; and maintaining transmission based precautions. Re-education will be provided for any areas of concern identified. A summary of the evacuation drill will be submitted to the Quality Assurance Committee by the Administrator for further review and recommendation. 13. A collaborative meeting was held on 03/26/19 with the Fire Chief of the City, Director of Nursing, Maintenance Director, Administrator, Chief Nursing Officer, Kentucky Education Director, and the Regional Director of Operations to review when to initiate evacuation. When a flood warning occurs, a collaborative discussion will occur with the Administrator, or designee, and the Fire Chief to determine if and when an evacuation should occur. The County makes determinations with team members based on local environmental conditions. Team members may include the Judge Executive, Police Chief, Fire Chief, School Superintendent, and Facility Administration (Administrator, Maintenance Director, and/or Director of Nursing). When a flood warning occurs the Administrator, or designee will start making contact with other Department Head Staff to inform them of the warning and discuss preparation needs in the event of evacuation. 14. On 03/21/19, the Maintenance Director attended the KY Health Care Coalition Region 10/11 meeting that reviews aspects of Community Emergency Preparedness Planning. ****The State Agency confirmed the following removed Immediate Jeopardy on 03/30/19: 1. Record review revealed Resident #87 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. No additional concerns were identified. 2. Record review revealed Resident #902 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. No additional concerns were identified. 3. Record review and interview on 04/01/19 with Registered Nurse (RN) #3 at 5:18 PM, RN #4 at 6:59 PM, and on 04/02/19 with the Director of Nursing (DON) at 11:09 AM revealed assessments were completed on all residents on 03/23/29 to identify any change in condition. No changes were identified. 4. Review of an inspection report and interview with the Director of Respiratory Therapy on 04/01/19 at 3:49 PM, the DON on 04/02/19 at 11:09 AM, and the Kentucky Clinical Education Director on 04/02/19 at 9:52 AM revealed an inspection (by the Oxygen Inspector) of all oxygen tanks was completed on 03/25/19 with no problems identified. 5. Based on interview on 04/02/19 with the Interim Administrator at 10:28 AM and the DON at 11:09 AM, the previous administrator's last day of employment was 03/22/19. 6. Review of the facility's revised Emergency Preparedness Plan (EPP) and interviews on 04/01/19 with the Maintenance Director at 3:30 PM, the Kentucky Clinical Education Director on 04/02/19 at 9:52 AM, with the DON at 11:09 AM, and the Administrator at 10:28 AM revealed the group meet on 03/29/19 to review and revise the EPP. The changes included tracking of residents and volunteers, communication, medical and pharmaceutical supplies, etc. 7. Review of training records and interview on 04/02/19 with the Interim Administrator at 10:28 AM and the Kentucky Clinical Education Director at 9:52 AM revealed the Administrator, DON, Maintenance Director, and Infection Control Nurse received training on 03/26/19 on implementing the EPP including tracking residents, identifying volunteers, providing transmission based precautions during evacuation, and medical equipment/pharmaceutical supplies transport during evacuation. 8. Review of training records, posttests, and interviews on 04/01/19 with the Maintenance Director at 3:35 PM, State Registered Nurse Aide (SRNA) #22 at 6:08 PM , SRNA #18 at 6:37 PM, SRNA #25 at 6:44 PM, Business Office Manager at 6:23 PM, Housekeeper #1 at 6:18 PM, Activities Director at 6:30 PM, SRNA #28 at 7:15 PM, SRNA #29 at 7:22 PM, Social Service Director at 5:51 PM, LPN #4 at 4:57 PM, LPN #7 at 5:33 PM, LPN #10 at 4:48 PM, Housekeeping Supervisor at 4:33 PM, Dietary Manager at 4:14 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, Director of Respiratory Therapy at 3:49 PM, and on 04/02/19 with SRNA #26 at 9:14 AM, SRNA #2 at 9:39 AM, SRNA #5 at 9:27 AM and the DON at 11:09 AM revealed all had received training on the facility's EPP as it relates to evacuation and the revisions in the plan. A posttest was taken after the training and all passed. 9. Review of training records and interviews on 04/01/19 with State Registered Nurse Aide (SRNA) #22 at 6:08 PM , SRNA #25 at 6:44 PM, LPN #4 at 4:57 PM, LPN #7 at 5:33 PM, LPN #10 at 4:48 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, and on 04/02/19 with SRNA #26 at 9:14 AM, SRNA #2 at 9:39 AM, and SRNA #5 at 9:27 AM revealed all had been educated on transportation of portable oxygen and not placing oxygen tanks in the bed with residents. 10. Review of Quality Performance Improvement Meeting (QAPI) minutes dated 03/29/19, and interviews on 04/01/19 with the Business Office Manager at 6:23 PM, Activities Director at 6:30 PM, Social Service D

Based on observation, interviews, record reviews, review of video surveillance footage at the evacuation site, review of 911 audio recordings, and review of facility policies, it was determined the facility failed to be administered effectively in a manner that ensured the comprehensive emergency preparedness program was maintained and implemented during a flood on 02/23-24/19 and the environment was free of accident hazards (Refer to E0001, E0015, E0018, E0020, E0023, E0024, and F689). The facility's Emergency Management Policy stated the Administrator was required to give staff direction during the evacuation process and was in full charge of the facility during any threat or emergency. The policy also stated the facility should be proactive in planning and not to wait for the situation to become dire, before evacuating residents. However, the Administrator failed to respond to concerns about flooding at the facility until after floodwater had already entered the facility and the County Emergency Management Director initiated an evacuation on 02/24/19 at 1:41 AM. The Emergency Management Policy also revealed the Administrator was required to give staff direction during the evacuation process and was in full charge of the facility during any threat or emergency. However, the Administrator failed to contact the oxygen supply vendor to ensure oxygen was transported and utilized at the evacuation site safely. Interviews with staff revealed they transported tanks that contained liquid oxygen to the evacuation site and stored a liquid oxygen supply tank, utilized to refill smaller portable tanks, in the gymnasium with residents. However, according to a Transportation Regulatory Specialist with the Federal Motor Safety Administration Hazardous Material Information Center, the facility could not transport liquid oxygen unless a waiver was obtained and the transport was escorted by a local or state official. He further stated the facility had not obtained a waiver to transport liquid oxygen. Further, the Administrator failed to ensure staff administered liquid oxygen to residents during the evacuation site in a safe manner. Interviews with staff revealed they placed liquid oxygen tanks, in a lying position, in bed with residents, even though the facility's policy stated the tanks should not be positioned in that manner to prevent injury to the resident (Liquid oxygen is stored at negative 300 degrees Fahrenheit. Skin exposed to liquid oxygen will suffer a frostbite thermal injury that is almost identical to a burn.). Resident #87 [MEDICAL CONDITION] the lower extremities during the evacuation. In addition, the Administrator failed to ensure staff implemented the Emergency Management Plan to ensure the one hundred eighteen (118) residents' location was tracked during the emergency evacuation; failed to ensure medical and pharmaceutical supplies were available for residents who evacuated the facility; failed to ensure medical records were available to ensure continuity of care was provided when residents were transferred to the hospital; and failed to implement their policy regarding registration of volunteers. The failure to ensure the facility was administered effectively has caused or is likely to cause injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/21/19, and determined to exist on 02/24/19 at 42 CFR 483.73 Emergency Preparedness (E0001, E0015, E0018, E0020, E0023, and E0024) and at 42 CFR 483.25 Quality of Care (F689), 42 CFR 483.70 Administration (F835), and 42 CFR 483.80 Infection Control (F880). The facility was notified of the Immediate Jeopardy on 03/21/19. An acceptable Allegation of Compliance was received on 03/26/19, which alleged removal of the Immediate Jeopardy on 03/30/19. The State Survey Agency determined the Immediate Jeopardy was removed on 03/30/19, prior to exit on 04/03/19, which lowered the scope and severity to F level at 42 CFR 483.73 Emergency Preparedness (E0001, E0015, E0018, E0020, E0023, and E0024), to F level at 42 CFR 483.25 Quality of Care (F689) and 42 CFR 483.70 Administration (F835), and to [NAME] level at 42 CFR 483.80 Infection Control (F880), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's job description revealed the Administrator was required to ensure that excellent care for residents was maintained by overseeing and monitoring patient care services delivered. The description also stated the Administrator was responsible for working with and supervising personnel in the facility. Review of the facility's policy titled Disaster and Emergency Planning revised 09/01/18 revealed the plan defined a flash flood warning, as a warning that was issued when flash flooding is imminent or occurring. The policy stated staff were required to monitor the facility's weather alerts via radio and/or television for changing conditions, alerts, and warnings, and should be prepared to relocate residents to safe areas well in advance of a storm. The policy also stated staff were to be proactive in planning and not to wait for the situation to become dire, before evacuating residents. According to the facility's emergency plan, the Administrator was required to give staff direction during the evacuation process and was in full charge of the facility during any threat or emergency. On 02/23/19 at 9:55 PM, a flash flood warning was issued for the area where the facility was located. Interview with Licensed Practical Nurse (LPN) #6 on 03/15/19 at 7:30 PM revealed she called the Director of Nursing (DON) at approximately 9:45 PM on 02/23/19, and informed her that the facility needed to start an evacuation because water had flooded a portion of the facility's parking lot and water was coming into the facility via drainage pipes and a toilet. However, the DON told the LPN that she had notified the Administrator and the facility was not going to evacuate Interviews with Registered Nurse (RN) #9 on 03/17/19 at 4:38 PM and with RN #20 on 03/21/19 at 5:00 PM revealed they also contacted the Director of Nursing (DON) on 02/23/19 and 02/24/19 and discussed concerns related to water rising around and coming into the facility via the sewer system. RN #9 stated she started notifying the DON of her concerns about the flooding at approximately 11:30 PM. RN #20 stated she sent photographs of the flooding to the DON on 02/23/19 at 11:27 PM, 11:32 PM, 12:22 AM, 12:43 AM and 12:52 AM because she was concerned that the water was rising around the facility, and felt the residents should be evacuated to ensure their safety. She stated the DON informed her that the Administrator had been made aware of staffs' concerns; however, she (the Administrator) was not going to evacuate the facility. The RNs stated neither the Administrator nor the DON responded to the staffs' concerns until the Emergency Management Director ordered an evacuation at 1:41 AM on 02/24/19. Interview with the Emergency Management Director on 03/17/19 at 3:50 PM revealed a City Councilman notified him that there was a video on Facebook that showed water rising around the facility on 02/24/19 (unable to recall the time he was notified). He stated the National Weather Service had issued a flash flood warning at 9:55 PM on 02/23/19 for the county in which the facility was located. However, he stated parts of the city, including the city fire station, had already flooded at approximately 9:00 PM. He stated no one had contacted him to request his guidance, even though water was visibly surrounding areas of the facility. Further interview revealed after the phone call from the City Councilman, he went to the facility. The Emergency Management Director stated when he arrived at approximately 1:40 AM, water had already entered the facility and he instructed the facility to evacuate the residents at 1:41 AM on 02/24/19. He stated after the he called for the evacuation, he notified dispatch, which alerted transportation providers of the need to transport residents to the evacuation site, which was a local school's gymnasium. Further review of the Disaster and Emergency Planning Policy revealed the policy did not address safe transportation/usage of oxygen. The policy stated that staff should notify vendors of medical and pharmaceutical supplies when an evacuation was necessary to ensure residents had adequate supplies. A review of the facility's policy titled, Oxygen therapy and devices not dated revealed, liquid portable oxygen tanks should be kept upright at all times, to prevent leakage of liquid oxygen which can [MEDICAL CONDITION] it comes in contact with a person's skin. Staff was directed to never place a liquid oxygen tank, on its side, or on a person's lap. The policy stated portable oxygen tanks were required to be transported in a stroller cart or in a shoulder strap, or draped on the back of a wheelchair. The oxygen policy did not address transportation of liquid oxygen outside the facility. A post survey interview on 04/15/19 at 2:08 PM with a Transportation Regulatory Specialist with the Federal Motor Safety Administration Hazardous Material Information Center revealed according to 49 CFR 177.823 all hazardous materials should be properly labeled and stored when transported. The Regulatory Specialist stated there were exceptions in emergencies. He stated that in emergencies the transportation of the material required a waiver (permission) from the Department of Transportation along with an emergency escort from state or local government. Continued interview revealed that liquid oxygen was a hazardous material defined under regulations specific requirements for transportation. According to the Regulatory Specialist, the facility had not been granted a waiver to transport liquid oxygen. However, interview with State Registered Nurse Aide (SRNA) #8 on 03/21/19 at 5:00 PM, revealed he and an unknown Volunteer loaded a liquid oxygen storage tank from the facility onto the back of a bus, and transported the oxygen tank to the evacuation site. He was unable to recall who directed him to place the oxygen cylinder on the bus, and was unaware of guidelines related to oxygen storage or transportation. Further interviews with Licensed Practical Nurse (LPN) #6 on 03/15/19 at 7:30 PM; State Registered Nurse Aide (SRNA) #20 on 03/13/19 at 4:15 PM; SRNA #6 on 03/18/19 at 5:45 PM; SRNA #25 on 03/21/19 at 3:01 PM; SRNA #23 on 03/25/19 at 12:13 PM; and Respiratory Therapist (RT) #5 on 03/15/19 at 9:25 AM revealed on the night of 02/23/19, staff placed portable liquid oxygen tanks on their side (not upright as required by the facility's policy) in bed with residents to keep them out of the flood water, even though the facility's policy stated the tanks should not be positioned in that manner to prevent injury to the resident (Liquid oxygen is stored at negative 300 degrees Fahrenheit. Skin exposed to liquid oxygen will suffer a frostbite thermal injury that is almost identical to a burn). Resident #87 [MEDICAL CONDITION] the lower extremities. The Disaster and Emergency Planning Policy further stated during evacuation operations, staff was required to prepare supplies and emergency items for travel, including medical supplies and equipment; pack and secure residents medications, or transport medication carts; ensure residents' medical records were available for continuity of care; and ensure a volunteer registration sheet was completed. However, there was no evidence the Administrator ensured the policy was implemented. However, interview with staff revealed the facility failed to ensure oxygen was available for Resident #87 at the evacuation site. The facility identified that Resident #87 was cyanotic (had a blue color due to lack of oxygen) on 02/24/19, and the resident's oxygen tank was empty. Interviews with staff revealed functional oxygen tanks were not readily available. The resident had to be transported to the hospital for respiratory distress on 02/24/19. Interview with staff revealed Resident #21, who had a [MEDICAL CONDITION] was the first resident to arrive to the evacuation site on 02/24/19. However, the evacuation site was empty; there were no beds, or required supplies to provide oral and tracheal suctioning, or supplies needed for emergency [MEDICAL CONDITION] care (a surgical opening in the windpipe (trachea) to assist with breathing). The resident was transported to the hospital and admitted on [DATE] with [DIAGNOSES REDACTED]. Interview with staff revealed Resident #902 had a change in condition while at the evacuation site on 02/24/19. The nurse assessed the resident to be have a cardiac event; the resident had a [DIAGNOSES REDACTED]. The resident was transported to the hospital on [DATE] and admitted with acute pancreatitis. Review of hospital records revealed the facility also transferred Resident #900 and Resident #901 to the hospital on [DATE] during the evacuation. However, review of the hospital records and interviews with hospital staff revealed the facility failed to provide any documentation to the hospital when Residents #87, #21, and #902 were transferred, including the resident's name, allergies [REDACTED]. Interviews with staff revealed the facility failed to track residents who were evacuated during the flood and failed to keep a staff and volunteer roster. Staff stated they were not aware they were required to track each resident's location, who/how they were transferred, etc., during the evacuation or that they were required to keep a staff roster. In addition, staff stated they were not aware they were supposed to keep a register for volunteers. Further interview revealed staff was not sure who some of the volunteers were or what they did at the facility. Interview with the Administrator on 03/13/19 at 8:55 AM, and on 03/21/19 at 4:15 PM and at 5:30 PM revealed she thinks the DON contacted her at 11:00 PM on 02/23/19 and informed her the water was up at the facility. The Administrator stated she contacted a maintenance staff member and directed him to evaluate the water at the facility. He informed the Administrator that the water was 12-15 feet from the facility, and it was not raining at that time. Further interview revealed the Administrator stated she told the maintenance staff member that no further action was needed and he could return home. The Administrator was unable to recall if she had been notified or was aware that a flash flood warning was issued at 02/23/19 at 9:55 AM. Further interview revealed no evidence the Administrator monitored the weather conditions and warning and prepared to relocate residents to safe areas well in advance; or, was proactive in planning and did not to wait for the situation to become dire, before evacuating residents, as required by the facility's policy. The Administrator stated she was notified on 02/24/19 (unable to recall time) that the facility was being evacuated, after the County Emergency Management Director had ordered the facility to be evacuated. Continued interview with the Administrator revealed she had not reviewed the facility's emergency management plan with administrative staff and had not informed administrative staff of their responsibilities should an emergency evacuation occur. The Administrator also acknowledged she was aware that she was responsible for the facility at all times, especially during an evacuation. However, the Administrator stated she did not visit the evacuation site when residents were evacuated to ensure the emergency plan was being followed. The Administrator was not aware staff transported liquid oxygen to the evacuation site, or that the liquid oxygen storage tank was not stored properly at the site. In addition, she stated she was not aware that liquid oxygen could only be transported under special circumstances and that the oxygen vendor should have been contacted for an alternative to liquid oxygen. Further interview with the Administrator revealed she was aware that Resident #87 sustained injuries to the legs. She stated the DON talked to staff and they told her the resident did not have blisters on his/her legs at the facility. However, the Administrator did not investigate the cause of the injury and was not aware staff stored liquid oxygen tanks in bed with residents during the evacuation. Continued interview with the Administrator on 03/13/19 at 8:55 AM, and on 03/21/19 at 4:15 PM and at 5:30 PM revealed she had not assessed the residents' medications, medical supplies, or equipment care needs prior to the evacuation or after the evacuation to ensure adequate supplies, equipment, and medications were available for residents. The Administrator further stated she was not aware that Resident #21 arrived to the evacuation site when no medical supplies or equipment was available; and she was not aware that an oxygen tank, blood glucose machine, or a crash cart was not readily available when Resident #87 and Resident #902 experienced a change in condition at the evacuation site on 02/24/19. The Administrator stated further on 03/13/19 at 8:55 AM, and on 03/21/19 at 4:15 PM and at 5:30 PM that she failed to track Volunteers that assisted during the evacuation, as required by her emergency plan. In addition, she stated she was not aware that medical information was not provided to the hospital when Residents #21, #87, #900, #901, and # 902 arrived to receive further evaluation and treatment on 02/24/19. The Administrator stated management staff told her everything went well, but she did not debrief with any other facility staff after the evacuation. ***The facility alleged the following actions removed Immediate Jeopardy on 03/30/19: 1. Resident #87 was transferred to theER on [DATE] and returned to the facility on [DATE]. Treatment per physician's orders [REDACTED]. 2. Resident #902 was transferred to theER on [DATE] and returned to the facility on [DATE]. Treatment per physician's orders [REDACTED]. 3. Licensed nurses completed an assessment of all current residents on 03/23/19 to determine any changes in condition. The changes in condition included, but was not limited to respiratory distress, changes in skin condition, and signs and symptoms of infection. No changes in condition were identified. 4. The Oxygen Inspector was at the facility on 03/25/19 and completed an assessment of all oxygen tanks to determine that they were stored and functioning as appropriate. No problems were identified. 5. The Administrator, on record during the evacuation, is no longer employed at the facility as of 03/22/19. 6. The Administrator, Director of Nursing (DON), Maintenance Director, Regional Director of Operations, Chief Nursing Officer, and the Kentucky Education Director reviewed and revised the Emergency Preparedness Plan (EPP) related to flooding and emergency evacuation as of 03/29/19. The EPP changes included, but were not limited to the following: when to initiate an evacuation based on associated environmental conditions (See attachment A); have medical and pharmaceutical supplies (including medical records, medications, blood sugar testing equipment, oxygen, suctioning equipment, and a crash cart) available at the receiving location prior to or in conjunction with the resident's arrival; a tracking tool to document who, when and where residents were transported during an evacuation; and the tracking of and knowledge of volunteers, duties performed and assignment of tasks. 7. The Kentucky Education Director educated the Administrator as of 03/29/19 on implementing the Emergency Preparedness Plan which included tracking resident transports, identifying volunteers and the duties they perform, infection control related to providing transmission-based precautions during an evacuation, oxygen transport, and making sure medical records, medical supplies (including but not limited to oxygen, suction equipment, blood sugar testing supplies and a crash cart) and pharmaceutical supplies were at the alternate site prior to, or in conjunction with the residents' arrival. 8. All facility staff have been re-educated on or before 03/29/19 by the Staff Development Coordinator, Education Director, Director of Nursing, Unit Manager, or Kentucky Education Director on the Emergency Preparedness Plan as related to evacuation, staff duties, including but not limited to: tracking resident transports; identifying volunteers and the duties they perform; infection control related to providing transmission based precautions during an evacuation; oxygen transport; making sure medical records, medical supplies (including but not limited to medical records, oxygen, suction equipment, blood sugar testing supplies, and a crash cart) and pharmaceutical supplies are at the alternate site prior to, or in conjunction with the residents' arrival. 9. All nursing staff were re-educated to the types of oxygen, how to appropriately transport oxygen (to include not laying oxygen cylinders on resident's beds or touching skin) on or before 03/29/19 by the Education Director. 10. The facility held an Ad hoc Performance Improvement Committee meeting on or before 03/29/19 with the Medical Director to review the Emergency Preparedness Plan related to evacuation including when to initiate an evacuation based on associated environmental conditions; having medical and pharmaceutical supplies (including medical records, medications, blood sugar testing equipment, oxygen, suctioning equipment, and a crash care) available at the receiving location prior to, or in conjunction with the resident's arrival; a tracking tool to document who, when and where residents were transported during an evacuation; and the tracking of and knowledge of volunteers, duties performed, and assignment of tasks. 11. An evacuation drill will be completed on or before 03/29/19 at the facility and led by the Administrator, or designee. The evacuation drill will include observations of staff response and verbal discussion to explain specific steps to take during an evacuation to include but not limited to: when to authorize the evacuation; implementing the Emergency Preparedness Plan; provide medical and pharmacological supplies such as resident medical records, medications, blood sugar testing equipment, oxygen, suctioning equipment, and crash cart; tracking of resident transports; volunteer tracking and assignments; and maintaining transmission based precautions. Re-education will be provided for any areas of concern identified. A summary of the evacuation drill will be submitted to the Quality Assurance Committee by the Administrator for further review and recommendation. 13. A collaborative meeting was held on 03/26/19 with the Fire Chief of the City, Director of Nursing, Maintenance Director, Administrator, Chief Nursing Officer, Kentucky Education Director, and the Regional Director of Operations to review when to initiate evacuation. When a flood warning occurs, a collaborative discussion will occur with the Administrator, or designee, and the Fire Chief to determine if and when an evacuation should occur. The County makes determinations with team members based on local environmental conditions. Team members may include the Judge Executive, Police Chief, Fire Chief, School Superintendent, and Facility Administration (Administrator, Maintenance Director, and/or Director of Nursing). When a flood warning occurs the Administrator, or designee will start making contact with other Department Head Staff to inform them of the warning and discuss preparation needs in the event of evacuation. 14. On 03/21/19, the Maintenance Director attended the KY Health Care Coalition Region 10/11 meeting that reviews aspects of Community Emergency Preparedness Planning. ****The State Agency confirmed the following removed Immediate Jeopardy on 03/30/19: 1. Record review revealed Resident #87 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. No additional concerns were identified. 2. Record review revealed Resident #902 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. No additional concerns were identified. 3. Record review and interview on 04/01/19 with Registered Nurse (RN) #3 at 5:18 PM, RN #4 at 6:59 PM, and on 04/02/19 with the Director of Nursing (DON) at 11:09 AM revealed assessments were completed on all residents on 03/23/29 to identify any change in condition. No changes were identified. 4. Review of an inspection report and interview with the Director of Respiratory Therapy on 04/01/19 at 3:49 PM, the DON on 04/02/19 at 11:09 AM, and the Kentucky Clinical Education Director on 04/02/19 at 9:52 AM revealed an inspection (by the Oxygen Inspector) of all oxygen tanks was completed on 03/25/19 with no problems identified. 5. Based on interview on 04/02/19 with the Interim Administrator at 10:28 AM and the DON at 11:09 AM, the previous administrator's last day of employment was 03/22/19. 6. Review of the facility's revised Emergency Preparedness Plan (EPP) and interviews on 04/01/19 with the Maintenance Director at 3:30 PM, the Kentucky Clinical Education Director on 04/02/19 at 9:52 AM, with the DON at 11:09 AM, and the Administrator at 10:28 AM revealed the group meet on 03/29/19 to review and revise the EPP. The changes included tracking of residents and volunteers, communication, medical and pharmaceutical supplies, etc. 7. Review of training records and interview on 04/02/19 with the Interim Administrator at 10:28 AM and the Kentucky Clinical Education Director at 9:52 AM revealed the Administrator, DON, Maintenance Director, and Infection Control Nurse received training on 03/26/19 on implementing the EPP including tracking residents, identifying volunteers, providing transmission based precautions during evacuation, and medical equipment/pharmaceutical supplies transport during evacuation. 8. Review of training records, posttests, and interviews on 04/01/19 with the Maintenance Director at 3:35 PM, State Registered Nurse Aide (SRNA) #22 at 6:08 PM , SRNA #18 at 6:37 PM, SRNA #25 at 6:44 PM, Business Office Manager at 6:23 PM, Housekeeper #1 at 6:18 PM, Activities Director at 6:30 PM, SRNA #28 at 7:15 PM, SRNA #29 at 7:22 PM, Social Service Director at 5:51 PM, LPN #4 at 4:57 PM, LPN #7 at 5:33 PM, LPN #10 at 4:48 PM, Housekeeping Supervisor at 4:33 PM, Dietary Manager at 4:14 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, Director of Respiratory Therapy at 3:49 PM, and on 04/02/19 with SRNA #26 at 9:14 AM, SRNA #2 at 9:39 AM, SRNA #5 at 9:27 AM and the DON at 11:09 AM revealed all had received training on the facility's EPP as it relates to evacuation and the revisions in the plan. A posttest was taken after the training and all passed. 9. Review of training records and interviews on 04/01/19 with State Registered Nurse Aide (SRNA) #22 at 6:08 PM , SRNA #25 at 6:44 PM, LPN #4 at 4:57 PM, LPN #7 at 5:33 PM, LPN #10 at 4:48 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, and on 04/02/19 with SRNA #26 at 9:14 AM, SRNA #2 at 9:39 AM, and SRNA #5 at 9:27 AM revealed all had been educated on transportation of portable oxygen and not placing oxygen tanks in the bed with residents. 10. Review of Quality Performance Improvement Meeting (QAPI) minutes dated 03/29/19, and interviews on 04/01/19 with the Business Office Manager at 6:23 PM, Activities Director at 6:30 PM, Social Service Director at 5:51 PM, Housekeeping Supervisor at 4:33 PM, Dietary Manager at 4:14 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, and on 04/02/19, with the KY Clinical Education Director at 9:52 AM and the DON at 11:09 AM revealed all had attended the QAPI meeting on 03/29/19. The Medical Director attended the meeting and all stated they discussed the EPP and the evacuation drill held that day. 11. Review of the Evacuation Drill checklist dated 03/29/19, sign-in sheets, and interviews on 04/01/19 with the Business Office Manager at 6:23 PM, Activities Director at 6:30 PM, Housekeeping Supervisor at 4:33 PM, Dietary Manager at 4:14 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, and on 04/02/19, with the KY Clinical Education Director at 9:52 AM, and the DON at 11:09 AM revealed an evacuation drill due to a flood warning was conducted on 03/29/19 and all stated the drill went well. The KY Clinical Education Director stated a discussion with staff after the drill was completed and additional ideas to improve the plan were discussed. 12. Review of the QAPI Minutes and interview on 04/01/19 with the Business Office Manager at 6:23 PM, Activities Director at 6:30 PM, Social Service Director at 5:51 PM, Housekeeping Supervisor at 4:33 PM, Dietary Manager at 4:14 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, and on 04/02/19, with the KY Clinical Education Director at 9:52 AM and the DON at 11:09 AM revealed all had attended the meeting on 03/29/19 and the evacuation drill was discussed in the meeting. 13. Review of Meeting Minutes and interview with the interim Administrator on 04/02/19 at 10:28 AM; and, on 04/10/19 at 1:15 PM with the local Fire Chief confirmed the facility had a meeting on 03/26/19 with the Fire Chief and discussed if and when evacuations should occur. Interview with the Maintenance Director on 04/01/19 at 3:35 PM revealed all Department Supervisors now had an app on their phones that could be used to communicate any needed facility evacuation. 14. Review of training records and interview with the Maintenance Director on 04/01/19 at 3:35 PM revealed the Maintenance Director had attended the KY Health Care Coalition Region 10/11 meeting on 03/21/19.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to establish and maintain an infection prevention and control program, that was designed to provide a safe, sanitary and comfortable environment that helped prevent the development and transmission of infections. During an emergency evacuation on 02/24/19 due to flooding, the facility failed to ensure that physician ordered contact precautions that were required to prevent the transmission of infections from five (5) of twenty-seven sampled residents (Residents #61, #96, #903, #912, and #913) were implemented at the alternate care site. Furthermore, the facility failed to develop written procedures for their infection control program which included when and how isolation should be used for facility residents, as well as the type and duration of the isolation, which depended on the infectious agent and/or organism involved. Record review and interviews with staff regarding Resident #13 on 04/01/19, revealed the resident was readmitted to the facility on [DATE], from a recent hospital stay. However, staff failed to identify the resident had been diagnosed with [REDACTED]. Observations conducted on 04/01/19, and interviews with direct care staff revealed no interventions had been implemented to prevent the transmission of the MRDO to staff and other residents since the resident had returned to the facility. The facility's failure to ensure an effective infection prevention program was established has caused or is likely to cause injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/21/19, and determined to exist on 02/24/19 at 42 CFR 483.25 Quality of Care (F689), 42 CFR 483.70 Administration (F839), and 42 CFR 483.80 Infection Control (F880). The facility was notified of the Immediate Jeopardy on 03/21/19. An acceptable Allegation of Compliance was received on 03/26/19, which alleged removal of the Immediate Jeopardy on 03/30/19. The State Survey Agency determined the Immediate Jeopardy was removed on 03/30/19, prior to exit on 04/03/19, which lowered the scope and severity to F level at 42 CFR 483.25 Quality of Care (F689) and 42 CFR 483.70 Administration (F839), and to [NAME] level at 42 CFR 483.80 Infection Control (F880), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Infection Control Guidelines for all Nursing Procedures not dated, revealed prior to having direct care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues which included the facility's protocols for isolation precautions, and preventing the transmission of Healthcare-Associated Infections as well as Multi-Drug Resistant Organisms. The policy also stated Standard Precautions would be used in the care of all residents in all situations, and Transmission-Based Precautions would be used when measures more stringent than Standard Precautions were needed to prevent the spread of infection. The policy stated staff was to refer to procedures for specific infection control precautions that may be warranted. The policy also stated contact precautions were intended to prevent transmission of infectious agents, which were spread by direct or indirect contact with the patient or the patient's environment. Personnel caring for residents on contact precautions should wear a gown and gloves for all interactions that involve contact with the patient or potentially contaminated areas in the resident's environment. 1.[NAME] Review of Resident #61's medical record revealed the facility admitted the resident on 06/24/14 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident required the assistance of two (2) staff members for bed mobility and bathing. The resident had severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score 99.0 Review of Resident #61's diagnostic lab report dated 02/18/19 revealed staff had obtained a culture of the resident's gastrostomy tube site (feeding tube site) and the following organisms were growing: Streptococcus Agalactiae-Group B, Pseudomonas Aeruginosa, Proteus Mirabilis, and Diphtheroid Bacillus. Review of Resident #61's physician's orders [REDACTED]. 1.B. Review of Resident #96's medical record revealed the facility admitted the resident on 06/13/18 with [DIAGNOSES REDACTED]. Review of Resident #96's most recent Quarterly ((MDS) dated [DATE] revealed the resident required assistance of two (2) staff members with transfers and bathing. Resident #96 was cognitively intact, with a Brief Interview for Mental Status score of fifteen (15). Review of Resident #96's diagnostic lab report dated 06/02/18, revealed he/she was diagnosed with [REDACTED]. Further review of the record revealed an order for [REDACTED].>1.C. Review of Resident #903's medical record revealed the facility admitted the resident on 11/02/18 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly MDS dated [DATE], revealed the resident required the assistance of two (2) staff members for bathing and transfers. The resident had severe cognitive impairment, and was not interviewable. Review of Resident #903's physician's orders [REDACTED]. 1.D. Review of Resident #912's medical record revealed the facility admitted the resident on 01/16/17 with [DIAGNOSES REDACTED]. Review of the most recent Annual MDS dated [DATE], revealed the resident required the assistance of two (2) staff members for bathing and transfers. The resident had a BIMS score of ten (10), which indicated the resident was interviewable. Review of Resident #912's physician's orders [REDACTED]. 1.E. Review of Resident #913's medical record revealed the facility admitted the resident on 02/18/19, with [DIAGNOSES REDACTED]. Review of the most recent Quarterly MDS dated [DATE], revealed the resident required the assistance of two (2) staff members for bathing and transfers. The resident had severe cognitive impairment, and was not interviewable. Review of Resident #913's diagnostic lab report dated 02/17/19, revealed staff had obtained a nasal swab for the resident which was positive for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). Review of Resident #913's physician's orders [REDACTED]. Interview with Registered Nurse (RN) #9 on 03/21/19 at 5:00 PM, RN #20 on 03/17/19 at 4:38 PM, and State Registered Nursing Assistant (SRNA) #8 on 03/21/19 at 5:00 PM revealed they had provided care to residents at the evacuation site on 02/24/19, and contact precautions were not implemented to protect staff or other residents from the transmission of diagnosed infectious disease processes. The RNs and the SRNA were unsure why residents that required contact precautions, were not provided that at the alternate site. Interview with the facility's Infection Control Nurse (RN #4) on 03/19/19 at 12:15 PM revealed she provided direct care to residents at the evacuation site, after they were evacuated due to flooding on 02/24/19. RN #4 stated that contact precautions were not implemented for any resident that had been diagnosed with [REDACTED]. RN #4 stated she was unsure why contact precautions were not implemented. She stated she had been informed when Resident #96 was admitted to the facility back in the summer that he/she had a bad super bug infection and would always require contact precautions to protect anyone else from getting it. However, no action was taken at the evacuation site, to protect residents and staff from the infection. 2. Review of Resident #13's medical record revealed the facility admitted the resident on 08/22/14 with [DIAGNOSES REDACTED]. Review of the most recent Quarterly MDS dated [DATE], revealed the resident required the assistance of two (2) staff members with bed mobility and toileting. The facility assessed Resident #13 to have a Brief Interview for Mental Status of eight (8). Further review of Resident #13's record revealed the resident was admitted to a local hospital on [DATE] and then readmitted to the facility on [DATE]. Review of the resident's labs, conducted during his/her hospital stay revealed the resident was diagnosed with [REDACTED]. Observations of Resident #13 on 04/01/19 at 3:00 PM, revealed the resident was lying in bed on his/her right side and the resident's urinary catheter bag, that contained tea colored urine, was observed lying on the floor, beside the resident's bed. Further observations revealed the resident's urinary catheter bag had a tea colored substance, dry in appearance, on various areas on the outside of the bag. The resident was also observed to have a roommate, and no contact precautions had been implemented. Further observations conducted on 04/01/19 at 4:00 PM and 6:00 PM revealed staff had covered the resident's urinary catheter with a dignity bag, and no contact precautions had been implemented. Review of Resident #13's physician's orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #3 on 04/01/19 at 6:50 PM, revealed she was the Unit Manager (UM) on the unit Resident #13 resided. She stated she was not aware that the resident had been diagnosed with [REDACTED]. She stated the nurse that readmitted the resident was required to review diagnostic tests conducted at the hospital. She also stated the resident's physician should have been notified and the resident should have been placed on contact precautions. Interview with Licensed Practical Nurse (LPN) #7 on 04/01/19 at 4:50 PM, revealed she was assigned to care for Resident #13 on 04/01/19 and was not aware the resident had been diagnosed with [REDACTED]. LPN #7 also stated she had not administered the resident's last dose of intravenous (IV) antibiotic, which was due at 10:00 AM (seven hours ago) because she was unable to locate it in the facility. She stated she notified the pharmacy at 10:00 AM on 04/01/19 that the medication was needed; however, no other actions were taken to obtain the resident's ordered medication. Interview with RN #8 on 04/02/19 at 1:00 PM revealed she had readmitted Resident #13 on 03/26/19 from an acute hospital stay. She stated she recalled reviewing the resident's readmission paperwork, which included diagnostic lab tests, but she did not recall identifying that the resident had been diagnosed with [REDACTED]. RN #8 stated if she had identified that on readmission, she would have contacted the physician and orders would have been obtained to place the resident on contact precautions, because that's what our doctors order for ESBL. She stated she had not been trained on any real process related to infection control in the facility. RN #8 stated staff have been directed to call the physician, but had not been directed to contact any Administrative staff when residents were diagnosed with [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on 04/02/19 at 12:10 PM, revealed she had been assigned to Resident #13 a few days ago and was not aware the resident had been diagnosed with [REDACTED]. The LPN further stated the resident had not been on contact precautions. LPN #1 stated if she would have been aware of the resident's recent diagnosis, she would have called the physician, implemented contact precautions and requested orders for a repeat culture. She also stated staff had no policies or procedures to reference related to isolation, or obtaining repeat cultures after the antibiotics were complete. She stated she had been directed by the facility's Infection Control Nurse to discontinue contact precautions after the last dose of antibiotic was administered, regardless of the infective organism that was treated. Interview with the Infection Control Nurse (RN #4) on 03/19/19 at 12:15 PM and on 04/01/19 at 5:45 PM, revealed she had been responsible for the facility's infection control program since (MONTH) (YEAR), and she did not feel like she received adequate training at the time she initially took over the program from the Director of Nursing (DON). She stated she had attended one (1) training in (MONTH) (YEAR), but stated things are always coming up. RN #4 stated that she has no policies or procedures, and no Infectious Disease Physician or Specialist to contact for guidance. She stated she referenced the Centers for Disease Control (CDC) guidelines; however, those guidelines, do not give clear direction on when and for how long to isolate residents, or when and if recultures should be obtained when infectious organisms were identified for the residents. Continued interview revealed she monitored infection control processes in the facility by reviewing Nurses' Notes, labs and chest x-rays daily (Monday-Friday) in the morning meetings. However, RN #4 stated she was required to work the floor on night shift at times, and she was not aware of anyone that was monitoring infections, in her absence of the morning meetings. She stated, I guess things are getting missed. RN #4 acknowledged residents with infectious organisms should be placed in rooms with other residents that have the same organisms. She stated she had voiced concerns with these practices not occurring in the facility to the DON and the Administrator. However, she stated the Administrator would not allow her to place residents appropriately and she was not sure why. She also stated she had directed staff to remove contact precautions for residents when the last dose of antibiotic was administered and that she had not had clear direction on when or, if specific organisms should have a repeat culture, therefore staff just do what the physician orders. However, she stated she was not aware if the facility's physicians had been trained in infection control processes or not. Further interview with RN #4 revealed she was not aware that Resident #13 was diagnosed with [REDACTED]. She stated the readmission nurse should have identified that, because the culture was in the paperwork that had accompanied the resident back to the facility. She stated the physician should have been notified at the time of readmission, and the resident should have been placed on contact isolation. RN #4 stated staff was not required to contact her, or anyone else besides the physicians, when residents were diagnosed with [REDACTED]. The RN acknowledged the risks of transmission of infectious organisms onto staffs' clothing, when catheter bags were emptied, or the location of the bag was changed if clothing protectors were not in use. Interview with the DON on 04/03/19 at 12:13 PM revealed she was not aware that contact precautions had not been implemented at the evacuation site for the residents on 02/24/19. The DON acknowledged that she had not directed anyone to do so. Further interview with the DON revealed she had not identified any concerns with infection control processes in the facility, prior to 04/01/19. She stated the nurse that readmitted Resident #13 should have identified the resident's infection and the nurse should have contacted the physician and implemented contact isolation precautions. The DON stated administrative staff reviewed all admission and readmission records during the morning meetings conducted Monday-Friday; however, she stated, We didn't pick up on it, because we just reviewed orders and not the labs. The DON stated the facility had not received any training related to infection control in the last year, until 03/27/19 when concerns were identified by the State Survey Agency related to the facility's Emergency Management process. ***The facility alleged the following actions removed Immediate Jeopardy on 03/30/19: 1. Resident #87 was transferred to theER on [DATE] and returned to the facility on [DATE]. Treatment per physician's orders [REDACTED]. 2. Resident #902 was transferred to theER on [DATE] and returned to the facility on [DATE]. Treatment per physician's orders [REDACTED]. 3. Licensed nurses completed an assessment of all current residents on 03/23/19 to determine any changes in condition. The changes in condition included, but was not limited to respiratory distress, changes in skin condition, and signs and symptoms of infection. No changes in condition were identified. 4. The Oxygen Inspector was at the facility on 03/25/19 and completed an assessment of all oxygen tanks to determine that they were stored and functioning as appropriate. No problems were identified. 5. The Administrator, on record during the evacuation, is no longer employed at the facility as of 03/22/19. 6. The Administrator, Director of Nursing (DON), Maintenance Director, Regional Director of Operations, Chief Nursing Officer, and the Kentucky Education Director reviewed and revised the Emergency Preparedness Plan (EPP) related to flooding and emergency evacuation as of 03/29/19. The EPP changes included, but were not limited to the following: when to initiate an evacuation based on associated environmental conditions (See attachment A); have medical and pharmaceutical supplies (including medical records, medications, blood sugar testing equipment, oxygen, suctioning equipment, and a crash cart) available at the receiving location prior to or in conjunction with the resident's arrival; a tracking tool to document who, when and where residents were transported during an evacuation; and the tracking of and knowledge of volunteers, duties performed and assignment of tasks. 7. The Kentucky Education Director educated the Administrator as of 03/29/19 on implementing the Emergency Preparedness Plan which included tracking resident transports, identifying volunteers and the duties they perform, infection control related to providing transmission-based precautions during an evacuation, oxygen transport, and making sure medical records, medical supplies (including but not limited to oxygen, suction equipment, blood sugar testing supplies and a crash cart) and pharmaceutical supplies were at the alternate site prior to, or in conjunction with the residents' arrival. 8. All facility staff have been re-educated on or before 03/29/19 by the Staff Development Coordinator, Education Director, Director of Nursing, Unit Manager, or Kentucky Education Director on the Emergency Preparedness Plan as related to evacuation, staff duties, including but not limited to: tracking resident transports; identifying volunteers and the duties they perform; infection control related to providing transmission based precautions during an evacuation; oxygen transport; making sure medical records, medical supplies (including but not limited to medical records, oxygen, suction equipment, blood sugar testing supplies, and a crash cart) and pharmaceutical supplies are at the alternate site prior to, or in conjunction with the residents' arrival. 9. All nursing staff were re-educated to the types of oxygen, how to appropriately transport oxygen (to include not laying oxygen cylinders on resident's beds or touching skin) on or before 03/29/19 by the Education Director. 10. The facility held an Ad hoc Performance Improvement Committee meeting on or before 03/29/19 with the Medical Director to review the Emergency Preparedness Plan related to evacuation including when to initiate an evacuation based on associated environmental conditions; having medical and pharmaceutical supplies (including medical records, medications, blood sugar testing equipment, oxygen, suctioning equipment, and a crash care) available at the receiving location prior to, or in conjunction with the resident's arrival; a tracking tool to document who, when and where residents were transported during an evacuation; and the tracking of and knowledge of volunteers, duties performed, and assignment of tasks. 11. An evacuation drill will be completed on or before 03/29/19 at the facility and led by the Administrator, or designee. The evacuation drill will include observations of staff response and verbal discussion to explain specific steps to take during an evacuation to include but not limited to: when to authorize the evacuation; implementing the Emergency Preparedness Plan; provide medical and pharmacological supplies such as resident medical records, medications, blood sugar testing equipment, oxygen, suctioning equipment, and crash cart; tracking of resident transports; volunteer tracking and assignments; and maintaining transmission based precautions. Re-education will be provided for any areas of concern identified. A summary of the evacuation drill will be submitted to the Quality Assurance Committee by the Administrator for further review and recommendation. 13. A collaborative meeting was held on 03/26/19 with the Fire Chief of the City, Director of Nursing, Maintenance Director, Administrator, Chief Nursing Officer, Kentucky Education Director, and the Regional Director of Operations to review when to initiate evacuation. When a flood warning occurs, a collaborative discussion will occur with the Administrator, or designee, and the Fire Chief to determine if and when an evacuation should occur. The County makes determinations with team members based on local environmental conditions. Team members may include the Judge Executive, Police Chief, Fire Chief, School Superintendent, and Facility Administration (Administrator, Maintenance Director, and/or Director of Nursing). When a flood warning occurs the Administrator, or designee will start making contact with other Department Head Staff to inform them of the warning and discuss preparation needs in the event of evacuation. 14. On 03/21/19, the Maintenance Director attended the KY Health Care Coalition Region 10/11 meeting that reviews aspects of Community Emergency Preparedness Planning. ****The State Agency confirmed the following removed Immediate Jeopardy on 03/30/19: 1. Record review revealed Resident #87 was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. No additional concerns were identified. 2. Record review revealed Resident #902 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. No additional concerns were identified. 3. Record review and interview on 04/01/19 with Registered Nurse (RN) #3 at 5:18 PM, RN #4 at 6:59 PM, and on 04/02/19 with the Director of Nursing (DON) at 11:09 AM revealed assessments were completed on all residents on 03/23/29 to identify any change in condition. No changes were identified. 4. Review of an inspection report and interview with the Director of Respiratory Therapy on 04/01/19 at 3:49 PM, the DON on 04/02/19 at 11:09 AM, and the Kentucky Clinical Education Director on 04/02/19 at 9:52 AM revealed an inspection (by the Oxygen Inspector) of all oxygen tanks was completed on 03/25/19 with no problems identified. 5. Based on interview on 04/02/19 with the Interim Administrator at 10:28 AM and the DON at 11:09 AM, the previous administrator's last day of employment was 03/22/19. 6. Review of the facility's revised Emergency Preparedness Plan (EPP) and interviews on 04/01/19 with the Maintenance Director at 3:30 PM, the Kentucky Clinical Education Director on 04/02/19 at 9:52 AM, with the DON at 11:09 AM, and the Administrator at 10:28 AM revealed the group meet on 03/29/19 to review and revise the EPP. The changes included tracking of residents and volunteers, communication, medical and pharmaceutical supplies, etc. 7. Review of training records and interview on 04/02/19 with the Interim Administrator at 10:28 AM and the Kentucky Clinical Education Director at 9:52 AM revealed the Administrator, DON, Maintenance Director, and Infection Control Nurse received training on 03/26/19 on implementing the EPP including tracking residents, identifying volunteers, providing transmission based precautions during evacuation, and medical equipment/pharmaceutical supplies transport during evacuation. 8. Review of training records, posttests, and interviews on 04/01/19 with the Maintenance Director at 3:35 PM, State Registered Nurse Aide (SRNA) #22 at 6:08 PM , SRNA #18 at 6:37 PM, SRNA #25 at 6:44 PM, Business Office Manager at 6:23 PM, Housekeeper #1 at 6:18 PM, Activities Director at 6:30 PM, SRNA #28 at 7:15 PM, SRNA #29 at 7:22 PM, Social Service Director at 5:51 PM, LPN #4 at 4:57 PM, LPN #7 at 5:33 PM, LPN #10 at 4:48 PM, Housekeeping Supervisor at 4:33 PM, Dietary Manager at 4:14 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, Director of Respiratory Therapy at 3:49 PM, and on 04/02/19 with SRNA #26 at 9:14 AM, SRNA #2 at 9:39 AM, SRNA #5 at 9:27 AM and the DON at 11:09 AM revealed all had received training on the facility's EPP as it relates to evacuation and the revisions in the plan. A posttest was taken after the training and all passed. 9. Review of training records and interviews on 04/01/19 with State Registered Nurse Aide (SRNA) #22 at 6:08 PM , SRNA #25 at 6:44 PM, LPN #4 at 4:57 PM, LPN #7 at 5:33 PM, LPN #10 at 4:48 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, and on 04/02/19 with SRNA #26 at 9:14 AM, SRNA #2 at 9:39 AM, and SRNA #5 at 9:27 AM revealed all had been educated on transportation of portable oxygen and not placing oxygen tanks in the bed with residents. 10. Review of Quality Performance Improvement Meeting (QAPI) minutes dated 03/29/19, and interviews on 04/01/19 with the Business Office Manager at 6:23 PM, Activities Director at 6:30 PM, Social Service Director at 5:51 PM, Housekeeping Supervisor at 4:33 PM, Dietary Manager at 4:14 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, and on 04/02/19, with the KY Clinical Education Director at 9:52 AM and the DON at 11:09 AM revealed all had attended the QAPI meeting on 03/29/19. The Medical Director attended the meeting and all stated they discussed the EPP and the evacuation drill held that day. 11. Review of the Evacuation Drill checklist dated 03/29/19, sign-in sheets, and interviews on 04/01/19 with the Business Office Manager at 6:23 PM, Activities Director at 6:30 PM, Housekeeping Supervisor at 4:33 PM, Dietary Manager at 4:14 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, and on 04/02/19, with the KY Clinical Education Director at 9:52 AM, and the DON at 11:09 AM revealed an evacuation drill due to a flood warning was conducted on 03/29/19 and all stated the drill went well. The KY Clinical Education Director stated a discussion with staff after the drill was completed and additional ideas to improve the plan were discussed. 12. Review of the QAPI Minutes and interview on 04/01/19 with the Business Office Manager at 6:23 PM, Activities Director at 6:30 PM, Social Service Director at 5:51 PM, Housekeeping Supervisor at 4:33 PM, Dietary Manager at 4:14 PM, RN #4 at 6:59 PM, RN #3 at 5:18 PM, and on 04/02/19, with the KY Clinical Education Director at 9:52 AM and the DON at 11:09 AM revealed all had attended the meeting on 03/29/19 and the evacuation drill was discussed in the meeting. 13. Review of Meeting Minutes and interview with the interim Administrator on 04/02/19 at 10:28 AM; and, on 04/10/19 at 1:15 PM with the local Fire Chief confirmed the facility had a meeting on 03/26/19 with the Fire Chief and discussed if and when evacuations should occur. Interview with the Maintenance Director on 04/01/19 at 3:35 PM revealed all Department Supervisors now had an app on their phones that could be used to communicate any needed facility evacuation. 14. Review of training records and interview with the Maintenance Director on 04/01/19 at 3:35 PM revealed the Maintenance Director had attended the KY Health Care Coalition Region 10/11 meeting on 03/21/19.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the physician of a significant change in the resident's physical and mental status for one (1) of twenty-seven (27) sampled residents (Resident #907). On 03/16/19, between approximately 8:00 AM and 9:00 AM, nursing staff assessed Resident #907 to have a decreased level of cognition. The resident was assessed to be unable to recognize staff, and was unable to form sentences; however, staff did not notify the resident's physician of the significant change in the resident's condition until approximately 2:30 PM on 03/16/19. After notifying the physician, the resident was transferred to the hospital and was assessed to be overly sedated, requiring [MEDICATION NAME] (treats narcotic overdose) to reverse sedation secondary to pain medications administered at the nursing facility. The findings include: Review of the facility's policy Change in a Resident's Condition or Status, not dated, revealed staff would promptly notify the attending physician and the resident's representative of changes in the resident's medical/mental condition. The policy stated the charge nurse would notify the resident's attending physician or on-call physician when there was a significant change in the resident's physical, emotional, or mental condition or if there was a need to transfer the resident to a hospital/treatment center. Resident #907 was admitted to the hospital on [DATE], and was not currently residing in the facility. Review of Resident #907's medical record revealed the facility admitted the resident on 10/10/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) indicating the resident had moderate cognitive impairment. Further review of the MDS assessment revealed the resident was administered as needed (PRN) pain medication for occasional pain that the resident rated at a six (6) on a pain scale of zero (0) to ten (10). Continued review of the MDS assessment revealed the resident received opioid pain medications during three (3) days of the lookback period. Review of the Narcotic Sheet and the Medication Administration Record [REDACTED]. Review of Resident #907's comprehensive care plan dated 10/17/16, revealed the facility identified the resident was at risk of impaired cognition. The facility developed interventions that included observing for changes in the resident's cognitive status; and, notifying the resident's Physician, family, and responsible party of changes, as needed. Review of a Nursing Departmental Note dated 03/16/19 at 11:34 AM, revealed the resident was lying in bed talking on the phone with his/her daughter, the resident had increased confusion, difficulty completing sentences, and hesitation when speaking. Continued review revealed the Resident's Physician was notified by fax and no new orders were received (did not receive a faxed response from the physician). Review of a Nursing Departmental Note dated 03/16/19 at 3:41 PM, revealed it was a late entry for 2:30 PM, the resident's daughter was at the facility and the resident continued to have altered mental status. The resident was unable to speak in complete sentences and unable to tell staff or his/her daughter his/her name. The resident's daughter requested that the resident be sent to the emergency room for evaluation. The resident's physician was notified with a new order to transfer the resident to the emergency room for evaluation. Continued review revealed emergency medical services (EMS) were in the facility at 3:15 PM to transport the resident to the emergency room for evaluation. Review of the resident's hospital record revealed the resident was assessed in the emergency department on 03/16/19 to be overly sedated, requiring [MEDICATION NAME] to reverse sedation secondary to pain medications administered at the nursing facility. After administration of the [MEDICATION NAME], the resident woke up with significant improvement of arousal and alertness. Interview with Licensed Practical Nurse (LPN) #2 on 04/01/19 at 6:53 PM and 04/02/19 at 3:38 PM, revealed she was Resident #907's nurse on 03/16/19. She stated during morning medication pass between approximately 8:00 AM and 9:00 AM, she was administering Resident #907's medications when the resident experienced a change in condition. LPN #2 stated the resident had taken his/her oral medication and she was attempting to administer the resident's inhaler when the resident began staring at her and could not form sentences. According to LPN #2, the resident usually talked to her and was alert and oriented, but that morning the resident would try to speak but had a hard time getting his/her words out. She further stated that the resident did not recognize her. LPN #2 stated that she did not speak with the resident's physician on the phone earlier that morning, but had faxed the physician the information about the resident's change in condition. The LPN stated she faxed the information to the physician's office on 03/16/19 (Saturday) but the physician was not in the office that day. Continued interview with LPN #2 revealed she did not phone Resident #907's physician until after the resident's daughter arrived at the facility at approximately 2:30 PM. Per the LPN, the resident's condition had worsened and she received an order to transfer the resident to the emergency room for evaluation. Interview with Physician #2 on 04/02/19 at 11:15 AM and 04/03/19 at 9:59 AM revealed he was not made aware of the resident's change in condition on 03/16/19 until after the resident's daughter had arrived to the facility and requested that the resident be transferred to the emergency room for evaluation. He stated he should have been notified when the resident first experienced a significant change in cognition on the morning of 03/16/19. Physician #2 stated that he had an ongoing concern with the facility staff faxing resident related concerns/needs which should be called to him instead of faxed. The physician stated on the weekends he was not in the office and would not receive the faxed notification until the following Monday. Interview with the Director of Nursing (DON) on 04/03/19 at 6:03 PM, revealed Resident #907's Physician should have been notified immediately of the resident's change in condition. She stated staff should not have waited until the afternoon to notify the physician. Per the DON, Resident #907's Physician should have been called with the resident's change in condition as soon as the resident was assessed by the nurse.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of twenty-seven (27) sampled residents (Resident #907) received care and treatment in accordance with the resident's care plan and professional standards of practice. Review of Resident #907's comprehensive care plan dated 10/17/16, revealed the facility identified the resident was at risk of impaired cognition with an intervention to notify the resident's Physician, family, and responsible party of changes as needed. On 3/16/19, between approximately 8:00 AM and 9:00 AM, staff observed the resident to have a decreased level of cognition and was unable to form sentences; however, the resident's physician was not notified of the resident's change in condition as required by the care plan until approximately 2:30 PM on 03/16/19. Resident #907 was transferred to the hospital where he/she was assessed to be overly sedated, requiring [MEDICATION NAME] (treats narcotic overdose) to reverse sedation. The findings include: Review of the facility's Comprehensive Care Plan policy, not dated, revealed the person-centered care plan was developed to promote communication of the resident's needs, goals, and interventions to promote successful goal attainment. The care plan would aid in preventing or reducing declines in the resident's functional status and/or functional levels and reflect currently recognized standards of practice for problem areas and conditions. The policy did not address how staff was to utilize the care plan when providing resident care. No observations were made of Resident #907 because the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #907's medical record revealed the facility admitted the resident on 10/10/16 with [DIAGNOSES REDACTED]. Review of Resident #907's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12), indicating the resident had moderate cognitive impairment. Further review of the MDS assessment revealed the resident received pain medication as needed (PRN) for occasional pain that the resident rated at a six (6) on a pain scale of zero (0) to ten (10). Continued review of the MDS assessment revealed the resident received opioid pain medications during three (3) days of the lookback period. Interview with the Director of Nursing (DON) on 04/01/19 at 6:33 PM revealed the resident received a physician's orders [REDACTED]. Review of Resident #907's comprehensive care plan dated 10/17/16, revealed the facility identified the resident was at risk of impaired cognition. The facility developed interventions that included observing for changes in the resident's cognitive status; and notifying the resident's Physician, family, and responsible party of changes, as needed. Interview with Family Member #3 on 04/01/19 at 6:11 PM, revealed she spoke with Resident #907 on the phone daily. She stated the only time the resident had an altered mental status was when he/she had a UTI, but was normally alert and oriented and able to speak to her on the phone. However, on 03/16/19, she stated she called the resident and the resident did not recognize her and could not respond verbally. She stated the nurse that worked on 03/16/19 told her that the resident may have been experiencing [MEDICAL CONDITION] (TIA) and that they were common and that she did not feel the resident needed to be sent to the hospital. Family Member #3 stated she told the nurse she was on her way to the facility and that it would take a few hours because she lived out of town. Continued interview revealed that when she arrived to the facility that afternoon, the resident was still at the facility and that she had to request that staff transfer the resident to the emergency room . Review of a Nursing Departmental Note dated 03/16/19 at 11:34 AM, revealed the resident was lying in bed talking on the phone with his/her daughter. The Note stated the resident had increased confusion, difficulty completing sentences, and hesitation when speaking. Continued review revealed the resident's physician was notified and no new orders had been received. Review of a Nursing Departmental Note dated 03/16/19 at 3:41 PM, revealed the note was a late entry for 2:30 PM, at which time the resident's daughter was at the facility and the resident continued to have altered mental status. The resident was unable to speak in complete sentences and unable to tell staff or the daughter his/her name. The note stated the resident's daughter requested that the resident be sent to the emergency room for evaluation. The resident's physician was notified with a new order to transfer the resident to the emergency room for evaluation and emergency medical services was in the facility at 3:15 PM to transport the resident to the emergency room for evaluation. Review of the resident's hospital record revealed the resident was assessed in the emergency department on 03/16/19 to be overly sedated, requiring [MEDICATION NAME] to reverse sedation secondary to pain medications administered at the nursing facility. After administration of the [MEDICATION NAME], the resident woke up with significant improvement of arousal and alertness. Interview with Licensed Practical Nurse (LPN) #2 on 04/01/19 at 6:53 PM and 04/02/19 at 3:38 PM revealed she was the nurse responsible for Resident #907's care on 03/16/19. She stated during morning medication pass between approximately 8:00 AM and 9:00 AM, she was administering Resident #907's medications when the resident experienced a change in condition. She stated the resident began staring at her, could not form sentences, had a hard time getting his/her words out, and did not recognize her. LPN #2 stated that she did not speak with the resident's physician on the phone, but faxed the physician the information about the resident's change in condition (even though it was Saturday and the physician was not in the office). Continued interview with LPN #2 revealed after the resident's daughter arrived at the facility at approximately 2:30 PM and the resident's condition had worsened, she called Resident #907's physician. She stated the physician ordered for the resident to be transferred to the emergency department for an evaluation. Further interview with LPN #2 revealed she did not look at resident care plans every shift because there was not enough time to look at care plans for every resident that she was responsible for each shift. Interview with Physician #2 on 04/02/19 at 11:15 AM and 04/03/19 at 9:59 AM revealed he was not made aware of the resident's change in condition on 03/16/19, until after the resident's daughter arrived at the facility and requested that the resident be transferred to the emergency department for evaluation. He stated he should have been notified when the resident initially experienced a significant change in cognition on the morning of 03/16/19. Physician #2 stated that he had an ongoing concern with the facility staff sending him a fax for things that they should call him about. Interview with the Director of Nursing (DON) on 04/03/19 at 6:03 PM revealed Resident #907's Physician should have been notified immediately of the resident's change in condition. She stated staff should not have waited until the afternoon to notify the physician. The DON stated that resident care plans were readily available at the nurse's stations for nursing staff to reference as needed. She further stated there was no set time frame for staff to look at resident care plans.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that one (1) of twenty-seven (27) sampled residents (Resident #907) received treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan, and the residents' choices. Nursing staff assessed Resident #807 on 03/16/19 at approximately 8:00-9:00 AM to have a change in mental status. The nurse stated the resident was staring and could not get words out. However, the facility failed to notify the resident's physician in a timely manner, as required by the resident's plan of care and failed to reassess the resident's condition. At approximately 2:30 PM on 03/16/19, the resident's daughter arrived at the facility and the resident could not form complete sentences and was unable to tell staff or his/her daughter his/her name. The resident's daughter insisted the resident be sent to the hospital. The hospital assessed the resident to be overly sedated, requiring [MEDICATION NAME] (treats narcotic overdose) to reverse sedation secondary to pain medications administered at the nursing facility. After administration of the [MEDICATION NAME], the resident woke up with significant improvement of arousal and alertness. The findings include: Review of the facility's Change in a Resident's Condition or Status policy, not dated, revealed the Nurse Supervisor/Charge Nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Record review revealed Resident #907 was admitted to the hospital on [DATE], and was not currently residing in the facility. Review of Resident #907's medical record revealed the facility admitted the resident on 10/10/16, with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #907 to have a Brief Interview for Mental Status (BIMS) score of twelve (12), indicating the resident had moderate cognitive impairment. Review of Resident #907's comprehensive care plan dated 10/17/16, revealed the facility identified the resident was at risk for impaired cognition, and developed interventions that included observing for changes in the resident's cognitive status and notifying the resident's Physician, family, and responsible party of changes, as needed. Review of Resident #907's Medication Administration Record [REDACTED]. According to the resident's Narcotic Sign out Sheet, the facility administered the medication to the resident on average of three (3) times daily. The facility administered the medication on 03/15/19 at 8:30 PM and on 03/16 at 3:00 AM and 9:00 AM. Interview with Licensed Practical Nurse (LPN) #2 on 04/01/19 at 6:53 PM and 04/02/19 at 3:38 PM, revealed she was Resident #907's nurse on 03/16/19. She stated sometime between 8:00 AM and 9:00 AM, she was administering Resident #907's medications (including [MEDICATION NAME]) and the resident experienced a change in condition. LPN #2 stated the resident had taken his/her oral medication and she was attempting to administer the resident's inhaler, when the resident began staring at her and could not form sentences. According to LPN #2, the resident usually talked to her and was alert and oriented, but that morning the resident would try to speak, but had a hard time getting his/her words out and the resident did not recognize her. Continued interview with LPN #2 revealed she assessed the resident periodically throughout the day for worsening in condition; however, she failed to document any further assessments that were made. LPN #2 stated she sent a fax (facsimile) to the resident's physician about the changes in the resident, even though it was Saturday and the physician's office was not open. She stated she did not speak to Resident #907's Physician until after the resident's daughter arrived at the facility at approximately 2:30 PM, at which time the resident's condition had worsened and she received an order to transfer the resident to the emergency room for evaluation. Interview with Certified Nursing Assistant (CNA) #4 on 04/02/19 at 10:23 AM revealed that during breakfast the resident experienced a change in condition; could not speak like he/she normally could and did not recognized her. She stated LPN #2 told her to monitor the resident more closely, every fifteen (15) minutes for worsening of condition. She stated the resident's condition did not worsen until after his/her daughter arrived at the facility that afternoon, at which time LPN #2 transferred the resident to the emergency department. Review of a Nursing Departmental Note dated 03/16/19 at 11:34 AM, (LPN #2 stated this was a late entry for 8-9:00 AM) revealed the resident was lying in bed talking on the phone with his/her daughter. The resident had increased confusion, difficulty completing sentences, and hesitation when speaking. Continued review revealed the resident's physician was notified by fax. Interview with Family Member #3 on 04/01/19 at 6:11 PM, revealed on the morning of 03/16/19, she called the resident and the resident did not recognize her and could not respond verbally, which was a change for the resident. She stated she asked a facility nurse that worked on 03/16/19 to send the resident to the hospital; however, the nurse told her that she did not feel the resident needed to go to the hospital because she felt the resident may have been experiencing [MEDICAL CONDITION] (TIAs or mini [MEDICAL CONDITION]), and TIAs were common. Family Member #3 stated she knew something was wrong with the resident and went to the facility. However, she stated she lived several hours away and did not arrive to the facility until that afternoon. Once she arrived, she had to request that the resident be sent to the hospital for evaluation. Review of a Nursing Departmental Note dated 03/16/19 at 3:41 PM, (late entry for 2:30 PM) revealed the resident's daughter was at the facility and the resident continued to have an altered mental status. The resident was unable to speak in complete sentences and was unable to state his/her name. The Note stated the resident's daughter requested that the resident be sent to the emergency department (ED) for evaluation. The Resident's Physician was notified with a new order to transfer the resident to the emergency room for evaluation. Review of Resident #87's hospital record revealed the resident was assessed in the ED on 03/16/19 to be overly sedated, requiring [MEDICATION NAME] to reverse sedation secondary to pain medications administered at the nursing facility. After administration of the [MEDICATION NAME], the resident woke up with significant improvement of arousal and alertness. Continued interview with Family Member #3 on 04/01/19 at 6:11 PM revealed after treatment with [MEDICATION NAME] in the ED, the resident's condition improved. The family member stated she did not want the resident to go back to the facility due to the incident. Resident #87 was transferred to a facility near where the family member lived. Interview with the Director of Nursing (DON) on 04/03/19 at 6:03 PM revealed a resident's condition should be assessed, documented, and monitored. According to the DON, when staff identified the change in the resident's condition the morning of 03/16/19, the physician should have been notified and action taken to treat the resident.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the medical record for one (1) of twenty-seven (27) sampled residents (Resident #907) was complete and correctly documented. Facility staff failed to document when narcotic pain medication, [MEDICATION NAME] 7.5/325 milligrams (mg) was administered to Resident #907 on the Medication Administration Record in the facility's computer system. Further review revealed Resident #907's (MONTH) 2019 monthly physician's orders [REDACTED]. The findings include: Review of the facility's policy, Medication Administration Controlled Substances dated (MONTH) 2007 revealed medications included in the Drug Enforcement Administration (DEA) classifications as controlled substances were subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. The policy stated that once a controlled medication was administered that it was to be documented on the Medication Administration Record (MAR). Review of the facility's policy Charting and Documenting with a revision date of (MONTH) 2008 revealed all services provided to the resident or any changes in the resident's medical or mental condition, would be documented in the resident's medical record. Review of Resident #907's medical record revealed the facility admitted the resident on 10/10/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) indicating the resident had moderate cognitive impairment. Further review of the MDS assessment revealed the resident was administered as needed (PRN) pain medication for occasional pain that the resident rated at a six (6) on a pain scale of zero (0) to ten (10). Continued review of the MDS assessment revealed the resident received opioid pain medications during three (3) days of the lookback period. Review of Resident #907's monthly physician's orders [REDACTED]. Interview with Medical Records personnel on 04/02/19 at 2:34 PM revealed she could not locate Resident #907's (MONTH) 2019 Physician Orders. Further review of the most recent monthly orders revealed an order for [REDACTED]. Review of the (MONTH) 2019 MAR revealed the resident had six (6) doses of PRN [MEDICATION NAME] 7.5/325 mg signed as administered on the Narcotic Sheet, but they were not signed off as administered on the MAR. Review of the (MONTH) 2019 MAR revealed the resident had twenty-nine doses of PRN [MEDICATION NAME] 7.5/325 mg that were signed as administered on the Narcotic Sheet, but not signed off as administered on the MAR. Review of the (MONTH) 2019 MAR revealed the resident had twelve (12) doses of PRN [MEDICATION NAME] 7.5/325 mg signed off as administered on the Narcotic Sheet, but not signed off as administered on the MAR. Further review of the MARs from (MONTH) 2019 through (MONTH) 2019 revealed the resident's [MEDICATION NAME] 7.5/325 mg was to be administered every six (6) hours PRN. However, review of the Narcotic Sheet for the same time frame revealed four (4) of the seven (7) sheets stated to administer the resident's [MEDICATION NAME] 7.5/325 mg every six (6) hours scheduled, not PRN. Interviews with LPN #1 on 04/02/19 at 11:57 AM, LPN #2 on 04/02/19 at 3:38 PM, Registered Nurse (RN) #8 on 04/02/19 at 12:40 PM, LPN #9 on 04/03/19 at 10:23 AM, and RN #9 on 04/04/19 at 7:31 PM revealed that they were expected to document on the Narcotic Sheet and the MAR when they administered a narcotic medication. They stated they were trained to compare the MAR with the Narcotic Sheet to ensure the orders were the same and if they found a discrepancy they were expected to notify the resident's physician for verification of orders and place a sticker on the Narcotic Sheet and narcotic pill pack stating there was a change in dosage. Interview on 04/02/19 at 12:27 PM, with RN #3, who is a Unit Manager revealed once staff administered the last pill in a narcotic packet that they were to staple the narcotic sheet to it and place it in her mailbox. She stated she performed audits approximately four (4) or five (5) times in the last thirteen (13) months that she had worked at the facility and had not identified concerns with staff not signing off on the MAR when they administered a narcotic. RN #3 stated that she had not identified that the MAR and the Narcotic Sheet for Resident #907 did not match for how often to administer the narcotic. Interview with the DON on 04/03/19 at 6:03 PM revealed she did random audits to ensure narcotic counts were correct, along with the resident receiving the correct ordered dosage. She stated the facility did not have a set date to perform the audits and how often they were performed. The DON stated she had not identified any concerns with the Narcotic Sheets and the MARs not matching. She stated if the computer was locked and the narcotic could not be signed off on the MAR, they were expected to notify her so she could have the nurse that locked the system unlock it. Further interview revealed that she had not identified any concerns with staff not signing off on the MAR when they administer a narcotic. The DON stated she reviewed all physician's orders [REDACTED]. Review of the resident's hospital record revealed the resident was assessed in the emergency department on 03/16/19 to be overly sedated, requiring [MEDICATION NAME] to reverse sedation secondary to pain medications administered at the nursing facility. After administration of the [MEDICATION NAME], the resident woke up with significant improvement of arousal and alertness.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure prompt efforts were made to resolve grievances for one (1) of forty-seven (47) sampled residents (Resident #117). On 01/09/19, Resident #117's family member voiced concerns to the Administrator and Director of Nursing (DON) that staff were not adequately suctioning secretions from Resident #117's [MEDICAL CONDITION] (an opening in the neck to the windpipe). Resident #117 had been treated in the Emergency Department (ED) on 01/08/19 and diagnosed with [REDACTED]. According to the family member, the ED Physician who treated the resident on 01/08/19 stated the resident was not receiving appropriate tracheal suctioning. However, the facility failed to take any action to investigate the concerns regarding Resident #117's respiratory care to ensure the resident was receiving appropriate respiratory care. Staff failed to provide [MEDICAL CONDITION] care/suctioning on 01/09/19 at 7:00 PM, and at 11:00 PM. On 01/10/19 at 6:40 AM, staff found Resident #117 unresponsive and not breathing. The resident was transferred to a hospital where he/she was pronounced dead due to Cardiopulmonary Arrest due to Upper Airway Obstruction. The facility's failure to ensure a resident's right for prompt resolution of grievances has caused or is likely to cause injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/23/19, and determined to exist on 01/09/19 at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on 01/23/19. An acceptable Allegation of Compliance was received on 02/04/19, which alleged removal of the Immediate Jeopardy on 02/02/19. The State Survey Agency determined the Immediate Jeopardy was removed on 02/02/19, prior to exit on 02/06/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Resident and Family Grievances policy, undated, revealed prompt efforts will be made by the facility to resolve grievances. The policy also revealed the grievance would be recorded on a Grievance Form, which would serve as communication to other staff members. Further review of the policy revealed the Administrator or designee would conduct an investigation if warranted. Review of Resident #117's closed medical record revealed the facility admitted the resident on 12/29/18 with [DIAGNOSES REDACTED]. Review of Resident #117's Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. Review of Resident #117's Physician order [REDACTED]. Review of Resident #117's (MONTH) (YEAR), Respiratory Medication Administration Record [REDACTED]. Review of Resident #117's Nursing Notes dated 01/08/19 revealed at 10:45 PM, the resident was very short of air, with an oxygen saturation of 83 percent (%) (normal is 95-100%) while receiving oxygen via the [MEDICAL CONDITION]. According to the Nursing Note, staff suctioned thick, yellow sputum from the resident's [MEDICAL CONDITION] and changed the inner cannula. The Note stated the resident's oxygen saturation improved to 87%, but decreased to 83% within five (5) minutes. Further review of the Nursing Note revealed the resident was transferred to the hospital at 10:45 PM on 01/08/19, and returned to the facility on [DATE] at 4:23 AM with a [DIAGNOSES REDACTED]. Interview with Resident #117's family member on 01/16/19 at 2:35 PM revealed the hospital physician told him that staff at the facility were not suctioning Resident #117 adequately. He stated he reported what the hospital staff told him to the Director of Nursing (DON) and the facility's Administrator on 01/09/19. According to the family member, the Administrator and DON only wanted to know who gave him the information, but nothing else was offered. Interview with the facility's Social Worker on 01/23/19 at 9:50 AM, revealed she was responsible for ensuring prompt resolution of grievances at the facility. She stated when a grievance was voiced, she completed a grievance form, and forwarded the form to the appropriate department (e.g., nursing, dietary, maintenance) for investigation. After the investigation was completed, the grievance form was returned to the Social Worker so she could inform the resident/family regarding the status/resolution of the grievance. The Social Worker stated she was not aware that Resident #117's family member had voiced a grievance on 01/09/19. Interview with the Director of Nursing (DON) on 01/23/19 at 9:50 AM, revealed that she and the Administrator met with Resident #117's family member on 01/09/19 sometime after lunch. The resident's family member reported that hospital staff stated that the resident had not been suctioned properly. She stated she was aware that Resident #117 had been transferred to the emergency roiagnom on [DATE], but was not sure of the reason for the transfer and did not review the resident's hospital medical record. She stated she made some notes regarding the family member's concerns on a piece of paper, but did not complete a grievance form. The DON stated that on 01/09/19, after the family member reported the grievance, she looked into the issues by reviewing the resident's Medication Administration Record [REDACTED]. According to the DON, she also reviewed Resident #117's physician's orders [REDACTED].#117 or any other resident who had a [MEDICAL CONDITION]. Interview with the Administrator on 01/23/19 at 9:55 AM, revealed she was present when Resident #117's family member voiced a grievance regarding not suctioning the resident adequately. She stated she was aware the DON reviewed documentation that the resident only required to be suctioned as needed and no concerns were identified. Further interview with the Administrator revealed that no further action/investigation was taken and that the family member's grievance was not handled per the facility's policy. Review of Resident #117's Medication Administration Record [REDACTED]. In addition, interview with Registered Nurse (RN) #3 on 01/17/19 at 12:50 PM, revealed she did not provide [MEDICAL CONDITION] care for the resident at 7:00 PM on 01/09/19. RN #3 stated she failed to suction the resident's [MEDICAL CONDITION] on 01/09/19 at approximately 11:00 PM, when the resident indicated he/she needed to be suctioned. Continued review of Nursing Notes revealed on 01/10/19 at 6:40 AM, staff found Resident #117 on the floor, not breathing, and the resident was transferred to the hospital. Review of Resident #117's hospital record revealed the resident was pronounced dead on 01/10/19 at 7:32 AM. According to the resident's Death Certificate, the cause of death was Cardiopulmonary Arrest due to Upper Airway Obstruction. **The facility alleged the following actions removed the Immediate Jeopardy on 02/02/19: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On 01/24/19, the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By 01/28/19 the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By 01/29/19 the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By 01/29/19 the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By 01/26/19, the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By 01/28/19, the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On 01/23/19, the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning 01/23/19, the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on 01/28/19. 4. A) On or before 01/31/19, education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after 01/31/19. The facility does not use agency staff. B) Beginning 01/30/19, the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning 01/30/19, the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before 01/26/19, the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a [MEDICAL CONDITION], which included a review of their care plans. On or before 01/28/19, the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care for their [MEDICAL CONDITION] and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with [MEDICAL CONDITION] needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before 01/29/19, each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by 01/29/19. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before 01/25/19, the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for [MEDICAL CONDITION] care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before 01/31/19, the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a [MEDICAL CONDITION] patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific [MEDICAL CONDITION] orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a [MEDICAL CONDITION] patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions [MEDICAL CONDITION], revision of care plans, if indicated, to include individualized care and services furnished related to their [MEDICAL CONDITION]/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by 01/31/19. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on 01/31/19, to ensure understanding of the [MEDICAL CONDITION] care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by 02/01/19. D) On or before 01/25/19, the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before 01/31/19, the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/[MEDICAL CONDITION] care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by 02/01/19. After 02/01/19, licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning 01/30/19, direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before 01/31/19, the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After 01/31/19, licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on 01/09/19 was in-serviced by the DON regarding performing [MEDICAL CONDITION] care as per physician order [REDACTED]. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders [REDACTED]. This verbal education was provided on 01/23/19 by the DON. 10. A) On or before 01/25/19, a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house [MEDICAL CONDITION] residents. Residents were in no distress and no issues were identified. B) On or before 1/31/19, a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before 01/29/19, the Director of Nursing reviewed the MARs, for dates of service from 01/24/19 to 01/31/19, consisting of two (2) in-house [MEDICAL CONDITION] residents. The audits included verified documentation of [MEDICAL CONDITION] care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before 01/28/19, a one-time audit was completed by the Respiratory Therapist to ensure all [MEDICAL CONDITION] residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On 01/25/19, the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in [MEDICAL CONDITION] care and the suctioning process. B) On or before 01/31/19, the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders [REDACTED]. This education will be completed by 01/31/19. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by 01/31/19. The facility does not use agency staff. C) On or before 01/31/19, the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on [MEDICAL CONDITION] care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for [MEDICAL CONDITION] care and suctioning. The in-service also educated regarding nursing responsibility to provide [MEDICAL CONDITION] care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after 01/31/19 until educated and passing post test. 12. A) Beginning 01/31/19, the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the [MEDICAL CONDITION] competency validation tool. 13. On or before 01/31/19, the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting 01/24/19 to identify if any insulin was not given per physician orders [REDACTED]. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before 01/31/19, the DON or Education Director will provide education to all licensed nurses regarding physician orders [REDACTED]. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders [REDACTED]. Documentation will be completed by the nursing management team by each licensed nurse by 01/29/19. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of 01/31/19. 15. Beginning 01/30/19, the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders [REDACTED]. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders [REDACTED]. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders [REDACTED]. 16. Beginning 01/31/19, the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physician orders [REDACTED]. Any discrepancy identified will be corrected at the time of discrepancy by notifying the MD and Family by the Director of Nursing and/or Unit Manager. 17. On or before 01/25/19, the Specialized Medical Services (SMS) [MEDICAL CONDITION] care and suctioning policy was adopted for use, by the facility, to ensure residents with a [MEDICAL CONDITION] receive care per physician order [REDACTED]. The Director of Nursing developed an ancillary [MEDICAL CONDITION] care and suctioning order for licensed nurses to utilize when admitting a resident to ensure that all appropriate physician orders [REDACTED]. 18. On or before 01/31/19, the Regional Director of Operations educated facility management (DON and Administrator) on their responsibilities as it relates to using resources effectively and efficiently to attain or maintain the highest practicable physical well-being for residents in the facility. On or before 01/31/19, the Regional Director of Operations gave a post test to the Administrator and Director of Nursing on their job duties and what is required daily to ensure the facility is operating in a manner that prompts quality of life for the residents. 19. An ADH[NAME]/Quality Assurance and Performance Improvement (QAPI) meeting was conducted on 01/24/19 to discuss the alleged deficient practices and corrective actions. The QAPI team met again on 01/30/19, with at least one Regional team member in attendance (either in person or by phone), and will continue weekly times four (4) weeks and then the facility will continue monthly thereafter. A QAPI meeting was held 02/01/19, for review of data from ongoing audits and staff education. This data will be reviewed weekly and continue times four (4) weeks and then monthly thereafter ongoing. Members of the facility's Quality Assurance Committee consist of the Administrator, Director of Nursing, Assistant Directors of Nursing, Dietary Manager, Business Office Manager, Activities Director, Director of Rehab, Maintenance Director, Social Services Manager, and Medical Director, who participates at least quarterly and as needed. The plan will be updated, as indicated, by the QAPI Committee. For all audits submitted to the QAPI Committee, the Administrator will assign follow-up as needed. ***The State Survey Agency determined the following removed Immediate Jeopardy on 02/02/19, as alleged by the facility: 1. Review of the medical records for Resident #117 revealed the resident was discharged from the facility on 01/10/19. 2. A) Review of the Resident Council Meeting Minutes, dated 01/24/19, revealed fourteen (14) residents attended the meeting and education was provided on the grievance process. Interview with Resident #59 on 02/06/19 at 2:20 PM, revealed the facility staff met with the resident council and reviewed the grievance process, and forms were located throughout the facility for the residents. Review of medical records for Residents #171, #322, and #323 revealed documentation of a social services interview with residents or residents' representatives regarding the grievance process. B) Interview with the Social Services Director on 02/06/19 at 1:56 PM, revealed she was the Grievance Officer for the facility. She stated grievance forms have been placed in several locations in the facility with a locked grievance box located on the Peach Wing. She further stated she would initiate the grievance process and would assign the grievance to the appropriate department. She added the Administrator was to be informed immediately of all grievances. The Grievance Officer also stated the initial response to the grievance must be within seventy-two (72) hours. Review of the Allegation of Compliance binder revealed the grievance log was up to date and maintained by the Administrator. C) Observations of the Blue, Peach, and Green Units on 02/05/19, revealed the Grievance Process Summary was posted with grievance forms available to staff and residents. D) Review of the facility's admission packet on 02/06/19, revealed presence of the Grievance Standards of Practice and Compliance forms. 3. Review of the facility's documentation on 02/06/19, revealed education on the grievance process was provided to the Director of Nursing (DON) and the Administrator on 01/23/19, per the sign-in sheet. The facility's documentation also revealed evidence that this education was provided to department heads on 01/28/19 and to all facility staff on or before 01/31/19 by the sign-in sheets. Interviews on 02/06/19, with State Registered Nurse Aide (SRNA) #15 at 1:00 PM, SRNA #16 at 3:44 PM, SRNA #2 at 1:13 PM, SRNA #4 at 1:30 PM, Licensed Practical Nurse (LPN) #7 at 1:25 PM, LPN #1 at 1:00 PM, LPN #3 at 1:15 PM, with Dietary Staff at 1:40 PM, Maintenance Staff at 1:51 PM, the Respiratory Director at 2:33 PM, and the MDS Coordinator at 1:50 PM revealed knowledge of the Grievance Standard of Practice and Compliance process. 4. A) Review of the facility's New Hire Orientation binder on 02/06/19, revealed presence of the Grievance Standard of Practice and Compliance policy. Review of the binder also revealed evidence of post tests administered to

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop/implement comprehensive, person-centered care plans for four (4) of forty-seven (47) sampled residents (Resident #117, #21, #98, and #106). The facility failed to implement Resident #117's care plan, which stated staff were required to provide [MEDICAL CONDITION] (an opening in the neck to the windpipe) care and administer insulin as ordered. On [DATE], at 7:00 PM staff failed to provide [MEDICAL CONDITION] care (which includes suctioning) and at 11:00 PM, when the resident indicated he/she needed to be suctioned, staff only suctioned the resident's oral cavity but did not suction the resident's [MEDICAL CONDITION]. Further, the facility failed to follow Resident #117's physician's orders [REDACTED]. On [DATE], staff did not administer the resident's insulin that was due at 12:00 AM, until 2:00 AM, two hours late. In addition, staff documented another dose of insulin was administered four (4) hours later at 6:00 AM, when the resident's blood sugar was 111 milligrams per deciliter (mg/dl). However, according to Resident #117's physician's orders [REDACTED]. sugar was below 140 mg/dl. In addition, the facility failed to develop a care plan for Resident #117, with individualized interventions to address the resident's need for assistance with transferring from the bed to a chair, ambulation, and toilet use. According to the resident's admission assessment, Resident #117 required extensive to total assistance; however, on [DATE] at approximately 5:30 AM, staff did not assist the resident and left the resident on a bedside commode. At 6:40 PM, staff found Resident #117 on the floor beside the bedside commode, not breathing. Resident #117 was transferred to the hospital, where he/she was pronounced dead at 7:32 AM. The cause of the resident's death was Cardiopulmonary Arrest due to Upper Airway Obstruction. The facility also failed to follow Resident #21 and #98's care plan and provide [MEDICAL CONDITION] care/suctioning of the residents' tracheostomies on [DATE]. In addition, the facility failed to develop a care plan for Resident #106 with interventions to address the resident's refusal to take medications and to utilize oxygen. The facility's failure to develop care plans with interventions has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed care plan interventions were designed after careful consideration of the relationship between the resident's problem areas and their causes. The policy stated an individualized comprehensive care plan should include measurable objectives and timetables to meet the resident's needs. 1. Interview with the facility's Administrator on [DATE] at 12:00 PM, the Respiratory Therapy Director on [DATE] at 9:30 AM, and the Director of Nursing (DON) on [DATE] at 9:12 AM, revealed the facility did not have policies regarding respiratory care, [MEDICAL CONDITION] care, suctioning, or oxygen. Review of Resident #117's closed medical record revealed that the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #117's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the resident required oxygen therapy, suctioning, and [MEDICAL CONDITION] care. 1. a. Review of Resident #117's care plan dated [DATE], revealed the facility identified the resident had a skin care problem and developed an intervention [MEDICAL CONDITION] as ordered. According to the care plan, nursing and respiratory technicians (respiratory therapists) were responsible for implementing the care plan. Review of Resident #117's physician's orders [REDACTED]. The order stated the care should include changing the inner cannula, cleaning around the stoma with sterile saline and Hydrogen Peroxide followed by cleaning with sterile saline, and then applying a dry dressing (However, [MEDICAL CONDITION] care also includes suctioning the resident's [MEDICAL CONDITION] to clear any secretions. Excess secretions are due to the reduced ability to swallow and cough.). Review of Resident #117's Respiratory Medication Administration Record [REDACTED]. However, there was no documented evidence that staff provided [MEDICAL CONDITION] care or suctioning at 7:00 PM as ordered by the resident's physician. Interview with Registered Nurse (RN) #3, the Unit Manager, on [DATE] at 12:50 PM revealed she was responsible for Resident #117's care on [DATE] from 7:00 PM until [DATE] at 7:00 AM. She stated she did not provide [MEDICAL CONDITION] care or suction the resident's [MEDICAL CONDITION] that night because she assumed that respiratory therapy staff provided the care. The Unit Manager stated she was in Resident #117's room at approximately 11:00 PM on [DATE], and the resident motioned to his/her mouth, indicating he/she needed to be suctioned. According to the Unit Manager, she suctioned the resident's oral cavity, but did not suction the resident's [MEDICAL CONDITION]. Review of Resident #117's Nursing Note dated [DATE] at 6:40 AM revealed staff found the resident face down on the floor, not breathing. Cardiopulmonary Resuscitation (CPR) was initiated, and the resident was transferred to the hospital. Interview with the DON on [DATE] at 10:30 AM revealed the Unit Supervisor (RN #3) should have been aware that nursing staff was responsible for providing respiratory care during the night shift, and should have provided [MEDICAL CONDITION] care/suctioning for Resident #117. 1. b. Further review of the care plan for Resident #117, dated [DATE], revealed the facility identified that the resident had Diabetes and developed an intervention to administer insulin as ordered. Review of Resident #117's (MONTH) 2019 physician's orders [REDACTED]. Further review of Resident #117's physician's orders [REDACTED]. sugar was less than 140 mg/dl. Review of Resident #117's Nurse Medication Administration Record [REDACTED]. On [DATE], at 6:00 AM, RN #3 documented that Resident #117's blood sugar was 111. Further review revealed RN #3 documented that [MEDICATION NAME] R insulin was administered, even though the physician's orders [REDACTED]. Interview on [DATE] at 2:04 PM with Registered Nurse (RN) #3 revealed she administered Resident #117's 12:00 AM dose of [MEDICATION NAME] R, two (2) hours late. She stated she did not administer the medication until 2:00 AM, because she was busy. According to the RN, she did not remember administering insulin to Resident #117 at 6:00 AM on [DATE]; however, the nurse documented that the medication was administered. Review of Resident #117's Nursing Notes revealed staff found the resident on the floor at 6:40 AM on [DATE]. The resident was unresponsive and not breathing. 1. c. Review of Resident #117's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance of two (2) or more persons for bed mobility, toilet use, and personal hygiene; limited assistance of one staff person for ambulation (utilized a wheelchair for ambulation); and limited assistance of two (2) or more persons for transfers. Review of Resident #117's care plan dated [DATE] and the Daily Care Guide (guide that State Registered Nurse Aides utilize to provide care) revealed the facility identified that the resident required assistance with Activities of Daily Living (ADL). However, the interventions the facility developed were not individualized. The interventions for bed mobility and toileting stated the resident required limited assistance of one person, extensive assistance of two persons, and total assistance of one to two persons, as needed. Further review of Resident #117's care plan revealed the resident required limited assistance of two (2) or more persons for transfers and utilized a wheelchair for mobility. Interview with State Registered Nurse Aide (SRNA) #4 on [DATE] at 10:15 AM, revealed she had been assigned to care for Resident #117 in the past. SRNA #4 stated the Daily Care Guides were confusing as to what level of assistance the resident required, but she provided limited assistance of one (1) staff member when transferring the resident from the bed or a chair. Interview with SRNA #10 on [DATE] at 10:30 AM, revealed she looked at a resident and decided how much assistance she thinks the resident needs. SRNA #10 further stated if she was not sure about how much assistance a resident required, she would ask a nurse. Interview with SRNA #11 on [DATE] at 6:20 PM, revealed on the morning of [DATE], she was assigned to provide care for Resident #117. She stated at approximately 5:30 AM, she observed the resident transfer from bed to the bedside commode. SRNA #11 stated she did not enter the resident's room and assist the resident, but watched from the hallway until the resident was on the bedside commode. According to SRNA #11, Resident #117 was independent with ADLs and did not require any assistance. The SRNA stated she then continued down the hallway to provide care for another resident and left the resident on the bedside commode. According to SRNA #11, at approximately 6:00 AM, Registered Nurse (RN) #3 notified her that the resident had fallen and asked her to help get Resident #117 up from the floor. Interview with RN #3 on [DATE] at 12:50 PM, revealed on [DATE] at approximately 6:30 AM, she found the resident lying face down on the floor. She stated it appeared the resident had been on the bedside commode because the resident's incontinence brief was down and there was feces in the bedside commode. RN #3 stated she could not get the resident to respond, but was able to feel a faint pulse. According to the RN, Cardiopulmonary Resuscitation (CPR) was initiated and the resident was transferred to the hospital. Review of Resident #117's hospital record revealed the resident was pronounced dead on [DATE] at 7:32 AM on [DATE], as a result of Cardiopulmonary Arrest. A review of Resident #117's Death Certificate revealed the cause of death was Cardiopulmonary Arrest due to upper airway obstruction. Interview with the Staff Development Nurse on [DATE] at 10:30 AM, revealed residents' care plans were somewhat confusing because they were standardized. She stated the Interdisciplinary Team (IDT) tried to individualize them, but stated the SRNAs could decide what level of assistance a resident needed when the care plan was not individualized. Interview with MDS Coordinator #2 on [DATE] at 11:15 AM, revealed she did not complete the MDS assessment or care plan for Resident #117. After reviewing the resident's MDS, she stated the resident's care plan should have stated that the resident required two (2) staff persons for assistance with ADLs. Interview on [DATE] at 10:50 AM with MDS Coordinator #1 revealed she considered Resident #117's care plan to be an individualized care plan, even though [MEDICAL CONDITION] care was listed under skin care and the care plan listed options for the level of assistance the resident required, that were not in accordance with the resident's assessed level of need. 2. Observation of Resident #21 on [DATE] at 10:15 AM revealed the resident had a [MEDICAL CONDITION] and was receiving oxygen via the [MEDICAL CONDITION]. Further observation revealed Registered Nurse (RN) #9 suctioned clear secretions from the resident's [MEDICAL CONDITION]. Review of Resident #21's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #21's Minimum Data Set ((MDS) dated [DATE], revealed the resident was in a persistent vegetative state with no discernible consciousness. The MDS also revealed the resident required respiratory treatments that included [MEDICAL CONDITION] care, suctioning, and oxygen. Review of Resident #21's care plan dated [DATE], revealed the facility developed an intervention to provide [MEDICAL CONDITION] care and suction as needed as ordered by the resident's physician. Review of Resident #21's physician's orders [REDACTED]. However, interview with the Unit Manager, RN #3, on [DATE] at 11:10 AM revealed she did not provide any [MEDICAL CONDITION] care for Patient #21 on [DATE] at 7:00 PM. She stated she was not aware nursing staff was required to provide any type of respiratory care during the night shift. 3. Review of Resident #98's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #98's Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated moderately impaired cognition. Further review of the MDS revealed the resident required respiratory treatments that included [MEDICAL CONDITION] care, suctioning, and oxygen. Review of Resident #98's care plan dated [DATE], revealed the facility developed an intervention to provide [MEDICAL CONDITION] care and to suction as needed, as ordered by the resident's physician. Review of Resident #98's physician's orders [REDACTED]. Interview with the Unit Manager, RN #3, on [DATE] at 11:10 AM revealed she was assigned to provide care for Resident #98 on [DATE] from 7:00 PM until [DATE] at 7:00 AM. She stated she did not suction the resident's [MEDICAL CONDITION] or provide any type of [MEDICAL CONDITION] care during that time. She stated she was not aware nursing staff was required to provide any type of respiratory care during the night shift. 4. Review of the facility's Med-Pass policy dated (MONTH) 2010 revealed each resident's comprehensive care plan was designed to incorporate identified problem areas and the risk factors associated with identified problems. The policy also revealed identified problem areas and their causes, and developed interventions that should be targeted and meaningful to the resident. Observation of Resident #106 on [DATE] at 8:48 AM, revealed the resident's oxygen concentrator was set on two (2) liters per minute (lpm). However, the oxygen tubing was hanging on the left side rail and the resident was not utilizing the oxygen. Interview with the resident on [DATE] at 8:49 AM, revealed he/she did not use the oxygen because It hurts my nose. The resident stated staff told him/her to utilize the oxygen or they (staff) would put it on the resident; however, the resident stated he/she would just remove it. Review of Resident #106's medical record revealed the facility admitted the resident on [DATE], and the resident had [DIAGNOSES REDACTED]. Review of Resident #106's physician's orders [REDACTED]. Review of Resident #106's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident had moderately impaired cognition. Further review of the MDS revealed the resident had rejected care during the seven (7) days prior to the assessment. Review of Resident #106's Medication Administration Records (MARs) for (MONTH) (YEAR) revealed the resident refused medications on (MONTH) 16, 20, and 21, which were within the seven (7) day look-back period for the [DATE] MDS assessment. Review of Resident #106's care plan dated [DATE] revealed the facility developed an intervention for the resident to utilize oxygen as ordered. Further review of the care plan revealed the resident was at risk for psychosocial well-being related to Dementia and Depression and on [DATE], the facility revised the resident's care plan to state the resident had refused laboratory testing. However, there was no documented evidence the facility identified that the resident refused to utilize oxygen and take medications, nor implemented interventions to address the resident's refusal (e.g., oxygen hurt the resident's nose). Interview with Registered Nurse (RN) #1 on [DATE] at 10:50 AM and RN #4 on [DATE] at 10:13 AM, revealed Resident #106 was noncompliant with oxygen and frequently refused medication, but was not aware of any interventions to address the behavior. RN #4 stated that Social Worker #1 was responsible for developing care plans for residents who refused care. Interview with Social Worker #1 on [DATE] at 3:50 PM, revealed she was responsible for developing care plans for residents who refused care. She stated she reviewed residents' medical records to identify behaviors. According to the Social Worker, staff had not documented that Resident #106 refused oxygen; subsequently, the Social Worker had not developed a care plan with interventions to address the resident's refusal. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a [MEDICAL CONDITION], which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care for their [MEDICAL CONDITION] and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with [MEDICAL CONDITION] needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for [MEDICAL CONDITION] care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a [MEDICAL CONDITION] patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific [MEDICAL CONDITION] orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a [MEDICAL CONDITION] patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions [MEDICAL CONDITION], revision of care plans, if indicated, to include individualized care and services furnished related to their [MEDICAL CONDITION]/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the [MEDICAL CONDITION] care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/[MEDICAL CONDITION] care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing [MEDICAL CONDITION] care as per physician order [REDACTED]. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders [REDACTED]. This

Based on interview, closed record review, and review of facility policy, it was determined that the facility failed to ensure one (1) of forty-seven (47) sampled residents (Resident #117) received adequate supervision to prevent accidents. A review of Resident #117's admission assessment and a Physical Therapy Note dated [DATE], revealed the resident required assistance with transfers to/from bed/chair. The admission assessment revealed the resident also required extensive assistance with ambulation and toileting. However, on [DATE], at approximately 5:30 AM, staff observed Resident #117 transfer from bed to the bedside commode alone without offering to assist the resident. In addition, staff left the resident on the bedside commode unassisted. At approximately 6:30 AM, one hour later, staff found the resident on the floor, face down, unresponsive and not breathing. The facility initiated Cardiopulmonary Resuscitation (CPR) and transferred the resident to the hospital where the resident was pronounced dead at 7:32 AM on [DATE]. The facility's failure to ensure residents were supervised to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The facility's failure to ensure [MEDICAL CONDITION] care and tracheal suctioning was provided to residents has caused or likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit, which lowered the scope and severity to D at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include Review of the facility's Incident and Accident Process policy, dated (MONTH) (YEAR), revealed the purpose of the process was to ensure each resident received adequate supervision and assistive devices to prevent avoidable accidents. Review of Resident #117's closed medical record revealed that the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #117's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. The MDS further revealed the resident required extensive assistance of two (2) or more persons for bed mobility, toilet use, and personal hygiene. Further review revealed the resident required limited assistance of one person for ambulation (via a wheelchair) and two (2) or more persons for transfers. Review of an Occupational Therapy (OT) Treatment Encounter Note dated [DATE], revealed OT evaluated Resident #117, and a plan of care was developed. The plan of care revealed the OT was treating the patient for gross motor coordination; and transfer training, range of motion techniques, and strengthening activities to increase functional task performance training with mobility. Review of the Physical Therapy (PT) Treatment Encounter Note dated [DATE], revealed an evaluation was completed on Resident #117 and a plan of care was developed. The plan of care revealed PT was treating the patient for bed mobility activities to increase functional skills, training in rolling, scooting, and bridging to facilitate independent bed mobility, and transfer training to increase functional task performance. According to a Physical Therapy Note dated [DATE], Resident #117 transferred with assistance of one (1) person. Review of Resident #117's comprehensive plan of care, dated [DATE], revealed the facility identified the resident needed assistance with activities of daily living (ADL) related to [MEDICAL CONDITIONS], Weakness, [MEDICAL CONDITION], and [MEDICAL CONDITION]. However, review of the resident's care plan revealed the facility developed interventions that were not individualized to the resident's assessed level of need. According to the care plan and the Daily Care Guide, Resident #117 required limited assistance of one person, extensive assistance of two (2) persons, and total assistance of one to two persons as needed for bed mobility and toileting; required limited assistance of two (2) or more persons for transfers; and required a wheelchair for mobility. Review of Resident #117's Nursing Notes revealed on [DATE], at 6:40 AM, Registered Nurse (RN) #3 found the resident lying face down on the floor beside the bedside commode. The Note stated the resident had a faint pulse, but was not breathing, and the resident's fingers were blue. Interview with SRNA #11 on [DATE] at 6:20 PM, revealed on the morning of [DATE], she was assigned to provide care for Resident #117. According to SRNA #11, the resident did not need assistance with ADLs. She stated that at approximately 5:30 AM, she observed the resident transfer from the bed to the bedside commode. SRNA #11 stated she did not enter the resident's room and assist the resident, but watched from the hallway until the resident was on the bedside commode. The SRNA stated she then continued down the hallway to provide care for another resident. According to SRNA #11, at approximately 6:00 AM, Registered Nurse (RN) #3 notified her that Resident #117 had fallen and asked her to help get Resident #117 up from the floor. Interview with RN #3 on [DATE] at 12:50 PM, revealed she was assigned to the care of Resident #117 during the night of ,[DATE]-,[DATE]. She stated that at approximately 6:30 AM, she found the resident lying face down on the floor. She stated it appeared the resident had been on the bedside commode because the resident's clothes were down and the resident had feces on his/her bottom. RN #3 stated the resident was not breathing, and initially had a faint pulse. Further review of Resident #117's Nursing Notes revealed the facility transferred the resident to a hospital on [DATE], where the resident was pronounced dead at 7:32 AM due to Cardiopulmonary Arrest due to Upper Airway Obstruction. Interview with MDS Coordinator #2 on [DATE] at 11:15 AM revealed she did not complete Resident #117's care plan. However, after reviewing the resident's MDS assessment, she stated the resident's care plan should have stated that the resident required two (2) staff persons for transferring and should have utilized a wheelchair for mobility. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a [MEDICAL CONDITION], which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care for their [MEDICAL CONDITION] and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with [MEDICAL CONDITION] needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for [MEDICAL CONDITION] care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a [MEDICAL CONDITION] patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific [MEDICAL CONDITION] orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a [MEDICAL CONDITION] patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions [MEDICAL CONDITION], revision of care plans, if indicated, to include individualized care and services furnished related to their [MEDICAL CONDITION]/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the [MEDICAL CONDITION] care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/[MEDICAL CONDITION] care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing [MEDICAL CONDITION] care as per physician order [REDACTED]. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders [REDACTED]. This verbal education was provided on [DATE] by the DON. 10. A) On or before [DATE], a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house [MEDICAL CONDITION] residents. Residents were in no distress and no issues were identified. B) On or before [DATE], a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before [DATE], the Director of Nursing reviewed the MARs, for dates of service from [DATE] to [DATE], consisting of two (2) in-house [MEDICAL CONDITION] residents. The audits included verified documentation of [MEDICAL CONDITION] care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before [DATE], a one-time audit was completed by the Respiratory Therapist to ensure all [MEDICAL CONDITION] residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On [DATE], the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in [MEDICAL CONDITION] care and the suctioning process. B) On or before [DATE], the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders [REDACTED]. This education will be completed by [DATE]. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by [DATE]. The facility does not use agency staff. C) On or before [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on [MEDICAL CONDITION] care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for [MEDICAL CONDITION] care and suctioning. The in-service also educated regarding nursing responsibility to provide [MEDICAL CONDITION] care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after [DATE] until educated and passing post test. 12. A) Beginning [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the [MEDICAL CONDITION] competency validation tool. 13. On or before [DATE], the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting [DATE] to identify if any insulin was not given per physician orders [REDACTED]. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before [DATE], the DON or Education Director will provide education to all licensed nurses regarding physician orders [REDACTED]. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders [REDACTED]. Documentation will be completed by the nursing management team by each licensed nurse by [DATE]. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of [DATE]. 15. Beginning [DATE], the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders [REDACTED]. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders [REDACTED]. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders [REDACTED]. 16. Beginning [DATE], the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physician orders [REDACTED]. Any discrepancy identified will be corrected at the time of discrepancy by notifying the MD and Family by the Director of Nursing and/or Unit Manager. 17. On or before [DATE], the Specialized Medical Services (SMS) [MEDICAL CONDITION] care and suctioning policy was adopted for use, by the facility, to ensure residents with a [MEDICAL CONDITION] receive care per physician order [REDACTED]. The Director of Nursing developed an ancillary [MEDICAL CONDITION] care and suctioning order for licensed nurses to utilize when admitting a resident to ensure that all appropriate physician orders [REDACTED]. 18. On or before [DATE], the Regional Director of Operations educated facility management (DON and Administrator) on their responsibilities as it relates to using resources effectively and efficiently to attain or maintain the highest practicable physical well-being for residents in the facility. On or before [DATE], the Regional Director of Operations gave a post test to the Administrator and Director of Nursing on their job duties and what is required daily to ensure the facility is operating in a manner that prompts quality of life for the residents. 19. An ADH[NAME]/Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE] to discuss the alleged deficient practices and corrective actions. The QAPI team met again on [DATE], with at least one Regional team member in attendance (either in person or by phone), and will continue weekly times four (4) weeks and then the facility will continue monthly thereafter. A QAPI meeting was held [DATE], for review of data from ongoing audits and staff education. This data will be reviewed weekly and continue times four (4) weeks and then monthly thereafter ongoing. Members of the facility's Quality Assurance Committee consist of the Administrator, Director of Nursing, Assistant Directors of Nursing, Dietary Manager, Business Office Manager, Activities Director, Director of Rehab, Maintenance Director, Social Services Manager, and Medical Director, who participates at least quarterly and as needed. The plan will be updated, as indicated, by the QAPI Committee. For all audits submitted to the QAPI Committee, the Administrator will assign follow-up as needed. ***The State Survey Agency determined the following removed Immediate Jeopardy on [DATE], as alleged by the facility: 1. Review of the medical records for Resident #117 revealed the resident was discharged from the facility on [DATE]. 2. A) Review of the Resident Council Meeting Minutes, dated [DATE], revealed fourteen (14) residents attended the meeting and education was provided on the grievance process. Interview with Resident #59 on [DATE] at 2:20 PM, revealed the facility staff met with the resident council and reviewed the grievance process, and forms were located throughout the facility for the residents. Review of medical records for Residents #171, #322, and #323 revealed documentation of a social services interview with residents or residents' representatives regarding the grievance process. B) Interview with the Social Services Director on [DATE] at 1:56 PM, revealed she was the Grievance Officer for the facility. She stated grievance forms have been placed in several locations in the facility with a locked grievance box located on the Peach Wing. She further stated she would initiate the grievance process and would assign the grievance to the appropriate department. She added the Administrator was to be informed immediately of all grievances. The Grievance Officer also stated the initial response to the grievance must be within seventy-two (72) hours. Review of the Allegation of Compliance binder revealed the grievance log was up to date and maintained by the Administrator. C) Observations of the Blue, Peach, and Green Units on [DATE], revealed the Grievance Process Summary was posted with grievance forms available to staff and residents. D) Review of the facility's admission packet on [DATE], revealed presence of the Grievance Standards of Practice and Compliance forms. 3. Review of the facility's documentation on [DATE], revealed education on the grievance process was provided to the Director of Nursing (DON) and the Administrator on [DATE], per the sign-in sheet. The facility's documentation also revealed evidence that this education was provided to department heads on [DATE] and to all facility staff on or before [DATE] by the sign-in sheets. Interviews on [DATE], with State Registered Nurse Aide (SRNA) #15 at 1:00 PM, SRNA #16 at 3:44 PM, SRNA #2 at 1:13 PM, SRNA #4 at 1:30 PM, Licensed Practical Nurse (LPN) #7 at 1:25 PM, LPN #1 at 1:00 PM, LPN #3 at 1:15 PM, with Dietary Staff at 1:40 PM, Maintenance Staff at 1:51 PM, the Respiratory Director at 2:33 PM, and the MDS Coordinator at 1:50 PM revealed knowledge of the Grievance Standard of Practice and Compliance process. 4. A) Review of the facility's New Hire Orientation binder on [DATE], revealed presence of the Grievance Standard of Practice and Compliance policy. Review of the binder also revealed evidence of post tests administered to the staff. B) Review of the facility's documentation on ,[DATE]//19, revealed results of the audit interviews, with stated population, related to the knowledge of the grievance process. C) Interview with the Administrator on [DATE] at 3:30 PM, revealed grievance logs and audits are reviewed daily with a Regional team member, who was still on sight. 5. A) Review of the facility's documentation on [DATE], revealed audits completed on 100% of [MEDICAL CONDITION] residents' respiratory needs, to include care plans on or before [DATE]. The information also revealed a [MEDICAL CONDITION] care plan was initiated on [DATE] on 100% of [MEDICAL CONDITION] residents. B) Review of Resident #98's care plan on [DATE], revealed the care plan was updated with [MEDICAL CONDITION] and activities of daily living (ADL) assistance on [DATE], upon re-entry from a hospital admission. C) Review of the faci (TRUNCATED)

Based on observation, interview, and record review, it was determined the facility failed to ensure that three (3) of four (4) residents who required [MEDICAL CONDITION] care and tracheal suctioning were provided such care, in accordance with physician's orders [REDACTED].#117 had a [MEDICAL CONDITION] (an opening in the neck to the windpipe) and had physician's orders [REDACTED]. On [DATE], the facility transferred Resident #117 to the hospital due to a low oxygen saturation and the resident returned to the facility on [DATE] at 4:23 AM, with a [DIAGNOSES REDACTED]. The resident's family member reported to the facility that the hospital physician stated staff were not suctioning the resident adequately. However, during the night of ,[DATE]-,[DATE], the facility failed to ensure [MEDICAL CONDITION] care/suctioning was provided for the resident. At 6:40 AM on [DATE], staff found the resident on the floor, unresponsive, and not breathing. The facility initiated Cardiopulmonary Resuscitation (CPR) and transferred the resident to the hospital where the resident was pronounced dead at 7:32 AM on [DATE], as a result of Cardiopulmonary Arrest due to Upper Airway Obstruction. The facility also failed to provide [MEDICAL CONDITION] care for Resident #21 and Resident #98 during the night shift of [DATE] at 7:00 PM until [DATE] at 7:00 AM. The facility's failure to ensure [MEDICAL CONDITION] care and tracheal suctioning was provided to residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the facility's Administrator on [DATE] at 12:00 PM, the Respiratory Therapy Director on [DATE] at 9:30 AM, and the Director of Nursing (DON) on [DATE] at 9:12 AM revealed the facility did not have policies regarding respiratory care, [MEDICAL CONDITION] care, suctioning, or oxygen. 1. Review of Resident #117's closed medical record revealed that the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #117's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the resident required oxygen therapy, suctioning, and [MEDICAL CONDITION] care. Review of Resident #117's physician's orders [REDACTED]. The care included changing the inner cannula, cleaning around the stoma with sterile saline and Hydrogen Peroxide followed by cleaning with sterile saline, and then applying a dry dressing ([MEDICAL CONDITION] care also includes suctioning the resident's [MEDICAL CONDITION] to clear any secretions. Excess secretions are due to the reduced ability to swallow and cough.). Review of Resident #117's (MONTH) (YEAR) Respiratory Medication Administration Record [REDACTED]. Review of Resident #117's Nursing Notes revealed on [DATE] at 10:45 PM, the resident was transferred to the hospital. The Note stated the resident was very short of air, with an oxygen saturation of 83 percent (%) (normal is ,[DATE]%) while receiving oxygen via the [MEDICAL CONDITION]. The Nursing Note also stated rales and rhonchi (crackling and rattling) were heard in the resident's lungs. According to the Nursing Note, staff suctioned thick, yellow sputum from the resident's [MEDICAL CONDITION] and changed the inner cannula. Further review revealed the Note stated the resident's oxygen saturation improved to 87%, but decreased to 83% within five (5) minutes. According to the Note, the resident returned to the facility on [DATE] at 4:23 AM, and was diagnosed with [REDACTED]. Interview with Resident #117's family member on [DATE] at 2:35 PM revealed he accompanied the resident to the hospital on [DATE]. The family member stated the hospital physician told him that staff at the facility were not suctioning Resident #117 adequately. Further interview with the family member revealed after hospital staff suctioned the resident's [MEDICAL CONDITION], the resident got better and was able to rest. The family member stated he reported what the hospital physician told him about inadequate suctioning to the facility's administrative staff (the Director of Nursing and Administrator) on [DATE]. Interview on [DATE] at 9:30 AM with the Respiratory Therapy Director revealed she cared for Resident #117 on [DATE] from 7:00 AM until 7:00 PM. The Director stated she provided [MEDICAL CONDITION] care and suctioned Resident #117 at 9:00 AM and suctioned the resident's [MEDICAL CONDITION] again at approximately 3:,[DATE]:00 PM that evening. The Director stated she did not provide [MEDICAL CONDITION] care or suctioning at 7:00 PM. She stated Nursing was responsible for providing respiratory care at 7:00 PM. However, further review of Resident #117's Respiratory MAR for [DATE] revealed no documented evidence that staff provided [MEDICAL CONDITION] care or suctioning at 7:00 PM as ordered by the resident's physician. Review of the resident's Nursing Note revealed at 6:40 AM on [DATE], staff found the resident face down on the floor, not breathing. Interview with RN #3, the Unit Manager, on [DATE] at 12:50 PM revealed she was responsible for Resident #117's care from [DATE] at 7:00 PM until [DATE] at 7:00 AM. She stated she did not provide [MEDICAL CONDITION] care or suction any resident's [MEDICAL CONDITION] that night because she assumed that respiratory therapy staff provided the care. The Unit Manager stated she was aware that the Respiratory Therapist's shift ended at 7:00 PM. RN #3 stated they (Respiratory Therapy) were there late some days and she was not aware that nurses who worked the night shift were required to provide [MEDICAL CONDITION] care/suctioning. The Unit Manager stated she was in Resident #117's room at approximately 11:00 PM on [DATE], and the resident had motioned to his/her mouth, indicating he/she needed to be suctioned. According to the Unit Manager, she did not suction the resident's [MEDICAL CONDITION], but suctioned the resident's oral cavity. The Unit Manager stated she was in Resident #117's room again at approximately 2:00 AM to 3:00 AM to provide tube feeding/administer insulin and the resident was in no distress. Further interview revealed when she entered the resident's room at approximately 6:40 AM, the resident was found face down on the floor, unresponsive, and not breathing. She stated Cardiopulmonary Resuscitation (CPR) was initiated and an ambulance arrived approximately fifteen (15) minutes later. The resident was transferred to the hospital where he/she was pronounced dead. Interview on [DATE] at 6:20 AM, with State Registered Nursing Aide (SRNA) #11 revealed on [DATE] at approximately 6:00 AM, the Unit Manager came to her and asked for help with Resident #117. SRNA #11 stated the resident was face down and his/her lips were blue. The SRNA stated two (2) nurses started CPR and she called the ambulance. Review of Resident #117's Emergency Medical Services (EMS) record dated [DATE] revealed EMS arrived at the facility at 7:06 AM. The primary impression was unresponsive, vital signs were recorded as UTO (unable to obtain), and the resident's EKG (Electrocardiography) showed PEA (Pulseless Electrical Activity, the EKG showed some heart activity, but the resident had no pulse). Review of Resident #117's hospital record revealed when the resident arrived at the ED, hospital staff suctioned a large amount of bloody sputum from the resident's [MEDICAL CONDITION]. Resident #117 was pronounced dead at 7:32 AM on [DATE], as a result of Cardiopulmonary Arrest. Review of Resident #117's Death Certificate revealed the cause of death was Cardiopulmonary Arrest due to upper airway obstruction. Interview with Physician #1 on [DATE] at 8:00 PM revealed Resident #117 was too far gone when the resident arrived at the Emergency Department. Physician #1 stated the resident's family also voiced concerns about the care the resident was receiving at the nursing facility and he did not think the resident had been suctioned adequately either. According to Physician #1, the cause of the resident's death was an upper airway obstruction, and not being suctioned would be a contributing factor. 2. Observation of Resident #21 on [DATE] at 10:15 AM revealed the resident had a [MEDICAL CONDITION] and was receiving oxygen via the [MEDICAL CONDITION]. Further observation revealed Registered Nurse (RN) #9 suctioned clear secretions from the resident's [MEDICAL CONDITION]. Review of Resident #21's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 21's Minimum Data Set ((MDS) dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). According to the MDS, the resident was in a persistent vegetative state with no discernible consciousness. Further review of the MDS revealed the resident required respiratory treatments that included [MEDICAL CONDITION] care, suctioning, and oxygen. Review of Resident #21's physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Interview with RN #9 on [DATE] at 7:10 PM revealed Resident #21 had a lot of secretions and usually required suctioning three to four times during the night shift. However, interview with the Unit Manager on [DATE] at 11:10 AM revealed she was assigned to provide care for Resident #21 on [DATE] at 7:00 PM until [DATE] at 7:00 AM. Further interview with the Unit Manager revealed she did not suction the resident or provide any type of [MEDICAL CONDITION] care during that time. She stated she was not aware nursing staff was required to provide [MEDICAL CONDITION] care or suctioning. 3. Review of Resident #98's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #98's Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated moderately impaired cognition. Further review of the MDS revealed the resident required respiratory treatments that included [MEDICAL CONDITION] care, suctioning, and oxygen. Review of Resident #98's physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Interview with the Unit Manager on [DATE] at 11:10 AM revealed she was assigned to provide care for Resident #98 on [DATE] at 7:00 PM until [DATE] at 7:00 AM. She stated she was not aware nursing staff was required to provide [MEDICAL CONDITION] care or suctioning and she did not suction the resident or provide [MEDICAL CONDITION] care. Interview on [DATE] at 10:30 AM with the DON revealed Respiratory Therapists were only in the building from 7:00 AM until 7:00 PM daily, and nursing staff were responsible for residents' respiratory care from 7:00 PM until 7:00 AM each day. The DON stated that the Unit Supervisor should have been aware that nursing staff was responsible for providing respiratory care during the night shift. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a [MEDICAL CONDITION], which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care for their [MEDICAL CONDITION] and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with [MEDICAL CONDITION] needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for [MEDICAL CONDITION] care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a [MEDICAL CONDITION] patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific [MEDICAL CONDITION] orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a [MEDICAL CONDITION] patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions [MEDICAL CONDITION], revision of care plans, if indicated, to include individualized care and services furnished related to their [MEDICAL CONDITION]/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the [MEDICAL CONDITION] care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/[MEDICAL CONDITION] care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing [MEDICAL CONDITION] care as per physician order [REDACTED]. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders [REDACTED]. This verbal education was provided on [DATE] by the DON. 10. A) On or before [DATE], a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house [MEDICAL CONDITION] residents. Residents were in no distress and no issues were identified. B) On or before [DATE], a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before [DATE], the Director of Nursing reviewed the MARs, for dates of service from [DATE] to [DATE], consisting of two (2) in-house [MEDICAL CONDITION] residents. The audits included verified documentation of [MEDICAL CONDITION] care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before [DATE], a one-time audit was completed by the Respiratory Therapist to ensure all [MEDICAL CONDITION] residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On [DATE], the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in [MEDICAL CONDITION] care and the suctioning process. B) On or before [DATE], the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders [REDACTED]. This education will be completed by [DATE]. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by [DATE]. The facility does not use agency staff. C) On or before [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on [MEDICAL CONDITION] care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for [MEDICAL CONDITION] care and suctioning. The in-service also educated regarding nursing responsibility to provide [MEDICAL CONDITION] care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after [DATE] until educated and passing post test. 12. A) Beginning [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the [MEDICAL CONDITION] competency validation tool. 13. On or before [DATE], the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting [DATE] to identify if any insulin was not given per physician orders [REDACTED]. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before [DATE], the DON or Education Director will provide education to all licensed nurses regarding physician orders [REDACTED]. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders [REDACTED]. Documentation will be completed by the nursing management team by each licensed nurse by [DATE]. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of [DATE]. 15. Beginning [DATE], the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders [REDACTED]. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders [REDACTED]. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders [REDACTED]. 16. Beginning [DATE], the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physic (TRUNCATED)

Based on interview, record review, and review of the facility's medication administration policy, it was determined the facility failed to ensure that one (1) of forty-seven (47) sampled residents (Resident #117) was free of significant medication errors. Resident #117 had a physician's orders [REDACTED]. According to the resident's medication record, [MEDICATION NAME] R insulin was due at 12:00 AM on [DATE]; however, interview with staff revealed the medication was not administered until 2:00 AM. Further review of the resident's medication record revealed staff administered another dose of [MEDICATION NAME] R insulin four (4) hours later at 6:00 AM on [DATE], when the resident's blood sugar was 111 mg/dl, even though the resident had a physician's orders [REDACTED]. Resident #117 was found on the floor on [DATE], at 6:40 AM, unresponsive and not breathing. The resident was transferred to the hospital where he/she was pronounced dead at 7:32 AM on [DATE]. The facility's failure to ensure residents were free of significant medication errors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Medication Administration General Guidelines, dated (MONTH) 2012, revealed medications were required to be administered within 60 minutes of the scheduled time. Further review of the policy revealed medications were required to be administered in accordance with the written orders of the prescriber. Review of Resident #117's closed medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #117's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was severely cognitively impaired. Review of Resident #117's physician's orders [REDACTED]. Further review of Resident #117's physician's orders [REDACTED]. sugar was less than 140 mg/dl. Review of Resident #117's Nurse Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Further review revealed on [DATE] at 6:00 AM, staff documented Resident #117's blood sugar was 111 mg/dl. Staff documented [MEDICATION NAME] R insulin was administered in the left lower quadrant (LLQ) of the resident's abdomen, even though the physician's orders [REDACTED]. Interview on [DATE] at 2:04 PM with Registered Nurse (RN) #3, who was also the Unit Manager, revealed she provided care for Resident #117 on [DATE] at 7:00 PM until 7:00 AM on [DATE], to cover for another nurse. RN #3 stated she recalled administering [MEDICATION NAME] to Resident #117 at 9:00 PM on [DATE]. RN #3 further stated she did not administer the resident's [MEDICATION NAME] R insulin that was due at 12:00 AM, until 2:00 AM, two (2) hours late, because she was busy. According to the RN, she did not remember administering insulin to Resident #117 at 6:00 AM on [DATE]; however, the nurse documented that the medication was administered. Review of Resident #117's Nursing Notes revealed on [DATE] at 6:40 AM, forty (40) minutes after the second dose of insulin was administered, RN #3 found the resident lying face down on the floor beside a bedside commode. The Note stated the resident had a faint pulse, but was not breathing and the resident's fingers were blue. According to the Nursing Note, staff initiated Cardiopulmonary Resuscitation (CPR) until paramedics arrived and transferred the resident to the hospital. Review of Resident #117's hospital medical record revealed the resident presented to the Emergency Department on [DATE] at 7:25 AM, and was pronounced dead at 7:32 AM. There was no documented evidence that the hospital tested the resident's blood sugar or any other laboratory testing. Interview with Physician #1 on [DATE] at 8:00 PM revealed Resident #117 was too far gone when the resident arrived at the Emergency Department. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a [MEDICAL CONDITION], which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care for their [MEDICAL CONDITION] and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with [MEDICAL CONDITION] needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for [MEDICAL CONDITION] care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a [MEDICAL CONDITION] patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific [MEDICAL CONDITION] orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a [MEDICAL CONDITION] patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions [MEDICAL CONDITION], revision of care plans, if indicated, to include individualized care and services furnished related to their [MEDICAL CONDITION]/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the [MEDICAL CONDITION] care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/[MEDICAL CONDITION] care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing [MEDICAL CONDITION] care as per physician order [REDACTED]. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders [REDACTED]. This verbal education was provided on [DATE] by the DON. 10. A) On or before [DATE], a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house [MEDICAL CONDITION] residents. Residents were in no distress and no issues were identified. B) On or before [DATE], a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before [DATE], the Director of Nursing reviewed the MARs, for dates of service from [DATE] to [DATE], consisting of two (2) in-house [MEDICAL CONDITION] residents. The audits included verified documentation of [MEDICAL CONDITION] care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before [DATE], a one-time audit was completed by the Respiratory Therapist to ensure all [MEDICAL CONDITION] residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On [DATE], the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in [MEDICAL CONDITION] care and the suctioning process. B) On or before [DATE], the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders [REDACTED]. This education will be completed by [DATE]. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by [DATE]. The facility does not use agency staff. C) On or before [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on [MEDICAL CONDITION] care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for [MEDICAL CONDITION] care and suctioning. The in-service also educated regarding nursing responsibility to provide [MEDICAL CONDITION] care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after [DATE] until educated and passing post test. 12. A) Beginning [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the [MEDICAL CONDITION] competency validation tool. 13. On or before [DATE], the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting [DATE] to identify if any insulin was not given per physician orders [REDACTED]. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before [DATE], the DON or Education Director will provide education to all licensed nurses regarding physician orders [REDACTED]. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders [REDACTED]. Documentation will be completed by the nursing management team by each licensed nurse by [DATE]. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of [DATE]. 15. Beginning [DATE], the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders [REDACTED]. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders [REDACTED]. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders [REDACTED]. 16. Beginning [DATE], the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physician orders [REDACTED]. Any discrepancy identified will be corrected at the time of discrepancy by notifying the MD and Family by the Director of Nursing and/or Unit Manager. 17. On or before [DATE], the Specialized Medical Services (SMS) [MEDICAL CONDITION] care and suctioning policy was adopted for use, by the facility, to ensure residents with a [MEDICAL CONDITION] receive care per physician order [REDACTED]. The Director of Nursing developed an ancillary [MEDICAL CONDITION] care and suctioning order for licensed nurses to utilize when admitting a resident to ensure that all appropriate physician orders [REDACTED]. 18. On or before [DATE], the Regional Director of Operations educated facility management (DON and Administrator) on their responsibilities as it relates to using resources effectively and efficiently to attain or maintain the highest practicable physical well-being for residents in the facility. On or before [DATE], the Regional Director of Operations gave a post test to the Administrator and Director of Nursing on their job duties and what is required daily to ensure the facility is operating in a manner that prompts quality of life for the residents. 19. An ADH[NAME]/Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE] to discuss the alleged deficient practices and corrective actions. The QAPI team met again on [DATE], with at least one Regional team member in attendance (either in person or by phone), and will continue weekly times four (4) weeks and then the facility will continue monthly thereafter. A QAPI meeting was held [DATE], for review of data from ongoing audits and staff education. This data will be reviewed weekly and continue times four (4) weeks and then monthly thereafter ongoing. Members of the facility's Quality Assurance Committee consist of the Administrator, Director of Nursing, Assistant Directors of Nursing, Dietary Manager, Business Office Manager, Activities Director, Director of Rehab, Maintenance Director, Social Services Manager, and Medical Director, who participates at least quarterly and as needed. The plan will be updated, as indicated, by the QAPI Committee. For all audits submitted to the QAPI Committee, the Administrator will assign follow-up as needed. ***The State Survey Agency determined the following removed Immediate Jeopardy on [DATE], as alleged by the facility: 1. Review of the medical records for Resident #117 revealed the resident was discharged from the facility on [DATE]. 2. A) Review of the Resident Council Meeting Minutes, dated [DATE], revealed fourteen (14) residents attended the meeting and education was provided on the grievance process. Interview with Resident #59 on [DATE] at 2:20 PM, revealed the facility staff met with the resident council and reviewed the grievance process, and forms were located throughout the facility for the residents. Review of medical records for Residents #171, #322, and #323 revealed documentation of a social services interview with residents or residents' representatives regarding the grievance process. B) Interview with the Social Services Director on [DATE] at 1:56 PM, revealed she was the Grievance Officer for the facility. She stated grievance forms have been placed in several locations in the facility with a locked grievance box located on the Peach Wing. She further stated she would initiate the grievance process and would assign the grievance to the appropriate department. She added the Administrator was to be informed immediately of all grievances. The Grievance Officer also stated the initial response to the grievance must be within seventy-two (72) hours. Review of the Allegation of Compliance binder revealed the grievance log was up to date and maintained by the Administrator. C) Observations of the Blue, Peach, and Green Units on [DATE], revealed the Grievance Process Summary was posted with grievance forms available to staff and residents. D) Review of the facility's admission packet on [DATE], revealed presence of the Grievance Standards of Practice and Compliance forms. 3. Review of the facility's documentation on [DATE], revealed education on the grievance process was provided to the Director of Nursing (DON) and the Administrator on [DATE], per the sign-in sheet. The facility's documentation also revealed evidence that this education was provided to department heads on [DATE] and to all facility staff on or before [DATE] by the sign-in sheets. Interviews on [DATE], with State Registered Nurse Aide (SRNA) #15 at 1:00 PM, SRNA #16 at 3:44 PM, SRNA #2 at 1:13 PM, SRNA #4 at 1:30 PM, Licensed Practical Nurse (LPN) #7 at 1:25 PM, LPN #1 at 1:00 PM, LPN #3 at 1:15 PM, with Dietary Staff at 1:40 PM, Maintenance Staff at 1:51 PM, the Respiratory Director at 2:33 PM, and the MDS Coordinator at 1:50 PM revealed knowledge of the Grievance Standard of Practice and Compliance process. 4. A) Review of the facility's New Hire Orientation binder on [DATE], revealed presence of the Grievance Standard of Practice and Compliance policy. Review of the binder also revealed evidence of post tests administered to the staff. B) Review of the facility's documentation on ,[DATE]//19, revealed results of the audit interviews, with stated population, related to the knowledge of the grievance process. C) Interview with the Administrator on [DATE] at 3:30 PM, revealed grievance logs and audits are reviewed daily with a Regional team member, who was still on sight. 5. A) Review of the facility's documentation on [DATE], revealed audits completed on 100% of [MEDICAL CONDITION] residents' respiratory needs, to include care plans on or before [DATE]. The information also revealed a [MEDICAL CONDITION] care plan was initiated on [DATE] on 100% of [MEDICAL CONDITION] residents. B) Review of Resident #98's care plan on [DATE], revealed the care plan was updated with [MEDICAL CONDITION] and activities of daily living (ADL) assistance on [DATE], upon re-entry from a hospital admission. C) Review of the facility's documentation on [DATE], revealed all facility residents had a review of their ADL assistance needs and were revised as indicated on [DATE]. 6. A) Review of the facility's documentation on [DATE], revealed education was provided to the Nurse Management Team on [DATE], by the Regional Quality Manager (RQM) related to completion and review of respiratory care plans and resident-centered [MEDICAL CONDITION] respiratory care needs. B) Review of the facility's documentation on [DATE], revealed the RQM provided education to the Nurse Management Team on [DATE], on completion of the [MEDICAL CONDITION] Patient Admission Questionnaire. C) Review of the facility's documentation on [DATE], revealed a post test was administered to the Nurse Management and Respiratory Therapist by [DATE]. Further review of the documentation revealed Nurse Management and the Respiratory Therapist had passed the post test. D) Review of the facility's documentation on [DATE], revealed education was provided by the Regional Reimbursement Nurse to the Interdisciplinary Team (IDT) on creating a person-centered car (TRUNCATED)

Based on interview, record review, and review of the facility's policy, it was determined the facility Administrator failed to use resources effectively and efficiently to attain or maintain the highest practicable physical well-being for Resident #117. The facility failed to develop respiratory policies and procedures to ensure Resident #117 received respiratory care as needed. The Administrator also failed to investigate and respond to a grievance presented by a family member of Resident #117 on [DATE], regarding the resident's respiratory care. On [DATE], staff failed to provide respiratory care as ordered by the resident's physician and the resident was found not breathing on [DATE]. The resident was transferred to a hospital where he/she was pronounced dead as a result of Cardiopulmonary Arrest due to Upper Airway Obstruction. The facility's failure to ensure the facility was administered in a manner that enables it to use resources effectively and efficiently has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F585), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689 and F695), 42 CFR 483.45 Pharmacy Services (F760), and 42 CFR 483.70 Administration (F835), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's job description revealed the Administrator was required to ensure that excellent care for residents was maintained by overseeing and monitoring patient care services delivered. The description also revealed the Administrator was responsible for working with and supervising personnel in the facility by providing opportunities for instruction, guidance, and counseling as necessary to ensure complete understanding of responsibilities. Review of the facility's policy, Resident and Family Grievances, undated, revealed prompt efforts will be made by the facility to resolve grievances. The policy also revealed the grievance would be recorded on a Grievance Form and recording of the grievance would serve as communication to other staff members. Further review of the policy revealed the Administrator or designee should conduct an investigation, if warranted. Interview with the facility Administrator on [DATE] at 12:00 PM revealed the facility did not have policies regarding respiratory care or [MEDICAL CONDITION] care/suctioning. Interview with Resident #117's family member on [DATE] at 2:35 PM revealed the facility transferred the resident to the hospital on [DATE] because the resident's oxygen saturation was low. He stated once the resident arrived at the hospital, hospital staff informed him that they suctioned a large amount of secretions from the resident's [MEDICAL CONDITION]. The family member stated after suctioning, the resident felt better and was able to rest. Further interview with the family member revealed he met with the Administrator and Director of Nursing (DON) on [DATE], and reported that the hospital physician told him that staff at the facility were not suctioning Resident #117 adequately. Interview with the Administrator on [DATE] at 9:55 AM, revealed Resident #117's family member voiced a grievance on [DATE], stating that the resident was not being suctioned adequately at the facility. She stated she was aware the DON reviewed documentation that the resident only required suctioning as needed, and no concerns were identified. Further interview with the Administrator revealed no further action/investigation was taken, and the family member's grievance was not handled per the facility's policy. Continued interview with the Administrator revealed she was not aware the facility did not have policies or procedures regarding providing [MEDICAL CONDITION] care or suctioning a [MEDICAL CONDITION]. Interview with Registered Nurse (RN) #3, who was also the Unit Manager, on [DATE] at 12:50 PM and review of Resident #117's Medication Administration Record [REDACTED]. In addition, further interview with RN #3 revealed she also failed to suction the resident's [MEDICAL CONDITION] on [DATE] at approximately 11:00 PM, when the resident indicated he/she needed to be suctioned. The Unit Manager stated she was not aware that she was required to provide [MEDICAL CONDITION] care at 7:00 PM because she thought Respiratory Therapy staff provided the care. Review of Resident #117's Nursing Notes dated [DATE] at 6:40 AM, revealed staff found Resident #117 on the floor, not breathing. Staff initiated Cardiopulmonary Resuscitation (CPR), and the resident was transferred to the hospital. Review of Resident #117's hospital record revealed the resident was pronounced dead on [DATE] at 7:32 AM. According to the resident's Death Certificate, the cause of death was Cardiopulmonary Arrest due to Upper airway obstruction. **The facility alleged the following actions removed the Immediate Jeopardy on [DATE]: 1. Resident #117 was transported to the hospital on [DATE] and no longer resides in the facility. 2. A) On [DATE], the Activities Director conducted a resident council meeting to review with the residents the Grievance Process and guidelines. By [DATE] the Activities Director, Social Services Director, or facility Administrator will provide education on the Grievance Standard of Practice and Compliance guideline for those resident(s) with a Brief Interview for Mental Status (BIMS) score of nine (9) or higher, who did not attend the resident council meeting. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will interview current in-house residents with a BIMS of nine (9) or higher to identify if there are any current grievances. By [DATE] the Social Services Director (Grievance Officer) or Social Services Assistant will contact the respective responsible party or guardian, for those residents with a BIMS of eight (8) or less, to identify if they have any concerns and address the concern(s) following the Grievance Standard of Practice and Compliance guideline. Any concerns/grievance(s) voiced will be addressed following the Grievance Standard of Practice and Compliance guideline. B) Grievances identified Monday through Friday will be addressed by the Social Services Director, who is the Grievance Official, and/or the Social Services staff. All grievances will be addressed per the Grievance Standard of Practice and Compliance Guidelines and submitted to the Administrator for review. The Administrator will log the grievance for review and recommendations in Quality Assurance/Performance Improvement (QAPI). The Social Services Director will send a letter to the resident's representative and/or resident with resolution per guidelines. C) By [DATE], the Administrator will post a copy of the Grievance Process summary along with the facility's administration contacts throughout the facility. Copies of blank grievance forms will accompany the posting. D) By [DATE], the Admissions Director will add a copy of the Grievance Standards of Practice and Compliance in the admission packets to provide information to any new residents/families. 3. On [DATE], the Regional Quality Manager (RQM) provided education to the Director of Nursing (DON) and the Administrator regarding the facility's Grievance Standards of Practice and Compliance Guidelines, which included, but was not limited to, ensuring investigation and resolution of a grievance per regulation. Beginning [DATE], the facility's Administrator educated the Education Training Director (ETD) regarding the facility's Grievance Process. Education was provided to the Department Heads (Business Office Manager, Social Services, DON, Activities Director, MDS, Unit Manager, Dietary Manager, Housekeeping Supervisor, Maintenance, Marketing, and Payroll) on the Grievance Process by the Administrator on [DATE]. 4. A) On or before [DATE], education was provided by the Administrator and Education Training Director on Grievance Standards of Practice and Compliance Guidelines to all facility staff. A post test accompanied the education to validate understanding of the materials. Newly hired staff will receive education during orientation regarding Grievance Standards of Practice and Compliance Guidelines, including a post test. Any employee who has not received the education and passed the post test will not be allowed to return to work after [DATE]. The facility does not use agency staff. B) Beginning [DATE], the Administrator, DON, Unit Manager (UM), or Grievance Officer will interview three (3) residents with a BIMS score of nine (9) or greater, three (3) random employees, and three (3) representatives of residents with a BIMS score of eight (8) or less weekly for four (4) weeks to ensure staff and residents understand the grievance process. Results of the audits will be reported to the Quality Assurance Committee for its review and recommendations. The Administrator will assign follow-up as needed. C) Beginning [DATE], the facility's Administrator will submit the grievance log, with completed concern/grievance investigation, and follow up daily with a member of the Regional Team for review. Any discrepancy noted during the review will be immediately addressed with the Administrator by the Regional Team Member. 5. A) On or before [DATE], the Nurse Management team, consisting of the Director of Nursing, RN Education Training Director, Unit Manager, MDS Coordinator(s), and/or Respiratory Therapist, completed a one hundred (100) percent (%) audit of respiratory care needs for each in-house resident having a [MEDICAL CONDITION], which included a review of their care plans. On or before [DATE], the respiratory care plans will be revised by the DON, if indicated, to include individualized care and services to be furnished related to their [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care for their [MEDICAL CONDITION] and in line with the resident's goals and desired outcomes. B) Any new admissions, or readmissions, with [MEDICAL CONDITION] needs for care and services, will be reviewed by the Nursing Administrative Team, Respiratory Therapist, and/or MDS Coordinator(s) within twenty-four (24) hours. This review will include individualized care approaches and services to be implemented related to their ongoing [MEDICAL CONDITION]/respiratory needs. This will include, but not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services related to respiratory care and in line with the resident's goals and desired outcomes. C) On or before [DATE], each resident will have their ADL (Activities of Daily Living) status reviewed for the level of assistance required, including toileting. The ADL comprehensive baseline and State Registered Nurse Aide (SRNA) care plan were audited to ensure ADL interventions described the appropriate level of assistance and/or supervision needed. This will be completed by the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager), MDS Coordinator(s), and nursing staff (nurses and SRNAs) and, if applicable, the resident by [DATE]. These will be resident-centered to reflect the amount of assistance and or supervision necessary to complete ADL tasks to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 6. A) On or before [DATE], the Regional Quality Manager completed education for the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) regarding completion and review of resident-centered respiratory care plans for [MEDICAL CONDITION] care. The Respiratory Care plan will be initiated by the Interdisciplinary Team (IDT) Team, in conjunction with Respiratory Therapy, consisting of, but not limited to, Administrator, DON, Unit Managers, Social Services, MDS Coordinator(s), Activities, and Dietary Manager. B) On or before [DATE], the Regional Quality Manager completed education to the Nurse Management Team (Director of Nursing, Education Training Director, RN, MDS Coordinator(s), and Unit Manager) on completing a [MEDICAL CONDITION] patient admission questionnaire. The questionnaire consists of the name of the resident, resident specific [MEDICAL CONDITION] orders, including care and suctioning, other services needed and who will provide any specialty services. On Saturday and Sunday, the clinical manager will initiate the respiratory care plan completing a [MEDICAL CONDITION] patient admission questionnaire. The MDS Coordinator(s) will review the plan to ensure it is appropriate and implemented within forty-eight (48) hours. This education includes referencing the respiratory care plan for specific interventions [MEDICAL CONDITION], revision of care plans, if indicated, to include individualized care and services furnished related to their [MEDICAL CONDITION]/respiratory needs and what, at a minimum, will be provided on the respiratory care plan. The care plan will include, but may not be limited to, [MEDICAL CONDITION] care, suctioning, and specialized services. Education includes communication of the respiratory care plan to licensed nurses and Respiratory Therapist (RT)s and changes in interventions by the IDT (Admin, DON, Unit Managers, Social Services, MDS Coordinator, Activities, and Dietary Manager) if indicated. The Regional Quality Manager will educate the outside Vendor Respiratory Therapy by [DATE]. C) A post test will be given to the Director of Nursing by the Regional Quality Manager on [DATE], to ensure understanding of the [MEDICAL CONDITION] care plans and expectations of care. The Director of Nursing will provide education to the Education Training Director, MDS Coordinators, Unit Manager, and Respiratory Therapist to ensure understanding of the material related to respiratory care plans. Education will be completed and post test passed prior to working by [DATE]. D) On or before [DATE], the Regional Reimbursement Nurse (RRN) provided an in-service for the Interdisciplinary Team (IDT) consisting of the Director of Nursing, Social Services, Assistant Dietary Manager, Activities Director, and Registered Nurse (RN) Education Training Director regarding person-centered care plan development related to ADLs for transferring and toileting. E) On or before [DATE], the Education Training Director will provide education to the nursing staff, to include SRNAs, regarding the comprehensive care plan, or baseline care plan, to include respiratory/[MEDICAL CONDITION] care. Education was provided regarding the SRNA care plan to include ADL interventions for the level of assistance and/or supervision needed. This education will include the expectation that the nursing staff (Nurses and SRNAs) use the SRNA care plan to determine the ADL status and level of assistance or supervision required for their assignment. A post test will be given to the nurses and SRNAs on the education provided to ensure understanding of the material by [DATE]. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education. This same education will be added to the new hire orientation packet for training during orientation. The facility does not use agency staff. 7. Beginning [DATE], direct observation audits will be conducted five (5) times weekly times four (4) weeks, of twenty (20) different residents each week to ensure that the comprehensive care plan, baseline care plan, and SRNA care plan is being followed while care is being provided. Observation audits will be completed by Nursing Administration (Director of Nursing, Education Training Director, RN Unit Manager, or MDS Coordinators) and will encompass observations of at least ten (10) SRNAs, on varying shifts a week. The auditor will address any discrepancy noted during the audit at that time and re-educate staff as needed. 8. On or before [DATE], the Education Training Director, Unit Manager, Director of Nursing, and the MDS Nurses completed education for all the nursing staff regarding comprehensive, baseline, and SRNA care plan. The education provided included following the care plan to provide adequate supervision and assistance to prevent accidents. It also included educating staff that each resident's ADL care plan is located in the kiosk and a printed version will be available in a book at the nurses' station. This same education will be added to the new hire orientation packets. After [DATE], licensed nurses and SRNAs will not be allowed to work without receiving the required education and passing a post test. The facility does not use agency staff. 9. The Nurse working the 7PM-7AM shift on [DATE] was in-serviced by the DON regarding performing [MEDICAL CONDITION] care as per physician order [REDACTED]. The nurse was in-serviced on the responsibility of the nurse of the 7PM-7AM shift. The nurse was provided with verbal instruction, by the DON, regarding following physician orders [REDACTED]. This verbal education was provided on [DATE] by the DON. 10. A) On or before [DATE], a one-time assessment was completed by the Education Training Director (RN), which consisted of a head to toe clinical assessment of four (4) in-house [MEDICAL CONDITION] residents. Residents were in no distress and no issues were identified. B) On or before [DATE], a one-time audit was completed by the RN Unit Manager on all residents with tracheostomies to validate orders. Any discrepancies noted were immediately corrected by notifying the MD. On or before [DATE], the Director of Nursing reviewed the MARs, for dates of service from [DATE] to [DATE], consisting of two (2) in-house [MEDICAL CONDITION] residents. The audits included verified documentation of [MEDICAL CONDITION] care in the medical record. No issues were identified. Any readmission will have documentation reviewed within 24 hours of return. On or before [DATE], a one-time audit was completed by the Respiratory Therapist to ensure all [MEDICAL CONDITION] residents with oxygen had valid orders. Any discrepancies noted were immediately corrected by notifying the MD by a licensed nurse. 11. A) On [DATE], the Contracted Respiratory Therapist (RT) completed education and skills competency for the Director of Nursing, Education Training Director, RN Unit Manager, and a Staff Respiratory Therapist to validate they were competent in [MEDICAL CONDITION] care and the suctioning process. B) On or before [DATE], the Respiratory Vendor (RT) and/or Nursing Management team, consisting of the DON, Education Training Director, and/or UM, began education for the licensed nurses on following the physician orders [REDACTED]. This education will be completed by [DATE]. This education has been added to the new hire-licensed nurse orientation packet. Facility staff will be in-serviced by [DATE]. The facility does not use agency staff. C) On or before [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) will complete return demonstration competencies for each licensed nurse on [MEDICAL CONDITION] care and suctioning. In addition, nursing administration (the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager)) will provide in-servicing regarding the facility Respiratory Therapist (RT) services availability for [MEDICAL CONDITION] care and suctioning. The in-service also educated regarding nursing responsibility to provide [MEDICAL CONDITION] care and suctioning if and/or when a RT is not available or on the schedule to provide such treatments. This education material will be added to the new hire-licensed nurse orientation packet. The facility does not use agency staff. No employees will work after [DATE] until educated and passing post test. 12. A) Beginning [DATE], the Nurse Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) MDS Nurses, or Contract Respiratory Therapy and/or facility Respiratory Therapist, will conduct audits of five (5) nurses and/or RTs each week, on varying shifts, using the [MEDICAL CONDITION] competency validation tool. 13. On or before [DATE], the Nursing Management Team, consisting of the DON, Unit Manager(s), and licensed nurses from sister facilities, completed a one-time audit on all residents with insulin orders starting [DATE] to identify if any insulin was not given per physician orders [REDACTED]. Any issues/concerns identified during the audit were discussed with the attending physician including a clinical assessment/observation to ensure there were no adverse reactions by the Director of Nursing and/or Nursing Management. It is the practice of the facility for insulin to be administered correctly, according to physician orders, and per the expected timeframe to prevent significant insulin medication errors. 14. On or before [DATE], the DON or Education Director will provide education to all licensed nurses regarding physician orders [REDACTED]. The education also included the notification of the physician if the administration fell outside the time parameters, incorrect dose given/omitted, and an assessment of the resident to ensure no adverse effects. A post education quiz for licensed nurses included education regarding the five (5) Rights of Medication administration, following physician's orders [REDACTED]. Documentation will be completed by the nursing management team by each licensed nurse by [DATE]. Licensed nurses must pass the quiz with 100% score or be re-educated by nursing administration and retake the quiz with a 100% score before returning to work on their next shift. No licensed staff will be permitted to work until test is passed as of [DATE]. 15. Beginning [DATE], the Nursing Management Team (Director of Nursing, Education Training Director, RN, and Unit Manager) and MDS Coordinator(s) will complete audits, related to insulin administration, to include if any insulin was not given per physician orders [REDACTED]. All residents with insulin orders will have Medication Administration documentation checked to ensure the insulin is documented given in accordance with physician orders [REDACTED]. The audit will be conducted five (5) days per week for four (4) weeks, then weekly times four (4) weeks, and then monthly. Any discrepancy identified during the audit, which consists of any insulin not given per physician orders [REDACTED]. 16. Beginning [DATE], the Nursing management team (DON, Education Training Director, Unit Manager, and MDS Nurses) will observe medication pass opportunities for 5 residents with insulin, to validate that licensed nurses are giving insulin per physician orders [REDACTED]. Any discrepancy identified will be corrected at the time of discrepancy by notifying the MD and Family by the Director of Nursing and/or Unit Manager. 17. On or before [DATE], the Specialized Medical Services (SMS) [MEDICAL CONDITION] care and suctioning policy was adopted for use, by the facility, to ensure residents with a [MEDICAL CONDITION] receive care per physician order [REDACTED]. The Director of Nursing developed an ancillary [MEDICAL CONDITION] care and suctioning order for licensed nurses to utilize when admitting a resident to ensure that all appropriate physician orders [REDACTED]. 18. On or before [DATE], the Regional Director of Operations educated facility management (DON and Administrator) on their responsibilities as it relates to using resources effectively and efficiently to attain or maintain the highest practicable physical well-being for residents in the facility. On or before [DATE], the Regional Director of Operations gave a post test to the Administrator and Director of Nursing on their job duties and what is required daily to ensure the facility is operating in a manner that prompts quality of life for the residents. 19. An ADH[NAME]/Quality Assurance and Performance Improvement (QAPI) meeting was conducted on [DATE] to discuss the alleged deficient practices and corrective actions. The QAPI team met again on [DATE], with at least one Regional team member in attendance (either in person or by phone), and will continue weekly times four (4) weeks and then the facility will continue monthly thereafter. A QAPI meeting was held [DATE], for review of data from ongoing audits and staff education. This data will be reviewed weekly and continue times four (4) weeks and then monthly thereafter ongoing. Members of the facility's Quality Assurance Committee consist of the Administrator, Director of Nursing, Assistant Directors of Nursing, Dietary Manager, Business Office Manager, Activities Director, Director of Rehab, Maintenance Director, Social Services Manager, and Medical Director, who participates at least quarterly and as needed. The plan will be updated, as indicated, by the QAPI Committee. For all audits submitted to the QAPI Committee, the Administrator will assign follow-up as needed. ***The State Survey Agency determined the following removed Immediate Jeopardy on [DATE], as alleged by the facility: 1. Review of the medical records for Resident #117 revealed the resident was discharged from the facility on [DATE]. 2. A) Review of the Resident Council Meeting Minutes, dated [DATE], revealed fourteen (14) residents attended the meeting and education was provided on the grievance process. Interview with Resident #59 on [DATE] at 2:20 PM, revealed the facility staff met with the resident council and reviewed the grievance process, and forms were located throughout the facility for the residents. Review of medical records for Residents #171, #322, and #323 revealed documentation of a social services interview with residents or residents' representatives regarding the grievance process. B) Interview with the Social Services Director on [DATE] at 1:56 PM, revealed she was the Grievance Officer for the facility. She stated grievance forms have been placed in several locations in the facility with a locked grievance box located on the Peach Wing. She further stated she would initiate the grievance process and would assign the grievance to the appropriate department. She added the Administrator was to be informed immediately of all grievances. The Grievance Officer also stated the initial response to the grievance must be within seventy-two (72) hours. Review of the Allegation of Compliance binder revealed the grievance log was up to date and maintained by the Administrator. C) Observations of the Blue, Peach, and Green Units on [DATE], revealed the Grievance Process Summary was posted with grievance forms available to staff and residents. D) Review of the facility's admission packet on [DATE], revealed presence of the Grievance Standards of Practice and Compliance forms. 3. Review of the facility's documentation on [DATE], revealed education on the grievance process was provided to the Director of Nursing (DON) and the Administrator on [DATE], per the sign-in sheet. The facility's documentation also revealed evidence that this education was provided to department heads on [DATE] and to all facility staff on or before [DATE] by the sign-in sheets. Interviews on [DATE], with State Registered Nurse Aide (SRNA) #15 at 1:00 PM, SRNA #16 at 3:44 PM, SRNA #2 at 1:13 PM, SRNA #4 at 1:30 PM, Licensed Practical Nurse (LPN) #7 at 1:25 PM, LPN #1 at 1:00 PM, LPN #3 at 1:15 PM, with Dietary Staff at 1:40 PM, Maintenance Staff at 1:51 PM, the Respiratory Director at 2:33 PM, and the MDS Coordinator at 1:50 PM revealed knowledge of the Grievance Standard of Practice and Compliance process. 4. A) Review of the facility's New Hire Orientation binder on [DATE], revealed presence of the Grievance Standard of Practice and Compliance policy. Review of the binder also revealed evidence of post tests administered to the staff. B) Review of the facility's documentation on ,[DATE]//19, revealed results of the audit interviews, with stated population, related to the knowledge of the grievance process. C) Interview with the Administrator on [DATE] at 3:30 PM, revealed grievance logs and audits are reviewed daily with a Regional team member, who was still on sight. 5. A) Review of the facility's documentation on [DATE], revealed audits completed on 100% of [MEDICAL CONDITION] residents' respiratory needs, to include care plans on or before [DATE]. The information also revealed a [MEDICAL CONDITION] care plan was initiated on [DATE] on 100% of [MEDICAL CONDITION] residents. B) Review of Resident #98's care plan on [DATE], revealed the care plan was updated with [MEDICAL CONDITION] and activities of daily living (ADL) assistance on [DATE], upon re-entry from a hospital admission. C) Review of the facility's documentation on [DATE], revealed all facility residents had a review of their ADL assistance needs and were revised as indicated on [DATE]. 6. A) Review of the facility's documentation on [DATE], revealed education was provided to the Nurse Management Team on [DATE], by the Regional Quality Manager (RQM) related to completion and review of respiratory care plans and resident-centered [MEDICAL CONDITION] respiratory care needs. B) Review of the facility's documentation on [DATE], revealed the RQM provided education to the Nurse Management Team on [DATE], on completion of the [MEDICAL CONDITION] Patient Admission Questionnaire. C) Review of the facility's documentation on [DATE], revealed a post test was administered to the Nurse Management and Respiratory Therapist by [DATE]. Further review of the documentation revealed Nurse Management and the Respiratory Therapist had passed the post test. D) Review of the facility's documentation on [DATE], revealed education was provided by the Regional Reimbursement Nurse to the Interdisciplinary Team (IDT) on creating a person-centered care plan. Members of the IDT were interviewed and confirmed education on person-centered care plans was provided. E) Review of the facility's documentation on [DATE], revealed education was provided by the Education Training Director to all nursing staff, to include SRNAs, regarding comprehensive care plan and baseline care plan to include respiratory/[MEDICAL CONDITION] care and SRNA care plan to define level of assistance required for ADL care. The information also revealed evidence that post tests were completed. Review of the new hire orientation packet revealed information on respiratory and

Based on observation, interview, record review, review of the facility's laboratory contract, and review of the facility's policy entitled, "Using The Care Plan," it was determined the facility failed to ensure services were provided in accordance with a written plan of care for one (1) of thirty-four (34) sampled residents (Resident #8). Review of the plan of care for Resident #8 dated [DATE], and revised [DATE], revealed facility staff had developed a plan of care related to the resident's [DIAGNOSES REDACTED]. The care plan included an intervention to obtain a "[MEDICATION NAME] Time (PT) with an International Normalized Ratio (INR) as ordered" (a test to check for bleeding time). Review of the physician's orders [REDACTED]. Record review revealed facility staff had administered the medications as ordered. However, the facility failed to ensure the laboratory test had been conducted as ordered and as required by the resident's plan of care. Further review revealed a PT with INR had been obtained on [DATE]; however, the next PT with INR was not conducted until [DATE], a timeframe of seven weeks after the previous test, at which time the PT was 85.1 seconds (reference range 9.5 to 11.6 seconds), and the INR was 7.0 (reference range 0.9 to 1.1). Documentation on the laboratory report revealed the PT and INR levels were "critical." Review of the Nurse's Notes on [DATE] revealed the resident's physician was notified of the abnormal PT and INR levels and the resident was transferred to the hospital. Review of the hospital medical record revealed Resident #8 had been admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]." The facility's failure to ensure residents received services in accordance with the resident's written plan of care caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on [DATE] at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F329). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. Prior to exit on [DATE], the State Survey Agency determined the Immediate Jeopardy was removed on [DATE] as alleged by the facility, which lowered the scope and severity to "D" at 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, "Using the Care Plan," with a revision date of [DATE], revealed the care plan would be used in developing the resident's daily care routines and would be available to staff personnel who had the responsibility to provide care or services to the resident. Review of the facility's contract with the laboratory, dated [DATE], revealed chart audit reviews of physician-ordered laboratory testing would be conducted on a monthly basis. The contract did not specify a timeframe for when a physician's orders [REDACTED]. However, interview on [DATE], at 2:00 PM with the laboratory's Corporate Manager revealed all routine standing laboratory orders expired 400 days after the initial receipt of the order. According to the Corporate Manager, the standing orders would need to be updated in the laboratory's computer system prior to the expiration date of the laboratory orders. Record review revealed the facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #8's medical record revealed on [DATE] the resident's physician ordered a "PT with INR Q (every) week." Review of the [DATE] physician's orders [REDACTED]." Continued review of physician's orders [REDACTED].#8 every night. On [DATE], the physician gave a verbal order to staff to reduce the resident's [MEDICATION NAME] to 5 milligrams every night. On [DATE], the physician gave a verbal order to discontinue the 5 milligrams of [MEDICATION NAME] and to administer 6 milligrams of [MEDICATION NAME] every night. Review of the Comprehensive Plan of Care, dated [DATE], revealed staff had developed a plan of care to address Resident #8's [DIAGNOSES REDACTED]. According to the plan of care, the resident was at risk for bleeding related to the use of [MEDICATION NAME] and the interventions included to obtain a "PT/INR" as ordered and to notify the physician of the "PT/INR" results. Review of Resident #8's laboratory records revealed on [DATE], the resident's PT was 24.6 seconds (reference range 9.5 to 11.6 seconds) and his/her INR level was 2.2 (reference range 0.9 to 1.1). However, continued review of Resident #8's medical record revealed staff failed to ensure the PT with INR laboratory tests were obtained on a weekly basis as ordered by the physician and in accordance with the plan of care. Record review revealed the next PT with an INR for Resident #8 was not completed until [DATE] (seven weeks after the previous test) at which time the resident's PT was 85.1 seconds (73.5 seconds above reference range) and the INR was 7.0 (5.9 above the reference range). Review of the laboratory report revealed both levels were "Critical." The resident's physician was notified of the abnormal lab results. On [DATE], the facility transferred Resident #8 to a hospital for further assessment and treatment in accordance with physician's orders [REDACTED]. Review of the hospital record for Resident #8 revealed the resident was admitted to the hospital on [DATE], placed on telemetry, and was diagnosed with [REDACTED]." Interview with Unit Manager #1 on [DATE] at 9:05 AM, revealed staff was to review the plan of care on a monthly basis to ensure care was provided in accordance with the plan of care. According to the Unit Manager, she became aware that a PT and INR had not been obtained on a weekly basis for Resident #8 when she was in the process of transcribing the monthly Physician order [REDACTED]. included monitoring laboratory tests to ensure the tests were completed as ordered. The Unit Manager also stated after the incident with Resident #8, she learned the company that obtained laboratory tests discontinued the orders for routine laboratory tests 400 days after the tests were initially ordered and required a new physician's orders [REDACTED]. According to the Unit Manager, the initial order for the PT with INR for Resident #8 had been ordered by the physician on [DATE] and staff had transcribed the laboratory tests to the resident's physician's orders [REDACTED].#8's PT and INR laboratory test 400 days from the time the test had been initially ordered, which would have been on [DATE], three days after the PT and INR had been obtained on [DATE]. An interview on [DATE], at 2:00 PM, conducted with the laboratory's Corporate Manager, revealed the laboratory sent an auditor once a month to verify the facility's laboratory orders. The Corporate Manager stated the auditor updated orders at that time and left reports of any identified concerns for the facility to follow up on. According to the Corporate Manager, ultimately it was the facility's responsibility to monitor to ensure laboratory orders were updated and the laboratory process had not changed. The Corporate Manager revealed the auditor had been to the facility on [DATE], and had updated the order for Resident #8's PT with INR to be collected on a weekly basis. However, the Corporate Manager stated the auditor had entered a start date of [DATE], instead of [DATE], for the PT and INR, which caused the laboratory orders to be missed from [DATE] until [DATE]. Interview conducted with the Laboratory Auditor on [DATE], at 3:15 PM, revealed she had been responsible for updating Resident #8's PT with INR orders in the computer system and had inadvertently placed the wrong start date in the computer. The Laboratory Auditor stated she had placed [DATE], as the start date for the PT with INRs and should have put [DATE], as the start date. The Laboratory Auditor stated she reviewed physician's orders [REDACTED]. The Laboratory Auditor stated she then provided a report to the DON of any discrepancies. Interview with the Director of Nursing on [DATE] at 1:15 PM revealed Unit Managers were responsible for monitoring to ensure residents' laboratory orders had been completed as ordered by the physician and that care had been provided in accordance with the resident's comprehensive plan of care. The DON stated she forwarded any reports left by the Laboratory Auditor to the Unit Managers to follow through. The DON stated she made rounds several times throughout the day to ensure care was being provided as directed in the plan of care, reviewed the residents' plans of care at random, and had not identified any problems related to laboratory tests not conducted as ordered by the physician. The Administrator acknowledged in interview conducted on [DATE], at 2:30 PM that she became aware that staff had failed to ensure the PT and INR laboratory tests had not been conducted as ordered by the physician. The Administrator stated the facility had not taken any action after the incident to ensure care was provided as planned in each resident's plan of care and in accordance with physician's orders [REDACTED]. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: -Resident #8 had a physician's orders [REDACTED]. Resident #8 had a PT with INR drawn on [DATE]. On [DATE], the lab noted that the PT with INR for Resident #8 was going to expire on [DATE] so she went in to renew the lab in the Medlab System. She mistakenly changed the start date to [DATE] through [DATE], which deleted the order out of the system until that date; therefore, there would be no PT with INR order in the system for Resident #8 from [DATE] until [DATE]. The Unit Manager discovered that a PT with 1NR was not being drawn during changeover on [DATE]. The physician was notified by the Unit Manager and a clarification order was obtained 0n [DATE] to obtained a PT with INR weekly. The Unit Manager put the PT with INR in the Medlab computer system to be drawn on the next lab day, which was [DATE]. The PT with INR was drawn on Resident #8 on [DATE]. The PT was 85.1 seconds and the INR was 7.0. The physician was notified by the LPN and new orders were received to transfer Resident #8 to the hospital for direct admission. Resident #8 was admitted to the hospital from [DATE] to [DATE]. -All residents who were to have routine labs ordered by the physician are at risk. The Regional Nurse Consultant provided an in-service for the DON and Staff Development Nurse on the lab policy on [DATE], prior to providing an in-service to Licensed Nursing Staff and Unit Managers. All of the nurses, as well as the Unit Managers, will be in-serviced by the DON, Staff Development Nurse or designee on the new laboratory policy and protocol. New protocol has been developed to ensure that laboratory tests are drawn as ordered by the physician and that the results are received in a timely manner. -The Administrator drafted a letter to the manager of the laboratory on [DATE], stating that the minimum expectation is that for any changes in renewing a lab order or any other changes to the laboratory system they must notify the Administrator and DON as well as provide education on those changes. Also stated in the letter from [DATE] is the expectation that no laboratory auditor will renew any labs at all, the facility will be responsible for that. The laboratory was also expected during their monthly audits to provide the Administrator and DON with a list of names for those orders expiring in the upcoming month so that they could renew the lab orders in the laboratory system timely. -A lab policy and protocol was developed by the Quality Assurance team on [DATE] to be used for all laboratory tests. This new policy and protocol includes the steps to take starting from receiving a laboratory order all the way to getting the results and monitoring for timeliness. -The Regional Nurse Consultant in-serviced the DON and the Staff Development Nurse on the lab policy and protocol on [DATE], before they in-serviced the licensed nursing staff. -All licensed nursing staff as well as the unit managers will be educated on the new lab policy and protocol by [DATE], by the DON, Staff Development Nurse or designee. All new nursing hires will be educated on the lab policy and protocol during orientation. No licensed nursing staff will be permitted to work prior to receiving this education. Six (6) licensed nursing staff had not received the in-service because of vacation and sick leave; however, the facility will provide in-service to the six employees before they return to work. -Administrative Nursing Staff completed a 100 percent audit of all labs on [DATE] to ensure labs were drawn per physicians order; any issues identified were addressed and taken through QA. Based on the information provided, Quality Assurance follow-up included completion of documentation, Physician order [REDACTED]. -The Unit Managers will have a laboratory calendar, which has all routine laboratory tests scheduled to be drawn for the rest of the year on it. They will compare the laboratory calendar to the laboratory tests in the laboratory book prior to the morning meetings Monday through Friday to ensure that they match and to ensure that they are drawn timely as ordered and results are received as well as family and physician notification as needed. The Administrator and/or DON or designee will monitor use of the laboratory book five (5) days a week, Monday through Friday, in the morning meeting to ensure that laboratory tests have been drawn as ordered and results have been returned to the facility and have been addressed. Routine laboratory tests are performed Monday through Thursday. -The Nurse on the rotating call schedule was in-serviced on the weekend lab-monitoring log on [DATE] by the Administrator. The Weekend Nurse on Call will call the facility on Saturday and Sunday at 9 AM, 5 PM, and 9 PM to see if any "stat" laboratory tests were ordered on the weekend. If "stat" laboratory tests have been ordered they will verbally verify that the results have been received and the physician and the family have been notified and if any new orders have been received. They will write this down on the weekend lab monitoring log beginning this upcoming weekend. -All staff has been in-serviced on abuse, the definition of abuse, and reporting abuse. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of [DATE]. No agency is used at the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -All staff will be in-serviced on Resident Rights. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of [DATE]. No agency staff are used the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -The Quality Assurance Committee consists of facility and contracted staff. This includes Administrator, DON, Unit Managers, Staff Development Nurse, Social Services, Activities Director, and the Dietary Director. Contracted membership includes the Medical Director. -The Quality Assurance Committee members reviewed the education material on [DATE]. The education materials created were reviewed by Quality Assurance and have been taught to staff by the DON and Staff Development Nurse, who were in-serviced by the Regional Nurse Consultant before they in-serviced the Licensed Nursing Staff. Records of the in-service include signatures of attendance, signature of in-services received, and copy of testing for efficacy of the training. Staff in-service education was provided on [DATE] and completed on [DATE]. Staff retained copies of all in-service materials for their use. -Members of the Quality Assurance Committee developed a policy on [DATE] to validate that Laboratory tests were obtained as ordered by the physician and results were received and followed up on timely per policy protocol. This was implemented [DATE] and is ongoing. The Unit Managers will compare the laboratory calendar to the laboratory tests listed on the laboratory-tracking sheet before morning meetings to verify they match. The Unit Manager will then follow up prior to the morning meeting to ensure that laboratory tests were drawn as listed, results have been received, and they have been followed up on timely. During the morning meetings, Monday through Friday, the Administrator, DON, or designee will check the Laboratory book as well as the laboratory calendar to ensure that laboratory tests have been drawn as physician ordered and results have been received. Any issues identified will be corrected immediately. This practice became effective [DATE]. If any weekend "stat" laboratory tests ordered, the Nurse on Call will call the Administrator or DON and will audit any laboratory tests ordered and received. -Quality Assurance Meetings will be held with two (2) or more team members in attendance daily, five (5) days a week and PRN for review of data to ensure compliance including: any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results. -Quality Assurance Committee members will review data (any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results) minimally five (5) days a week and PRN for thirty (30) days or additionally as necessary until [DATE]; then one (1) time weekly until [DATE] or as needed; then monthly thereafter or as needed sooner. -Regional Nurse Consultant or the Regional Direct of Operations will review, comment, recommend, and/or approve Quality Assurance meetings as per the monitoring protocol. -The Pharmacy Consultant reviewed Resident #8's medical record on [DATE] and on [DATE]. The pharmacist noted on the [DATE] review in Omniview (the pharmacy's computerized system) that Resident #8 hadn't been having their PT with INR drawn weekly per physician's orders [REDACTED]. During the audit, the pharmacist failed to review all [MEDICATION NAME] or other blood thinning laboratory tests, which placed all residents with this type of medication at risk. -The DON spoke with the current Pharmacy Consultant on [DATE], who had conducted the pharmacy review for Resident #8 in May and [DATE], and the Pharmacy Consultant stated that he was resigning and someone else would be doing the pharmacy consulting for the facility starting in August. -The Administrator drafted a letter to the General Manager of the pharmacy on [DATE], stating that during the pharmacist's monthly review, the minimum expectation is that all residents with an order for [REDACTED]. -On [DATE], the Administrator called and spoke with the General Manager of the pharmacy and explained to him that the pharmacy consultant must exit with the Administrator and/or DON and go over their consultant reports when reports are ready and provide the facility with a hard copy of the consultant reports. -The Administrator and/ or DON will educate the Pharmacy Consultant before their next regular review to ensure they assess the following areas: monitoring labs for critical levels, drug-to-drug interactions, and recommended drug alternatives. The education will also include that the Pharmacy Consultant must exit with the Administrator and/or DON upon completion of their review to go over the consultant reports and provide the facility with a hard copy of the consultant reports. The Pharmacy Consultant will be required to sign verification of education. -The Administrator and DON now have access to the pharmacy computer system effective [DATE], so they can go in and look at the consultant reports as well as any notes that had been made. The Administrator and DON will review the reports in the pharmacy computer system when they become available after the Pharmacy Consultant has completed his exit. The Administrator and DON will check the computer system daily after the pharmacy consultant has exited to see if the reports are on the computer. When the reports are available on the computer the Administrator and DON will compare the computer to the hard copy pharmacy reports to ensure that they match. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -The Administrator and DON will review the Pharmacy Consultant's report monthly to see what recommendations have been made, and to identify any issues found. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -If any weekend stat labs are ordered, the Nurse on Call will call the Administrator or DON and will document any labs on the audit tool for the weekend lab tests ordered and received. -Resident #8 has a care plan for anticoagulants, which stated to obtain a PT/INR as ordered, at least monthly. However, the PT with INR laboratory tests for Resident #8 were not drawn weekly as ordered by the physician or as care planned from [DATE] to [DATE]. -Based on the fact that the Care Plan was not followed for anticoagulant therapy the root cause has been determined to be lack of use of the care plan as a communication tool to licensed nursing staff. -Licensed Nursing staff will be in-serviced on the comprehensive care plan use in directing resident care by [DATE]. In-services will be conducted by the Staff Development Nurse, DON or designee. In-services will include documentation required for the use of interventions on the care plans. All new hires will be educated during general orientation by the Staff Development Nurse. Six (6) licensed staff members have not been in-serviced due to vacation, or sick leave and they will be educated before they are allowed to return to work. -One hundred percent (100%) of all anti-coagulant care plans were reviewed and/or updated by the Regional Nurse Consultant as necessary on [DATE]. -One hundred percent (100%) of the care plans have been reviewed and/or updated for labs on [DATE] by members of the care planning team including the DON, MDS, Unit managers, Dietary Manager, Social Services. -The Administrator did not have sufficient lab protocols in place to assure that Resident #8 had received labs per physician orders. -The Regional Director of Operations or the Clinical Nurse Consultant will be in the building daily until the facility has abated the immediate jeopardy to provide facility oversight. After the facility has abated the immediate jeopardy, they will be in the facility to provide management oversight throughout the survey process at least weekly. **The surveyors validated the Immediate Jeopardy was removed as follows: -Review of the laboratory reports for Resident #8 revealed a PT with INR dated [DATE] with the results being 85.1 for the PT and the INR results being 7.0. -Review of the Nurse's Notes for Resident #8 dated [DATE], at 5:41 PM, revealed Resident #8's physician was notified regarding the results of the resident's PT with INR, and the resident was sent to the hospital. -Interview conducted with Registered Nurse (RN) #2 on [DATE] at 9:05 AM, revealed Resident #8 had not received his/her PT with INRs weekly as was ordered by the physician in the [DATE] physician orders. The RN stated on [DATE] she notified Resident #8's physician that the resident had not received a PT with INR laboratory test as ordered and received an order to obtain weekly PT with INR. A PT with INR was completed on [DATE], the resident's physician was notified of the results, and the resident was sent to a hospital. -Interview with the laboratory Corporate Manager on [DATE], at 2:00 PM, revealed during her monthly review of laboratory orders, the Laboratory Auditor had updated Resident #8's PT with INR order in the computer, which was set to expire on [DATE], and had inadvertently set the new start date for [DATE], instead of [DATE]. -Review of the Laboratory Policy and Protocol developed by the facility on [DATE], revealed a posttest had been completed by all facility nurses. -Review of an in-service roster dated [DATE], revealed the DON and Staff Development Nurse (SDN) attended an in-service by the Regional Nurse Consultant on the lab policy, neglect, resident rights, and care plans. -Interview conducted with the DON and the SDN on [DATE], at 4:40 PM, revealed they had attended an in-service on [DATE], by the Regional Corporate Nurse on the lab policy and protocol, abuse, resident rights, and care plans. The DON and SDN stated they had then provided the in-service to the nursing staff. -Interview conducted on [DATE], at 4:15 PM, with the Regional Nurse Consultant revealed she had been responsible for providing an in-service to both the DON and the SDN on [DATE], related to the lab policy and protocol, abuse, resident rights, and care plans prior to them providing an in-service to the nursing staff. -Review of the in-service roster revealed 43 facility nurses attended the in-service provided by the DON and SDN on the lab policy and protocol and care plans. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, State Registered Nurse Aide (SRNA) #8 at 2:24 PM, SRNA #10 at 2:00 PM, SRNA #14 at 2:11 PM, SRNA #15 at 2:15 PM, and SRNA #16 at 2:28 PM all revealed they had attended an in-service on abuse, and resident rights. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, and LPN #6 at 2:02 PM revealed they had attended an in-service related to the lab policy and protocol regarding how to put a laboratory order into the computer, the tracking process, and documentation required. -Review of the letter sent to the laboratory dated [DATE], revealed the laboratory service was not to renew any laboratory orders that were near expiration, and that the facility would do all renewals. The laboratory was required to immediately notify the Administrator and the DON of any changes or any laboratory orders that were about to expire. -Interview conducted with the Administrator on [DATE], at 4:30 PM, and the DON at 4:40 PM, revealed the Administrator had notified the laboratory's General Manager by phone and then by letter and had instructed them that they were to no longer update any laboratory orders in the computer, that the facility would do all laboratory updates, and that the facility expected the Laboratory Auditor to give the Administrator and the DON a list of all residents whose laboratory orders were nearing expiration. -Review of an audit completed by the DON, RN #2, RN #8, RN #9, and RN #10 on [DATE], of all residents' laboratory orders to ensure laboratory orders had been completed as ordered by the physician revealed all had been completed. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, RN #8 at 2:30 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, and the DON at 4:40 PM, revealed they had all assisted in completing an audit on [DATE], of all residents' laboratory orders to ensure the orders had been completed as ordered by the physician and the reports had been placed on the resident's medical record and the results reported to the physician as necessary. -Review of the laboratory calendars for each nursing station revealed all Unit Managers had documented all laboratory orders and the date the laboratory test was due for the residents on their unit. -Observations of the laboratory calendars were conducted on [DATE], on the Blue Wing at 2:40 PM, Peach Wing at 2:45 PM, and the Green Wing at 2:50 PM. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, and RN #9 at 2:38 PM, revealed they used the calendars to monitor laboratory orders to ensure the laboratory test were completed. The RNs also revealed they were required to check laboratory orders daily prior to attending the morning Quality Assurance meeting and were required to report any concerns with laboratory orders not being completed. -Interview conducted with the Administrator on [DATE], at 4:30 PM, and the DON at 4:40 PM, revealed they reviewed the laboratory calendars every morning in the Quality Assurance morning meeting to ensure laboratory orders had been completed as ordered by the physician. -Review of the Nurse on Call schedule revealed a nurse was scheduled every weekend to take Administrative call. -Review of an in-service by the Administrator dated [DATE], and attended by the DON, RN #2, and RN #9 revealed the weekend On-Call Nurse was required to call the facility on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any "stat" laboratory orders had been conducted. If any were ordered, the RN was then required to verbally verify if the results had been received by the facility. The weekend Nurse on Call was required to document the information on the weekend log beginning [DATE]. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, RN #9 at 2:38 PM, and the DON at 4:40 PM, all revealed they had attended an in-service by the Administrator on [DATE]. The interviews revealed they were required to call the facility when on call on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any stat laboratory orders had been ordered, and the results returned. The interview revealed they were also required to document the information on a weekend lab-monitoring tool as part of the Quality Assurance program, which began on [DATE]. -Interview conducted with the Administrator on [DATE], at 4:30 PM, revealed she had conducted an in-service for nurses who would be taking administrative call on weekends on [DATE]. The Administrator stated the on-call nurses were required to call the facility at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM to ensure all stat laboratory orders had been completed and the results were on the resident's medical record. The Administrator stated the process would begin on Saturday, [DATE]. The Administrator stated she would be reviewing the audits every Monday in the morning meeting

Based on observation, interview, record review, review of the facility's policies entitled "Lab and Diagnostic Test Results-Clinical Protocol" and "Medication Administration," and a review of the facility's contract for Laboratory Services, it was determined the facility failed to ensure nursing staff effectively monitored medications and laboratory results for one (1) of thirty-four (34) sampled residents (Resident #8). Review of physician's orders [REDACTED].#8 at night, and for a [MEDICATION NAME] Time (PT) with an International Normalized Ratio (INR) (laboratory tests to check bleeding time) to be completed weekly. A review of Resident #8's medical record revealed the facility administered [MEDICATION NAME] on a daily basis at night and a PT and INR was obtained on [DATE] and on [DATE]. The PT/INR that was obtained on [DATE] revealed the resident's PT was 24.6 seconds (reference range 9.5 to 11.6 seconds), and the resident's INR was 2.2 (reference range 0.9 to 1.1). Documentation revealed facility staff continued to administer 6 mg of [MEDICATION NAME] to Resident #8 at night; however, staff failed to ensure the PT and INR was collected on a weekly basis as ordered by the resident's physician. review of the resident's medical record revealed [REDACTED].#8 again until [DATE] (seven weeks after the previous test on [DATE]) at which time the resident's PT was 85.1 seconds (73.5 seconds above reference range), the INR was 7.0 seconds (5.9 above the reference range), and was identified by the laboratory to be at a "Critical" level. Review of the Nurse's Notes dated [DATE], revealed Resident #8's physician was notified of the abnormal lab results and the resident was transported and admitted to a hospital where he/she was placed on telemetry (heart monitoring) and diagnosed with [REDACTED]." The facility's failure to ensure facility staff provided adequate monitoring of drugs and laboratory testing and failure to ensure residents were free from significant medication errors caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on [DATE] at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F329). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AOC) was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. Prior to exit on [DATE], the State Survey Agency determined the Immediate Jeopardy was removed on [DATE] as alleged by the facility, which lowered the scope and severity to "D" at 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, "Lab and Diagnostic Test Results-Clinical Protocol," with a revision date of [DATE], revealed the physician would identify and order diagnostic and laboratory testing based on diagnostic and monitoring needs. The policy stated nursing staff would process the test requisition and arrange for the tests to be completed by the laboratory. Review of the facility's policy titled, "Medication Administration," which was undated, revealed nursing staff would evaluate if the medication was implicated in an adverse consequence and had achieved the therapeutic goal. However, the policy failed to address monitoring medication/medication errors. Review of the facility's contract titled, "Laboratory Contract Addendum," dated [DATE], revealed the laboratory "will provide chart audit services for facility on a monthly basis." However, the contract did not address a specific amount of time in which a laboratory test order would expire/stop being collected. Review of the facility's contract titled, "Pharmacy Consultant Agreement," dated [DATE], revealed the Pharmacist (RPh) would review the drug regimen of each resident in the facility and would report in writing any irregularity to the facility's Administrator, Medical Director, the resident's physician, and the DON. Record review revealed the facility initially admitted Resident #8 to the facility on [DATE] following a hospitalization , and was readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #8's [DATE] physician's orders [REDACTED].#8's medical record revealed facility staff administered 6 mg of [MEDICATION NAME] to the resident nightly; however, staff failed to ensure the PT/INR was collected on a weekly basis from [DATE] through [DATE] (a timeframe of seven weeks). A PT and INR laboratory test was conducted on [DATE], which revealed Resident #8's PT was 85.1 seconds (73.5 seconds above the reference range), his/her INR was 7.0 seconds (5.9 above the reference range), and the laboratory results revealed the levels were "Critical." Review of the Nurse's Notes dated [DATE], revealed Resident #8's physician was notified of the "Critical" lab results and the resident was transported to a hospital. Review of the Hospital record revealed Resident #8 was admitted to the hospital, placed on telemetry, and diagnosed with [REDACTED]." (According to the Occupational Safety and Health Administration (n.d.), the signs and symptoms of [MEDICATION NAME] toxicity include bloody nose; bleeding gums; muscle and joint pain; hematomas of the arms, legs, buttocks, and/or joints; frank blood in the urine and feces; anorexia, nausea, vomiting, diarrhea or abdominal pain; pallor and fatigue caused by [MEDICAL CONDITION]; paralysis caused by [MEDICAL CONDITION]; blurry vision, eye pain, and [MEDICAL CONDITION]; [MEDICAL CONDITION] and petechiae, necrosis, or gangrene). A review of the resident's facility and hospital medical records and interviews with staff revealed Resident #8 did not exhibit any outward signs or symptoms of [MEDICATION NAME] Toxicity. Interview with Unit Manager #1, on [DATE] at 9:05 AM, revealed she was responsible to ensure laboratory orders were completed. However, according to the Unit Manager, on [DATE] she discovered the PT with INR had not been collected for Resident #8 since [DATE]. The Unit Manager stated she contacted the laboratory on [DATE], and was told the order for Resident #8's PT with an INR had "expired." According to the Unit Manager, the Corporate Manager for the laboratory informed her standing orders for laboratory tests expired after 400 days. The Unit Manager stated she was not aware of the date the laboratory request had expired. Interview on [DATE] at 1:20 PM with Resident #8's physician revealed the failure to ensure Resident #8's PT and INR levels were obtained and reported weekly could have caused the resident harm. The physician stated he assessed the resident on [DATE], and had documented Resident #8's PT with INRs were being monitored weekly in his Progress Notes, but stated he had just reviewed the laboratory reports that were on the resident's medical record and had not identified the PT with INRs had not been completed weekly for Resident #8 as he had ordered. Interview conducted on [DATE], at 2:00 PM with the Corporate Manager for the laboratory utilized by the facility revealed the laboratory sent an Auditor to the facility on ce a month to verify laboratory orders. The Corporate Manager stated the Auditor would update an order at that time, but it was ultimately the facility's responsibility to ensure laboratory orders were updated and the process had not changed. The Corporate Manager stated when the Auditor verified Physician order [REDACTED]. laboratory tests of [DATE], instead of [DATE], and that had caused the laboratory orders to be missed from [DATE] until [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 1:15 PM revealed the Laboratory the facility utilized to perform laboratory testing maintained standing orders for laboratory tests for a timeframe of 400 days, and then discontinued the order unless it was reordered by the physician. According to the DON, the Laboratory had conducted the PT and INR for Resident #1 in accordance with the physician's initial order, but had discontinued the test the first day after the standing order expired (the 400th day). The DON stated facility staff was required to update standing orders for the Laboratory to continue to conduct laboratory tests. The DON stated until the incident with Resident #8, neither she nor the facility had been aware of the expiration of a laboratory order after 400 days, nor was it specified in the contract between the facility and the laboratory. The DON stated the facility had not put any monitors in place other than the Laboratory Auditor until after Resident #8's PT with INRs had been missed. Interview with the Administrator on [DATE], at 2:30 PM, revealed she was informed of the facility's failure to obtain PT and INR laboratory tests for Resident #8 on [DATE]. The Administrator stated the facility had not taken any action after the incident to ensure care was provided in accordance with physician's orders [REDACTED]. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: -Resident #8 had a physician's orders [REDACTED]. Resident #8 had a PT with INR drawn on [DATE]. On [DATE], the lab noted that the PT with INR for Resident #8 was going to expire on [DATE] so she went in to renew the lab in the Medlab System. She mistakenly changed the start date to [DATE] through [DATE], which deleted the order out of the system until that date; therefore, there would be no PT with INR order in the system for Resident #8 from [DATE] until [DATE]. The Unit Manager discovered that a PT with 1NR was not being drawn during changeover on [DATE]. The physician was notified by the Unit Manager and a clarification order was obtained 0n [DATE] to obtained a PT with INR weekly. The Unit Manager put the PT with INR in the Medlab computer system to be drawn on the next lab day, which was [DATE]. The PT with INR was drawn on Resident #8 on [DATE]. The PT was 85.1 seconds and the INR was 7.0. The physician was notified by the LPN and new orders were received to transfer Resident #8 to the hospital for direct admission. Resident #8 was admitted to the hospital from [DATE] to [DATE]. -All residents who were to have routine labs ordered by the physician are at risk. The Regional Nurse Consultant provided an in-service for the DON and Staff Development Nurse on the lab policy on [DATE], prior to providing an in-service to Licensed Nursing Staff and Unit Managers. All of the nurses, as well as the Unit Managers, will be in-serviced by the DON, Staff Development Nurse or designee on the new laboratory policy and protocol. New protocol has been developed to ensure that laboratory tests are drawn as ordered by the physician and that the results are received in a timely manner. -The Administrator drafted a letter to the manager of the laboratory on [DATE], stating that the minimum expectation is that for any changes in renewing a lab order or any other changes to the laboratory system they must notify the Administrator and DON as well as provide education on those changes. Also stated in the letter from [DATE] is the expectation that no laboratory auditor will renew any labs at all, the facility will be responsible for that. The laboratory was also expected during their monthly audits to provide the Administrator and DON with a list of names for those orders expiring in the upcoming month so that they could renew the lab orders in the laboratory system timely. -A lab policy and protocol was developed by the Quality Assurance team on [DATE] to be used for all laboratory tests. This new policy and protocol includes the steps to take starting from receiving a laboratory order all the way to getting the results and monitoring for timeliness. -The Regional Nurse Consultant in-serviced the DON and the Staff Development Nurse on the lab policy and protocol on [DATE], before they in-serviced the licensed nursing staff. -All licensed nursing staff as well as the unit managers will be educated on the new lab policy and protocol by [DATE], by the DON, Staff Development Nurse or designee. All new nursing hires will be educated on the lab policy and protocol during orientation. No licensed nursing staff will be permitted to work prior to receiving this education. Six (6) licensed nursing staff had not received the in-service because of vacation and sick leave; however, the facility will provide in-service to the six employees before they return to work. -Administrative Nursing Staff completed a 100 percent audit of all labs on [DATE] to ensure labs were drawn per physicians order; any issues identified were addressed and taken through QA. Based on the information provided, Quality Assurance follow-up included completion of documentation, Physician order [REDACTED]. -The Unit Managers will have a laboratory calendar, which has all routine laboratory tests scheduled to be drawn for the rest of the year on it. They will compare the laboratory calendar to the laboratory tests in the laboratory book prior to the morning meetings Monday through Friday to ensure that they match and to ensure that they are drawn timely as ordered and results are received as well as family and physician notification as needed. The Administrator and/or DON or designee will monitor use of the laboratory book five (5) days a week, Monday through Friday, in the morning meeting to ensure that laboratory tests have been drawn as ordered and results have been returned to the facility and have been addressed. Routine laboratory tests are performed Monday through Thursday. -The Nurse on the rotating call schedule was in-serviced on the weekend lab-monitoring log on [DATE] by the Administrator. The Weekend Nurse on Call will call the facility on Saturday and Sunday at 9 AM, 5 PM, and 9 PM to see if any "stat" laboratory tests were ordered on the weekend. If "stat" laboratory tests have been ordered they will verbally verify that the results have been received and the physician and the family have been notified and if any new orders have been received. They will write this down on the weekend lab monitoring log beginning this upcoming weekend. -All staff has been in-serviced on abuse, the definition of abuse, and reporting abuse. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of [DATE]. No agency is used at the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -All staff will be in-serviced on Resident Rights. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of [DATE]. No agency staff are used the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -The Quality Assurance Committee consists of facility and contracted staff. This includes Administrator, DON, Unit Managers, Staff Development Nurse, Social Services, Activities Director, and the Dietary Director. Contracted membership includes the Medical Director. -The Quality Assurance Committee members reviewed the education material on [DATE]. The education materials created were reviewed by Quality Assurance and have been taught to staff by the DON and Staff Development Nurse, who were in-serviced by the Regional Nurse Consultant before they in-serviced the Licensed Nursing Staff. Records of the in-service include signatures of attendance, signature of in-services received, and copy of testing for efficacy of the training. Staff in-service education was provided on [DATE] and completed on [DATE]. Staff retained copies of all in-service materials for their use. -Members of the Quality Assurance Committee developed a policy on [DATE] to validate that Laboratory tests were obtained as ordered by the physician and results were received and followed up on timely per policy protocol. This was implemented [DATE] and is ongoing. The Unit Managers will compare the laboratory calendar to the laboratory tests listed on the laboratory-tracking sheet before morning meetings to verify they match. The Unit Manager will then follow up prior to the morning meeting to ensure that laboratory tests were drawn as listed, results have been received, and they have been followed up on timely. During the morning meetings, Monday through Friday, the Administrator, DON, or designee will check the Laboratory book as well as the laboratory calendar to ensure that laboratory tests have been drawn as physician ordered and results have been received. Any issues identified will be corrected immediately. This practice became effective [DATE]. If any weekend "stat" laboratory tests ordered, the Nurse on Call will call the Administrator or DON and will audit any laboratory tests ordered and received. -Quality Assurance Meetings will be held with two (2) or more team members in attendance daily, five (5) days a week and PRN for review of data to ensure compliance including: any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results. -Quality Assurance Committee members will review data (any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results) minimally five (5) days a week and PRN for thirty (30) days or additionally as necessary until [DATE]; then one (1) time weekly until [DATE] or as needed; then monthly thereafter or as needed sooner. -Regional Nurse Consultant or the Regional Direct of Operations will review, comment, recommend, and/or approve Quality Assurance meetings as per the monitoring protocol. -The Pharmacy Consultant reviewed Resident #8's medical record on [DATE] and on [DATE]. The pharmacist noted on the [DATE] review in Omniview (the pharmacy's computerized system) that Resident #8 hadn't been having their PT with INR drawn weekly per physician's orders [REDACTED]. During the audit, the pharmacist failed to review all [MEDICATION NAME] or other blood thinning laboratory tests, which placed all residents with this type of medication at risk. -The DON spoke with the current Pharmacy Consultant on [DATE], who had conducted the pharmacy review for Resident #8 in May and [DATE], and the Pharmacy Consultant stated that he was resigning and someone else would be doing the pharmacy consulting for the facility starting in August. -The Administrator drafted a letter to the General Manager of the pharmacy on [DATE], stating that during the pharmacist's monthly review, the minimum expectation is that all residents with an order for [REDACTED]. -On [DATE], the Administrator called and spoke with the General Manager of the pharmacy and explained to him that the pharmacy consultant must exit with the Administrator and/or DON and go over their consultant reports when reports are ready and provide the facility with a hard copy of the consultant reports. -The Administrator and/ or DON will educate the Pharmacy Consultant before their next regular review to ensure they assess the following areas: monitoring labs for critical levels, drug-to-drug interactions, and recommended drug alternatives. The education will also include that the Pharmacy Consultant must exit with the Administrator and/or DON upon completion of their review to go over the consultant reports and provide the facility with a hard copy of the consultant reports. The Pharmacy Consultant will be required to sign verification of education. -The Administrator and DON now have access to the pharmacy computer system effective [DATE], so they can go in and look at the consultant reports as well as any notes that had been made. The Administrator and DON will review the reports in the pharmacy computer system when they become available after the Pharmacy Consultant has completed his exit. The Administrator and DON will check the computer system daily after the pharmacy consultant has exited to see if the reports are on the computer. When the reports are available on the computer the Administrator and DON will compare the computer to the hard copy pharmacy reports to ensure that they match. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -The Administrator and DON will review the Pharmacy Consultant's report monthly to see what recommendations have been made, and to identify any issues found. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -If any weekend stat labs are ordered, the Nurse on Call will call the Administrator or DON and will document any labs on the audit tool for the weekend lab tests ordered and received. -Resident #8 has a care plan for anticoagulants, which stated to obtain a PT/INR as ordered, at least monthly. However, the PT with INR laboratory tests for Resident #8 were not drawn weekly as ordered by the physician or as care planned from [DATE] to [DATE]. -Based on the fact that the Care Plan was not followed for anticoagulant therapy the root cause has been determined to be lack of use of the care plan as a communication tool to licensed nursing staff. -Licensed Nursing staff will be in-serviced on the comprehensive care plan use in directing resident care by [DATE]. In-services will be conducted by the Staff Development Nurse, DON or designee. In-services will include documentation required for the use of interventions on the care plans. All new hires will be educated during general orientation by the Staff Development Nurse. Six (6) licensed staff members have not been in-serviced due to vacation, or sick leave and they will be educated before they are allowed to return to work. -One hundred percent (100%) of all anti-coagulant care plans were reviewed and/or updated by the Regional Nurse Consultant as necessary on [DATE]. -One hundred percent (100%) of the care plans have been reviewed and/or updated for labs on [DATE] by members of the care planning team including the DON, MDS, Unit managers, Dietary Manager, Social Services. -The Administrator did not have sufficient lab protocols in place to assure that Resident #8 had received labs per physician orders. -The Regional Director of Operations or the Clinical Nurse Consultant will be in the building daily until the facility has abated the immediate jeopardy to provide facility oversight. After the facility has abated the immediate jeopardy, they will be in the facility to provide management oversight throughout the survey process at least weekly. **The surveyors validated the Immediate Jeopardy was removed as follows: -Review of the laboratory reports for Resident #8 revealed a PT with INR dated [DATE] with the results being 85.1 for the PT and the INR results being 7.0. -Review of the Nurse's Notes for Resident #8 dated [DATE], at 5:41 PM, revealed Resident #8's physician was notified regarding the results of the resident's PT with INR, and the resident was sent to the hospital. -Interview conducted with Registered Nurse (RN) #2 on [DATE] at 9:05 AM, revealed Resident #8 had not received his/her PT with INRs weekly as was ordered by the physician in the [DATE] physician orders. The RN stated on [DATE] she notified Resident #8's physician that the resident had not received a PT with INR laboratory test as ordered and received an order to obtain weekly PT with INR. A PT with INR was completed on [DATE], the resident's physician was notified of the results, and the resident was sent to a hospital. -Interview with the laboratory Corporate Manager on [DATE], at 2:00 PM, revealed during her monthly review of laboratory orders, the Laboratory Auditor had updated Resident #8's PT with INR order in the computer, which was set to expire on [DATE], and had inadvertently set the new start date for [DATE], instead of [DATE]. -Review of the Laboratory Policy and Protocol developed by the facility on [DATE], revealed a posttest had been completed by all facility nurses. -Review of an in-service roster dated [DATE], revealed the DON and Staff Development Nurse (SDN) attended an in-service by the Regional Nurse Consultant on the lab policy, neglect, resident rights, and care plans. -Interview conducted with the DON and the SDN on [DATE], at 4:40 PM, revealed they had attended an in-service on [DATE], by the Regional Corporate Nurse on the lab policy and protocol, abuse, resident rights, and care plans. The DON and SDN stated they had then provided the in-service to the nursing staff. -Interview conducted on [DATE], at 4:15 PM, with the Regional Nurse Consultant revealed she had been responsible for providing an in-service to both the DON and the SDN on [DATE], related to the lab policy and protocol, abuse, resident rights, and care plans prior to them providing an in-service to the nursing staff. -Review of the in-service roster revealed 43 facility nurses attended the in-service provided by the DON and SDN on the lab policy and protocol and care plans. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, State Registered Nurse Aide (SRNA) #8 at 2:24 PM, SRNA #10 at 2:00 PM, SRNA #14 at 2:11 PM, SRNA #15 at 2:15 PM, and SRNA #16 at 2:28 PM all revealed they had attended an in-service on abuse, and resident rights. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, and LPN #6 at 2:02 PM revealed they had attended an in-service related to the lab policy and protocol regarding how to put a laboratory order into the computer, the tracking process, and documentation required. -Review of the letter sent to the laboratory dated [DATE], revealed the laboratory service was not to renew any laboratory orders that were near expiration, and that the facility would do all renewals. The laboratory was required to immediately notify the Administrator and the DON of any changes or any laboratory orders that were about to expire. -Interview conducted with the Administrator on [DATE], at 4:30 PM, and the DON at 4:40 PM, revealed the Administrator had notified the laboratory's General Manager by phone and then by letter and had instructed them that they were to no longer update any laboratory orders in the computer, that the facility would do all laboratory updates, and that the facility expected the Laboratory Auditor to give the Administrator and the DON a list of all residents whose laboratory orders were nearing expiration. -Review of an audit completed by the DON, RN #2, RN #8, RN #9, and RN #10 on [DATE], of all residents' laboratory orders to ensure laboratory orders had been completed as ordered by the physician revealed all had been completed. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, RN #8 at 2:30 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, and the DON at 4:40 PM, revealed they had all assisted in completing an audit on [DATE], of all residents' laboratory orders to ensure the orders had been completed as ordered by the physician and the reports had been placed on the resident's medical record and the results reported to the physician as necessary. -Review of the laboratory calendars for each nursing station revealed all Unit Managers had documented all laboratory orders and the date the laboratory test was due for the residents on their unit. -Observations of the laboratory calendars were conducted on [DATE], on the Blue Wing at 2:40 PM, Peach Wing at 2:45 PM, and the Green Wing at 2:50 PM. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, and RN #9 at 2:38 PM, revealed they used the calendars to monitor laboratory orders to ensure the laboratory test were completed. The RNs also revealed they were required to check laboratory orders daily prior to attending the morning Quality Assurance meeting and were required to report any concerns with laboratory orders not being completed. -Interview conducted with the Administrator on [DATE], at 4:30 PM, and the DON at 4:40 PM, revealed they reviewed the laboratory calendars every morning in the Quality Assurance morning meeting to ensure laboratory orders had been completed as ordered by the physician. -Review of the Nurse on Call schedule revealed a nurse was scheduled every weekend to take Administrative call. -Review of an in-service by the Administrator dated [DATE], and attended by the DON, RN #2, and RN #9 revealed the weekend On-Call Nurse was required to call the facility on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any "stat" laboratory orders had been conducted. If any were ordered, the RN was then required to verbally verify if the results had been received by the facility. The weekend Nurse on Call was required to document the information on the weekend log beginning [DATE]. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, RN #9 at 2:38 PM, and the DON at 4:40 PM, all revealed they had attended an in-service by the Administrator on [DATE]. The interviews revealed they were required to call the facility when on call on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any stat laboratory orders had been ordered, and the results returned. The interview revealed they were also required to document the information on a weekend lab-monitoring tool as part of the Quality Assurance program, which began on [DATE]. -Interview conducted with the Administrator on [DATE], at 4:30 PM, revealed she had conducted an in-service for nurses who would be taking administrative call on weekends on [DATE]. The Administrator stated the on-call nurses were required to call the facility at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM to ensure all stat laboratory orders had been completed and the results were on the resident's medical record. The Administrator stated the process would begin on Saturday, [DATE]. The Administrator stated she would be reviewing the audits every Monday in the morning meeting, which was a part of the Quality Assurance program. -An in-service roster dated [DATE], regarding Abuse and Resident Rights with a posttest, revealed all employees had attended the in-service. -Review of a new hire in-service syllabus was reviewed and the laboratory policy in-service was added to the new hire orientation. -Interviews conducted on [DATE], with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, State Registered Nurse Aide (SRNA) #8 at 2:24 PM, SRNA #10 at 2:00 PM, SRNA #14 at 2:11 PM, SRNA #15 at 2:15 PM, and SRNA #16 at 2:28 PM revealed they had attended an in-service on abuse and resident rights and had also completed a posttest. -Interview conducted with the SDN on [DATE], at 12:55 PM, revealed she had prov

Based on observation, interview, record review, and review of the facility's contract with the pharmacy, it was determined the facility failed to ensure the pharmacist reported irregularities to the attending physician and to the Director of Nursing (DON) in order for the reports to be acted upon for one (1) of thirty-four (34) sampled residents (Resident #8). Resident #8 had physician's orders [REDACTED]. Review of Resident #8's May 2014 monthly Physician order [REDACTED]. Record review revealed a PT and INR was obtained on 05/12/14 and revealed the resident's PT was 24.6 seconds (reference range 9.5 to 11.6 seconds), and the INR was 2.2 (reference range 0.9 to 1.1). However, the next PT with an INR for Resident #8 was not completed until 07/02/14 (seven weeks after the previous PT/INR had been obtained on 05/12/14) and the resident's PT was 85.1 seconds (73.5 seconds above reference) and the INR was 7.0 (5.9 above the reference range). Review of the Laboratory report revealed the resident's PT and INR at that time was "Critical." Resident #8 was admitted to the hospital on [DATE], was placed on telemetry, and diagnosed with [REDACTED].#8's medical record on 05/19/14 and 06/26/14. However, there was no evidence the pharmacist had notified the physician or the DON that the resident's PT and INR had not been obtained as ordered by the physician. The facility's failure to ensure residents received adequate drug monitoring and was free from significant medication errors caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/19/14 at 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F490 and F520 at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F329). The facility was notified of the Immediate Jeopardy on 07/18/14. An acceptable Allegation of Compliance (AOC) was received on 07/24/14, which alleged removal of the Immediate Jeopardy on 07/24/14. On 07/25/14, the State Survey Agency determined the Immediate Jeopardy was removed on 07/24/14, as alleged, which lowered the scope and severity to "D" at 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's contract with the pharmacy entitled, "Pharmacy Consultant Agreement," dated 02/01/99, revealed the Pharmacist (RPh) would review the drug regimen of each resident in the facility and would report in writing any irregularity to the facility's Administrator, Medical Director, the resident's physician, and the DON. Record review revealed the facility admitted Resident #8 on 09/07/12 with a [DIAGNOSES REDACTED]. Further review of Resident #8's medical record revealed physician's orders [REDACTED].#8 was to receive 6 milligrams of Coumadin (anticoagulant) every night, and a Prothrombin Time (PT) with an International Normalized Ratio (INR) (laboratory tests to check for bleeding time) every week. Review of Physician order [REDACTED]. In addition, the physician gave a verbal order dated 05/12/14 for the resident's Coumadin to be increased to 6 milligrams every night. Review of Resident #8's laboratory records dated 05/12/14 revealed the PT was 24.6 seconds with the normal range being 9.5 to 11.6 seconds. The INR was 2.2 with the normal range being 0.9 to 1.1 seconds. Further review of laboratory results for Resident #8 revealed the laboratory testing had not been completed on a weekly basis as ordered. Review of laboratory reports revealed a PT and INR was conducted on 07/02/14, seven weeks after the most recent tests on 05/12/14, and the resident's PT was 85.1 seconds (73.5 seconds above the reference range) and the INR was 7.0 (5.9 above the reference range). The laboratory report indicated both levels were "Critical." A hand written note on the laboratory report revealed a Registered Nurse (RN) notified the resident's physician of the abnormal lab results and Resident #8 was transported to a hospital. Review of the hospital record for Resident #8 revealed the resident was admitted to the hospital on [DATE], placed on telemetry, and was diagnosed with [REDACTED]. Review of the Medication Regimen Review revealed the RPh had reviewed the medication regimen for Resident #8 on 05/19/14 and 06/26/14. However, there was no documented evidence the RPh had identified and/or notified the Administrator, DON, Medical Director, or the resident's physician that the weekly PT and INR laboratory tests had not been conducted as prescribed for Resident #8. Interview conducted with the RPh on 07/18/14, at 1:40 PM, revealed he conducted monthly medication regimen reviews, and reviewed laboratory reports of those residents that received Coumadin (anticoagulant). The RPh stated he had not recorded Resident #8's PT with INR on 06/26/14, and that he had "missed" the fact that the resident had not had a PT with INR completed since 05/12/14. Interview with the Director of Nursing on 07/18/14 at 1:15 PM revealed she had not received any communication from the RPh that the weekly PT and INR that had been ordered by Resident #'8s physician had not been done. The DON stated she would have expected the pharmacist to notify her. Interview on 07/18/14 at 1:20 PM with the Medical Director revealed he was also Resident #8's physician. According to the Medical Director, he expected the pharmacist that conducted the monthly drug regimen reviews at the facility to notify him of any drug irregularities and that the weekly PT and INRs that he had ordered for Resident #8 had not been completed as ordered. Interview conducted with the Administrator on 07/18/14, at 2:30 PM, revealed the pharmacist conducted drug regimen on a monthly basis and the pharmacist was to notify her of any drug irregularities as the result of his monthly drug regimen review. The Administrator stated the pharmacist had conducted a monthly drug regimen review for Resident #8 on 05/19/14 and 06/26/14. However, according to the Administrator, the pharmacist had not notified her of any drug irregularities or that the laboratory tests used to monitor Resident #8's Coumadin use had not been conducted as ordered by the physician. **The facility provided an acceptable Allegation of Compliance (AOC) on 07/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: -Resident #8 had a physician's orders [REDACTED]. Resident #8 had a PT with INR drawn on 5/12/14. On 06/12/14, the lab noted that the PT with INR for Resident #8 was going to expire on 07/31/14 so she went in to renew the lab in the Medlab System. She mistakenly changed the start date to 07/31/14 through 07/31/14, which deleted the order out of the system until that date; therefore, there would be no PT with INR order in the system for Resident #8 from 05/12/14 until 07/01/14. The Unit Manager discovered that a PT with 1NR was not being drawn during changeover on 6/30/14. The physician was notified by the Unit Manager and a clarification order was obtained 0n 06/30/14 to obtained a PT with INR weekly. The Unit Manager put the PT with INR in the Medlab computer system to be drawn on the next lab day, which was 7/1/14. The PT with INR was drawn on Resident #8 on 7/2/14. The PT was 85.1 seconds and the INR was 7.0. The physician was notified by the LPN and new orders were received to transfer Resident #8 to the hospital for direct admission. Resident #8 was admitted to the hospital from 07/02/14 to 07/04/14. -All residents who were to have routine labs ordered by the physician are at risk. The Regional Nurse Consultant provided an in-service for the DON and Staff Development Nurse on the lab policy on 07/19/14, prior to providing an in-service to Licensed Nursing Staff and Unit Managers. All of the nurses, as well as the Unit Managers, will be in-serviced by the DON, Staff Development Nurse or designee on the new laboratory policy and protocol. New protocol has been developed to ensure that laboratory tests are drawn as ordered by the physician and that the results are received in a timely manner. -The Administrator drafted a letter to the manager of the laboratory on 07/22/14, stating that the minimum expectation is that for any changes in renewing a lab order or any other changes to the laboratory system they must notify the Administrator and DON as well as provide education on those changes. Also stated in the letter from 07/22/14 is the expectation that no laboratory auditor will renew any labs at all, the facility will be responsible for that. The laboratory was also expected during their monthly audits to provide the Administrator and DON with a list of names for those orders expiring in the upcoming month so that they could renew the lab orders in the laboratory system timely. -A lab policy and protocol was developed by the Quality Assurance team on 07/19/14 to be used for all laboratory tests. This new policy and protocol includes the steps to take starting from receiving a laboratory order all the way to getting the results and monitoring for timeliness. -The Regional Nurse Consultant in-serviced the DON and the Staff Development Nurse on the lab policy and protocol on 07/19/14, before they in-serviced the licensed nursing staff. -All licensed nursing staff as well as the unit managers will be educated on the new lab policy and protocol by 7/20/14, by the DON, Staff Development Nurse or designee. All new nursing hires will be educated on the lab policy and protocol during orientation. No licensed nursing staff will be permitted to work prior to receiving this education. Six (6) licensed nursing staff had not received the in-service because of vacation and sick leave; however, the facility will provide in-service to the six employees before they return to work. -Administrative Nursing Staff completed a 100 percent audit of all labs on 07/22/14 to ensure labs were drawn per physicians order; any issues identified were addressed and taken through QA. Based on the information provided, Quality Assurance follow-up included completion of documentation, Physician order [REDACTED]. -The Unit Managers will have a laboratory calendar, which has all routine laboratory tests scheduled to be drawn for the rest of the year on it. They will compare the laboratory calendar to the laboratory tests in the laboratory book prior to the morning meetings Monday through Friday to ensure that they match and to ensure that they are drawn timely as ordered and results are received as well as family and physician notification as needed. The Administrator and/or DON or designee will monitor use of the laboratory book five (5) days a week, Monday through Friday, in the morning meeting to ensure that laboratory tests have been drawn as ordered and results have been returned to the facility and have been addressed. Routine laboratory tests are performed Monday through Thursday. -The Nurse on the rotating call schedule was in-serviced on the weekend lab-monitoring log on 07/22/14 by the Administrator. The Weekend Nurse on Call will call the facility on Saturday and Sunday at 9 AM, 5 PM, and 9 PM to see if any "stat" laboratory tests were ordered on the weekend. If "stat" laboratory tests have been ordered they will verbally verify that the results have been received and the physician and the family have been notified and if any new orders have been received. They will write this down on the weekend lab monitoring log beginning this upcoming weekend. -All staff has been in-serviced on abuse, the definition of abuse, and reporting abuse. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of 07/20/14. No agency is used at the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -All staff will be in-serviced on Resident Rights. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of 07/20/14. No agency staff are used the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -The Quality Assurance Committee consists of facility and contracted staff. This includes Administrator, DON, Unit Managers, Staff Development Nurse, Social Services, Activities Director, and the Dietary Director. Contracted membership includes the Medical Director. -The Quality Assurance Committee members reviewed the education material on 07/19/14. The education materials created were reviewed by Quality Assurance and have been taught to staff by the DON and Staff Development Nurse, who were in-serviced by the Regional Nurse Consultant before they in-serviced the Licensed Nursing Staff. Records of the in-service include signatures of attendance, signature of in-services received, and copy of testing for efficacy of the training. Staff in-service education was provided on 07/19/14 and completed on 07/20/14. Staff retained copies of all in-service materials for their use. -Members of the Quality Assurance Committee developed a policy on 07/19/14 to validate that Laboratory tests were obtained as ordered by the physician and results were received and followed up on timely per policy protocol. This was implemented 07/19/14 and is ongoing. The Unit Managers will compare the laboratory calendar to the laboratory tests listed on the laboratory-tracking sheet before morning meetings to verify they match. The Unit Manager will then follow up prior to the morning meeting to ensure that laboratory tests were drawn as listed, results have been received, and they have been followed up on timely. During the morning meetings, Monday through Friday, the Administrator, DON, or designee will check the Laboratory book as well as the laboratory calendar to ensure that laboratory tests have been drawn as physician ordered and results have been received. Any issues identified will be corrected immediately. This practice became effective 07/19/14. If any weekend "stat" laboratory tests ordered, the Nurse on Call will call the Administrator or DON and will audit any laboratory tests ordered and received. -Quality Assurance Meetings will be held with two (2) or more team members in attendance daily, five (5) days a week and PRN for review of data to ensure compliance including: any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results. -Quality Assurance Committee members will review data (any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results) minimally five (5) days a week and PRN for thirty (30) days or additionally as necessary until 08/15/14; then one (1) time weekly until 09/12/14 or as needed; then monthly thereafter or as needed sooner. -Regional Nurse Consultant or the Regional Direct of Operations will review, comment, recommend, and/or approve Quality Assurance meetings as per the monitoring protocol. -The Pharmacy Consultant reviewed Resident #8's medical record on 05/19/14 and on 06/26/14. The pharmacist noted on the 06/26/14 review in Omniview (the pharmacy's computerized system) that Resident #8 hadn't been having their PT with INR drawn weekly per physician's orders [REDACTED]. During the audit, the pharmacist failed to review all Coumadin or other blood thinning laboratory tests, which placed all residents with this type of medication at risk. -The DON spoke with the current Pharmacy Consultant on 07/18/14, who had conducted the pharmacy review for Resident #8 in May and June 2014, and the Pharmacy Consultant stated that he was resigning and someone else would be doing the pharmacy consulting for the facility starting in August. -The Administrator drafted a letter to the General Manager of the pharmacy on 07/23/14, stating that during the pharmacist's monthly review, the minimum expectation is that all residents with an order for [REDACTED]. -On 07/21/14, the Administrator called and spoke with the General Manager of the pharmacy and explained to him that the pharmacy consultant must exit with the Administrator and/or DON and go over their consultant reports when reports are ready and provide the facility with a hard copy of the consultant reports. -The Administrator and/ or DON will educate the Pharmacy Consultant before their next regular review to ensure they assess the following areas: monitoring labs for critical levels, drug-to-drug interactions, and recommended drug alternatives. The education will also include that the Pharmacy Consultant must exit with the Administrator and/or DON upon completion of their review to go over the consultant reports and provide the facility with a hard copy of the consultant reports. The Pharmacy Consultant will be required to sign verification of education. -The Administrator and DON now have access to the pharmacy computer system effective 07/23/14, so they can go in and look at the consultant reports as well as any notes that had been made. The Administrator and DON will review the reports in the pharmacy computer system when they become available after the Pharmacy Consultant has completed his exit. The Administrator and DON will check the computer system daily after the pharmacy consultant has exited to see if the reports are on the computer. When the reports are available on the computer the Administrator and DON will compare the computer to the hard copy pharmacy reports to ensure that they match. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -The Administrator and DON will review the Pharmacy Consultant's report monthly to see what recommendations have been made, and to identify any issues found. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -If any weekend stat labs are ordered, the Nurse on Call will call the Administrator or DON and will document any labs on the audit tool for the weekend lab tests ordered and received. -Resident #8 has a care plan for anticoagulants, which stated to obtain a PT/INR as ordered, at least monthly. However, the PT with INR laboratory tests for Resident #8 were not drawn weekly as ordered by the physician or as care planned from 05/12/14 to 07/02/14. -Based on the fact that the Care Plan was not followed for anticoagulant therapy the root cause has been determined to be lack of use of the care plan as a communication tool to licensed nursing staff. -Licensed Nursing staff will be in-serviced on the comprehensive care plan use in directing resident care by 7/21/14. In-services will be conducted by the Staff Development Nurse, DON or designee. In-services will include documentation required for the use of interventions on the care plans. All new hires will be educated during general orientation by the Staff Development Nurse. Six (6) licensed staff members have not been in-serviced due to vacation, or sick leave and they will be educated before they are allowed to return to work. -One hundred percent (100%) of all anti-coagulant care plans were reviewed and/or updated by the Regional Nurse Consultant as necessary on 07/20/14. -One hundred percent (100%) of the care plans have been reviewed and/or updated for labs on 07/21/14 by members of the care planning team including the DON, MDS, Unit managers, Dietary Manager, Social Services. -The Administrator did not have sufficient lab protocols in place to assure that Resident #8 had received labs per physician orders. -The Regional Director of Operations or the Clinical Nurse Consultant will be in the building daily until the facility has abated the immediate jeopardy to provide facility oversight. After the facility has abated the immediate jeopardy, they will be in the facility to provide management oversight throughout the survey process at least weekly. **The surveyors validated the Immediate Jeopardy was removed as follows: -Review of the laboratory reports for Resident #8 revealed a PT with INR dated 07/02/14 with the results being 85.1 for the PT and the INR results being 7.0. -Review of the Nurse's Notes for Resident #8 dated 07/02/14, at 5:41 PM, revealed Resident #8's physician was notified regarding the results of the resident's PT with INR, and the resident was sent to the hospital. -Interview conducted with Registered Nurse (RN) #2 on 07/18/14 at 9:05 AM, revealed Resident #8 had not received his/her PT with INRs weekly as was ordered by the physician in the May 2014 physician orders. The RN stated on 06/30/14 she notified Resident #8's physician that the resident had not received a PT with INR laboratory test as ordered and received an order to obtain weekly PT with INR. A PT with INR was completed on 07/02/14, the resident's physician was notified of the results, and the resident was sent to a hospital. -Interview with the laboratory Corporate Manager on 07/22/14, at 2:00 PM, revealed during her monthly review of laboratory orders, the Laboratory Auditor had updated Resident #8's PT with INR order in the computer, which was set to expire on 07/31/14, and had inadvertently set the new start date for 07/01/14, instead of 05/19/14. -Review of the Laboratory Policy and Protocol developed by the facility on 07/19/14, revealed a posttest had been completed by all facility nurses. -Review of an in-service roster dated 07/19/14, revealed the DON and Staff Development Nurse (SDN) attended an in-service by the Regional Nurse Consultant on the lab policy, neglect, resident rights, and care plans. -Interview conducted with the DON and the SDN on 07/25/14, at 4:40 PM, revealed they had attended an in-service on 07/19/14, by the Regional Corporate Nurse on the lab policy and protocol, abuse, resident rights, and care plans. The DON and SDN stated they had then provided the in-service to the nursing staff. -Interview conducted on 07/25/14, at 4:15 PM, with the Regional Nurse Consultant revealed she had been responsible for providing an in-service to both the DON and the SDN on 07/19/14, related to the lab policy and protocol, abuse, resident rights, and care plans prior to them providing an in-service to the nursing staff. -Review of the in-service roster revealed 43 facility nurses attended the in-service provided by the DON and SDN on the lab policy and protocol and care plans. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, State Registered Nurse Aide (SRNA) #8 at 2:24 PM, SRNA #10 at 2:00 PM, SRNA #14 at 2:11 PM, SRNA #15 at 2:15 PM, and SRNA #16 at 2:28 PM all revealed they had attended an in-service on abuse, and resident rights. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, and LPN #6 at 2:02 PM revealed they had attended an in-service related to the lab policy and protocol regarding how to put a laboratory order into the computer, the tracking process, and documentation required. -Review of the letter sent to the laboratory dated 07/22/14, revealed the laboratory service was not to renew any laboratory orders that were near expiration, and that the facility would do all renewals. The laboratory was required to immediately notify the Administrator and the DON of any changes or any laboratory orders that were about to expire. -Interview conducted with the Administrator on 07/25/14, at 4:30 PM, and the DON at 4:40 PM, revealed the Administrator had notified the laboratory's General Manager by phone and then by letter and had instructed them that they were to no longer update any laboratory orders in the computer, that the facility would do all laboratory updates, and that the facility expected the Laboratory Auditor to give the Administrator and the DON a list of all residents whose laboratory orders were nearing expiration. -Review of an audit completed by the DON, RN #2, RN #8, RN #9, and RN #10 on 07/22/14, of all residents' laboratory orders to ensure laboratory orders had been completed as ordered by the physician revealed all had been completed. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #8 at 2:30 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, and the DON at 4:40 PM, revealed they had all assisted in completing an audit on 07/22/14, of all residents' laboratory orders to ensure the orders had been completed as ordered by the physician and the reports had been placed on the resident's medical record and the results reported to the physician as necessary. -Review of the laboratory calendars for each nursing station revealed all Unit Managers had documented all laboratory orders and the date the laboratory test was due for the residents on their unit. -Observations of the laboratory calendars were conducted on 07/25/14, on the Blue Wing at 2:40 PM, Peach Wing at 2:45 PM, and the Green Wing at 2:50 PM. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, and RN #9 at 2:38 PM, revealed they used the calendars to monitor laboratory orders to ensure the laboratory test were completed. The RNs also revealed they were required to check laboratory orders daily prior to attending the morning Quality Assurance meeting and were required to report any concerns with laboratory orders not being completed. -Interview conducted with the Administrator on 07/25/14, at 4:30 PM, and the DON at 4:40 PM, revealed they reviewed the laboratory calendars every morning in the Quality Assurance morning meeting to ensure laboratory orders had been completed as ordered by the physician. -Review of the Nurse on Call schedule revealed a nurse was scheduled every weekend to take Administrative call. -Review of an in-service by the Administrator dated 07/22/14, and attended by the DON, RN #2, and RN #9 revealed the weekend On-Call Nurse was required to call the facility on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any "stat" laboratory orders had been conducted. If any were ordered, the RN was then required to verbally verify if the results had been received by the facility. The weekend Nurse on Call was required to document the information on the weekend log beginning 07/26/14. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, and the DON at 4:40 PM, all revealed they had attended an in-service by the Administrator on 07/22/14. The interviews revealed they were required to call the facility when on call on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any stat laboratory orders had been ordered, and the results returned. The interview revealed they were also required to document the information on a weekend lab-monitoring tool as part of the Quality Assurance program, which began on 07/26/14. -Interview conducted with the Administrator on 07/25/14, at 4:30 PM, revealed she had conducted an in-service for nurses who would be taking administrative call on weekends on 07/22/14. The Administrator stated the on-call nurses were required to call the facility at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM to ensure all stat laboratory orders had been completed and the results were on the resident's medical record. The Administrator stated the process would begin on Saturday, 07/26/14. The Administrator stated she would be reviewing the audits every Monday in the morning meeting, which was a part of the Quality Assurance program. -An in-service roster dated 07/20/14, regarding Abuse and Resident Rights with a posttest, revealed all employees had attended the in-service. -Review of a new hire in-service syllabus was reviewed and the laboratory policy in-service was added to the new hire orientation. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, State Registered Nurse Aide (SRNA) #8 at 2:24 PM, SRNA #10 at 2:00 PM, SRNA #14 at 2:11 PM, SRNA #15 at 2:15 PM, and SRNA #16 at 2:28 PM revealed they had attended an in-service on abuse and resident rights and had also completed a posttest. -Interview conducted with the SDN on 07/24/14, at 12:55 PM, revealed she had provided in-service for staff on the lab policy and protocol, abuse, resident rights, and the required usage of the care plans. -Review of a list of Quality Assurance Team Committee members was conducted. -Review of an audit completed by the DON, RN #2, RN #8, RN #9, and RN #10 on 07/22/14, revealed the facility had reviewed all residents' laboratory orders to ensure laboratory orders had been completed as ordered by the physician. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #8 at 2:30 PM, RN #9 at 2:38 PM, DON at 4:40 PM, and the Administrator at 4:30 PM, revealed they were all part of the Quality Assurance Committee and attended meetings daily Monday through Friday during the morning meeting which was part of the Quality Assurance program. The staff revealed they developed and reviewed education in-services and policies for the lab policy and protocol, care plans, and the abuse and resident rights in-service, as well as the audit tools that will be used. The staff stated they would also be reviewing the audit tools. -Review of Quality Assurance morning meeting minutes dated 07/19/14, 07/20/14, 07/21/14, 07/22/14, 07/23/14, 07/24/14, and 07/25/14, which had all been reviewed and signed by the Regional Nurse Consultant or the Regional Director of Operations, was conducted. -Interviews conducted on 07/25/14, at 4:45 PM, with the Regional Corporate Nurse Consultant and the Regional Director of Operations, revealed they had reviewed and signed all daily Quality Assurance minutes beginning on 07/19/14 through 07/25/14. The Regional Corporate Nurse Consultant stated she had been in the facility every day since immediate jeopardy had been identified. -Review of Resident #8's Comprehensive Plan of Care regarding anticoagulant therapy revealed the resident had a care plan intervention to obtain a PT with INR as ordered by the physician. -Review of Care Plan Protocol staff were informed where care plans were located at each nursing station, and staff were required to follow the plans of care for each resident, and directed that care plans would be updated with any change in condition that would impact a resident's care. -Review of an in-service roster dated 07/21/14, regarding the Care Plan Protocol attended by licensed nursing staff revealed the nurses were provided education on the Care Plan Protocol as well as required to take a posttest. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, a

Based on observation, interview, record review, review of facility policies entitled "Medication Administration" and "Lab and Diagnostic test results-Clinical Protocol," and the Administrator's position description, it was determined the facility's Administration failed to ensure its resources were used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one (1) of thirty-four (34) sampled residents (Resident #8). The facility admitted Resident #8 on 09/07/12 with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#8's physician's orders [REDACTED].#8 as ordered. Review of laboratory reports revealed a PT with INR had been conducted on 05/12/14; however, the next PT with INR had not been conducted until 07/02/14, a timeframe of seven weeks. Review of the laboratory report for the PT and INR conducted on 07/02/14 revealed Resident #8's PT and INR levels were "Critical," and the resident was transferred and admitted to a hospital, placed on telemetry, and diagnosed with [REDACTED]." Interview conducted with the Administrator revealed the Director of Nursing (DON) informed her on 07/01/14 that the routine laboratory tests used to monitor Resident #8's [MEDICATION NAME] use had not been conducted as ordered by the physician since 05/12/14, even though it had been ordered to be conducted on a weekly basis. The Administrator stated the Unit Managers and DON were present on 07/01/14, when the incident was discussed. According to the Administrator, because the Unit Managers were required to monitor laboratory tests to ensure the tests were done and were present when the DON was notified of the incident, the facility had not conducted staff in-services related to the incident and had not monitored any other resident records, including physician orders [REDACTED]. [REDACTED]. The facility's failure to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for its residents caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/19/14 at 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.60 Pharmacy Services (F428), 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F329). The facility was notified of the Immediate Jeopardy on 07/18/14. An acceptable Allegation of Compliance (AOC) was received on 07/24/14, which alleged removal of the Immediate Jeopardy on 07/24/14. On 07/25/14, the State Survey Agency determined the Immediate Jeopardy was removed on 07/24/14, as alleged, which lowered the scope and severity to "D" at 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.60 Pharmacy Services (F428), 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's "Position Description" dated and signed by the Administrator on 02/12/13, revealed the Administrator was responsible for directing the day to day functions of the facility in accordance with current federal, state, and local guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times. The position description also revealed it was the Administrator's responsibility to ensure excellent care was maintained for residents by overseeing and monitoring patient care services delivered. Review of an undated facility policy titled, "Medication Administration," revealed the nursing staff would evaluate medications to determine if a resident had an adverse consequence such as an abnormal laboratory test result, or had achieved the therapeutic drug level (within the desired level), or a level that was too high or too low. Review of the facility's policy titled, "Lab and Diagnostic test results-Clinical Protocol," with a revision date of October 2010, revealed the physician would identify and order diagnostic and laboratory testing based on diagnostic and monitoring needs. The policy revealed nursing staff would process the test requisitions and arrange for the tests to be completed by the laboratory. Review of the contract between the laboratory and the facility dated 10/02/06, revealed the contract did not specify an amount of time at which a physician's routine laboratory order would expire. The contract revealed the laboratory would furnish to the facility the results of all routine tests as outlined in the physician's orders [REDACTED]. Medical record review revealed the facility initially admitted Resident #8 on 09/07/12, with a [DIAGNOSES REDACTED]. Review of the monthly May 2014 physician's orders [REDACTED].#8's laboratory results revealed a PT with INR had been conducted on 05/12/14; however, no further PT with INR had been conducted until 07/02/14, at which time the resident's PT was 85.1 seconds (73.5 seconds above the reference range of 9.5 to 11.6 seconds) and his/her INR was 7.0 (5.9 above the reference range of 0.9 to 1.1). According to the laboratory report, both levels were "Critical." Documentation in the Nursing Notes revealed on 07/02/14, at 5:41 PM, facility staff notified the resident's physician of the elevated PT and INR laboratory results and the resident was transported to a hospital for further evaluation and treatment. Documentation in the resident's hospital record revealed Resident #8 was admitted to the hospital on [DATE], placed on telemetry to monitor his/her vital signs, and the physician at the hospital diagnosed Resident #8 to have "[MEDICATION NAME] Toxicity." Interview conducted with the Administrator on 07/18/14, at 2:30 PM, revealed the Director of Nursing (DON) had informed her on 07/01/14 that the routine laboratory tests used to monitor Resident #8's [MEDICATION NAME] use had not been conducted as ordered by the physician since 05/12/14 even though it had been ordered to be conducted on a weekly basis. The Administrator stated the pharmacist and nursing staff failed to identify and/or report that the routine laboratory tests for Resident #8 had not been conducted as ordered by the physician. The Administrator stated a Unit Manager had learned on 06/30/14 that the laboratory tests had not been conducted as ordered by the physician for Resident #8 and contacted the resident's physician. According to the Administrator, the Unit Manager that learned the laboratory tests had not been conducted notified the DON on 07/01/14 in the presence of the facility's Unit Managers, who were responsible to monitor the laboratory requests to ensure they had been completed. According to the Administrator, because the Unit Managers were present when the DON was notified of the omission of the laboratory tests for Resident #8, the Administrator had not taken any action to educate staff of the facility's policies related to the incident and had not monitored any other resident records, including physician orders [REDACTED]. In addition, the Administrator stated that prior to 07/01/14 she was not aware laboratory orders would expire in the computer system after 400 days nor was that information in the contract between the facility and the laboratory. However, when the Administrator became aware on 07/01/14, no action was taken to ensure laboratory testing orders did not expire and laboratory tests were obtained as ordered by residents' physicians. **The facility provided an acceptable Allegation of Compliance (AOC) on 07/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: -Resident #8 had a physician's orders [REDACTED]. Resident #8 had a PT with INR drawn on 5/12/14. On 06/12/14, the lab noted that the PT with INR for Resident #8 was going to expire on 07/31/14 so she went in to renew the lab in the Medlab System. She mistakenly changed the start date to 07/31/14 through 07/31/14, which deleted the order out of the system until that date; therefore, there would be no PT with INR order in the system for Resident #8 from 05/12/14 until 07/01/14. The Unit Manager discovered that a PT with 1NR was not being drawn during changeover on 6/30/14. The physician was notified by the Unit Manager and a clarification order was obtained 0n 06/30/14 to obtained a PT with INR weekly. The Unit Manager put the PT with INR in the Medlab computer system to be drawn on the next lab day, which was 7/1/14. The PT with INR was drawn on Resident #8 on 7/2/14. The PT was 85.1 seconds and the INR was 7.0. The physician was notified by the LPN and new orders were received to transfer Resident #8 to the hospital for direct admission. Resident #8 was admitted to the hospital from 07/02/14 to 07/04/14. -All residents who were to have routine labs ordered by the physician are at risk. The Regional Nurse Consultant provided an in-service for the DON and Staff Development Nurse on the lab policy on 07/19/14, prior to providing an in-service to Licensed Nursing Staff and Unit Managers. All of the nurses, as well as the Unit Managers, will be in-serviced by the DON, Staff Development Nurse or designee on the new laboratory policy and protocol. New protocol has been developed to ensure that laboratory tests are drawn as ordered by the physician and that the results are received in a timely manner. -The Administrator drafted a letter to the manager of the laboratory on 07/22/14, stating that the minimum expectation is that for any changes in renewing a lab order or any other changes to the laboratory system they must notify the Administrator and DON as well as provide education on those changes. Also stated in the letter from 07/22/14 is the expectation that no laboratory auditor will renew any labs at all, the facility will be responsible for that. The laboratory was also expected during their monthly audits to provide the Administrator and DON with a list of names for those orders expiring in the upcoming month so that they could renew the lab orders in the laboratory system timely. -A lab policy and protocol was developed by the Quality Assurance team on 07/19/14 to be used for all laboratory tests. This new policy and protocol includes the steps to take starting from receiving a laboratory order all the way to getting the results and monitoring for timeliness. -The Regional Nurse Consultant in-serviced the DON and the Staff Development Nurse on the lab policy and protocol on 07/19/14, before they in-serviced the licensed nursing staff. -All licensed nursing staff as well as the unit managers will be educated on the new lab policy and protocol by 7/20/14, by the DON, Staff Development Nurse or designee. All new nursing hires will be educated on the lab policy and protocol during orientation. No licensed nursing staff will be permitted to work prior to receiving this education. Six (6) licensed nursing staff had not received the in-service because of vacation and sick leave; however, the facility will provide in-service to the six employees before they return to work. -Administrative Nursing Staff completed a 100 percent audit of all labs on 07/22/14 to ensure labs were drawn per physicians order; any issues identified were addressed and taken through QA. Based on the information provided, Quality Assurance follow-up included completion of documentation, Physician order [REDACTED]. -The Unit Managers will have a laboratory calendar, which has all routine laboratory tests scheduled to be drawn for the rest of the year on it. They will compare the laboratory calendar to the laboratory tests in the laboratory book prior to the morning meetings Monday through Friday to ensure that they match and to ensure that they are drawn timely as ordered and results are received as well as family and physician notification as needed. The Administrator and/or DON or designee will monitor use of the laboratory book five (5) days a week, Monday through Friday, in the morning meeting to ensure that laboratory tests have been drawn as ordered and results have been returned to the facility and have been addressed. Routine laboratory tests are performed Monday through Thursday. -The Nurse on the rotating call schedule was in-serviced on the weekend lab-monitoring log on 07/22/14 by the Administrator. The Weekend Nurse on Call will call the facility on Saturday and Sunday at 9 AM, 5 PM, and 9 PM to see if any "stat" laboratory tests were ordered on the weekend. If "stat" laboratory tests have been ordered they will verbally verify that the results have been received and the physician and the family have been notified and if any new orders have been received. They will write this down on the weekend lab monitoring log beginning this upcoming weekend. -All staff has been in-serviced on abuse, the definition of abuse, and reporting abuse. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of 07/20/14. No agency is used at the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -All staff will be in-serviced on Resident Rights. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of 07/20/14. No agency staff are used the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -The Quality Assurance Committee consists of facility and contracted staff. This includes Administrator, DON, Unit Managers, Staff Development Nurse, Social Services, Activities Director, and the Dietary Director. Contracted membership includes the Medical Director. -The Quality Assurance Committee members reviewed the education material on 07/19/14. The education materials created were reviewed by Quality Assurance and have been taught to staff by the DON and Staff Development Nurse, who were in-serviced by the Regional Nurse Consultant before they in-serviced the Licensed Nursing Staff. Records of the in-service include signatures of attendance, signature of in-services received, and copy of testing for efficacy of the training. Staff in-service education was provided on 07/19/14 and completed on 07/20/14. Staff retained copies of all in-service materials for their use. -Members of the Quality Assurance Committee developed a policy on 07/19/14 to validate that Laboratory tests were obtained as ordered by the physician and results were received and followed up on timely per policy protocol. This was implemented 07/19/14 and is ongoing. The Unit Managers will compare the laboratory calendar to the laboratory tests listed on the laboratory-tracking sheet before morning meetings to verify they match. The Unit Manager will then follow up prior to the morning meeting to ensure that laboratory tests were drawn as listed, results have been received, and they have been followed up on timely. During the morning meetings, Monday through Friday, the Administrator, DON, or designee will check the Laboratory book as well as the laboratory calendar to ensure that laboratory tests have been drawn as physician ordered and results have been received. Any issues identified will be corrected immediately. This practice became effective 07/19/14. If any weekend "stat" laboratory tests ordered, the Nurse on Call will call the Administrator or DON and will audit any laboratory tests ordered and received. -Quality Assurance Meetings will be held with two (2) or more team members in attendance daily, five (5) days a week and PRN for review of data to ensure compliance including: any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results. -Quality Assurance Committee members will review data (any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results) minimally five (5) days a week and PRN for thirty (30) days or additionally as necessary until 08/15/14; then one (1) time weekly until 09/12/14 or as needed; then monthly thereafter or as needed sooner. -Regional Nurse Consultant or the Regional Direct of Operations will review, comment, recommend, and/or approve Quality Assurance meetings as per the monitoring protocol. -The Pharmacy Consultant reviewed Resident #8's medical record on 05/19/14 and on 06/26/14. The pharmacist noted on the 06/26/14 review in Omniview (the pharmacy's computerized system) that Resident #8 hadn't been having their PT with INR drawn weekly per physician's orders [REDACTED]. During the audit, the pharmacist failed to review all [MEDICATION NAME] or other blood thinning laboratory tests, which placed all residents with this type of medication at risk. -The DON spoke with the current Pharmacy Consultant on 07/18/14, who had conducted the pharmacy review for Resident #8 in May and June 2014, and the Pharmacy Consultant stated that he was resigning and someone else would be doing the pharmacy consulting for the facility starting in August. -The Administrator drafted a letter to the General Manager of the pharmacy on 07/23/14, stating that during the pharmacist's monthly review, the minimum expectation is that all residents with an order for [REDACTED]. -On 07/21/14, the Administrator called and spoke with the General Manager of the pharmacy and explained to him that the pharmacy consultant must exit with the Administrator and/or DON and go over their consultant reports when reports are ready and provide the facility with a hard copy of the consultant reports. -The Administrator and/ or DON will educate the Pharmacy Consultant before their next regular review to ensure they assess the following areas: monitoring labs for critical levels, drug-to-drug interactions, and recommended drug alternatives. The education will also include that the Pharmacy Consultant must exit with the Administrator and/or DON upon completion of their review to go over the consultant reports and provide the facility with a hard copy of the consultant reports. The Pharmacy Consultant will be required to sign verification of education. -The Administrator and DON now have access to the pharmacy computer system effective 07/23/14, so they can go in and look at the consultant reports as well as any notes that had been made. The Administrator and DON will review the reports in the pharmacy computer system when they become available after the Pharmacy Consultant has completed his exit. The Administrator and DON will check the computer system daily after the pharmacy consultant has exited to see if the reports are on the computer. When the reports are available on the computer the Administrator and DON will compare the computer to the hard copy pharmacy reports to ensure that they match. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -The Administrator and DON will review the Pharmacy Consultant's report monthly to see what recommendations have been made, and to identify any issues found. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -If any weekend stat labs are ordered, the Nurse on Call will call the Administrator or DON and will document any labs on the audit tool for the weekend lab tests ordered and received. -Resident #8 has a care plan for anticoagulants, which stated to obtain a PT/INR as ordered, at least monthly. However, the PT with INR laboratory tests for Resident #8 were not drawn weekly as ordered by the physician or as care planned from 05/12/14 to 07/02/14. -Based on the fact that the Care Plan was not followed for anticoagulant therapy the root cause has been determined to be lack of use of the care plan as a communication tool to licensed nursing staff. -Licensed Nursing staff will be in-serviced on the comprehensive care plan use in directing resident care by 7/21/14. In-services will be conducted by the Staff Development Nurse, DON or designee. In-services will include documentation required for the use of interventions on the care plans. All new hires will be educated during general orientation by the Staff Development Nurse. Six (6) licensed staff members have not been in-serviced due to vacation, or sick leave and they will be educated before they are allowed to return to work. -One hundred percent (100%) of all anti-coagulant care plans were reviewed and/or updated by the Regional Nurse Consultant as necessary on 07/20/14. -One hundred percent (100%) of the care plans have been reviewed and/or updated for labs on 07/21/14 by members of the care planning team including the DON, MDS, Unit managers, Dietary Manager, Social Services. -The Administrator did not have sufficient lab protocols in place to assure that Resident #8 had received labs per physician orders. -The Regional Director of Operations or the Clinical Nurse Consultant will be in the building daily until the facility has abated the immediate jeopardy to provide facility oversight. After the facility has abated the immediate jeopardy, they will be in the facility to provide management oversight throughout the survey process at least weekly. **The surveyors validated the Immediate Jeopardy was removed as follows: -Review of the laboratory reports for Resident #8 revealed a PT with INR dated 07/02/14 with the results being 85.1 for the PT and the INR results being 7.0. -Review of the Nurse's Notes for Resident #8 dated 07/02/14, at 5:41 PM, revealed Resident #8's physician was notified regarding the results of the resident's PT with INR, and the resident was sent to the hospital. -Interview conducted with Registered Nurse (RN) #2 on 07/18/14 at 9:05 AM, revealed Resident #8 had not received his/her PT with INRs weekly as was ordered by the physician in the May 2014 physician orders. The RN stated on 06/30/14 she notified Resident #8's physician that the resident had not received a PT with INR laboratory test as ordered and received an order to obtain weekly PT with INR. A PT with INR was completed on 07/02/14, the resident's physician was notified of the results, and the resident was sent to a hospital. -Interview with the laboratory Corporate Manager on 07/22/14, at 2:00 PM, revealed during her monthly review of laboratory orders, the Laboratory Auditor had updated Resident #8's PT with INR order in the computer, which was set to expire on 07/31/14, and had inadvertently set the new start date for 07/01/14, instead of 05/19/14. -Review of the Laboratory Policy and Protocol developed by the facility on 07/19/14, revealed a posttest had been completed by all facility nurses. -Review of an in-service roster dated 07/19/14, revealed the DON and Staff Development Nurse (SDN) attended an in-service by the Regional Nurse Consultant on the lab policy, neglect, resident rights, and care plans. -Interview conducted with the DON and the SDN on 07/25/14, at 4:40 PM, revealed they had attended an in-service on 07/19/14, by the Regional Corporate Nurse on the lab policy and protocol, abuse, resident rights, and care plans. The DON and SDN stated they had then provided the in-service to the nursing staff. -Interview conducted on 07/25/14, at 4:15 PM, with the Regional Nurse Consultant revealed she had been responsible for providing an in-service to both the DON and the SDN on 07/19/14, related to the lab policy and protocol, abuse, resident rights, and care plans prior to them providing an in-service to the nursing staff. -Review of the in-service roster revealed 43 facility nurses attended the in-service provided by the DON and SDN on the lab policy and protocol and care plans. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, State Registered Nurse Aide (SRNA) #8 at 2:24 PM, SRNA #10 at 2:00 PM, SRNA #14 at 2:11 PM, SRNA #15 at 2:15 PM, and SRNA #16 at 2:28 PM all revealed they had attended an in-service on abuse, and resident rights. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, and LPN #6 at 2:02 PM revealed they had attended an in-service related to the lab policy and protocol regarding how to put a laboratory order into the computer, the tracking process, and documentation required. -Review of the letter sent to the laboratory dated 07/22/14, revealed the laboratory service was not to renew any laboratory orders that were near expiration, and that the facility would do all renewals. The laboratory was required to immediately notify the Administrator and the DON of any changes or any laboratory orders that were about to expire. -Interview conducted with the Administrator on 07/25/14, at 4:30 PM, and the DON at 4:40 PM, revealed the Administrator had notified the laboratory's General Manager by phone and then by letter and had instructed them that they were to no longer update any laboratory orders in the computer, that the facility would do all laboratory updates, and that the facility expected the Laboratory Auditor to give the Administrator and the DON a list of all residents whose laboratory orders were nearing expiration. -Review of an audit completed by the DON, RN #2, RN #8, RN #9, and RN #10 on 07/22/14, of all residents' laboratory orders to ensure laboratory orders had been completed as ordered by the physician revealed all had been completed. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #8 at 2:30 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, and the DON at 4:40 PM, revealed they had all assisted in completing an audit on 07/22/14, of all residents' laboratory orders to ensure the orders had been completed as ordered by the physician and the reports had been placed on the resident's medical record and the results reported to the physician as necessary. -Review of the laboratory calendars for each nursing station revealed all Unit Managers had documented all laboratory orders and the date the laboratory test was due for the residents on their unit. -Observations of the laboratory calendars were conducted on 07/25/14, on the Blue Wing at 2:40 PM, Peach Wing at 2:45 PM, and the Green Wing at 2:50 PM. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, and RN #9 at 2:38 PM, revealed they used the calendars to monitor laboratory orders to ensure the laboratory test were completed. The RNs also revealed they were required to check laboratory orders daily prior to attending the morning Quality Assurance meeting and were required to report any concerns with laboratory orders not being completed. -Interview conducted with the Administrator on 07/25/14, at 4:30 PM, and the DON at 4:40 PM, revealed they reviewed the laboratory calendars every morning in the Quality Assurance morning meeting to ensure laboratory orders had been completed as ordered by the physician. -Review of the Nurse on Call schedule revealed a nurse was scheduled every weekend to take Administrative call. -Review of an in-service by the Administrator dated 07/22/14, and attended by the DON, RN #2, and RN #9 revealed the weekend On-Call Nurse was required to call the facility on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any "stat" laboratory orders had been conducted. If any were ordered, the RN was then required to verbally verify if the results had been received by the facility. The weekend Nurse on Call was required to document the information on the weekend log beginning 07/26/14. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, and the DON at 4:40 PM, all revealed they had attended an in-service by the Administrator on 07/22/14. The interviews revealed they were required to call the facility when on call on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any stat laboratory orders had been ordered, and the results returned. The interview revealed they were also required to document the information on a weekend lab-monitoring tool as part of the Quality Assurance program, which began on 07/26/14. -Interview conducted with the Administrator on 07/25/14, at 4:30 PM, revealed she had conducted an in-service for nurses who would be taking administrative call on weekends on 07/22/14. The Administrator stated the on-call nurses were required to call the facility at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM to ensure all stat laboratory orders had been completed and the results were on the resident's medical record. The Administrator stated the process would begin on Saturday, 07/26/14. The Administrator stated she would be reviewing the audits every Monday in the morning meeting, which was a part of the Quality Assurance program. -An in-service roster dated 07/20/14, regarding Abuse and Resident Rights with a posttest, revealed all employees had attended the in-service. -Review of a new hire in-service syllabus was reviewed and the laboratory policy in-service was added to the new hire orientation. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, State Registered Nurse Aide (SRNA) #8 at 2:24 PM, SRNA #10 at 2:00 PM, SRNA #14 at 2:11 PM, SRNA #15 at 2:15 PM, and SRNA #16 at 2:28 PM revealed they had attended an in-service on abuse and resident rights and had also completed a posttest. -Interview conducted with the SDN on 07/24/14, at 12:55 PM, revealed she had provided in-service for staff on the lab policy and protocol, abuse, resident rights, and the required usage of the care plans. -Review of a list of Quality Assurance Team Committee members was conducted. -Review of an audit completed by the DON, RN #2, RN #8, RN #9, and RN #10 on 07/22/14, revealed the facility had reviewed all residents' laboratory orders to ensure laboratory orders had been completed as ordered by the physician. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #8 at 2:30 PM, RN #9 at 2:38 PM, DON at 4:40 PM, and the Administrator at 4:30 PM, revealed they were all part of the Quality Assurance Committee and attended meetings daily Monday through Friday during the morning meeting which was part of the Quality Assurance program. The staff revealed they developed and reviewed education in-services and policies for the lab policy and protocol, care plans, and the abuse and resident rights in-service, as well as the audit tools that will be used. The staff stated they would also be reviewing the audit tools. -Review of Quality Assurance morning meeting minutes dated 07/19/14, 07/20/

Based on interview, record review, and review of the facility's policy entitled, "Quality Assessment and Assurance Plan," it was determined the facility failed to maintain a Quality Assessment and Assurance Committee that identified quality deficiencies and failed to develop and implement appropriate plans of action to correct identified deficiencies for one (1) of thirty-four (34) sampled residents (Resident #8). Review of the May 2014 Physician order [REDACTED]. time, to be completed on a weekly basis. On 05/05/14, the physician gave staff a verbal order to decrease Resident #8's [MEDICATION NAME] dosage from 6 milligrams daily to 5 milligrams a day. Review of laboratory results dated [DATE], revealed the resident's PT was 24.6 seconds with a reference range of 9.5 to 11.6 seconds. The INR was 2.2 seconds with a reference range of 0.9 to 1.1 seconds. Further review of the laboratory results for Resident #8 revealed after 05/12/14, the facility failed to obtain a PT and INR for Resident #8 until 07/02/14 (a timeframe of seven weeks after the previous PT and INR had been obtained), at which time the resident's PT was 85.1 seconds (73.5 seconds above the normal range of 9.5 to 11.6 seconds) and his/her INR level was 7.0 (5.9 above the normal range of 0.9 to 1.1). Review of the laboratory report revealed the PT and INR levels obtained on 07/02/14 were "Critical." Review of the Nurse's Notes revealed Resident #8's physician was notified of the abnormal lab results on 07/02/14 and the resident was taken to a hospital where he/she was placed on telemetry and diagnosed with [REDACTED]." Interview revealed the facility failed to identify that a PT and INR had not been conducted on a weekly basis (for a timeframe of seven weeks) as ordered by Resident #8's physician and, as a result, failed to develop and implement appropriate plans of action through a Quality Assurance Program to correct the identified deficiency to prevent medication and laboratory monitoring errors, the pharmacist's failure to identify and report drug irregularities to the physician and the Director of Nursing, and the facility's failure to be administered in a manner to ensure each resident maintained the highest practicable physical, mental, and psychosocial wellbeing of each resident. (Refer to F282, F329, F428, and F490.) The facility's failure to ensure residents received adequate drug monitoring and was free from significant medication errors caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/19/14 at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F329). The facility was notified of the Immediate Jeopardy on 07/18/14. An acceptable Allegation of Compliance (AOC) was received on 07/24/14, which alleged removal of the Immediate Jeopardy on 07/24/14. Prior to exit on 07/25/14, the State Survey Agency determined the Immediate Jeopardy was removed on 07/24/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.25 Quality of Care (F329), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, "Quality Assessment and Assurance Plan," with a revision date of December 2009, revealed the facility would develop, implement, and maintain an ongoing, facilitywide Quality Assessment and Assurance Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. The policy revealed the Administrator was responsible for ensuring the facility's Quality Assessment and Assurance Program complied with federal, state, and local regulatory agency requirements. Record review revealed the facility admitted Resident #8 on 09/07/12, with a [DIAGNOSES REDACTED]. Review of Resident #8's May 2014 monthly physician's orders [REDACTED]. Review of Resident #8's physician's orders [REDACTED]. to 6 milligrams every night. Review of Resident #8's PT with INR results, which were dated 05/12/14, revealed the resident's PT was 24.6 seconds, with a reference range of 9.5 to 11.6 seconds and the resident's INR level was 2.2, with a reference range of 0.9 to 1.1. Continued review of the laboratory results for Resident #8 revealed no documented evidence the weekly lab testing had been completed as ordered by the physician until 07/02/14 (a timeframe of seven weeks), at which time the resident's PT level was 85.1 seconds (73.5 seconds above the reference range of 9.5 to 11.6 seconds) and the INR was 7.0 (5.9 above the reference range of 0.9 to 1.1 seconds). According to the lab report dated 07/02/14, the resident's PT and INR levels were "Critical." Review of Resident #8's Nurse's Notes revealed the resident's physician was notified of the abnormal lab results and Resident #8 was transported to a local hospital. Review of Resident #8's hospital record revealed the resident was admitted to on 07/02/14, placed on telemetry, and was diagnosed to have "[MEDICATION NAME] Toxicity." Interview conducted with the Director of Nursing (DON) on 07/17/14, at 6:30 PM, revealed she was responsible for the Quality Assurance Program for the facility. The DON stated even though she became aware on 07/01/14 that Resident #8's laboratory tests (PT and INR) had not been conducted as ordered, no additional education in-services or monitors had been put into place. The DON stated the Unit Managers, who were responsible for monitoring to ensure all residents laboratory testing had been completed as it was ordered by the physician, had been present when she learned of the omission of Resident #8's laboratory tests. According to the DON, she and the Unit Managers discussed the situation and the DON determined they had been sufficiently educated on the omission of laboratory tests. The Administrator stated in interview conducted on 07/18/14, at 2:30 PM that the pharmacist had not notified her that the laboratory tests used to monitor Resident #8's [MEDICATION NAME] use had not been conducted as ordered by the physician. The Administrator stated nursing staff had also failed to identify that the routine laboratory tests had not been conducted as ordered by the physician until 06/30/14. The Administrator stated the Unit Manager notified the DON of the incident on 07/01/14 in the presence of the facility's Unit Managers. According to the Administrator, because the Unit Managers were present when the DON was notified of the omission of the laboratory tests for Resident #8, the facility had not conducted staff in-services related to the incident and had not monitored any other resident records, including physician orders [REDACTED]. **The facility provided an acceptable Allegation of Compliance (AOC) on 07/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: -Resident #8 had a physician's orders [REDACTED]. Resident #8 had a PT with INR drawn on 5/12/14. On 06/12/14, the lab noted that the PT with INR for Resident #8 was going to expire on 07/31/14 so she went in to renew the lab in the Medlab System. She mistakenly changed the start date to 07/31/14 through 07/31/14, which deleted the order out of the system until that date; therefore, there would be no PT with INR order in the system for Resident #8 from 05/12/14 until 07/01/14. The Unit Manager discovered that a PT with 1NR was not being drawn during changeover on 6/30/14. The physician was notified by the Unit Manager and a clarification order was obtained 0n 06/30/14 to obtained a PT with INR weekly. The Unit Manager put the PT with INR in the Medlab computer system to be drawn on the next lab day, which was 7/1/14. The PT with INR was drawn on Resident #8 on 7/2/14. The PT was 85.1 seconds and the INR was 7.0. The physician was notified by the LPN and new orders were received to transfer Resident #8 to the hospital for direct admission. Resident #8 was admitted to the hospital from 07/02/14 to 07/04/14. -All residents who were to have routine labs ordered by the physician are at risk. The Regional Nurse Consultant provided an in-service for the DON and Staff Development Nurse on the lab policy on 07/19/14, prior to providing an in-service to Licensed Nursing Staff and Unit Managers. All of the nurses, as well as the Unit Managers, will be in-serviced by the DON, Staff Development Nurse or designee on the new laboratory policy and protocol. New protocol has been developed to ensure that laboratory tests are drawn as ordered by the physician and that the results are received in a timely manner. -The Administrator drafted a letter to the manager of the laboratory on 07/22/14, stating that the minimum expectation is that for any changes in renewing a lab order or any other changes to the laboratory system they must notify the Administrator and DON as well as provide education on those changes. Also stated in the letter from 07/22/14 is the expectation that no laboratory auditor will renew any labs at all, the facility will be responsible for that. The laboratory was also expected during their monthly audits to provide the Administrator and DON with a list of names for those orders expiring in the upcoming month so that they could renew the lab orders in the laboratory system timely. -A lab policy and protocol was developed by the Quality Assurance team on 07/19/14 to be used for all laboratory tests. This new policy and protocol includes the steps to take starting from receiving a laboratory order all the way to getting the results and monitoring for timeliness. -The Regional Nurse Consultant in-serviced the DON and the Staff Development Nurse on the lab policy and protocol on 07/19/14, before they in-serviced the licensed nursing staff. -All licensed nursing staff as well as the unit managers will be educated on the new lab policy and protocol by 7/20/14, by the DON, Staff Development Nurse or designee. All new nursing hires will be educated on the lab policy and protocol during orientation. No licensed nursing staff will be permitted to work prior to receiving this education. Six (6) licensed nursing staff had not received the in-service because of vacation and sick leave; however, the facility will provide in-service to the six employees before they return to work. -Administrative Nursing Staff completed a 100 percent audit of all labs on 07/22/14 to ensure labs were drawn per physicians order; any issues identified were addressed and taken through QA. Based on the information provided, Quality Assurance follow-up included completion of documentation, Physician order [REDACTED]. -The Unit Managers will have a laboratory calendar, which has all routine laboratory tests scheduled to be drawn for the rest of the year on it. They will compare the laboratory calendar to the laboratory tests in the laboratory book prior to the morning meetings Monday through Friday to ensure that they match and to ensure that they are drawn timely as ordered and results are received as well as family and physician notification as needed. The Administrator and/or DON or designee will monitor use of the laboratory book five (5) days a week, Monday through Friday, in the morning meeting to ensure that laboratory tests have been drawn as ordered and results have been returned to the facility and have been addressed. Routine laboratory tests are performed Monday through Thursday. -The Nurse on the rotating call schedule was in-serviced on the weekend lab-monitoring log on 07/22/14 by the Administrator. The Weekend Nurse on Call will call the facility on Saturday and Sunday at 9 AM, 5 PM, and 9 PM to see if any "stat" laboratory tests were ordered on the weekend. If "stat" laboratory tests have been ordered they will verbally verify that the results have been received and the physician and the family have been notified and if any new orders have been received. They will write this down on the weekend lab monitoring log beginning this upcoming weekend. -All staff has been in-serviced on abuse, the definition of abuse, and reporting abuse. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of 07/20/14. No agency is used at the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -All staff will be in-serviced on Resident Rights. Education will be conducted by DON, Staff Development Nurse or designee with a completion date of 07/20/14. No agency staff are used the facility. All new hires will be educated during general orientation by the Staff Development Nurse. -The Quality Assurance Committee consists of facility and contracted staff. This includes Administrator, DON, Unit Managers, Staff Development Nurse, Social Services, Activities Director, and the Dietary Director. Contracted membership includes the Medical Director. -The Quality Assurance Committee members reviewed the education material on 07/19/14. The education materials created were reviewed by Quality Assurance and have been taught to staff by the DON and Staff Development Nurse, who were in-serviced by the Regional Nurse Consultant before they in-serviced the Licensed Nursing Staff. Records of the in-service include signatures of attendance, signature of in-services received, and copy of testing for efficacy of the training. Staff in-service education was provided on 07/19/14 and completed on 07/20/14. Staff retained copies of all in-service materials for their use. -Members of the Quality Assurance Committee developed a policy on 07/19/14 to validate that Laboratory tests were obtained as ordered by the physician and results were received and followed up on timely per policy protocol. This was implemented 07/19/14 and is ongoing. The Unit Managers will compare the laboratory calendar to the laboratory tests listed on the laboratory-tracking sheet before morning meetings to verify they match. The Unit Manager will then follow up prior to the morning meeting to ensure that laboratory tests were drawn as listed, results have been received, and they have been followed up on timely. During the morning meetings, Monday through Friday, the Administrator, DON, or designee will check the Laboratory book as well as the laboratory calendar to ensure that laboratory tests have been drawn as physician ordered and results have been received. Any issues identified will be corrected immediately. This practice became effective 07/19/14. If any weekend "stat" laboratory tests ordered, the Nurse on Call will call the Administrator or DON and will audit any laboratory tests ordered and received. -Quality Assurance Meetings will be held with two (2) or more team members in attendance daily, five (5) days a week and PRN for review of data to ensure compliance including: any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results. -Quality Assurance Committee members will review data (any findings of laboratory tests not completed per physician order, any abnormal lab results found without physician notification, or any critical lab results) minimally five (5) days a week and PRN for thirty (30) days or additionally as necessary until 08/15/14; then one (1) time weekly until 09/12/14 or as needed; then monthly thereafter or as needed sooner. -Regional Nurse Consultant or the Regional Direct of Operations will review, comment, recommend, and/or approve Quality Assurance meetings as per the monitoring protocol. -The Pharmacy Consultant reviewed Resident #8's medical record on 05/19/14 and on 06/26/14. The pharmacist noted on the 06/26/14 review in Omniview (the pharmacy's computerized system) that Resident #8 hadn't been having their PT with INR drawn weekly per physician's orders [REDACTED]. During the audit, the pharmacist failed to review all [MEDICATION NAME] or other blood thinning laboratory tests, which placed all residents with this type of medication at risk. -The DON spoke with the current Pharmacy Consultant on 07/18/14, who had conducted the pharmacy review for Resident #8 in May and June 2014, and the Pharmacy Consultant stated that he was resigning and someone else would be doing the pharmacy consulting for the facility starting in August. -The Administrator drafted a letter to the General Manager of the pharmacy on 07/23/14, stating that during the pharmacist's monthly review, the minimum expectation is that all residents with an order for [REDACTED]. -On 07/21/14, the Administrator called and spoke with the General Manager of the pharmacy and explained to him that the pharmacy consultant must exit with the Administrator and/or DON and go over their consultant reports when reports are ready and provide the facility with a hard copy of the consultant reports. -The Administrator and/ or DON will educate the Pharmacy Consultant before their next regular review to ensure they assess the following areas: monitoring labs for critical levels, drug-to-drug interactions, and recommended drug alternatives. The education will also include that the Pharmacy Consultant must exit with the Administrator and/or DON upon completion of their review to go over the consultant reports and provide the facility with a hard copy of the consultant reports. The Pharmacy Consultant will be required to sign verification of education. -The Administrator and DON now have access to the pharmacy computer system effective 07/23/14, so they can go in and look at the consultant reports as well as any notes that had been made. The Administrator and DON will review the reports in the pharmacy computer system when they become available after the Pharmacy Consultant has completed his exit. The Administrator and DON will check the computer system daily after the pharmacy consultant has exited to see if the reports are on the computer. When the reports are available on the computer the Administrator and DON will compare the computer to the hard copy pharmacy reports to ensure that they match. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -The Administrator and DON will review the Pharmacy Consultant's report monthly to see what recommendations have been made, and to identify any issues found. Any issues found will be addressed through quality assurance and taken to quality assurance meetings for follow-up. -If any weekend stat labs are ordered, the Nurse on Call will call the Administrator or DON and will document any labs on the audit tool for the weekend lab tests ordered and received. -Resident #8 has a care plan for anticoagulants, which stated to obtain a PT/INR as ordered, at least monthly. However, the PT with INR laboratory tests for Resident #8 were not drawn weekly as ordered by the physician or as care planned from 05/12/14 to 07/02/14. -Based on the fact that the Care Plan was not followed for anticoagulant therapy the root cause has been determined to be lack of use of the care plan as a communication tool to licensed nursing staff. -Licensed Nursing staff will be in-serviced on the comprehensive care plan use in directing resident care by 7/21/14. In-services will be conducted by the Staff Development Nurse, DON or designee. In-services will include documentation required for the use of interventions on the care plans. All new hires will be educated during general orientation by the Staff Development Nurse. Six (6) licensed staff members have not been in-serviced due to vacation, or sick leave and they will be educated before they are allowed to return to work. -One hundred percent (100%) of all anti-coagulant care plans were reviewed and/or updated by the Regional Nurse Consultant as necessary on 07/20/14. -One hundred percent (100%) of the care plans have been reviewed and/or updated for labs on 07/21/14 by members of the care planning team including the DON, MDS, Unit managers, Dietary Manager, Social Services. -The Administrator did not have sufficient lab protocols in place to assure that Resident #8 had received labs per physician orders. -The Regional Director of Operations or the Clinical Nurse Consultant will be in the building daily until the facility has abated the immediate jeopardy to provide facility oversight. After the facility has abated the immediate jeopardy, they will be in the facility to provide management oversight throughout the survey process at least weekly. **The surveyors validated the Immediate Jeopardy was removed as follows: -Review of the laboratory reports for Resident #8 revealed a PT with INR dated 07/02/14 with the results being 85.1 for the PT and the INR results being 7.0. -Review of the Nurse's Notes for Resident #8 dated 07/02/14, at 5:41 PM, revealed Resident #8's physician was notified regarding the results of the resident's PT with INR, and the resident was sent to the hospital. -Interview conducted with Registered Nurse (RN) #2 on 07/18/14 at 9:05 AM, revealed Resident #8 had not received his/her PT with INRs weekly as was ordered by the physician in the May 2014 physician orders. The RN stated on 06/30/14 she notified Resident #8's physician that the resident had not received a PT with INR laboratory test as ordered and received an order to obtain weekly PT with INR. A PT with INR was completed on 07/02/14, the resident's physician was notified of the results, and the resident was sent to a hospital. -Interview with the laboratory Corporate Manager on 07/22/14, at 2:00 PM, revealed during her monthly review of laboratory orders, the Laboratory Auditor had updated Resident #8's PT with INR order in the computer, which was set to expire on 07/31/14, and had inadvertently set the new start date for 07/01/14, instead of 05/19/14. -Review of the Laboratory Policy and Protocol developed by the facility on 07/19/14, revealed a posttest had been completed by all facility nurses. -Review of an in-service roster dated 07/19/14, revealed the DON and Staff Development Nurse (SDN) attended an in-service by the Regional Nurse Consultant on the lab policy, neglect, resident rights, and care plans. -Interview conducted with the DON and the SDN on 07/25/14, at 4:40 PM, revealed they had attended an in-service on 07/19/14, by the Regional Corporate Nurse on the lab policy and protocol, abuse, resident rights, and care plans. The DON and SDN stated they had then provided the in-service to the nursing staff. -Interview conducted on 07/25/14, at 4:15 PM, with the Regional Nurse Consultant revealed she had been responsible for providing an in-service to both the DON and the SDN on 07/19/14, related to the lab policy and protocol, abuse, resident rights, and care plans prior to them providing an in-service to the nursing staff. -Review of the in-service roster revealed 43 facility nurses attended the in-service provided by the DON and SDN on the lab policy and protocol and care plans. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, State Registered Nurse Aide (SRNA) #8 at 2:24 PM, SRNA #10 at 2:00 PM, SRNA #14 at 2:11 PM, SRNA #15 at 2:15 PM, and SRNA #16 at 2:28 PM all revealed they had attended an in-service on abuse, and resident rights. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, and LPN #6 at 2:02 PM revealed they had attended an in-service related to the lab policy and protocol regarding how to put a laboratory order into the computer, the tracking process, and documentation required. -Review of the letter sent to the laboratory dated 07/22/14, revealed the laboratory service was not to renew any laboratory orders that were near expiration, and that the facility would do all renewals. The laboratory was required to immediately notify the Administrator and the DON of any changes or any laboratory orders that were about to expire. -Interview conducted with the Administrator on 07/25/14, at 4:30 PM, and the DON at 4:40 PM, revealed the Administrator had notified the laboratory's General Manager by phone and then by letter and had instructed them that they were to no longer update any laboratory orders in the computer, that the facility would do all laboratory updates, and that the facility expected the Laboratory Auditor to give the Administrator and the DON a list of all residents whose laboratory orders were nearing expiration. -Review of an audit completed by the DON, RN #2, RN #8, RN #9, and RN #10 on 07/22/14, of all residents' laboratory orders to ensure laboratory orders had been completed as ordered by the physician revealed all had been completed. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #8 at 2:30 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, and the DON at 4:40 PM, revealed they had all assisted in completing an audit on 07/22/14, of all residents' laboratory orders to ensure the orders had been completed as ordered by the physician and the reports had been placed on the resident's medical record and the results reported to the physician as necessary. -Review of the laboratory calendars for each nursing station revealed all Unit Managers had documented all laboratory orders and the date the laboratory test was due for the residents on their unit. -Observations of the laboratory calendars were conducted on 07/25/14, on the Blue Wing at 2:40 PM, Peach Wing at 2:45 PM, and the Green Wing at 2:50 PM. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, and RN #9 at 2:38 PM, revealed they used the calendars to monitor laboratory orders to ensure the laboratory test were completed. The RNs also revealed they were required to check laboratory orders daily prior to attending the morning Quality Assurance meeting and were required to report any concerns with laboratory orders not being completed. -Interview conducted with the Administrator on 07/25/14, at 4:30 PM, and the DON at 4:40 PM, revealed they reviewed the laboratory calendars every morning in the Quality Assurance morning meeting to ensure laboratory orders had been completed as ordered by the physician. -Review of the Nurse on Call schedule revealed a nurse was scheduled every weekend to take Administrative call. -Review of an in-service by the Administrator dated 07/22/14, and attended by the DON, RN #2, and RN #9 revealed the weekend On-Call Nurse was required to call the facility on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any "stat" laboratory orders had been conducted. If any were ordered, the RN was then required to verbally verify if the results had been received by the facility. The weekend Nurse on Call was required to document the information on the weekend log beginning 07/26/14. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, and the DON at 4:40 PM, all revealed they had attended an in-service by the Administrator on 07/22/14. The interviews revealed they were required to call the facility when on call on Saturday and Sunday at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM, to ensure any stat laboratory orders had been ordered, and the results returned. The interview revealed they were also required to document the information on a weekend lab-monitoring tool as part of the Quality Assurance program, which began on 07/26/14. -Interview conducted with the Administrator on 07/25/14, at 4:30 PM, revealed she had conducted an in-service for nurses who would be taking administrative call on weekends on 07/22/14. The Administrator stated the on-call nurses were required to call the facility at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM to ensure all stat laboratory orders had been completed and the results were on the resident's medical record. The Administrator stated the process would begin on Saturday, 07/26/14. The Administrator stated she would be reviewing the audits every Monday in the morning meeting, which was a part of the Quality Assurance program. -An in-service roster dated 07/20/14, regarding Abuse and Resident Rights with a posttest, revealed all employees had attended the in-service. -Review of a new hire in-service syllabus was reviewed and the laboratory policy in-service was added to the new hire orientation. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #9 at 2:38 PM, Licensed Practical Nurse (LPN) #3 at 2:46 PM, LPN #5 at 2:56 PM, LPN #6 at 2:02 PM, State Registered Nurse Aide (SRNA) #8 at 2:24 PM, SRNA #10 at 2:00 PM, SRNA #14 at 2:11 PM, SRNA #15 at 2:15 PM, and SRNA #16 at 2:28 PM revealed they had attended an in-service on abuse and resident rights and had also completed a posttest. -Interview conducted with the SDN on 07/24/14, at 12:55 PM, revealed she had provided in-service for staff on the lab policy and protocol, abuse, resident rights, and the required usage of the care plans. -Review of a list of Quality Assurance Team Committee members was conducted. -Review of an audit completed by the DON, RN #2, RN #8, RN #9, and RN #10 on 07/22/14, revealed the facility had reviewed all residents' laboratory orders to ensure laboratory orders had been completed as ordered by the physician. -Interviews conducted on 07/25/14, with RN #2 at 4:43 PM, RN #8 at 2:30 PM, RN #9 at 2:38 PM, DON at 4:40 PM, and the Administrator at 4:30 PM, revealed they were all part of the Quality Assurance Committee and attended meetings daily Monday through Friday during the morning meeting which was part of the Quality Assurance program. The staff revealed they developed and reviewed education in-services and policies for the lab policy and protocol, care plans, and the abuse and resident rights in-service, as well as the audit tools that will be used. The staff stated they would also be reviewing the audit tools. -Review of Quality Assurance morning meeting minutes dated 07/19/14, 07/20/14, 07/21/14, 07/22/14, 07/23/14, 07/24/14, and 07/25/14, which had all been reviewed and signed by the Regional Nurse Consultant or the Regional Director of Operations, was conducted. -Interviews conducted on 07/25/14, at 4:45 PM, with the Regional Corporate Nurse Consultant and the Regional Director of Operations, revealed they had reviewed and signed all daily Quality Assurance minutes beginning on 07/19/14 through 07/25/14. The Regional Corporate Nurse Consultant stated she had been in the facility every day since immediate jeopardy had been identified. -Review of Resident #8's Comprehensive Plan of Care regarding anticoagulant therapy revealed the resident had a care plan intervention to obtain a PT with INR as ordered by the physician. -Review of Care Plan Protocol staff were informed where care plans were located at e

Based on interview, record review, and a review of the facility's policy, the incident report, and manufacturer's instructions, it was determined the facility failed to ensure services provided by the facility were provided in accordance with the written plan of care for one of three sampled residents (Resident #1). Facility staff assessed Resident #1 to require the assistance of a minimum of two staff persons with the use of a "sit to stand lift" for transfers. However, on 01/20/13, two staff persons transferred Resident #1 from the wheelchair to the bed without the use of the "sit to stand lift" and the resident sustained [REDACTED]. (Refer to F323.) The findings include: A review of the facility's policy entitled "Care Plan Policy Statement" (not dated) revealed care plans were to be developed that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. The policy further revealed the care plan was designed to incorporate identified problem areas, incorporate risk factors associated with the identified problems, build on the resident's strengths, and aid in preventing or reducing declines in the resident's functional status or levels. Interview with The Director of Nursing (DON) on 02/06/13 at 12:15 PM revealed the facility also utilized an "AccuNurse" audio system to access each resident's care plan. A review of the "AccuNurse" user manual, dated 2011, revealed the system was command-based speech recognition software that provided staff with real time access to each resident's care plan and interventions by means of a headset. In addition, the user manual revealed staff could update the care plans in the "AccuNurse" system by documenting custom notes under each section; however, according to the directions, staff was not to type the custom notes in capital letters. A review of the medical record of Resident #1 revealed the facility admitted the resident on 02/01/09 with [DIAGNOSES REDACTED]. A review of Resident #1's written comprehensive care plan that addressed Activities of Daily Living (ADL), dated 01/07/13, revealed the resident required extensive assistance of two persons with the use of a "sit to stand" lift for transfers. In addition, a Quarterly Minimum Data Set (MDS) assessment, dated 01/13/13, revealed the facility had assessed Resident #1 to require the extensive assistance of two persons for transfers. A review of an Accident/Incident Report, dated 01/20/13, revealed on 01/20/13 at approximately 9:00 PM, Certified Nurse Aide (CNA) #1 and CNA #2 transferred Resident #1 from the wheelchair to the bed and the resident stated, "They hurt my arm." The Accident/Incident Report further revealed the resident's physician was contacted on 01/20/13 at 10:15 PM and an order was given to monitor the resident's shoulder. In addition the report revealed staff was reeducated on the resident's care plan for transfers. A review of Resident #1's x-ray obtained on 01/21/13 and the computerized tomography (CT) obtained on 01/23/13 revealed Resident #1 had sustained a fracture to the left shoulder. Interview on 02/06/13 at 12:17 PM with Resident #1 revealed when two aides were helping the resident transfer from the wheelchair to the bed, the resident experienced pain in his/her left shoulder. The interview further revealed that during the transfer one of the aides held onto the resident's left arm and had her hand between the resident's left arm and the resident's body and the other aide held onto the resident's pants. According to the resident, when the aides assisted the resident up from the chair to help him/her to the bed, the resident heard a pop and his/her left shoulder began to hurt. Resident #1 stated staff did not use a "lift" to transfer the resident. Interview on 02/06/13 at 5:19 PM with Licensed Practical Nurse (LPN) #1 revealed she went into Resident #1's room on 01/20/13 and upon entering the room, observed CNA #1 and CNA #2 in the room and Resident #1 sitting on the side of the bed. According to LPN #1, she did not observe a "lift" in the resident's room when she entered. The interview further revealed CNA #1 and CNA #2 proceeded to assist the resident to lie down in bed and Resident #1 stated, "They hurt my arm." Interview on 02/06/13 at 3:15 PM with CNA #1 revealed she and CNA #2 transferred Resident #1 the same way they always do with two-person physical assistance. The interview further revealed the CNA was not aware Resident #1 required a lift for transfers and stated the "AccuNurse" only stated the resident required the assistance of two persons for assistance with transfers. CNA #1 stated a paper copy of the care plan was available to staff, but it was to be used if the "AccuNurse" system was not functioning. Interview on 02/06/13 at 3:00 PM with CNA #2 confirmed he and CNA #1 transferred Resident #1 from the wheelchair to the bed without a lift on 01/20/13. The interview further revealed CNA #2 was not aware Resident #1 required a lift. According to CNA #2, on the day of the incident, the "AccuNurse" system only stated Resident #1 required the physical assistance of two persons and then the system started "saying letters." CNA #2 stated he did not know what the letters meant, that it just sounded like random letters and that a paper care plan was available if the "AccuNurse" system was not functioning. According to CNA #2, on the day of the incident, he did not look at the paper care plan even though he did not know what the "letters" stated by the "AccuNurse" meant. Interview on 02/06/13 at 6:41 PM with LPN #2 revealed the LPN had been trained not to enter items into the comment section of the "AccuNurse" system using capital letters. The interview further revealed if only one capital letter was entered into the "AccuNurse" system, the system would only say the letter that was capitalized, and then attempt to say the rest of the word; for example if the word "the" was entered as "The" the system would say the letter "t" and then the word "he." LPN #2 stated he had not entered Resident #1's information into the "AccuNurse" system, and was unable to determine who had entered the information. On 02/06/13 at approximately 3:45 PM, CNA #3 was requested to demonstrate the use of the "AccuNurse" system as if she was going to transfer Resident #1. According to CNA #3, at that time, the "AccuNurse" system stated the resident required the physical assistance of two with the use of a standing lift. In addition, a review of the "AccuNurse" ADL plan of care on 02/06/13 also revealed Resident #1 required the physical assistance of two or more persons, with the use of a "standing lift" for transfers; however, the only date on the care plan was the date the care plan was printed (02/06/13) and, as a result, it could not be determined when the care plan had been developed/updated. Interview on 02/06/13 at 8:34 PM with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) revealed the facility was not aware of the problem related to the "AccuNurse" system and the use of capital letters until the incident occurred. The DON and the RNC stated it was learned after the incident that staff had entered information related to the use of the lift for Resident #1 into the "AccuNurse" system in all capital letters which caused the system to spell out "SIT AND STAND LIFT" instead of speaking the words. Interview also revealed the facility did not have a system in place prior to the incident to monitor the AccuNurse system for accuracy. According to the DON and RNC, they did not have any way of determining who had made the entry into the "AccuNurse" system using all capital letters, and stated that since the incident, all written care plans and "AccuNurse" care plans had been checked for accuracy and corrected. The interview further revealed if the CNAs had any questions about what assistance a resident required a paper copy of the care plan was always available.

Based on interview, record review, a review of the facility's policy, the incident report, and manufacturer's instruction, it was determined the facility failed to ensure adequate supervision and assistive devices to prevent accidents were provided for one of three sampled residents (Resident #1). Interviews and a review of Resident #1's Care Plan and a Quarterly Minimum Data Set (MDS) assessment, revealed facility staff was to utilize a "sit to stand lift" when transferring the resident. However, on 01/20/13, two staff persons transferred Resident #1 from the wheelchair to the bed without the use of the "sit to stand lift." At the time of the transfer, Resident #1 complained of pain in the left arm, the resident's physician was notified, and radiology reports revealed the resident sustained [REDACTED]. The findings include: A review of the facility's policy entitled "Care Plan Policy Statement" (not dated) revealed the care plan was designed to incorporate identified problem areas, incorporate risk factors associated with the identified problems, build on the resident's strengths, and aid in preventing or reducing declines in the resident's functional status or levels. In addition, interview with the Director of Nursing (DON) on 02/06/13 at 12:15 PM revealed the facility also utilized an "AccuNurse" audio system as a means for staff to access each resident's care plan. A review of the "AccuNurse" user manual, dated 2011, revealed the system was command-based speech recognition software that provided staff with real time access to each resident's care plan and interventions by means of a headset. In addition, the user manual revealed staff could update the care plans in the "AccuNurse" system by documenting custom notes under each section; however, according to the directions, staff was not to type the custom notes in capital letters. A review of an in-service provided to staff by the facility in August 2012 revealed Certified Nursing Assistants (CNAs) were instructed on proper resident lifting and transfers. In addition, a review of an in-service conducted on 10/13/12 revealed staff was instructed to review each resident's "AccuNurse" care plan before providing care to residents and to report any interventions that did not match the paper care plan to a Supervisor. A review of the medical record of Resident #1 revealed the facility admitted the resident on 02/01/09 with [DIAGNOSES REDACTED]. A review of Resident #1's written comprehensive care plan dated 01/07/13 revealed the resident required extensive assistance of two persons with the use of a "sit to stand" lift for transfers. In addition, a Quarterly Minimum Data Set (MDS) assessment, dated 01/13/13, revealed the facility assessed Resident #1 to require the extensive assistance of two persons for transfers. On 01/20/13, staff documented in an Accident/Incident Report that Resident #1 had complained of pain in the arm after two staff persons transferred the resident from a wheelchair to the resident's bed on 01/20/13 at 9:00 PM. Continued review of the report revealed Resident #1's physician was notified on 01/20/13 at 10:15 PM of the resident's complaints of pain, and the physician requested for staff to monitor the resident. On 01/21/13 at 6:20 AM, nursing staff documented Resident #1 continued to complain of pain of the left shoulder, the physician was contacted, and a portable x-ray of the resident's shoulder was ordered and obtained. Continued review of nursing documentation in the nurse's notes revealed the results of the shoulder x-ray were received by the facility on 01/22/13 and a (Computerized Tomography) CT of the shoulder was ordered and completed on 01/23/13. A review of a radiology report dated 01/21/13, one day after the incident, revealed Resident #1 sustained a fracture of the left shoulder area. A review of a report of Resident #1's CT scan, dated 01/23/13 (three days after the incident), also revealed the resident had a non-displaced fracture of the shoulder area. Based on documentation in the medical record, facility staff administered pain medications to the resident on an as needed basis as ordered by the physician. In addition, the report revealed evidence the resident had osteopenia/osteoporosis. Resident #1 stated in an interview on 02/06/13 at 12:17 PM that two nurse aides had assisted the resident to transfer from the wheelchair to the bed by holding onto the resident's left arm between the arm and body, and to the resident's pants. According to Resident #1, during the transfer he/she heard a "pop" and his/her left shoulder began to hurt. Resident #1 stated staff did not use a "lift" to transfer the resident. Licensed Practical Nurse (LPN) #1 stated in an interview on 02/06/13 at 5:19 PM that she went into Resident #1's room on 01/20/13 to check the resident's blood sugar and, upon entering the room, observed Certified Nurse Aides (CNAs) #1 and #2 in the room and Resident #1 sitting on the side of the bed. The interview further revealed CNAs #1 and #2 proceeded to assist the resident to lie down in bed and Resident #1 stated, "They hurt my arm." LPN #1 stated Resident #1 was assessed, the resident's doctor was contacted and requested staff to monitor the resident. Further interview revealed Resident #1 continued to complain of pain throughout the night and on the morning of 01/21/13, the resident's physician was contacted again, and orders were received for a portable x-ray of the resident's left arm/shoulder. LPN #1 stated she did not observe a "lift" in the resident's room when she entered on 01/20/13. CNA #1 stated in an interview on 02/06/13 at 3:15 PM that she and CNA #2 transferred Resident #1 on 01/20/13 and was not aware Resident #1 required a lift for transfers. According to CNA #1, the "AccuNurse" only stated the resident required the assistance of two persons for assistance with transfers. CNA #1 stated a paper copy of the care plan was available to staff, but it was to be used if the "AccuNurse" system was not functioning. CNA #2 acknowledged in an interview conducted on 02/06/13 at 3:00 PM that he and CNA #1 transferred Resident #1 from the wheelchair to the bed without a lift on 01/20/13. The interview further revealed CNA #2 was not aware Resident #1 required a lift. According to CNA #2, on the day of the incident, the "AccuNurse" system only stated Resident #1 required the physical assistance of two persons and then the system started "saying letters." CNA #2 stated he did not know what the letters meant, that it just sounded like random letters and that a paper care plan was available if the "AccuNurse" system was not functioning. According to CNA #2, on the day of the incident, he did not look at the paper care plan even though he did not know what the "letters" stated by the "AccuNurse" meant. Interview on 02/06/13 at 6:41 PM with LPN #2 revealed if staff entered any letters into the "AccuNurse" using capital letters, the system would only say the letter that was capitalized, and then attempt to say the rest of the word; for example if the word "the" was entered as "The," the system would say the letter "t" and then the word "he." LPN #2 stated he had not entered Resident #1's information into the "AccuNurse" system, and was unable to determine who had entered the information. Interviews were conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) on 02/06/13 at 8:34 PM. The DON and the RNC stated it was identified after the incident that staff had entered information related to the use of the lift for Resident #1 into the "AccuNurse" system in all capital letters which caused the system to spell out "SIT AND STAND LIFT" instead of speaking the words. Interview also revealed the facility did not have a system in place prior to the incident to monitor the "AccuNurse" system for accuracy. The interview further revealed if the CNAs had any questions about what assistance a resident required, a paper copy of the care plan was always available. According to the DON and RNC, since the incident, all written care plans and "AccuNurse" care plans have been checked for accuracy and corrected.