Every finding on record at The Brightpointe

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 17 residents (Resident #30, #31, and #97) reviewed for care plans. -The facility failed to develop and implement a comprehensive care plan for Resident #30 for cardiac telemetry status (a monitoring system that tracks electrical activity of the heart using electrodes and a monitor). -The facility failed to develop and implement a comprehensive care plan for Resident #30, #31, and #97 for the use of bedrails. This deficient practice could place residents at risk of not receiving proper care and services. Findings included: Record review of Resident #30's face sheet dated 05/31/2024, revealed an [AGE] year-old admitted to the facility on [DATE]. Resident #30's diagnoses included a fracture of the upper left arm, muscle wasting, Parkinson's disease (a progressive disorder that affects the nervous system), dementia, heart failure, hyperlipidemia (abnormally high levels of fats in the blood), sprain of left wrist, bradycardia (heart rate slower than 60 beats per minute), hypertension (elevated blood pressure), presence of cardiac pacemaker, and history of falling. Record review of Resident #30's annual MDS dated [DATE] revealed a BIMS score of 9 out of 15 indicating moderate cognitive impairment. Resident #30 had impairment to one side of the upper extremity and used a walker for mobility. Resident #30 required partial assist from a helper with bed mobility and personal hygiene. Resident #30 required substantial assist with sitting to lying, sitting to standing, as well as toileting and transfers. Resident #30 was receiving physical therapy. Section P: Physical Restraints, of the MDS indicated the bed rail was not used. Further review of the MDS revealed a fall history in the last month. Record review of Resident #30's order summary report dated 05/29/2024 at 2:22 PM revealed a verbal order dated 05/06/2024 to put the resident on telemetry. Record review of Resident #30's physician progress note written by the MD, dated 05/29/2024 at 8:13 AM, revealed Resident #30 had bradycardia and the plan included to monitor telemetry. Record review of Resident #30's pulse summary revealed the remote telemetry system was continually recording heartbeat at least every hour beginning 05/06/2024 at 10:56 PM. Record review of Resident #30's Bedrail Assessment, with the effective date of 03/14/2024 and signed by LVN A revealed side rails/assist bar were indicated and served as an enabler to promote independence. Record review of Resident #30's undated Side Rail Assessment and Consent revealed the type of rails to be used were: top half and two sides. The Consent was signed by Resident #30's family. Record review of Resident #30's undated care plan did not address the use of telemetry or bedrails. Further review indicated Resident #30 required 1-2 staff assistance with all ADL's, date initiated was 03/15/2024. Record review of Resident #31's face sheet dated 05/29/2024 revealed a [AGE] year-old admitted to the facility on [DATE] with diagnoses to include critical illness myopathy (a condition of muscle weakness that affects critically ill patients), Diabetes, chronic kidney disease, hyperlipidemia, hypertension, gastrostomy status (g-tube for feeding), Bell's palsy (a condition that causes temporary weakness or paralysis of the muscles in the face), and polyneuropathy (damage to multiple peripheral nerves). Record review of Resident #31's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #31 had no impairments to both upper and lower extremities. Resident #31 was independent with bed mobility. Resident #31 required set up only for transfers. Section P of the MDS indicated bed rail was not used. Record review of Resident #31's undated care plan did not address the use of bedrails. Further review indicated Resident #31 required 1-2 staff assistance with all ADL's, date initiated was 02/22/2024. Record review of Resident #31's Bedrail Assessment, with the effective date of 02/22/2024 and signed by the DON revealed side rail placement recommendations were for the left side and side rails/assist bar were indicated and served as an enabler to promote independence. Record review of Resident #31's undated Side Rail Assessment and Consent was signed by Resident #31. Record review of Resident #97's face sheet dated 05/29/2024 revealed a [AGE] year-old admitted to the facility on [DATE] with the diagnoses to include encephalopathy (damage or disease that affects the brain), periprosthetic fracture (broken bone) around a hip or knee joint replacement, atrial fibrillation (irregular, rapid heart rhythm), heart disease, cardiac pacemaker, obesity, seizures, history of falling, and abnormal reflex. Record review of Resident #97's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #97 had impairment on both sides of upper extremities and used a walker for mobility. Resident #97 was dependent on staff for toileting and dressing. Resident #97 required partial assistance with bed mobility and substantial assistance with sitting to lying, lying to sitting on the side of the bed, and sitting to standing positions. Resident #97 had a fall in the last month and had a fracture related to a fall in the last 6 months. Section P of the MDS indicated bed rail was not used. Record review of Resident #97's undated care plan did not address the use of bedrails. Further review indicated Resident #97 required 1-2 staff assistance with all ADL's, date initiated was 05/23/2024. Record review of Resident #97's Side Rail Assessment and Consent dated 05/23/2024 revealed risks and benefits were explained to the resident/family, including the risk of significant injury if a fall occurred. The Consent was signed by Resident #97's family and RN B. Observation and interview on 05/28/2024 at 12:45 PM, Resident #30 was sitting up in the wheelchair and was connected, with electrodes, to the cardiac telemetry monitoring system. There were bedrails attached to both sides of the bed frame and the bedrails were in the down position. Resident #30's family stated that he was on telemetry because he had issues with his heart. In an interview on 05/28/2024 at 3:59PM the DON stated all data for the telemetry residents goes directly into point click care. She stated it was the responsibility of the MDS and the DON to ensure that the care plans were updated. She stated all residents that are receiving telemetry, should be care planned because it is an intervention for cardiac. She stated the care plan should be updated when the orders were received. In an interview on 05/29/2024 at 3:53 PM, the DON stated telemetry should be in the resident care plan and that the MDS nurse and the ADON were responsible for making sure it was care planned. The DON stated it should be included in the care plan because it was an intervention for cardiac issues and should be updated when the order was received. In an interview on 05/29/2024 at 4:42 PM, the MDS nurse stated that telemetry was not required to be care planned d/t it was a service the facility provided. The MDS nurse stated the nursing staff would not know if the resident was on telemetry if they were to check the care plan. The MDS nurse stated there was no code for telemetry in the MDS, that it was not billed, and there was no place in the MDS to bill for it. In an interview on 05/30/2024 at 12:06 PM, the ADON stated the facility did not give bedrails unless the resident had a high BIMS score to be able to communicate their needs for them or if physical therapy evaluated the need for bed rails. The ADON stated demi rails were equivalent to a shower rail in the bathroom. The ADON stated demi rails were not care planned but the bigger bed rails that would be exit limiting would be care planned. Observation and interview on 05/30/2024 at 12:40 PM, Resident #31 was in bed with the HOB raised and there was a short grab bar to his left side that was raised. Resident #31 stated the grab bar was already on the bed when he first admitted , and it was helpful when he needed it. Observation on 05/30/2024 at 12:48 PM, Resident #30 was lying on his back in bed asleep with the HOB raised. Both side rails were connected to the top half of the bed frame and were in the raised position. In a telephone interview on 05/30/2024 at 2:11 PM, the NP stated he believed Resident #30 had atrial fibrillation and bradycardia and that was the reason he wanted him on telemetry. In an interview on 05/30/2024 at 2:35 PM, RN C stated Resident #30 had left side weakness and the bed rails were there to help with bed mobility. RN C stated Resident #97 also had left side weakness and used the bed rail for bed mobility. RN C stated that the bed rails should be written in the care plan but did not know if this was the facility policy and procedure. RN C stated she believed the residents benefit from the bed rails and it would be a negative if they were considered restraints. RN C stated it was important to include in the care plan because if a resident can use the bedrails to move around it could help prevent skin injuries and could help protect and promote independence. RN C states she believed Resident #31 had the bed rail assist early on when he was very dependent. RN C stated she did believe bed rails were considered a restraint in the facility and that any full bed rail would be a restraint. RN C stated a full bed rail would be at least 3/4 the length of the bed. RN C stated Resident #30 had bed rails to both sides of the upper part of the bed and Resident #97 had loop bars on both sides. RN C stated Resident #31 had a loop bar and that when he first came to the facility, he could not reposition himself in the bed. She stated he could not get up at all and required 2-person assistance but was now walking and transferring himself. In an interview on 5/30/2024 at 3:04 PM, the DON stated Resident #30 needed the bed rails upon admission. In an interview on 05/30/2024 at 3:51 PM, the MDS nurse stated Residents #30, #31 and #97 did not have bed rails and that bed rails restrict movement. MDS nurse stated Residents #30, #31 and #97 had mobility bars that did not restrict movement. MDS nurse stated if they used bedrails then she would code them as such, and assessments and consents would be needed. In an interview on 05/30/2024 at 4:12 PM, Resident #30's family stated the bed rails had always been on the bed and that it helped him get out of bed because of the height. The family stated Resident #30 had shoulder replacement and had difficulty getting out of bed without the bed rails. When asked if Resident #30 was restricted by the bed rails, the family stated it did not because it helped him. In an observation and interview on 05/30/2024 at 4:25 PM, Resident #97's family stated the bed rails were discussed with the facility and it helped with his movement to get out of bed. The family stated in the past he did not need it but now he needed it. Resident #97 was in bed and the bed had a loop/grab assist bar mounted to the bed frame. In an interview on 05/30/2024 at 4:51 PM, the CCO stated bed rails should be addressed in the care plan, in the ADLs, and the risks would depend on the reason for the use such as left sided weakness. Record review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered, revised on March 2022, read in part: .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are a. provided by qualified persons .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Record review of the facility policy and procedure for Bed Safety and Bed Rails, revised August 2022 read in part: .Use of Bed Rails, 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths .For the purpose of this policy bed rails include: a. side rails; b. safety rails; and c. grab/assist bars .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 2 of 5 residents (Resident #2 and Resident #3) reviewed for pharmacy services in that: - The facility failed to enter orders as well as acquire and administer medications to Resident #2 as ordered immediately upon admission. - The facility failed to retrieve Resident #2's initial dose of medication from the facility emergency kit. - The facility failed to acquire and administer medications to Resident #3 as ordered immediately upon admission. These failures could place residents at risk of not receiving medications as ordered by their physician, inadequate disease management, uncontrolled pain, seizures, and serious harm. The findings included: Resident #2 Record review of Resident #2's Face Sheet dated 02/29/24 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: Parkinson's Disease, hypertension, restless syndrome, hallucinations and depression. Record review of Resident #2's Entry MDS dated [DATE] revealed, the resident admitted from a short-term general hospital. Record review of Resident #2's undated Care Plan revealed, focus- pain r/t restless leg syndrome and Parkinson's disease; intervention- administer pain meds as ordered. An observation and interview of Resident #2 on 02/27/24 at 12:45 PM revealed, Resident #2 sitting in his wheelchair in his room, in no immediate distress and with no observed tremors. The resident said he was doing well and he had no issues with his medications or delay in care when he admitted to the facility. Resident #2 said everything is great. Record review of the facility provided Emergency Drug Kit Inventory filled 02/14/24 revealed, the kit contained: - Carbidopa/Levodopa 25-100 mg. Record review of Resident #2's Hospital Discharge Medication List dated 02/25/24 at 12:05 PM revealed: - Horizant 600 mg (medication used for nerve damage)- 1 tablet daily; next dose due at 6 PM. - Carbidopa-Levodopa 25-100 mg (medication used to treat Parkinson's disease)- 4 times daily. - Latanoprost 0.005% eye drops (medication used to treat glaucoma)- 1 drop every evening. - Pramipexole 0.5 mg (medication used to treat the symptoms of Parkinson's disease)- t ab by mouth - Ranolazine 500 mg (medication used to treat chronic chest pain)- 1 tablet 2 times a day - Sucralfate 1g (medication used to treat stomach ulcers)- 1 tablet by mouth four times daily before meals and at bedtime. Record review of Resident #2's Admission Summary dated 02/25/24 at 02:30 PM signed by RN D revealed, history of Parkinson's disease, restless leg syndrome, and neuropathy. Resident #2's speech was minimal due to his progression of Parkinson's but his behavior was pleasant and cooperative. The facility staff and Resident #2's NP were notified of the residents admission. There was no documentation about medication availability, or communication with the pharmacy or resident's MD or NP about medication availability. Record review of Resident #2's Order Summary Report revealed, - Carbidopa-Levodopa Oral Tablet 25-100 MG- Give 1 tablet by mouth four times a day - Horizant Oral Tablet Extended Release 600 MG- (Gabapentin Enacarbil) Give 1 tablet by mouth at bedtime for restless legs - Latanoprost Ophthalmic Solution 0.005 %- (Latanoprost) Instill 1 drop in both eyes at bedtime for Glaucoma. Start date scheduled for 02/26/23. Ranolazine ER Oral Tablet Extended Release 12- Hour 500 MG (Ranolazine) Give 1 tablet by mouth two times a day. - Sucralfate Oral Tablet 1 GM (Sucralfate) Give 1 tablet by mouth four times a day for antacid Give before meals and at bedtime. Record review of Resident #2's February 2024 MAR revealed, - Horizant 600 mg- 1 tablet by mouth scheduled for 08:00 PM not administered on 02/25/24. - Latanoprost 0.006% eye drops- 1 drop in both eyes; scheduled for 08:00 PM not administered on 02/25/24. - Ranolazine 500 mg ER, scheduled for 08:00 PM not administered on 02/25/24. - Ranolazine 500 mg ER, scheduled for 08:00 PM not administered on 02/26/24 at 08:00 AM. - Carbidopa-Levodopa 25-100 mg- not administered on scheduled doses on 02/25/24 at 08:00 PM and 02/26/25 at 08:00 AM - Sucralfate 1 gm- not administered on 02/25/24 at 08:00 PM, 02/26/24 at 07:00 AM and 02/26/24 at 11:30 AM. Record review of Resident #2's Progress Notes dated 02/27/24 at 12:56 PM revealed, Note: [Family Member] concerned with Carbidopa-Levodopa dosage, stated the dose was cut in half and client's Parkinson's symptoms were worsening. Providers notified and new order started. In an interview on 02/29/24 at 10:05 AM, RN D said she was Resident #2's admitting nurse. She said Resident #2's admission was the first one she completed on her own and she stayed over her shift to ensure she completed everything. RN D said Resident #2 admitted over the weekend so the facility admission nurse was unavailable to assist her during the admissions process. RN D said the time documented on the resident's admission note (02:30 PM) was the time she actually received the patient. RN D said when a resident admits nursing staff are expected to start the medications based on the discharge records and first doses can be retrieved from the facility e-kit but if medications were not in the kit she was expected to call the pharmacy to try and get a stat order, contact the doctor for an alternative if necessary and document any action taken if necessary. She said when she admitted Resident #2 she did not identify any missing doses, did not check the e-kit for any of the resident's first doses, did not contact the pharmacy to receive a stat delivery, did not contact the physician for alternative medications, did not notify the next nurse at change of shift of the unavailable medications, and did not document any medication issues in the resident's chart. RN D said she started in the facility in December of 2023 and she never completed her training on admissions and physician notification in the facility because on her 3rd day of training she was placed on the floor but she had completed admissions at her previous job. She said she just missed that Resident #2 did not have medications available for immediate administration and if since the Resident #2 admitted at 02:30 PM she should have received his medications through a stat delivery or the e-kit and the error was on her. RN D said failure to administer medication timely on admission could result in adverse reactions, and in Resident #2's case upset stomach from not receiving his sucralfate or worsening of Parkinson's symptoms as a result of missing his Carbidopa-Levodopa. Resident #3 Record review of Resident #3's Face Sheet dated 02/29/24 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of: type 2 diabetes, high blood pressure and irregular heartbeat. Record review of Resident #3's Admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15 and an active diagnoses of high blood pressure and irregular heartbeat. Record review of Resident #3's undated Care Plan revealed, focus- on anticoagulant (blood thinner) for unspecified irregular heart beat; intervention administer anticoagulant as ordered. Focus- resident has diabetes; intervention- administer diabetes medications as ordered by doctor. An observation and interview on 02/27/24 revealed, Resident #3 in her room, she appeared well groomed, well fed and in no immediate distress. She said when she arrived at the facility there was no delay in care and she promptly received her medications. She reported no symptoms of high or low blood sugars. Record review of Resident #3's Hospital Discharge Medication List dated 02/22/24 at 09:09 AM revealed: - Amiodarone 200 mg ( medication for irregular heartbeat) - 2 times daily at 09:00 AM and 5 PM; last dose at 02/22/24 at 09:03 AM - Atorvastatin 40 mg (medication for high cholesterol)- 1 time daily at bedtime; last dose on 02/21/24 at 09:49 PM. - Rivaroxaban 20 mg (a blood thinner)- 1 time daily with dinner; last dose on 02/21/24 at 05:19 PM. - Metformin XR 1000 mg- take 2 tablets twice a day with meals. Record review of Resident #3's Order Summary Report revealed, - Amiodarone HCl Oral Tablet 200 MG - Give 1 tablet by mouth every 12 hours for Irregular heart beat; start 02/22/24. - Atorvastatin Calcium Oral Tablet 40 MG- Give 1 tablet by mouth at bedtime for irregular heart beat; start 02/22/24. - Metformin Extended Release 24 Hour 1000 MG - Give 1 tablet by mouth two times a day with meals for type 2 diabetes. - Rivaroxaban 20 mg- 1 tablet by mouth in the evening for irregular heart beat; start 02/22/24. Record review of Resident #3's February MAR revealed: - Amiodarone 200 mg scheduled for 02/22/24 at 08:00 PM was not administered. - Atorvastatin 40 mg scheduled for 02/22/24 at 08:00 PM was not administered. - Metformin ER 1000 mg scheduled for 02/22/24 at 02:00 PM was not administered - Rivaroxaban 20 mg scheduled for 02/22/24 at 04:00 PM was not administered. Record review of the facility provided Emergency Drug Kit Inventory filled 02/14/24 revealed, the kit contained: - the emergency kit did not contain Resident #3's Amiodarone 200 mg, Atorvastatin 40 mg, Rivaroxaban 20 mg or Metformin XR 1000mg. Record review of Resident #3's Progress Note dated 02/22/24 at 02:07 PM by RN D revealed, a past medical history of irregular heartbeat, type 2 diabetes and hypertension. There was no documentation about medication availability, or communication with the pharmacy or resident's MD or NP about medication availability. Record review of Resident #3's medication order Audit details revealed, the admitting nurse entered Resident #3's medications promptly upon admission at 02:08 PM (8 minutes after admission). Record review of Resident #3's Progress Notes for 02/22/24 to 02/23/24 revealed, no documentation explaining why Resident #3 did not receive her medications on 02/22/24. Record review of Resident #3's Blood Sugars from 02/22/24 to 02/29/24 revealed, Resident #3's blood sugars ranged from 82 mg/dL to 145 mg/dL there was no documented hypo or hyperglycemia (low or high blood sugars). In an interview on 02/29/24 at 08:49 AM, DON B said when a resident admits the admitting nurse and the admission nurse work together to receive the patient, check vitals and then enter admitting orders. She said medication orders should be entered and started based on the discharge medication med list and the next due dose. She said admission orders should be entered within an hour of admission and the pharmacy had specific cut off times but there was always the option for stat deliveries. DON B said if a resident arrived around 2:00 PM nurses are expected to retrieve their first doses from the e-kit and if the medication was not available they could follow up with the resident's family to see if they had any available or request a stat order from the pharmacy. DON B said if a nurse identifies a medication as unavailable they are expected to call the pharmacy to coordinate a stat deliver and if the medication was unavailable call the MD to ask for an alternative medication. She said nurses are expected to document the steps they took to resolve the medication discrepancy, who they talked to and the outcome in the resident's chart. DON B said failure to enter medication orders timely, or administer medications immediately upon admission could result in a delay in care, or missed doses that could place a resident at risk of a change of condition. In an interview on 02/29/24 at 10:05 AM, RN D said she was Resident #3's admitting nurse. She said she was only responsible for assessing Resident #3 and the admissions nurse entered the residents medication orders. In an interview on 02/29/24 at 10:39 AM, DON B said the facility did not have a specific policy addressing physician notifications and nursing staff were expected to follow the Admission Checklist but it was not expected to be included in the resident's chart, the document was just to be used as a reference. In an interview and record review on 02/29/24 at 01:40 PM, the Chief Clinical Officer provided the surveyors with training records for RN D. The documented presented was blank there were no recorded trainings and the Chief Clinical Officer said the facility had no documented training for RN D. Record review of the facility provided blank Admission Checklist revealed, nursing items to be completed: verify order from MD, verify order from pharmacy, contact pharmacy to confirm orders and delivery time. Record review of the facility policy titled Reconciliation of Medication on Admission revised 07/2017 revealed, General Guidelines. 1-medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route and indication for use for the purpose of preventing unintended changes or omissions at transition points of care. 2- Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during admission/transfer process. Steps in the procedure. 6- if there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: d- contact the resident's primary physician(s) in the community; e- contact the resident's secondary physician(s) in the community; f- contact the community pharmacy used by the resident; g- contact the admitting and/or attending physician. 7- document findings and actions. Documentation. 1- document was actions were taken by the nurse to resolve the discrepancy; 3- if the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, 4- medications are administered in accordance with prescribers orders, including any required timeframe. 5- Medication administration times are determined by resident need and benefit, not staff convenience. Factures that are considered include: a- enhancing optimal therapeutic effect of medication; b- preventing potential medication or food interactions' and honoring resident choices and preferences, consistent with his or her care plan.

Based on interview and record review the facility failed to thoroughly investigate and to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action must be taken for 1 of 5 Residents (CR #1) reviewed for misappropriation of property. - The facility failed to thoroughly investigate allegations of misappropriation and ensure corrective actions were in place to ensure there was no further misappropriation of control substances after LVN A was identified for misappropriating CR #1's Tylenol #3 over a period of 3 months (June through August of 2023). This failures could place residents at risk of misappropriation of residents property Findings included: Record review of CR #1's Face Sheet dated 02/29/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: right dominant side paralysis, muscle weakness, history of falling and unspecified pain. CR #1 discharged from the facility of 08/29/23. Record review of CR#1's Admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, the resident reported occasional pain over the five days received that did not limit his day to day activities and did not make it hard to sleep. Record review of CR #1's undated Care Plan revealed, focus- the resident on pain medication therapy related to pain, 08/15/23: resident prefers to take Norco and not Tylenol #3. Intervention- when the resident requests PRN medication Norco will be administered per MD order and not Tylenol #3. Record review of CR #1's Physician's Order dated 06/11/23 revealed, Tylenol with Codeine #3- 1 tablet every 6 hours as needed for pain scale 4-7. Record review of CR #1's Physician's Progress Note dated 06/14/23 revealed, date of service 06/12/23, I have changed his Tylenol Codeine to Norco 7.5 mg, continue with muscle relaxants and Neurontin [medication for nerve pain] as tolerated. Record review of CR #1's Progress Note dated 06/14/24 signed by RN A revealed, OT reported CR #1 was in a lot of pain and needed something for pain but the resident had been offered pain medications all morning but kept refusing it. CR #1 said he did not want narcotics but accepted Ibuprofen and Bio freeze (a topical used to treat pain). Record review of CR #1's Tylenol #3 Controlled Drug Record started 06/11/23 revealed, LVN A signed out 11 of the 15 doses documented as administered/retrieved. - 06/11/23 at 01:00 PM by LVN C - 06/11/23 at 09:00 PM by RN B - 06/22/23- LVN A documented a pill was documented on the floor of the cart resulting in a total of 27 pills. There was no second nurse signature - 07/02/23- a dose was dispensed, the time of administration was illegible. - 07/02/23 at 12:00 AM a dose was dispensed by LVNA. - 07/06/23 at 01:00 AM a dose was dispensed by LVNA. - 07/15/23 at 09:00 PM a dose was dispensed by LVNA. - 07/24/23 at 06:51 PM a dose was dispensed by RN C. - 07/30/23 at 02:00 AM a dose was dispensed by LVNA. - 07/30/23 at 07:26 PM a dose was dispensed by LVNA. - 08/03/23 at 12:00 AM a dose was dispensed by LVNA. - 08/03/23 at 08:15 AM a dose was dispensed by LVNA. - 08/07/23 at an illegible time a dose was dispensed by LVN A. - 08/13/23 at 08:16 PM a dose was dispensed by LVNA. - 08/13/23 at 06:58 PM a dose was dispensed by LVNA. This dose was documented out of time order. Record review of CR #1's July 2023 MAR revealed, only 2 of the 6 doses signed out by LVN A on CR #1's Control Log for Tylenol #3 were documented. - doses on 07/15/23 at 09:00 PM and 07/30/23 at 07:26 PM were signed on the MAR by LVN A. - 2 doses on 07/02/23, 1 dose on 07/23 at 01:00 AM and 1 dose on 07/30/23 at 02:00 AM that were documented in the control log were not documented in the MAR. Record review of CR #1's August 2023 MAR revealed, 4 of the 5 doses signed out by LVN A on CR #1's Control Log for Tylenol #3 were documented. - 08/03/23 at 12:00 AM a dose was dispensed by LVNA. - 08/07/23 at 08:00 PM a dose was dispensed by LVN A. - 08/12/23 at 08:16 PM a dose was dispensed by LVNA. - 08/13/23 at 06:58 PM a dose was dispensed by LVNA - the dose on 08/03/23 at 08:15 AM dose documented in the control log was not documented in the MAR. Record review of an undated and unsigned interview of CR #1 revealed, CR #1 said he took Norco and he did not take Codeine because when he took it he did not like it and he was concerned it could be addictive. CR #1 stated that when he was admitted to the facility he told the nurse he did not want to take Tylenol #3. Record review of the facility provided undated and unsigned investigation summary revealed: - CR #1 stated he did not like Tylenol #3 and only wanted to take Norco. - Interview with multiple staff revealed, that CR #1 only asked for Norco and interviews were completed on different rotations, and shift. - LVN A said she only gave CR #1 Tylenol #3 at the residents request but documentation showed she also gave the resident Norco on multiple occasions across multiple shift. - Investigation revealed only 2 out of 7 doses signed out by LVN A on the control log were documented in PCC (in July) for Tylenol #3 and 3 out of 8 administrations were documented for LVN's administration of Norco. This is unusual because all other medication is consistently documented in [EMR]. - LVN A was escorted to a third-party vendor to perform a urine drug test which she avoided with the excuse of past trauma. - on 08/13/23 LVN A was witnessed cornering RN C asking her to waste a narcotic but MA A intervened. - CR #1's MD stated that the resident said that Tylenol #3 did not work. There was no documentation of a facility wide audit of control substances, no documentation of interviews with other staff and no documentation of interviews with other residents. In an interview on 02/27/24 at 02:10 PM, DON B said she had been the DON for 1 month but she was previously the ADON under DON A. She said in August of 2023 MA A brought LVN A's suspected diversion to DON A's attention and once notified DON A looked into all control medications administered that day but the investigation was expanded to identify any other potential cases of drug diversion. DON B said she was not currently auditing the facility control logs, or resident MARs for potential diversion but it was her plan to start auditing the facility's controlled substances. In an interview on 02/27/24 at 02:21 PM the Chief Clinical Officer said to her knowledge DON A only performed a cart audit of the facility's controlled substances. She said he did not perform a complete audit of all residents and he did not audit the resident's MARs comparing them to the control log to identify any further diversion or other residents that might have been impacted by LVN A's suspected diversion. The Chief Clinical Officer said to her knowledge there was no evidence of control audits completed by DON A or any other DON but the pharmacist did perform random audits. In an interview on 02/29/24 at 10:45 AM, the Administrator said he was the facility abuse coordinator and he was responsible for investigations into alleged abuse, neglect or misappropriation. When asked who is responsible for ensuring nursing related investigations are thorough and complete he said the DON/or designees was and he was just responsible for pulling that information together. The Administrator said the drug diversion investigation was completed by DON A who he trusted to complete the investigation at the time. He said he did not honestly have any other information regarding the drug diversion case. The Administrator said no evidence of additional interviews or controlled drug audits completed as a result of the alleged drug diversion. He could not say how the facility responded to the identified concerns in the Pharmacist Consultant control log audits that were completed during and after LVN A's tenure at the facility since it was the DON/Designees responsibility. The Administrator could not state if the allegation of drug diversion by LVN A was confirmed even though the police were notified. The Administrator said failure to thoroughly investigate drug diversion cold place residents at risk for misappropriation. In an interview on 02/29/24 at 12:05 PM, DON B said when drug diversion is suspected the DON is expected to start a thorough investigation. The investigation should start off with any residents potentially impacted by the alleged perpetrator and then expand to all controls in the building. She said an audit should be performed inspecting/counting the actual controls and verifying them against the documentation ( control log and the MAR) to identify any discrepancies. DON B said when alerted of any discrepancies during the pharmacist control audit the expectation is that the facility initiate an investigation to identify any issues like inadequate documentation or drug diversion. She said she did not have any evidence DON A followed up on any of the Pharmacist Consultants identified discrepancies, completed a facility wide control audit or a thorough investigation into LVN A's alleged drug diversion. DON B said failure to take action on discrepancies identified in random control drug audits and failure to thoroughly investigate allegations of drug diversion could place residents at risk for further misappropriation and decline in health due to missed pain medications. In an interview on 02/29/24 at 01:20 PM, the Pharmacist Consultant said in his monthly tasks he randomly selected 3 residents to ensure their control count was correct, that there was no evidence of borrowing and to ensure the control log matched the MAR. He said he notifies the facility of any identified discrepancies but is not required to follow up with the facility if action was taken, that it was the facilities responsibility to address his findings. The Pharmacist Consultant said he had not been informed by the facility of a suspicion of drug diversion in August of 2023 and he had not completed any large-scale audits for drug diversion outside of his random audits. In an interview on 02/29/24 at 04:19 PM, MA A said CR #1 was a nice man who did not really want to take pain medications, rarely received them, and felt the Tylenol #3 and Norco were messing him up so he only took them when he needed them. MA A said after reviewing CR #1's Tylenol #3 control log it appeared that majority of the doses administered were by LVN A, the signature on the control log differed from her regular signature and appeared to be a c with a squiggly line almost in an effort to hide her identity. MA A said on an unknown day in August of 2023 he observed LVN A, who worked on the 1st floor, attempted to convince an unknown nurse on the 2nd floor to take Hydrocodone- Acetaminophen (Norco) from one of the second floor residents for administration to a 1st floor resident. He said the nurses in corroboration planned to document the pill retrieved as wasted because it fell on the floor but he interjected and told LVN A that it was against facility rules and it would not be done, so LVN A returned to the 1st floor. MA A said he immediately reported LVN A's attempt to misappropriate a resident's controlled medication to DON A. He said DON A was responsible for the investigation and he did not know any specifics except for the fact that DON A attempted to test LVN A for drugs but it was unsuccessful. MA A said he did not know if the facility audited all controls in the building and he did not see any audits of controls being performed but after the incident the facility held in-services on documentation in the EMR. Record review of LVN A's Disciplinary Record dated 08/21/23 revealed, type of violation- suspicion of drug diversion; date of violation- July & August 2023; time: several. Reason for action- investigation of LVN A's routine administration of scheduled Tylenol #3 revealed she was the only one to administer the medication when CR #1 reported he never received it in the facility. LVN A would not complete a urinalysis and was removed from the schedule. Record review of the facility in-service document completed on 08/24/23 revealed, 3- recognizing signs of drug diversion: multiple narcotic sign outs on the narcotic sheet when the patient is known not to request or take very many narcotics, multiple documentation of narcotic wastage on the narcotic sheet by one nurse. 4- Preventative Measures: conducting regular audits and inspections to identify any discrepancies. Record review of the undated Administrators Job Description revealed, maintains operations by ensuring compliance with all appropriate internal policies and procedure and with external regulatory and accrediting agencies. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, 2- the DON supervises and directs all personnel who administer medications and have related functions. Record review of the facility policy titled Identifying Exploitation, Theft and Misappropriation of Resident Property revised 04/2021 revealed, 4- misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 5- examples of misappropriation of resident property include: f- drug diversion (taking the resident's medication). Record review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 09/2022 revealed, 5- Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews staff members, h. interviews other residents to whom the accused employee provides care or services; i. reviews all events leading up to the alleged incident; and j. documents the investigation completely and thoroughly.

Based on interview and record review the facility failed to ensure the resident was free from misappropriation of property for 4 of 5 residents (Resident #1. CR #1, CR #3 and CR #4) reviewed for misappropriation of property. - The facility failed to ensure that LVN A did not misappropriate CR #1's Tylenol #3 over a 3-month period (June 2023 to August 2023). - The facility failed to have a system in place to identify drug diversion of controlled substances and to take action on the pharmacist consultant's identified discrepancies during random control drug audits for Resident #1, CR #3 and CR #4 even after an alleged case of drug diversion by LVN A over a three-month period. These failure could place residents at risk for misappropriation of medications and uncontrolled pain. Findings included: CR#1 Record review of CR #1's Face Sheet dated 02/29/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: right dominant side paralysis, muscle weakness, history of falling and unspecified pain. CR #1 discharged from the facility of 08/29/23. Record review of CR#1's Admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, the resident reported occasional pain over the five days received that did not limit his day-to-day activities and did not make it hard to sleep. Record review of CR #1's undated Care Plan revealed, focus- the resident on pain medication therapy related to pain, 08/15/23: resident prefers to take Norco and not Tylenol #3. Intervention- when the resident requests PRN medication Norco will be administered per MD order and not Tylenol #3. Record review of CR #1's Physician's Order dated 06/11/23 revealed, Tylenol with Codeine #3- 1 tablet every 6 hours as needed for pain scale 4-7. Record review of CR #1's Physician's Progress Note dated 06/14/23 revealed, date of service 06/12/23, I have changed his Tylenol Codeine to Norco 7.5 mg, continue with muscle relaxants and Neurontin [medication for nerve pain] as tolerated. Record review of CR #1's Progress Note dated 06/14/24 signed by RN A revealed, OT reported CR #1 was in a lot of pain and needed something for pain, but the resident had been offered pain medications all morning but kept refusing it. CR #1 said he did not want narcotics but accepted Ibuprofen and Bio freeze (a topical used to treat pain). Record review of CR #1's Tylenol #3 Controlled Drug Record started 06/11/23 revealed, LVN A signed out 11 of the 15 doses documented as administered/retrieved. - 06/11/23 at 01:00 PM by LVN C - 06/11/23 at 09:00 PM by RN B - 06/22/23- LVN A documented a pill was documented on the floor of the cart resulting in a total of 27 pills. There was no second nurse signature. - 07/02/23- a dose was dispensed; the time of administration was illegible. - 07/02/23 at 12:00 AM a dose was dispensed by LVNA. - 07/06/23 at 01:00 AM a dose was dispensed by LVNA. - 07/15/23 at 09:00 PM a dose was dispensed by LVNA. - 07/24/23 at 06:51 PM a dose was dispensed by RN C. - 07/30/23 at 02:00 AM a dose was dispensed by LVNA. - 07/30/23 at 07:26 PM a dose was dispensed by LVNA. - 08/03/23 at 12:00 AM a dose was dispensed by LVNA. - 08/03/23 at 08:15 AM a dose was dispensed by LVNA. - 08/07/23 at an illegible time a dose was dispensed by LVN A. - 08/13/23 at 08:16 PM a dose was dispensed by LVNA. - 08/13/23 at 06:58 PM a dose was dispensed by LVNA. This dose was documented out of time order. Record review of CR #1's July 2023 MAR revealed, only 2 of the 6 doses signed out by LVN A on CR #1's Control Log for Tylenol #3 were documented. - doses on 07/15/23 at 09:00 PM and 07/30/23 at 07:26 PM were signed on the MAR by LVN A. - 2 doses on 07/02/23, 1 dose on 07/23 at 01:00 AM and 1 dose on 07/30/23 at 02:00 AM were not documented in the MAR. Record review of CR #1's August 2023 MAR revealed, 4 of the 5 doses signed out by LVN A on CR #1's Control Log for Tylenol #3 were documented. - 08/03/23 at 12:00 AM a dose was dispensed by LVNA. - 08/07/23 at 08:00 PM a dose was dispensed by LVN A. - 08/12/23 at 08:16 PM a dose was dispensed by LVNA. - 08/13/23 at 06:58 PM a dose was dispensed by LVNA - the dose on 08/03/23 at 08:15 AM dose documented in the control log was not documented in the MAR. Record review of the facility provided undated and unsigned investigation summary revealed: - CR #1 stated he did not like Tylenol #3 and only wanted to take Norco. - Interview with multiple staff revealed, that CR #1 only asked for Norco and interviews were completed on different rotations and shifts. - LVN A said she only gave CR #1 Tylenol #3 at the residents request but documentation showed she also gave the resident Norco on multiple occasions across multiple shifts. - Investigation revealed only 2 out of 7 doses signed out by LVN A on the control log were documented in [EMR] (in July 2023) for Tylenol #3 and 3 out of 8 administrations were documented for LVN's administration of Norco. This is unusual because all other medication is consistently documented in [EMR]. - LVN A was escorted to a third-party vendor to perform a urine drug test which she avoided with the excuse of past trauma. - on 08/13/23 LVN A was witnessed cornering RN C asking her to waste a narcotic but MA A intervened. - CR #1's MD stated that the resident said that Tylenol #3 did not work. There was no documentation of a facility wide audit of control substances, no documentation of interviews with other staff and no documentation of interviews with other residents. Record review of an undated interview of CR #1 revealed, CR #1 said he took Norco, and he did not take Codeine because when he took it, he did not like it and he was concerned it could be addictive. CR #1 stated that when he was admitted to the facility, he told the nurse he did not want to take Tylenol #3. CR #3 Record review of CR #3's Face Sheet dated 02/29/24 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of: muscle weakness and pain in an unspecified joint. The resident discharged on [DATE]. Record review of CR #3's Admission MDS dated [DATE] revealed, intact cognition indicated by a BIMS score of 15 out of 15, frequent pain that made it hard for him to sleep and limited his day to day activities. Record review of CR #3's undated Care Plan revealed, focus- risk of pain r/t arthritis and abdominal bacterial skin infection; intervention- administer pain medication as ordered. Record review of CR #3's Order Summary Report dated 02/29/24 revealed, Hydrocodone- Acetaminophen 10-325 mg- t tablet every 4 hours as needed for pain ordered on 06/02/23. Record Review of the Control Substance Random Audit dated 06/07/23 signed by the pharmacist consultant revealed, 3 residents were randomly audited and discrepancies of doses initialed on the MAR that are signed out on the count sheet? were observed for CR #3's Norco 10 mg for doses on 06/05/23 and 06/06/23. CR #4 Record review of CR #4's Face Sheet dated 03/20/24 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: muscle wasting, slurred speech, difficulty swallowing, dementia, congestive heart failure, high blood pressure, heartburn, history of falling and hip fracture. Record review of CR #4's Admission MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, receipt of PRN pain medication, with rare pain that had no/rare impact on his ability to sleep and ability to complete therapy activities or day-to-day activities. CR #2 reported his worst pain level over the last 5 days at 06 out of 10. Record review of CR #4's undated Care Plan revealed, focus-acute pain; intervention- administer pain medications as ordered. Record review of CR #4's Physician Order dated 10/27/23 revealed, Hydrocodone-Acetaminophen 5/325 mg (Norco)- give 1 tablet via G-tube every 12 hours as needed for pain 07 out of 10. Record Review of the Control Substance Random Audit dated 11/16/23 signed by the pharmacist consultant revealed, 3 residents were randomly audited and a discrepancy of unclear count sheet documentation and doses initialed on the MAR that are signed out on the count sheet? were observed for CR #4's Norco 5mg for a dose on 11/10/23 and a quantity change without a date or signature on the count sheet that might have indicated an additional administered dose on 11/06/23. Resident #1 Record review of Resident #1's Face Sheet dated 02/29/24 revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: muscle weakness and muscle wasting. There was no documented diagnosis of anxiety. Record review of Resident #1's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, and no use of antianxiety medication documented. Record review of Resident #1's undated Care Plan revealed, no documented focus area addressing anxiety. Record review of Resident #1's Physician's Orders dated 12/03/23 revealed, Alprazolam 0.25 mg- 2 tablets every 12 hours PRN anxiety. Record Review of the Control Substance Random Audit dated 12/08/23 signed by the pharmacist consultant revealed, 3 residents were randomly audited and a discrepancy of doses initialed on the MAR that are signed out on the count sheet? were observed for Resident #1's Xanax 0.25 mg (an antianxiety medication) on 12/03/23. In an interview on 02/27/24 at 02:10 PM, DON B said she had only been the DON for a month but she was previously the ADON under DON A. She said in August of 2023 MA A brought LVN A's suspected diversion to DON A's attention and once notified DON A looked into all control medications administered that day but the investigation was expanded to identify any other potential cases of drug diversion. DON B said she was not currently auditing the facility control logs, or resident MARs for potential diversion but it was her plan to start auditing the facility's controlled substances. In an interview on 02/27/24 at 02:21 PM the Chief Clinical Officer said to her knowledge DON A only performed a cart audit of the facility's controlled substances. She said he did not perform a complete audit of all residents and he did not audit the resident's MARs comparing them to the control log to identify any further diversion or other residents that might have been impacted by LVN A's suspected diversion. The Chief Clinical Officer said to her knowledge there was no evidence of control audits completed by DON A or any other DON but the pharmacist did perform random audits. In an interview on 02/29/24 at 10:45 AM, the Administrator said he was the facility abuse coordinator and he was responsible for investigations into alleged abuse, neglect or misappropriation. When asked who is responsible for ensuring nursing related investigations are thorough and complete he said the DON/or designees was and he was just responsible for pulling that information together. The Administrator said the drug diversion investigation was completed by DON A who he trusted to complete the investigation at the time. He said he did not honestly have any other information regarding the drug diversion case. The Administrator said no evidence of additional interviews or controlled drug audits completed as a result of the alleged drug diversion. He could not say how the facility responded to the identified concerns in the Pharmacist Consultant control log audits that were completed during and after LVN A's tenure at the facility since it was the DON/Designees responsibility. The Administrator could not state if the allegation of drug diversion by LVN A was confirmed even though the police were notified. The Administrator said failure to thoroughly investigate drug diversion cold place residents at risk for misappropriation. In an interview on 02/29/24 at 12:05 PM, DON B said when drug diversion is suspected the DON is expected to start a thorough investigation. The investigation should start off with any residents potentially impacted by the alleged perpetrator and then expand to all controls in the building. She said an audit should be performed inspecting/counting the actual controls and verifying them against the documentation ( control log and the MAR) to identify any discrepancies. DON B said when alerted of any discrepancies during the pharmacist control audit the expectation is that the facility initiate an investigation to identify any issues like inadequate documentation or drug diversion. She said she did not have any evidence DON A followed up on any of the Pharmacist Consultants identified discrepancies, completed a facility wide control audit or a thorough investigation into LVN A's alleged drug diversion. DON B said failure to take action on discrepancies identified in random control drug audits and failure to thoroughly investigate allegations of drug diversion could place residents at risk for further misappropriation and decline in health due to missed pain meds. In an interview of 02/29/24 at 02:05 PM, when asked about what action was taken regarding any discrepancies identified in the Pharmacists Random Control Audit the Administrator said I absolutely read it. He would not provide any information regarding the required action's following the Pharmacists control drug audits. In an interview on 02/29/24 at 01:20 PM, the Pharmacist Consultant said as part of his monthly tasks he randomly selected 3 residents to ensure their control count was correct, that there was no evidence of borrowing and to ensure the control log matched the MAR. He said he notifies the facility of any identified discrepancies but is not required to follow up with the facility if action was taken, that it was the facilities responsibility to address his findings. The Pharmacist Consultant said he had not been informed by the facility of a suspicion of drug diversion in August of 2023 and he had not completed any large-scale audits for drug diversion outside of his random audits. In an interview on 02/29/24 at 04:19 PM, MA A said CR #1 was a nice man who did not really want to take pain medications, rarely received them, and felt the Tylenol #3 and Norco were messing him up so he only took them when he needed them. MA A said after reviewing CR #1's Tylenol #3 control log it appeared that majority of the doses administered were by LVN A, the signature on the control log differed from her regular signature and appeared to be a c with a squiggly line almost in an effort to hide her identity. MA A said on an unknown day in August of 2023 he observed LVN A, who worked on the 1st floor, attempted to convince an unknown nurse on the 2nd floor to take Hydrocodone- Acetaminophen (Norco) from one of the second floor residents for administration to a 1st floor resident. He said the nurses in corroboration planned to document the pill retrieved as wasted because it fell on the floor but he interjected and told LVN A that it was against facility rules and it would not be done, so LVN A returned to the 1st floor. MA A said he immediately reported LVN A's attempt to misappropriate a resident's controlled medication to DON A. He said DON A was responsible for the investigation and he did not know any specifics except for the fact that DON A attempted to test LVN A for drugs but it was unsuccessful. MA A said he did not know if the facility audited all controlled medications in the building and he did not witness any audits of controls being performed but after the incident the facility held in-services on documentation in the EMR. Record review of LVN A's Disciplinary Record dated 08/21/23 revealed, type of violation- suspicion of drug diversion; date of violation- July & August 2023; time: several. Reason for action- investigation of LVN A's routine administration of scheduled Tylenol #3 revealed she was the only one to administer the medication when CR #1 reported he never received it in the facility. LVN A would not complete a urinalysis and was removed from the schedule. Record review of the facility in-service document completed on 08/24/23 revealed . 3- recognizing signs of drug diversion: multiple narcotic sign outs on the narcotic sheet when the patient is known not to request or take very many narcotics, multiple documentation of narcotic wastage on the narcotic sheet by one nurse. 4- Preventative Measures: conducting regular audits and inspections to identify any discrepancies. Record review of the undated Administrators Job Description revealed, maintains operations by ensuring compliance with all appropriate internal policies and procedure and with external regulatory and accrediting agencies. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, 2- the DON supervises and directs all personnel who administer medications and have related functions. Record review of the facility policy titled Identifying Exploitation, Theft and Misappropriation of Resident Property revised 04/2021 revealed, 4- misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 5- examples of misappropriation of resident property include: f- drug diversion (taking the resident's medication). Record review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 09/2022 revealed, 5- Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews staff members, h. interviews other residents to whom the accused employee provides care or services; i. reviews all events leading up to the alleged incident; and j. documents the investigation completely and thoroughly.

Based on observation, interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care and the facility failed to provide care which included but not limited to assessing, evaluating, planning and implementing resident care plans and responded to resident needs for 1 of 5 residents (Residents #2) and 1 of 3 nurses (RN D) reviewed for nurse competency. - The facility failed to ensure RN D was trained to admit residents and reconcile medications, prior to providing nursing services for Resident #2. This failure could place residents at risk of receiving inadequate care and harm. Findings included: Record review of Resident #2's Face Sheet dated 02/29/24 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: Parkinson's Disease, hypertension, restless syndrome, hallucinations and depression. Record review of Resident #2's Entry MDS dated [DATE] revealed, the resident admitted from a short-term general hospital. Record review of Resident #2's undated Care Plan revealed, focus- pain r/t restless leg syndrome and Parkinson's disease; intervention- administer pain meds as ordered. An observation and interview of Resident #2 on 02/27/24 at 12:45 PM revealed, Resident #2 sitting in his wheelchair in his room, in no immediate distress and with no observed tremors. The resident said he was doing well, and he had no issues with his medications or delay in care when he admitted to the facility. Resident #2 said everything is great. Record review of the facility provided Emergency Drug Kit Inventory filled 02/14/24 revealed, the kit contained: - Carbidopa/Levodopa 25-100 mg. Record review of Resident #2's Hospital Discharge Medication List dated 02/25/24 at 12:05 PM revealed: - Horizant 600 mg (medication used for nerve damage)- 1 tablet daily; next dose due at 6 PM. - Carbidopa-Levodopa 25-100 mg (medication used to treat Parkinson's disease)- 4 times daily. - Latanoprost 0.005% eye drops (medication used to treat glaucoma)- 1 drop every evening. - Pramipexole 0.5 mg (medication used to treat the symptoms of Parkinson's disease)- t ab by mouth - Ranolazine 500 mg (medication used to treat chronic chest pain)- 1 tablet 2 times a day - Sucralfate 1g (medication used to treat stomach ulcers)- 1 tablet by mouth four times daily before meals and at bedtime. Record review of Resident #2's Admission Summary dated 02/25/24 at 02:30 PM signed by RN D revealed, history of Parkinson's disease, restless leg syndrome, and neuropathy. Resident #2's speech was minimal due to his progression of Parkinson's but his behavior was pleasant and cooperative. The facility staff and Resident #2's NP were notified of the residents admission. There was no documentation about medication availability, or communication with the pharmacy or resident's MD or NP about medication availability. Record review of Resident #2's Order Summary Report revealed: - Carbidopa-Levodopa Oral Tablet 25-100 MG- Give 1 tablet by mouth four times a day - Horizant Oral Tablet Extended Release 600 MG- (Gabapentin Enacarbil) Give 1 tablet by mouth at bedtime for restless legs - Latanoprost Ophthalmic Solution 0.005 %- (Latanoprost) Instill 1 drop in both eyes at bedtime for Glaucoma. Start date scheduled for 02/26/23. Ranolazine ER Oral Tablet Extended Release 12- Hour 500 MG (Ranolazine) Give 1 tablet by mouth two times a day. - Sucralfate Oral Tablet 1 GM (Sucralfate) Give 1 tablet by mouth four times a day for antacid Give before meals and at bedtime. Record review of Resident #2's February 2024 MAR revealed:, - Horizant 600 mg- 1 tablet by mouth scheduled for 08:00 PM not administered on 02/25/24. - Latanoprost 0.006% eye drops- 1 drop in both eyes; scheduled for 08:00 PM not administered on 02/25/24. - Ranolazine 500 mg ER, scheduled for 08:00 PM not administered on 02/25/24. - Ranolazine 500 mg ER, scheduled for 08:00 PM not administered on 02/26/24 at 08:00 AM. - Carbidopa-Levodopa 25-100 mg- not administered on scheduled doses on 02/25/24 at 08:00 PM and 02/26/25 at 08:00 AM - Sucralfate 1 gm- not administered on 02/25/24 at 08:00 PM, 02/26/24 at 07:00 AM and 02/26/24 at 11:30 AM. Record review of Resident #2's Progress Notes dated 02/27/24 at 12:56 PM revealed, Note: [Family Member] concerned with Carbidopa-Levodopa dosage, stated the dose was cut in half and client's Parkinson's symptoms were worsening. Providers notified and new order started. In an interview on 02/27/24 at 02:10 PM, DON B said she just took over the role a month ago and she was still in the process of reviewing/auditing trainings, in services and processes to ensure the facility was in compliance. In an interview on 02/29/24 at 08:49 AM, DON B said when a resident admits the admitting nurse and the admission nurse work together to receive the patient, check vitals and then enter admitting orders. She said medication orders should be entered and started based on the discharge medication med list and the next due dose. She said admission orders should be entered within an hour of admission and the pharmacy had specific cut off times but there was always the option for stat deliveries. DON B said if a resident arrived around 2:00 PM nurses are expected to retrieve their first doses from the e-kit and if the medication was not available they could follow up with the resident's family to see if they had any available or request a stat order from the pharmacy. DON B said if a nurse identifies a medication as unavailable they are expected to call the pharmacy to coordinate a stat deliver and if the medication was unavailable call the MD to ask for an alternative medication. She said nurses are expected to document the steps they took to resolve the medication discrepancy, who they talked to and the outcome in the resident's chart. DON B said failure to enter medication orders timely, or administer medications immediately upon admission could result in a delay in care, or missed doses that could place a resident at risk of a change of condition. DON B said training on admissions was done during a nurses onboarding. In an interview on 02/29/24 at 10:05 AM, RN D said she was Resident #2's admitting nurse. She said Resident #2's admission was the first one she completed on her own and she stayed over her shift to ensure she completed everything. RN D said Resident #2 admitted over the weekend so the facility admission nurse was unavailable to assist her during the admissions process. RN D said she started in the facility in December of 2023 and she never completed her training on admissions and physician notification in the facility because on her 3rd day of training she was placed on the floor but she had completed admissions at her previous job. She said she just missed that Resident #2 did not have medications available for immediate administration and if since the Resident #2 admitted at 02:30 PM she should have received his medications through a stat delivery or the e-kit and the error was on her. RN D said the time documented on the resident's admission note (02:30 PM) was the time she actually received the patient. RN D said when a resident admits nursing staff are expected to start the medications based on the discharge records and first doses can be retrieved from the facility e-kit but if medications were not in the kit she was expected to call the pharmacy to try and get a stat order, contact the doctor for an alternative if necessary and document any action taken if necessary. She said when she admitted Resident #2 she did not identify any missing doses, did not check the e-kit for any of the resident's first doses, did not contact the pharmacy to receive a stat delivery, did not contact the physician for alternative medications, did not notify the next nurse at change of shift of the unavailable medications, and did not document any medication issues in the resident's chart RN D said failure to administer medication timely on admission could result in adverse reactions, and in Resident #2's case upset stomach from not receiving his sucralfate or worsening of Parkinson's symptoms as a result of missing his Carbidopa-Levodopa. In an interview on 02/29/24 at 10:39 AM, DON B said the facility did not have a specific policy addressing physician notifications and nursing staff were expected to follow the Admission Checklist but it was not expected to be included in the resident's chart, the document was just to be used as a reference. In an interview and record review on 02/29/24 at 01:40 PM, the Chief Clinical Officer provided the surveyors with training records for RN D. The document presented was blank there were no recorded trainings, and the Chief Clinical Officer said the facility had no documented training for RN D. In an interview on 03/20/24 at 04:34 PM, DON B said the DON was responsible for ensuring that training for all nursing staff was completed and failure to complete training could place resident at risk for adverse events, incorrect documentation and incorrect assessments. In an interview on 03/20/24 at 04:34 PM, the Chief Clinical Officer said that prior the surveyors visit the facility did not have a formal auditing process for staff training and it was solely the responsibility of the DON but going forward the DON and HR director would be monitoring each staff member to ensure their training was completed before they hit the nursing floor. Record review of the facility provided blank Admission Checklist revealed, nursing items to be completed: verify order from MD, verify order from pharmacy, contact pharmacy to confirm orders and delivery time. Record review of the facility policy titled Reconciliation of Medication on Admission revised 07/2017 revealed, General Guidelines. 1-medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route and indication for use for the purpose of preventing unintended changes or omissions at transition points of care. 2- Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during admission/transfer process. Steps in the procedure. 6- if there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: d- contact the resident's primary physician(s) in the community; e- contact the resident's secondary physician(s) in the community; f- contact the community pharmacy used by the resident; g- contact the admitting and/or attending physician. 7- document findings and actions. Documentation. 1- document was actions were taken by the nurse to resolve the discrepancy; 3- if the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, 4- medications are administered in accordance with prescribers orders, including any required timeframe. 5- Medication administration times are determined by resident need and benefit, not staff convenience. Factures that are considered include: a- enhancing optimal therapeutic effect of medication; b- preventing potential medication or food interactions' and honoring resident choices and preferences, consistent with his or her care plan.

Based on interview and record review the facility failed to ensure residents were free from accidents for 1 of 12 residents (CR #2) reviewed for accidents hazards. - The facility failed to complete neurological checks per the facility policy when CR #2 had an unwitnessed fall on 11/24/23 after the initial 30 minutes following the fall. - The facility failed to complete neurological checks per the facility policy when CR #2 had an unwitnessed fall on 11/26/23 after the initial assessment until discharge to the hospital after a fall that resulted in head injury with brief loss of consciousness, small intra cranial bleed, hematoma, laceration and hospitalization . These failures could place residents at risk for unidentified changes in condition, decline in health and hospitalization . Findings included: Record review of CR #2's Face Sheet dated 02/29/24 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: hypertension and muscle wasting. The resident was transferred to the hospital on 11/26/23. Record review of CR #2's undated Care Plan revealed, focus- risk for falls r/t muscle wasting, history of falls; intervention- if fall occurs initiate frequent neuro and bleeding evaluation per facility policy. Record review of CR #2's EMR revealed, the MDS was yet to be completed because the resident was a new admission. Record review of CR #2's Clinical Assessments revealed: - CR #2's neuros were only documented twice on 11/24/23, and no neuros were performed on 11/25/23 or 11/26/23. Record review of CR #2's EMR revealed, no additional neurological checks uploaded except for dose found under the clinical assessments. Record review of CR #2's Fall Risk Evaluation dated 11/24/23 at 05:45 PM revealed, CR #2 had a history of falls in the past 3 months. CR #2's predisposing factors for falls included: his gait/balance, use of an assistive device, and medication used. His fall risk score was calculated as 11 indicating a moderate fall risk. Record review of CR #2's Progress Notes dated 11/24/23 at 08:00 PM signed by LVN D revealed CR #2 had an unwitnessed fall in his room. The cause of the fall was not evident, and the resident hit his head, but the fall did not result in an ER visit. CR #2's MD was notified, and no new orders were received. Record review of CR #2's Neurological Checklist dated 11/24/23 at 08:15 PM signed by LVN D revealed, CR #2 was not oriented to time was confused, had normal pupil responses and ROM and a pain score of 06 out of 10. Record review of CR #2's Neurological Checklist dated 11/24/23 at 08:30 PM signed by LVN D revealed, CR #2 was not oriented to time, had normal pupil responses and ROM and a pain score of 04 out of 10. CR #2 had not complaints of any pain, dizziness, nausea or vomiting. Record review of CR #2's Clinical Assessments revealed, no neurological checks documented after 11/24/23 at 08:30 PM. Record review of CR #2's Progress Notes from 11/24/23 to 11/26/23 revealed, no documented interventions between CR #2's falls on 11/24/23 and 11/26/23. Record review of CR #2's Provider Note dated 11/26/23 at 01:40 PM, Per nurse, the patient had fall on 1st day of admit [11/24/23]. The resident was A&O X 3 and able to move all extremities. Record review of CR #2's Progress Notes dated 11/26/23 at 08:00 PM signed by LVN D revealed, CR #2 had an unwitnessed fall in his bathroom., He was found of the floor of the bathroom with blood coming out of his head. Record review of CR #2's Activity Participation Note dated 11/26/23 signed by LVN D revealed: - 08:00 PM CR #2 was found on the floor of the bathroom shower. There was blood all over the bathroom with further investigation there was a laceration approximal 1.5 inches in the back of his head. - 08:15 PM Patient was assisted off floor of the bathroom to his wheelchair for further assessment. Wound was cleaned and measured for size and damage. Neuro checks were performed and vital signs were taken all WNL. - 09:00 PM 911 was called, NP had a message left for her since there was no answer. CR #2's family member was called and informed of the incident and which hospital we were sending the patient. She advised that she would meet him at the ER. Record review of CR #2's Hospital EMS record dated 11/26/23 revealed: the facility called in the incident on 11/26/23 at 08:43 PM, the ambulance was notified, dispatched and enroute at 08:45 PM, the ambulance arrived on the scene at 08:47 PM, arrived at CR #2 at 08:54 PM, departed the facility with CR #2 at 09:00 PM and arrived at the hospital at 09:12 PM. The EMS staff arrived to the facility and found CR #2 sitting in a wheelchair by the nursing station waiting for transport to the hospital and CR #2 said he lost his footing while going to the bathroom and fell to the ground where he struck the back of his head. CR #2 had a 1 inch long laceration to the back of his head and his bleeding was controlled by CR #2 with a towel. Record review of CR #2's E-interact Transfer Form dated 11/26/23 at 09:30 PM by LVN B revealed, CR #2 was transferred to the hospital on 11/26/23 at 09:30 PM. Review of CR #2's Clinical Assessments revealed, no neurological checks documented on 11/26/24. Record review of the facility provided Discharge Summary dated 11/30/23 revealed, CR #2 admitted to the hospital on 11/26/23 and discharged on [DATE] with diagnoses of: head injury with brief loss of consciousness, small intra cranial blead, scalp hematoma and laceration. In an interview on 02/29/24 at 08:49 AM, DON B said when a resident has an unwitnessed fall nursing staff are expected to assess the resident for injuries, changes in ROM and pain from baseline as well as performing neurological checks. She said if the resident suffered from a bleeding head injury the nurse must take measures to stop the bleeding and must likely call 911, send out notifications and then completed the required documentation. DON B said 911 comes promptly but while awaiting transfer to the hospital nursing staff must still provide care to the resident until they are transported out. She said after reviewing CR #2's file they identified that nursing staff failed to complete neuro checks on the resident following the fall on 11/24/23 and 11/26/23. DON B said if neuro checks were performed on CR #2 correctly on 11/24/23 not just the 2 15 minute checks the resident would have still been receiving neurological checks on 11/26/23 when he suffered the second fall. DON B said the purpose of performing neuro checks after unwitnessed falls or head injuries was to identify any potential brain injuries/bleeds and failure to complete neuro checks as ordered could result in a delayed identification of a change in condition that could result in seizures and/or hospitalization . DON B said she did not know what particular corrective action/investigation was completed regarding CR #2's fall because DON A was the DON at the time of the fall. In an interview on 02/29/24 at 12:05 PM, DON B said that following a fall the DON and ADON should be notified and investigation into the fall should start on the next working day. She said the DON was expected to start reviewing that the fall risk management, pain assessments, notifications, skin assessments and neurological checks were either completed or initiated. DON B said the DON must ensure that all documentation was completed with specific details including a change of condition and transfer documentation if necessary. She said following a fall nursing staff are expected to monitor the residents for 72 hours. DON B said failure to report a fall could result in failure to investigate the fall, while failure to assess residents appropriately after a fall could result in an unidentified change of condition, continued delay in treatment and failure to investigate a fall could result in continued falls and change of condition. In an interview on 02/29/24 at 01:19 PM, DON B said the facility did not complete nurse assessments for the fall protocol and it was part of nurse onboarding. A request was made by the surveyor for in-service training records for LVN D addressing the facility's fall protocol but DON B could not provide evidence of LVN D's onboarding or in-service training records on the facility fall protocol prior to exit. In an interview on 03/15/24 at 01:27 PM, LVN D said on 11/24/23 CR #2 apparently slid out of his wheelchair trying to get into the chair. She said the resident was assessed and was found to have no bruising, injuries, skin intact and no evidence of injury. LVN D said the resident was not hurt and did not hit his head per his statement but she initiated neuro checks and notified the MD. She said the MD (not specified) said neuro checks only had to be done every 4 hours since the resident was not injured and was able to verbalize that he did not hit his head. LVN D said after the first fall staff ensured that CR #2's bed was in the lowest position and fall mats were placed by his bed. She said the resident did not like the feeling of the mats on his feet so it kept him from getting out of bed unassisted. LVN D said the facility staff checked on him frequently but she did not document that he was being monitored. She said on 11/26/23 she saw the resident at 07:30 PM sitting in his wheelchair watching television in his room and at approximately 08:00 PM the resident was found on the floor in the bathroom. LVN D said she assessed the resident , started neuro checks at 08:15 PM and the EMS arrived at approximately 08:30 PM. She said once the EMS arrived she handed off the resident and the EMS were on sight for 20-25 minutes prior to leaving for the hospital. LVN D she might have not documented all CR #2's neuro checks but they were done and she was working to improve her documentation. LVN D said she should have done a better job on her documentation. In an interview on 03/15/24 at 04:30 PM, DON B said CR #2 had a BIMS score of 15, was asked not to go to the bathroom on his own but he did it anyway. She said the resident could make his own decisions and both falls occurred in the bathroom when the resident went by himself. DON B said she asked the CNA about the falls but the CNA did not remember because the falls occurred many months ago and the resident was only there for a few days. In an interview on 03/18/24 at 10:30 AM, Family Member #1 said CR #2 was having trouble with his balance which is why he went to the facility for physical therapy. She said when the resident was at the facility, he got up during the night to go to the bathroom and fell so he was hospitalized . Family Member #1 said after the hospitalization the resident was moved to a facility closer to home in which he had an alarm placed on him to notify staff when he tried to get up. She said CR #2 was doing well now and was receiving PT three times a day. In an interview on 03/18/24 at 01:04 PM, DON C said she was the interim DON between DON A and DON B when CR #2 had his fall in 11/2023. She said all new residents received a fall assessment and all new admissions are considered a high fall risk due to the change in environment. DON C said residents who are considered to be at high risk for falls have their call light as well as all necessities placed within reach and nursing staff round on them every 2 hours. She said rounding every 2 hours was a standard protocol upon admission and it did not require an order documented the EMR. DON C said after a resident falls nursing staff are expected to assess the resident for injuries, check vitals, complete a post fall risk evaluation and then notify the family, the resident's physician and nursing administration. She said if the resident's fall was unwitnessed then neuro checks must be performed following the facility protocol at set intervals for 72 hours, these checks should be documented in the EMR or on paper and the information about the fall should be communicated during shift change and entered into the 24 hour report DON C said CR #2 admitted into the facility on Thanksgiving weekend in 2023 and she never saw him or met him. She said the resident had a fall on admission (11/24/23) and 2 days (11/26/23) later but she was not notified of the fall that occurred until 11/26/23 when the resident fell again and was sent out to the hospital. DON C said after CR #2's first fall on 11/24/23 nursing staff placed the resident's bed in a low position and placed fall mats around his bed. She said these interventions were put into place by LVN D but there was no documentation in the resident's record but she received this information from interviews with staff. DON C said placing a resident's bed in low position or the use of fall mats did not require an order so it would not be documented as an order but in a progress note to address interventions in place. She said normally the DON reviews the resident's chart after a fall investigating the fall and initiating any interventions/training but since CR #2 was transferred to the hospital on 11/26/23 she did not investigate his fall on 11/24/23. DON C said there was no other documentation outside of the resident's chart and looking back at the incident she identified discrepancies between the documentation and interviews in LVN D's timeline of the fall on 11/26/23. In an interview on 03/18/24 at 05:39 PM, CNA B said she didn't remember specific details about CR #2's fall. She said on 11/26/23 CR #2 fell and there was blood all over the wall, but she didn't know what assessments were performed on the resident after the fall or what interventions were in place prior. Record review of LVN D's Official Training Transcript dated 02/29/24 revealed, no documented training on falls. The only training on her transcript was Monitoring Changes of Condition completed on 08/24/23. Record review of the facility policy titled Neurological Assessment revised 10/2019 revealed, 1- neurological assessments are indicated: b- following an unwitnessed fall; c- following a fall or other accident/injury involving head trauma. Record review of the facility policy titled Falls-Clinical Protocol revised 03/2018 revealed, Cause Identification- for an individual who has fallen the staff and practitioner will being to try to identify possible causes of the fall within 24 hours. Record review of the facility provided document titled Assessments Protocol for Patient Falls with no revision date revealed, 5- Neuro checks to be completed and charted as follows: every 15 minutes for 4 hours; every 30 minutes for 2 hours; every hour for 6 hours and every shift for 3 days.

Based on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (CR #2) whose records were reviewed for resident identifiable records. - The facility failed to completely and accurately document interventions, assessments and neurological checks performed on CR #2 following falls on 11/24/23 and 11/26/23. This failure could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings included: Record review of CR #2's Face Sheet dated 02/29/24 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: hypertension and muscle wasting. The resident was transferred to the hospital on 11/26/23. Record review of CR #2's undated Care Plan revealed, focus- risk for falls r/t muscle wasting, history of falls; intervention- if fall occurs initiate frequent neuro and bleeding evaluation per facility policy. Record review of CR #2's EMR revealed, the MDS was yet to be completed because the resident was a new admission. Record review of CR #2's Clinical Assessments revealed: - CR #2's neuros were only documented twice on 11/24/23 at 08:15 Pm and 08:30 PM. No neuros were performed on 11/25/23 or 11/26/23. Record review of CR #2's EMR revealed, no additional paper neurological checks uploaded except for dose found under the clinical assessments. Record review of CR #2's Progress Notes dated 11/24/23 at 08:00 PM signed by LVN D revealed, CR #2 had an unwitnessed fall in his room. The cause of the fall was not evident, and the resident hit his head, but the fall did not result in an ER visit. CR #2's MD was notified, and no new orders were received. Record review of CR #2's Neurological Checklist dated 11/24/23 at 08:15 PM signed by LVN D revealed, CR #2 was not oriented to time, was confused, had normal pupil responses and ROM and a pain score of 06 out of 10. Record review of CR #2's Neurological Checklist dated 11/24/23 at 08:30 PM signed by LVN D revealed, CR #2 was not oriented to time, had normal pupil responses and ROM and a pain score of 04 out of 10. CR #2 had not complaints of any pain, dizziness, nausea or vomiting. Record review of CR #2's Clinical Assessments revealed, no neurological checks documented after 11/24/23 at 08:30 PM. Record review of CR #2's Progress Notes from 11/24/23 to 11/26/23 revealed, no documented interventions between CR #2's two falls. Record review of CR #2's Provider Note dated 11/26/23 at 01:40 PM, Per nurse, the patient had fall on 1st day of admit [11/24/23]. The resident was A&O X 3 and able to move all extremities. Record review of CR #2's Progress Notes dated 11/26/23 at 08:00 PM signed by LVN D revealed, CR #2 had an unwitnessed fall in his bathroom., He was found of the floor of the bathroom with blood coming out of his head. Record review of CR #2's Activity Participation Note dated 11/26/23 signed by LVN D revealed: - 08:00 PM CR #2 was found on the floor of the bathroom shower. There was blood all over the bathroom with further investigation there was a laceration approximal 1.5 inches in the back of his head. - 08:15 PM Patient was assisted off floor of the bathroom to his wheelchair for further assessment. Wound was cleaned and measured for size and damage. Neuro checks were performed and vital signs were taken all WNL. - 09:00 PM 911 was called, NP had a message left for her since there was no answer. CR #2's family member was called and informed of the incident and which hospital we were sending the patient. She advised that she would meet him at the ER. Record review of CR #2's Hospital EMS record dated 11/26/23 revealed: the facility called in the incident on 11/26/23 at 08:43 PM, the ambulance was notified, dispatched and enroute at 08:45 PM, the ambulance arrived on the scene at 08:47 PM, arrived at CR #2 at 08:54 PM, departed the facility with CR #2 at 09:00 PM and arrived at the hospital at 09:12 PM. The EMS staff arrived to the facility and found CR #2 sitting in a wheelchair by the nursing station waiting for transport to the hospital and CR #2 said he lost his footing while going to the bathroom and fell to the ground where he struck the back of his head. CR #2 had a 1 inch long laceration to the back of his head and his bleeding was controlled by CR #2 with a towel. In an interview on 02/29/24 at 08:49 AM, DON B said when a resident has an unwitnessed fall nursing staff are expected to assess the resident for injuries, changes in ROM and pain from baseline as well as performing neurological checks and details should be documented in the residents chart completely. She said after reviewing CR #2's file they identified that nursing staff failed to complete neuro checks on the resident following the fall on 11/24/23 and 11/26/23. There was no documentation that neuro checks were performed on CR #2 correctly on 11/24/23 not just the 2 15 minute checks the resident would have still been receiving neurological checks on 11/26/23 when he suffered the second fall. DON B said the purpose of performing neuro checks after unwitnessed falls or head injuries is to identify any potential brain injuries/bleeds. DON B said she did not know what particular corrective interventions was completed regarding CR #2's fall because DON A was the DON at the time of the fall and interventions were not documented in the chart. DON B said failure to document completely and accurately could result in inaccurate records and an inaccurate representation of the patient. In an interview on 03/15/24 at 01:27 PM, LVN D said on 11/24/23 CR #2 apparently slid out of his wheelchair trying to get into the chair. She said the resident was assessed and was found to have no bruising, injuries, skin intact and no evidence of injury. LVN D said the resident was not hurt and did not hit his head per his statement but she initiated neuro checks and notified the MD. She said the MD (not specified) said neuro checks only had to be done every 4 hours since the resident was not injured and was able to verbalize that he did not hit his head. LVN D said after the first fall staff ensured that CR #2's bed was in the lowest position and fall mats were placed by his bed. She said the resident did not like the feeling of the mats on his feet so it kept him from getting out of bed unassisted. LVN D said the facility staff checked on him frequently but she did not document that he was being monitored. She said on 11/26/23 she saw the resident at 07:30 PM sitting in his wheelchair watching television in his room and at approximately 08:00 PM the resident was found on the floor in the bathroom. LVN D said she assessed the resident , started neuro checks at 08:15 PM and the EMS arrived at approximately 08:30 PM. She said once the EMS arrived she handed off the resident and the EMS were on sight for 20-25 minutes prior to leaving for the hospital. LVN D she might have not documented all CR #2's neuro checks but they were done and she was working to improve her documentation. LVN D said she should have done a better job on her documentation. In an interview on 03/18/24 at 01:04 PM, DON C said she was the interim DON between DON A and DON B when CR #2 had his fall in 11/2023. She said all new residents received a fall assessment and all new admissions are considered a high fall risk due to the change in environment. DON C said residents who are considered to be at high risk for falls have their call light as well as all necessities placed within reach and nursing staff round on them every 2 hours. She said rounding every 2 hours was a standard protocol upon admission and it did not require an order documented the EMR. DON C said after a resident falls nursing staff are expected to assess the resident for injuries, check vitals, complete a post fall risk evaluation and then notify the family, the resident's physician and nursing administration. She said if the resident's fall was unwitnessed then neuro checks must be performed following the facility protocol at set intervals for 72 hours, these checks should be documented in the EMR or on paper and the information about the fall should be communicated during shift change and entered into the 24 hour report DON C said CR #2 admitted into the facility on Thanksgiving weekend in 2023 and she never saw him or met him. She said the resident had a fall on admission (11/24/23) and 2 days (11/26/23) later but she was not notified of the fall that occurred until 11/26/23 when the resident fell again and was sent out to the hospital. DON C said after CR #2's first fall on 11/24/23 nursing staff placed the resident's bed in a low position and placed fall mats around his bed. She said these interventions were put into place by LVN D but there was no documentation in the resident's record but she received this information from interviews with staff. DON C said placing a resident's bed in low position or the use of fall mats did not require an order so it would not be documented as an order but in a progress note to address interventions in place. DON C said after the resident transferred to the hospital on 11/26/23 she did not look into the fall from 11/24/23 or investigate it further because the resident was in the hospital. DON C said there was no other documentation outside of the resident's chart and looking back at the incident she identified discrepancies between the documentation and interviews in LVN D's timeline of the fall on 11/26/23. Record review of the facility policy titled Charting and Documentation revised 07/2017 revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. Record review of the facility policy titled Falls-Clinical Protocol revised 03/2018 revealed, Cause Identification- for an individual who has fallen the staff and practitioner will being to try to identify possible causes of the fall within 24 hours. 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness; e. Neurological status; f. Pain; g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred; i. All current medications, especially those associated with dizziness or lethargy; and j. All active diagnoses. 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Record review of the facility provided document titled Assessments Protocol for Patient Falls with no revision date revealed, 5- Neuro checks to be completed and charted as follows: every 15 minutes for 4 hours; every 30 minutes for 2 hours; every hour for 6 hours and every shift for 3 days. Record review of the facility policy titled Neurological Assessment revised 10/2019 revealed, 1- neurological assessments are indicated: b- following an unwitnessed fall; c- following a fall or other accident/injury involving head trauma. Documentation- The following information should be recorded in the resident's medical record: 1- The date and time the procedure was performed; 2- The name and title of the individual(s) who performed the procedure; 3- All assessment data obtained during the procedure; 4- How the resident tolerated the procedure; 5- If the resident refused the procedure, the reason(s) why and the intervention taken; 6- The signature and title of the person recording the data. Record review of the facility policy titled Change in a Resident's Conditions or Status revised 02/2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review the facility failed to immediately inform resident's physician when a resident experienced increased shortness of breath for 1 of 1 resident (CR #1) reviewed for physician notification. LVN A failed to notify MD A in a timely manner on 8/5/23 when CR #1 was having increased shortness of breath. This caused a delay in CR #1 going to the hospital for to respiratory distress. RN A consulted with the NP but not the physician when CR#1 was having a change in condition An Immediate Jeopardy (IJ) situation was identified on 9/15/2023 9:10 am. While the IJ was removed on 09/19/2023 at 1:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for inadequate or delayed treatment and interventions. Findings included: Record review of CR #1's undated face sheet, revealed an [AGE] year-old male admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing problems), acute respiratory failure with hypoxia (not enough oxygen in the body/blood), sepsis (infection involving the whole body), congestive heart failure (heart failure that causes back up of fluid in the lungs and legs) and atrial fibrillation (abnormal heart rhythm). Record review of CR #1's medical record on 8/6/23, revealed an Minimum Data Set ((MDS) an assessment tool) had not been completed yet. Record review of CR #1's baseline care plan, initiated on 7/29/23, revealed the resident was at risk for falls r/t neuropathy (nerve pain), obesity, CKD 3 (kidneys are not working properly), AFIB, hypoxia (not getting enough oxygen), hypotension (low blood pressure), SOB, CHF, depression, HTN (high blood pressure), COPD, sepsis, Anemia (low iron in the blood), joint pain, use of supplemental O2, use of opiate pain medication, use of diuretics (medications that take fluid out of the body), use of antidepressants. Record review of CR #1's medical records revealed previous hospital records from 7/22/23 that indicated he was hospitalized for SOB and CHF. Record review of CR #1's provider notes from 8/4/23 at 2:17pm revealed Per pt, doing ok and some sob still on 4L NC at this time. Appeared comfortable .no edema [swelling] noted in bil. [both sides] Lower ext, no other overnight episode reported evaluated by NP A. Record review of CR #1's medical record on 8/6/23 revealed the following orders from MD A: - Oxygen at 4lpm via NC ordered on 7/28/23. - Albuterol Sulfate HFA Inhalation Aerosol Solution mcg/act, 1 puff inhale PO Q6hr PRN for wheezing, ordered on 7/31/23. - Arformoterol Tartrate Inhalation Nebulization Solution 15 mcg/2ml, 2ml inhale PO via nebulizer QD for COPD, ordered on 7/28/23. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhale PO Q12hr for COPD, ordered on 7/28/23. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhale PO Q4hr PRN for SOB related to COPD, ordered on 8/2/23. Record review of CR #1's medical record revealed a Skilled Nursing Evaluation performed on 8/4/23 by LVN B, that revealed the resident had no difficulty breathing, had clear lungs, had a cough with effective airway and retained secretions, and was on respiratory antibiotics. Record review of CR #1's August 2023 MAR revealed, on 8/4/23 he had clear lung sounds at 9:00am before and after nebulizer treatments, assessed by RN B. He also had clear lung sounds before and after nebulizer treatments at 9:00pm, assessed by RN A. On 8/5/23 at 9:00am CR #1 had wheezy lung sounds before and after nebulizer treatments, assessed by LVN A. Record review of CR #1's August 2023 MAR revealed on 8/5/23 he received the following medications: - Arformoterol Tartrate Inhalation 15mcg/2ml, 2ml inhaled via nebulizer at 9:00am given by LVN A. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhaled at 9:00am given by LVN A. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled at 6:25pm given by RN A. Record review of CR #1's medical record revealed on 8/5/23 Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act, 1 puff Q6hr PRN wheezing, AND Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled Q4hr PRN SOB, were not given by LVN A. Record review of CR #1's medical record revealed a progress note from RN A on 8/5/23 at 6:20pm that stated, Seen patient sitting at bedside having SOB, difficulty speaking, using accessory muscles [muscles other than the diaphragm that indicate labored breathing] and breathing through his mouth, heard crackles, gave PRN Ipratropium-Albuterol inhalation- not working - still having respi distress; checked vital signs BP 128/72 PR 112 Temp 98.2 and O2 sat at 97% with O2 at 4LPM via NC; reported to NP as patient said he was having this the whole day; [NP A] sent message to send patient out to hospital due to worsening respi distress; called 911, informed DON, and family since [family] is in the room. Called [name of the hospital] and gave report. Ambulance came and left with patient at left at 1910 [7:10pm]. Record review of CR #1's medical record revealed an administration note on 8/5/23 at 6:25pm by RN A that stated, she gave Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3ml. She also stated, patient complained of SOB, heard crackles, unable to speak properly, breathing to his mouth [breathing through his mouth], vital signs checked; 128/72; pulse 113; 97% O2 sat via 4LNC. Record review of CR #1's EMS Transport Report from 8/5/23 revealed they arrived at the facility at 6:57pm. According to the report, his primary symptom was respiratory distress. Per the report at 7:01pm, Pt was found to have an increased respiratory effort. Lung sounds were found to be diminished in the lower lobes bilaterally and rhonchi [continuous gurgling/bubbling sounds heard during inhalation and exhalation] in the apexes [very top] bilaterally. At 7:05pm EMS placed a non-rebreather mask on the resident and increased his oxygen to 10LPM and Pt respiratory effort improved once on the non-rebreather mask. According to the EMS narrative report taken by EMS #1 They found the patient sitting upright in his bed with a nebulizer mask on in the process of finishing a treatment. The patient was awake, alert, and appeared to have an increased effort for respirations. The patient's [family] reported she arrived at the facility about 4:00pm today. She stated she found him having difficulty breathing. She stated he could only get one word out at a time. The patient's [family] stated she had to make a scene to have the nursing staff come in to treat him. The [family] stated he was supposed to be getting nebulizer treatments throughout the day and they had not done one until she arrived. She stated he did not appear to be getting any better and the facility staff did not want to call for EMS . In an interview with family at the hospital on 8/6/23 at 3:44pm, she revealed staff were not listening to CR #1's lungs regularly on 8/5/23, to know if he needed his neb treatments. She said that CR #1 had bad COPD and was not getting his PRN neb treatments regularly throughout the day on 8/5/23. She said that CR #1 knew when his COPD was flaring up and when he needed his neb treatments, but staff were not giving them to him, so when she got to the facility on [DATE] at around 4:00pm he was gasping for air, pale, and making guggling sounds. LVN B, a nurse from another hall came in the room to assess him, and the family member asked her to have an MD come assess CR #1 or to send him to the hospital. The family member stated LVN B told them that he did not need to go to the hospital. CR #1 tried to explain how he was feeling and LVN B cut him off and said, Listen to me! The family member said she was very rude, demanding, and did not want to listen to anything they had to say. The family member also said that LVN B told them he was having problems from drinking/eating lying down. The family member said that was ridiculous and they were never sent to the hospital. The family member said finally RN A nurse came and listened to what they were saying and called the MD for an ER transfer order, and they were sent to the hospital. The family member stated RN A was the only one who listened to them. In an interview on 8/6/23 at 4:30pm with the Charge Nurse at the hospital, she said the admitting diagnosis for CR #1 was shortness of breath and he would be there for a few days, getting diuretics (water pills), neb treatments, steroids (helps with inflammation), and antibiotics. In an interview on 8/6/23 at 6:27pm with RN A she said she was the nurse who came on shift at 6pm on 8/5/23. She took report from LVN A and he said that CR #1 had been requesting to go to the hospital all day, so she saw him first at about 6:30pm. She said she took his vital signs, and they were ok, but he appeared to be physically having a hard time breathing. She stated he was using his accessory muscles to breathe, and he looked uncomfortable. She said she gave him some neb treatments, but they did not work, so she called the MD and told her that CR #1 had been breathing like that all day. The MD said to send CR #1 to the hospital. RN A was not sure why LVN A did not send CR #1 to the hospital. She said if the resident/family requests to go to the hospital, they do not tell them no, but staff would perform a nursing assessment first to see what was wrong and if the resident really needed to go to the hospital. She said, then they call the MD with the assessment findings, and it was up to the MD if they wanted to send the resident or not. RN A stated the family had mentioned to her that no one was helping them (CR #1 and family) the whole day until she arrived, and she was the first one to help them. Record review of CR #1's medical record on 8/5/23 revealed no documentation from LVN A that he contacted the MD or the NP. There was no documentation of an assessment of CR #1's lungs, or vitals taken around the time CR #1 complained of increased shortness of breath. In an interview on 8/6/23 at 3:12pm with EMS A he revealed when he arrived in CR #1's room it was evident he was struggling to breathe. He said CR #1 had increased respirations, belly breathing, and could only say a few words at a time without stopping to catch his breath. He stated the family member had told him she got there at about 4:00pm and had to really fight for CR #1 to get neb treatments. CR #1 was on his 2nd neb treatment when EMS arrived. Record review of CR #1's hospital records from 8/6/23, revealed he was diagnosed with respiratory failure, COPD exacerbation, and CHF exacerbation. In an interview on 8/17/23 at 10:23am LVN A stated CR #1 was congested when he assessed his lungs in the morning. He remembered that CNA A came and told him that CR #1 had eaten something, and it went in the wrong tube. He said CR #1 started complaining of increased SOB around 5:00pm and when he assessed his lungs he was still just as congested as he was in the morning, and his vitals were normal. He stated the family wanted him to go to the hospital, so he called the MD. He said the MD called back and said he was not taking care of the resident and for him to call his NP. He said he then called the NP and she said to send the resident to the hospital. LVN A said by the time the NP said to send the resident to the hospital, it was shift change already. He stated CR #1 did not appear to be working harder to breathe and looked the same. He said he did not remember if he gave the resident neb treatments but knew he was already on Levaquin (antibiotic) and had other meds ordered. LVN A also did not remember if he had documented his phone call, assessment, or vitals. He did not know why he did not document them, he said he must have forgotten. In an interview on 8/17/23 at 2:10pm with NP A she stated she was notified about CR #1's condition by the nurse via text at 6:23pm and she replied via text to send him to the hospital at 6:27pm. She said she did not talk to anyone else regarding CR #1 prior to that date/time. A message was left for MD A on 8/17/23 at 11:09am, but he did not call back. In an interview with the DON on 8/17/23 at 3:06pm he revealed it was his expectation of staff to assess the resident, give PRN meds, and reach out to the MD when a resident came to the facility, newly discharged from the hospital with COPD exacerbation, and had shortness of breath. The DON said he assessed the nurses for competency and provided yearly competencies as well as in-services/trainings. He stated that LVN A was PRN, new to the facility, and worked at a couple other places as well. The DON stated that a change in condition would be anything outside of the normal for the resident. He said if the resident had COPD, then it would be anything that was not normal for him, which would include increased shortness of breath. He also stated it was his expectation that if there was a change in condition that a progress note be filled out, an assessment of the resident, vitals, what treatment was given, and when the provider was spoken to and what they said should also be documented. The DON stated he expected the nurses to provide a focused assessment for the particular concern at hand. He said if the resident complained of being SOB, he expected a focused respiratory assessment, to give any medications available for that concern, and then call the MD if the resident did not improve. He stated the same would apply if the resident complained but everything was normal with the resident. The DON stated the nurse should contact the MD immediately if the meds did not help. He also stated the 5:00pm nurse should have evaluated, provided treatment, and called the MD before change of shift, and this incident would not be something to hand off to the next shift. The DON did not think LVN A did what he was supposed to do in the situation and should have called the MD himself instead of passing it off to the next shift. The DON also said LVN A should have documented everything that he did and the assessment and vitals of the resident. Record review of the facility's Policy and Procedure on Acute Condition Changes- Clinical Protocol (Revised March 2018) read in part: .2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs .d. Level of consciousness .g. Onset, duration, severity .3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident .and how to communicate these changes to the Nurse .5. The physician and nursing staff will review the details of any recent hospitalization s and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having addition complications .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician .8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or practitioner) will respond in a timely manner to notification of problems or changes in condition and status .10. The nurse and physician will discuss and evaluate the situation .1. The physician will help identify and authorize appropriate treatments .3. If it is decided .the physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting .1. The staff will monitor and document the resident's progress and responses to treatment . Record review of the facility's Policy and Procedure for Chronic Obstructive Pulmonary Disease (COPD)- Clinical Protocol (Revised November 2018) read in part: .2. In addition, the nurse shall assess and document/report the following: a. Vital signs (including detailed descriptions of respirations) b. Full lung assessment (including sounds of wheezing, sputum production) .d. Pulse oximetry result e. Onset, duration, frequency, severity . 3. The physician and staff will identify individuals with risk factors for developing COPD or for exacerbation of existing COPD .7. The physician will identify individuals with complications of COPD; for example, cor pulmonale [alteration in structure/function of the right ventricle of the heart caused by respiratory system, causing pulmonary hypertension], arrhythmia [irregular heart rhythm] or lethargy [very tired and hard to wake up], or confusion due to hypoxia .3. The physician and staff will identify relevant elements of the care plan; for example, what symptoms to expect (dyspnea, cough, fever, progressive activity intolerance, etc.), how often and what to monitor, when to report findings to the physician .4. Key objectives of COPD management include: a. Minimize disease progression b. Relieve symptoms .e. Prevent and treat exacerbations .11. The physician and staff will identify and manage complications of COPD, such as acute infections, hypoxia .and respiratory failure .12. The staff and physician will identify and treat acute exacerbations of COPD; for example, recognizing and reporting when an individual with COPD has a change in function or activity tolerance, increased dyspnea [trouble breathing], additional sputum production, cough, increasing lethargy or confusion, increased wheezing, increased respiratory or heart rates .1. The staff and physician will monitor the progress of individuals with COPD, including ongoing evaluation and documentation of signs and symptoms and condition changes . Record review of the facility's Policy and Procedure for Change in a Resident's Condition or Status (Revised February 2021) read in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician of physician on call when there has been a(n): .d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly .i. Specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions .3. Prior to notifying the physician or healthcare provider, the nurse will make details observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . On 9/15/2023 9:10 a.m. an Immediate Jeopardy (IJ) was identified. The Administrator was notified and provided the IJ template on 9/15/2023 9:10 a.m.; and a POR was requested at that time. After several revisions, the POR submitted by the Administrator was accepted on 9/19/2023 at 3:30 pm. PLAN OF REMOVAL The DON, ADON in-serviced all licensed staff, via live in-service, on observing for changes of condition on September 15th, continuing through September 18, 2023. The training included when to notify MD of a change of condition. All nurses should inform the MD after the following steps have been taken. 1. A nursing assessment has been completed. 2. PRN medications are administered as ordered. 3. A reassessment is completed and determined that interventions were not effective. 4. Call MD with information obtained and carry out any new orders provided. In the instance a patient or family member was requesting to go to the hospital the following steps should be taken: 1. Reassure patient and family 2. Follow nursing process and complete a nursing assessment 3. Provide PRN medications as ordered 4. Reassess patient and determine if interventions are effective 5. Call MD with information and carry out any new orders provided In the instance when the MD does not answer in a prompt manner, (within 2 calls), the nurse should call the Medical Director for further instructions. If the patient was unstable the nurse should call 911 immediately. This would include abnormal vital signs outside of the patients previously assessed normal, for example a sustained oxygen saturation of 85% or lower with no success increasing after oxygen therapy. On 9/15/2023, a chart audit for recent significant changes of condition was completed by management nurses. All changes were reported to the MD's. Current patients with the above conditions were assessed by licensed nurses. Assessments included blood pressure, pulse, respirations at rest, respirations with activity, temperature, lung sounds and oxygen saturations. In addition, return demonstrations were observed by the assigned nurse managers to ensure competency. There were no incidents when prn respiratory treatments were required, based on nursing assessment. Those assessments were placed in the appropriate medical chart upon completion. All non-PRN licensed nurses were trained by September 19th, 2023. Staff will have had training before their next scheduled shift or will not be allowed to work the floor until said training is completed. MONITORING During IJ implementation dates 9/15/2023-9/19/2023, investigation, interview and monitoring for Notify of Changes, this surveyor observed nursing staff doing their work, interviewed nurses on day and night shift, interviewed other staff members regarding and new and recent trainings by, computer, licensed in person in-service. 12 of 12 nursing staff were able to verbalize and verify new and reinforced training regarding changes of condition, SBAR documentation, Oxygen therapy, respiratory medication, following orders, PRN medications and documentation of refusal of medications. Record review of Training 9/15/2023-9/19/2023 included: call the doctor or the nurse practitioner, and if the doctor or nurse practitioner do not respond timely or appropriately when the patients change of condition is reported- they should report to DON/ADON and the Medical Director if ADON/DON not available. The training consisted of specifically observing acute changes in patients with COPD, respiratory infections and other diseases of the lungs. Patients were assessed with COPD, respiratory infections by licensed nurses. Assessments included blood pressure, pulse, respiration at rest, respiration with activity, temperature, lung sounds and, oxygen saturation. Nurses report in the event family member or resident request to be sent to hospital, they will inquire as to why, perform assessment, SBAR, contact medical doctor or nurse practitioner, explain to the doctor/nurse practitioner what the resident is requesting, the vital signs, signs and symptoms they observed, receive orders, follow orders, in the event no new orders are given, DON will be contacted and medical director may be contacted. Interviews between 9/15/2023-9/19/2023, 12 of 12 Nurses were able to verbalize: signs and symptoms of COPD, signs and symptoms of COPD, ineffective breathing pattern assessment, ineffective breathing pattern interventions, activity intolerance assessment, activity intolerance interventions, deficient knowledge assessment, deficient knowledge interventions, respiratory assessment, oxygen administration, nebulizer therapy, small volume, and proper documentation. Record Reviews between 9/15/2023-9/19/2023, were performed regarding the training and monitoring to be done by management when and found to be compliant with standards of care. Residents were interviewed between 9/15/2023-9/19/2023 and were pleased with the care received by all staff members in the facility and reported they got their medications timely and when they asked for prn medications, the prn medications were given timely. Plan of Removal (POR) on 9/19/2023 at 3:30 pm. The Administrator, DON were informed the Immediate Jeopardy (IJ) was removed on 09/19/2023 at 1:09 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 resident of 1 (CR #1) reviewed for quality of care. The facility failed to adequately assess and provide PRN respiratory treatments to CR #1 on 8/5/23 when he had increased shortness of breath, which led to respiratory distress and hospitalization . CR #1 was admitted to the hospital for shortness of breath. An Immediate Jeopardy (IJ) situation was identified on 9/15/2023 9:10 am. While the IJ was removed on 09/19/2023 at 1:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for worsening shortness of breath and potential respiratory distress. Findings included: Record review of CR #1's undated face sheet, revealed an [AGE] year-old male admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing problems), acute respiratory failure with hypoxia (not enough oxygen in the body/blood), sepsis (infection involving the whole body), congestive heart failure (heart failure that causes back up of fluid in the lungs and legs) and atrial fibrillation (abnormal heart rhythm). Record review of CR #1's medical record on 8/6/23, revealed an MDS had not been completed yet. Record review of CR #1's baseline care plan, initiated on 7/29/23, revealed the resident was at risk for falls r/t neuropathy, obesity, CKD 3, AFIB, hypoxia, hypotension, SOB, CHF, depression, HTN, COPD, sepsis, Anemia, joint pain, use of supplemental O2, use of opiate pain medication, use of diuretics, use of antidepressants. Record review of CR #1's medical records revealed previous hospital records from 7/22/23 that indicated he was hospitalized for SOB and CHF. Record review of CR #1's provider notes from 8/4/23 at 2:17pm revealed Per pt, doing ok and some sob still on 4L NC at this time. Appeared comfortable .no edema [swelling] noted in bil. [both sides] Lower ext, no other overnight episode reported evaluated by NP A. Record review of CR #1's medical record on 8/6/23 revealed the following orders from MD A: - Oxygen at 4lpm via NC ordered on 7/28/23. - Albuterol Sulfate HFA Inhalation Aerosol Solution mcg/act, 1 puff inhale PO Q6hr PRN for wheezing, ordered on 7/31/23. - Arformoterol Tartrate Inhalation Nebulization Solution 15 mcg/2ml, 2ml inhale PO via nebulizer QD for COPD, ordered on 7/28/23. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhale PO Q12hr for COPD, ordered on 7/28/23. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhale PO Q4hr PRN for SOB related to COPD, ordered on 8/2/23. Record review of CR #1's medical record revealed a Skilled Nursing Evaluation performed on 8/4/23 by LVN B, that revealed the resident had no difficulty breathing, had clear lungs, had a cough with effective airway and retained secretions, and was on respiratory antibiotics. Record review of CR #1's August 2023 MAR revealed, on 8/4/23 he had clear lung sounds at 9:00am before and after nebulizer treatments, assessed by RN B. He also had clear lung sounds before and after nebulizer treatments at 9:00pm, assessed by RN A. On 8/5/23 at 9:00am CR #1 had wheezy lung sounds before and after nebulizer treatments, assessed by LVN A. Record review of CR #1's August 2023 MAR revealed on 8/5/23 he received the following medications: - Arformoterol Tartrate Inhalation 15mcg/2ml, 2ml inhaled via nebulizer at 9:00am given by LVN A. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhaled at 9:00am given by LVN A. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled at 6:25pm given by RN A. Record review of CR #1's medical record revealed on 8/5/23 Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act, 1 puff Q6hr PRN wheezing, AND Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled Q4hr PRN SOB, were not given by LVN A. Record review of CR #1's medical record revealed a progress note from RN A on 8/5/23 at 6:20pm that stated, Seen patient sitting at bedside having SOB, difficulty speaking, using accessory muscles [using muscles other than diaphragm which indicates labored breathing] and breathing through his mouth, heard crackles, gave PRN Ipratropium-Albuterol inhalation- not working - still having respi distress; checked vital signs BP 128/72 PR 112 Temp 98.2 [F] and O2 sat at 97% with O2 at 4LPM via NC; reported to NP as patient said he was having this the whole day; [NP A] sent message to send patient out to hospital due to worsening respi distress; called 911, informed DON, and family since [family] is in the room. Called [name of the hospital] and gave report. Ambulance came and left with patient at left at 1910. [7:10pm] Record review of CR #1's medical record revealed an administration note on 8/5/23 at 6:25pm by RN A that stated, she gave Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3ml. She also stated, patient complained of SOB, heard crackles, unable to speak properly, breathing to his mouth [breathing through his mouth], vital signs checked; 128/72; pulse 113; respirations 16, 97% O2 sat via 4LNC. Record review of CR #1's EMS Transport Report from 8/5/23 revealed they arrived at the facility at 6:57pm. According to the report, his primary symptom was respiratory distress. Per the report at 7:01pm, Pt was found to have an increased respiratory effort. Lung sounds were found to be diminished in the lower lobes bilaterally and rhonchi rhonchi [continuous gurgling/bubbling sounds heard during inhalation and exhalation] in the apexes [very top] bilaterally. At 7:02pm CR #1's vitals were blood pressure: 124/78, heart rate: 107, respirations: 28, and oxygen saturation 93%. At 7:05pm EMS placed a non-rebreather mask on the resident and increased his oxygen to 10LPM and Pt respiratory effort improved once on the non-rebreather mask. According to the EMS narrative report taken by EMS #1 They found the patient sitting upright in his bed with a nebulizer mask on in the process of finishing a treatment. The patient was awake, alert, and appeared to have an increased effort for respirations. The patient's [family] reported she arrived to the facility about 4:00pm today. She stated she found him having difficulty breathing. She stated he could only get one word out at a time. The patient's [family] stated she had to make a scene to have the nursing staff come in to treat him. The [family] stated he was supposed to be getting nebulizer treatments throughout the day and they had not done one until she arrived. She stated he did not appear to be getting any better and the facility staff did not want to call for EMS . In an interview with family at the hospital on 8/6/23 at 3:44pm, she revealed staff were not listening to CR #1's lungs regularly on 8/5/23 to know if he needed his neb treatments. She said that CR #1 had bad COPD and was not getting his PRN neb treatments regularly throughout the day on 8/5/23. She said that CR #1 knew when his COPD was flaring up and when he needed his neb treatments, but staff were not giving them to him, so when she got to the facility on [DATE] at around 4:00pm he was gasping for air, pale, and making guggling sounds. LVN B, a nurse from another hall came in the room to assess him, and the family member asked her to have an MD come assess CR #1 or to send him to the hospital. The family member stated LVN B told them that he did not need to go to the hospital. CR #1 tried to explain how he was feeling and LVN B cut him off and said, Listen to me! The family member said she was very rude, demanding, and did not want to listen to anything they had to say. The family member also said that LVN B told them he was having problems from drinking/eating lying down. The family member said that was ridiculous and they were never sent to the hospital. The family member said finally a RN A came and listened to what they were saying and called the MD for an ER transfer order, and they were sent to the hospital. The family member stated RN A was the only one who listened to them. In an interview with CR #1 on 8/6/23 at 3:44pm, he confirmed that he had increased shortness of breath on 8/5/23 and was telling the staff there was something wrong with him and he wanted to be sent to the hospital, but they were not listening to him. In an interview on 8/6/23 at 4:30pm with the Charge Nurse at the hospital, she said the admitting diagnosis for CR #1 was shortness of breath and he would be there for a few days getting diuretics (water pills), steroids (helps with inflammation), antibiotics, and neb treatments. In an interview on 8/6/23 at 6:27pm with RN A she said she was the nurse who came on shift at 6pm on 8/5/23. She took report from LVN A and he said that CR #1 had been requesting to go to the hospital all day, so she saw him first at about 6:30pm. She said she took his vital signs, and they were ok, but he appeared to be physically having a hard time breathing. She stated he was using his accessory muscles to breathe, and he looked uncomfortable. She said she gave him some neb treatments, but they did not work, so she called the MD and told her that CR #1 had been breathing like that all day. The MD said to send CR #1 to the hospital. RN A was not sure why LVN A did not send CR #1 to the hospital. She said if the resident/family requests to go to the hospital, they do not tell them no, but staff would perform a nursing assessment first to see what was wrong and if the resident really needed to go to the hospital. She said, then they called the MD with the assessment findings, and it was up to the MD if they wanted to send the resident or not. RN A stated the family had mentioned to her that no one was helping them (CR #1 and the family) the whole day until she arrived, and she was the first one to help them. Record review of CR #1's medical record on 8/5/23 revealed no documentation from LVN A that he contacted the MD or the NP. There was no documentation of an assessment of CR #1's lungs, or vitals taken around the time CR #1 complained of increased shortness of breath. In an interview on 8/6/23 at 3:12pm with EMS A he revealed when he arrived in CR #1's room it was evident he was struggling to breathe. He said CR #1 had increased respirations, belly breathing, and could only say a few words at a time without stopping to catch his breath. He stated the family member had told him she got there at about 4:00pm and had to really fight for CR #1 to get neb treatments. CR #1 was on his 2nd neb treatment when EMS arrived. Record review of CR #1's hospital records from 8/6/23, revealed he was diagnosed with respiratory failure, COPD exacerbation, and CHF exacerbation. In an interview with LVN B on 8/8/23 at 12:12pm, she said she was not CR #1's nurse on 8/5/23 but went and assessed him to help out. She said the family and the resident were concerned about his breathing and wanted him to go to the hospital. LVN B informed the family/resident that she would need to call the MD first to get an order and it ay take a while because it was the weekend. She did see that he was using accessory muscles while breathing, but said he always did. LVN B did not think CR #1 was in respiratory distress. In an interview on 8/17/23 at 10:23am LVN A stated CR #1 was congested when he assessed his lungs in the morning. He remembered that CNA A came and told him that CR #1 had eaten something, and it went in the wrong tube. He said CR #1 started complaining of increased SOB around 5:00pm and when he assessed his lungs he was still just as congested as he was in the morning, and his vitals were normal. LVN A stated he did not feel CR #1 had a change in condition because his lungs sounded the same as they had in the morning and his vitals were stable. He did not feel the resident was serious enough to call 911, so he called the MD instead. He stated the family wanted him to go to the hospital, so he called the MD. He stated the protocol was the nurse assessed the resident and then called the MD with the assessment findings and it was up to the MD to decide if they wanted to send the resident to the hospital or not. He said the MD called back and said he was not taking care of the resident and for him to call his NP. He said he then called the NP and she said to send the resident to the hospital. LVN A said by the time the NP said to send the resident to the hospital, it was shift change already. He stated CR #1 did not appear to be working harder to breathe and looked the same. He said he did not remember if he gave the resident neb treatments but knew he was already on Levaquin (antibiotic) and had other meds ordered. LVN A also did not remember if he had documented his phone call, assessment, or vitals. He did not know why he did not document them, he said he must have forgotten. In an interview on 8/17/23 at 2:10pm with NP A she stated she was notified about CR #1's condition by the nurse via text at 6:23pm and she replied via text to send him to the hospital at 6:27pm. She said she did not talk to anyone else regarding CR #1 prior to that date/time. A message was left for MD A on 8/17/23 at 11:09am, but he did not call back. In an interview with the DON on 8/17/23 at 3:06pm he revealed it was his expectation of staff to assess the resident, give PRN meds, and reach out to the MD when a resident came to the facility, newly discharged from the hospital with COPD exacerbation, and had shortness of breath. The DON said he assessed the nurses for competency and provided yearly competencies as well as in-services/trainings. He stated that LVN A was PRN, new to the facility, and worked at a couple other places as well. The DON stated that a change in condition would be anything outside of the normal for the resident. He said if the resident had COPD, then it would be anything that was not normal for him, which would include increased shortness of breath. He also stated it was his expectation that if there was a change in condition that a progress note be filled out, an assessment of the resident, vitals, what treatment was given, and when the provider was spoken to and what they said should also be documented. The DON stated he expected the nurses to provide a focused assessment for the particular concern at hand. He said if the resident complained of being SOB, he expected a focused respiratory assessment, to give any medications available for that concern, and then call the MD if the resident did not improve. He stated the same would apply if the resident complained but everything was normal with the resident. The DON stated the nurse should contact the MD immediately if the meds did not help. He also stated the 5:00pm nurse should have evaluated, provided treatment, and called the MD before change of shift, and this incident would not be something to hand off to the next shift. The DON did not think LVN A did what he was supposed to do in the situation and should have called the MD himself instead of passing it off to the next shift. The DON also said LVN A should have documented everything that he did and the assessment and vitals of the resident. Record review of the facility's Policy and Procedure for Chronic Obstructive Pulmonary Disease (COPD)- Clinical Protocol (Revised November 2018) read in part: .2. In addition, the nurse shall assess and document/report the following: a. Vital signs (including detailed descriptions of respirations) b. Full lung assessment (including sounds of wheezing, sputum production) .d. Pulse oximetry result e. Onset, duration, frequency, severity . 3. The physician and staff will identify individuals with risk factors for developing COPD or for exacerbation of existing COPD .7. The physician will identify individuals with complications of COPD; for example, cor pulmonale, arrhythmia or lethargy, or confusion due to hypoxia .3. The physician and staff will identify relevant elements of the care plan; for example, what symptoms to expect (dyspnea, cough, fever, progressive activity intolerance, etc.), how often and what to monitor, when to report findings to the physician .4. Key objectives of COPD management include: a. Minimize disease progression b. Relieve symptoms .e. Prevent and treat exacerbations .11. The physician and staff will identify and manage complications of COPD, such as acute infections, hypoxia .and respiratory failure .12. The staff and physician will identify and treat acute exacerbations of COPD; for example, recognizing and reporting when an individual with COPD has a change in function or activity tolerance, increased dyspnea, additional sputum production, cough, increasing lethargy or confusion, increased wheezing, increased respiratory or heart rates .1. The staff and physician will monitor the progress of individuals with COPD, including ongoing evaluation and documentation of signs and symptoms and condition changes . Record review of the facility's Policy and Procedure for Administering Medications Through a Small Volume (Handheld) Nebulizer (Revised October 2016) read in part: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .2, If the resident suffers from Chronic Obstructive Pulmonary Disease (COPD), refer to the Chronic Obstructive Pulmonary Disease (COPD), Clinical Protocol in addition to this procedure .5. Position the resident in semi-fowler's position. 6. Obtain baseline pulse, respiratory rate, and lung sounds .9. Dispense medication into nebulizer cup .13. Turn on the nebulizer and check the outflow port for visible mist. 14. Ask the resident to hold the mouthpiece gently between his/her lips (or apply face mask). 15. Encourage the resident to take a deep breath, pause briefly and then exhale normally. 16. Encourage the resident to repeat the above breathing pattern until the medication is completely nebulized, or until the designated time of treatment has been reached. 17. Remain with the resident for the treatment. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment .21. Tap the nebulizer cup occasionally to ensure release of droplets from the sides of the cup. 22. Encourage the resident to cough and expectorate as needed. 23. Administer therapy until medication is gone .26. Obtain post-treatment pulse, respiratory rate and lung sounds .The following information should be recorded in the resident's medical record. 1. The name, title and initials of the person administering the treatment. 2. The date, time and length of treatment .3. The type and amount of medication administered .4. The type and source of gas. 5. Pulse, respiratory rate and lung sounds before and after the treatment. 6. Pulse during treatment. 7. Amount and characteristics of sputum production. 8. The resident's tolerance of the treatment. 9. Any adverse effects of the medication and/or treatment and physician notification . On 9/15/2023 9:10 a.m. an Immediate Jeopardy (IJ) was identified. The Administrator was notified and provided the IJ template on 9/15/2023 9:10 a.m.; and a POR was requested at that time. After several revisions, the POR submitted by the Administrator was accepted on 9/19/2023 at 3:30 pm. PLAN OF REMOVAL The DON, ADON in-serviced all licensed staff, via live in-service, on observing for changes of condition on September 15th, continuing through September 18, 2023. The training included when to notify MD of a change of condition. All nurses should inform the MD after the following steps have been taken. 1. A nursing assessment has been completed. 2. PRN medications are administered as ordered. 3. A reassessment is completed and determined that interventions were not effective. 4. Call MD with information obtained and carry out any new orders provided. In the instance a patient or family member was requesting to go to the hospital the following steps should be taken: 1. Reassure patient and family 2. Follow nursing process and complete a nursing assessment 3. Provide PRN medications as ordered 4. Reassess patient and determine if interventions are effective 5. Call MD with information and carry out any new orders provided In the instance when the MD does not answer in a prompt manner, (within 2 calls), the nurse should call the Medical Director for further instructions. If the patient was unstable the nurse should call 911 immediately. This would include abnormal vital signs outside of the patients previously assessed normal, for example a sustained oxygen saturation of 85% or lower with no success increasing after oxygen therapy. On 9/15/2023, a chart audit for recent significant changes of condition was completed by management nurses. All changes were reported to the MD's. Current patients with the above conditions were assessed by licensed nurses. Assessments included blood pressure, pulse, respirations at rest, respirations with activity, temperature, lung sounds and oxygen saturations. In addition, return demonstrations were observed by the assigned nurse managers to ensure competency. There were no incidents when prn respiratory treatments were required, based on nursing assessment. Those assessments were placed in the appropriate medical chart upon completion. All non-PRN licensed nurses were trained by September 19th, 2023. Staff will have had training before their next scheduled shift or will not be allowed to work the floor until said training is completed. MONITORING During IJ implementation dates 9/15/2023-9/19/2023, investigation, interview and monitoring for Notify of Changes, this surveyor observed nursing staff doing their work, interviewed nurses on day and night shift, interviewed other staff members regarding and new and recent trainings by, computer, licensed in person in-service. 12 of 12 nursing staff were able to verbalize and verify new and reinforced training regarding changes of condition, SBAR documentation, Oxygen therapy, respiratory medication, following orders, PRN medications and documentation of refusal of medications. Record review of Training between 9/15/2023-9/19/2023 included: call the doctor or the nurse practitioner, and if the doctor or nurse practitioner do not respond timely or appropriately when the patients change of condition is reported- they should report to DON/ADON and the Medical Director if ADON/DON not available. The training consisted of specifically observing acute changes in patients with COPD, respiratory infections and other diseases of the lungs. Patients were assessed with COPD, respiratory infections by licensed nurses. Assessments included blood pressure, pulse, respiration at rest, respiration with activity, temperature, lung sounds and, oxygen saturation. Nurses report in the event family member or resident request to be sent to hospital, they will inquire as to why, perform assessment, SBAR, contact medical doctor or nurse practitioner, explain to the doctor/nurse practitioner what the resident is requesting, the vital signs, signs and symptoms they observed, receive orders, follow orders, in the event no new orders are given, DON will be contacted and medical director may be contacted. Interviews between 9/15/2023-9/19/2023, 12 of 12 Nurses were able to verbalize: signs and symptoms of COPD, signs and symptoms of COPD, ineffective breathing pattern assessment, ineffective breathing pattern interventions, activity intolerance assessment, activity intolerance interventions, deficient knowledge assessment, deficient knowledge interventions, respiratory assessment, oxygen administration, nebulizer therapy, small volume, and proper documentation. Record Reviews between 9/15/2023-9/19/2023, were performed regarding the training and monitoring to be done by management when and found to be compliant with standards of care. Residents were interviewed between 9/15/2023-9/19/2023 and were pleased with the care received by all staff members in the facility and reported they got their medications timely and when they asked for prn medications, the prn medications were given timely. Plan of Removal (POR) on 9/19/2023 at 3:30 pm. The Administrator, DON were informed the Immediate Jeopardy (IJ) was removed on 09/19/2023 at 1:09 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 nurse (LVN A) reviewed for nursing services. LVN A failed to have required documentation of competencies on change of condition. An Immediate Jeopardy (IJ) situation was identified on 9/15/2023 9:10 am. While the IJ was removed on 09/19/2023 at 1:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for inadequate or delayed treatment and interventions. Findings included: Record review of CR #1's undated face sheet, revealed an [AGE] year-old male admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing problems), acute respiratory failure with hypoxia (not enough oxygen in the body/blood), sepsis (infection involving the whole body), congestive heart failure (heart failure that causes back up of fluid in the lungs and legs) and atrial fibrillation (abnormal heart rhythm). Record review of CR #1's medical record on 8/6/23, revealed an MDS had not been completed yet. Record review of CR #1's baseline care plan, initiated on 7/29/23, revealed the resident was at risk for falls r/t neuropathy (nerve pain), obesity, CKD 3 (kidneys are not working properly), AFIB, hypoxia (not getting enough oxygen), hypotension (low blood pressure), SOB, CHF, depression, HTN (high blood pressure), COPD, sepsis, Anemia (low iron in the blood), joint pain, use of supplemental O2, use of opiate pain medication, use of diuretics (medications that take fluid out of the body), use of antidepressants. Record review of CR #1's medical records revealed previous hospital records from 7/22/23 that indicated he was hospitalized for SOB and CHF. Record review of CR #1's provider notes from 8/4/23 at 2:17pm revealed Per pt, doing ok and some sob still on 4L NC at this time. Appeared comfortable .no edema [swelling] noted in bil. [both sides] Lower ext, no other overnight episode reported evaluated by NP A. Record review of CR #1's medical record on 8/6/23 revealed the following orders from MD A: - Oxygen at 4lpm via NC ordered on 7/28/23. - Albuterol Sulfate HFA Inhalation Aerosol Solution mcg/act, 1 puff inhale PO Q6hr PRN for wheezing, ordered on 7/31/23. - Arformoterol Tartrate Inhalation Nebulization Solution 15 mcg/2ml, 2ml inhale PO via nebulizer QD for COPD, ordered on 7/28/23. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhale PO Q12hr for COPD, ordered on 7/28/23. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhale PO Q4hr PRN for SOB related to COPD, ordered on 8/2/23. Record review of CR #1's medical record revealed a Skilled Nursing Evaluation performed on 8/4/23 by LVN B, that revealed the resident had no difficulty breathing, had clear lungs, had a cough with effective airway and retained secretions, and was on respiratory antibiotics. Record review of CR #1's August 2023 MAR revealed, on 8/4/23 he had clear lung sounds at 9:00am before and after nebulizer treatments, assessed by RN B. He also had clear lung sounds before and after nebulizer treatments at 9:00pm, assessed by RN A. On 8/5/23 at 9:00am CR #1 had wheezy lung sounds before and after nebulizer treatments, assessed by LVN A. Record review of CR #1's August 2023 MAR revealed on 8/5/23 he received the following medications: - Arformoterol Tartrate Inhalation 15mcg/2ml, 2ml inhaled via nebulizer at 9:00am given by LVN A. - Budesonide Inhalation Suspension 0.5mg/2ml, 2ml inhaled at 9:00am given by LVN A. - Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled at 6:25pm given by RN A. Record review of CR #1's medical record revealed on 8/5/23 Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act, 1 puff Q6hr PRN wheezing, AND Ipratropium-Albuterol Inhalation Solution 0.5-2.5mg/3ml, 1 vial inhaled Q4hr PRN SOB, were not given by LVN A. Record review of CR #1's medical record revealed a progress note from RN A on 8/5/23 at 6:20pm that stated, Seen patient sitting at bedside having SOB, difficulty speaking, using accessory muscles [muscles other than the diaphragm that indicate labored breathing] and breathing through his mouth, heard crackles, gave PRN Ipratropium-Albuterol inhalation- not working - still having respi distress; checked vital signs BP 128/72 PR 112 Temp 98.2 and O2 sat at 97% with O2 at 4LPM via NC; reported to NP as patient said he was having this the whole day; [NP A] sent message to send patient out to hospital due to worsening respi distress; called 911, informed DON, and family since [family] is in the room. Called [name of the hospital] and gave report. Ambulance came and left with patient at left at 1910 [7:10pm]. Record review of CR #1's medical record revealed an administration note on 8/5/23 at 6:25pm by RN A that stated, she gave Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3ml. She also stated, patient complained of SOB, heard crackles, unable to speak properly, breathing to his mouth [breathing through his mouth], vital signs checked; 128/72; pulse 113; 97% O2 sat via 4LNC. Record review of CR #1's EMS Transport Report from 8/5/23 revealed they arrived at the facility at 6:57pm. According to the report, his primary symptom was respiratory distress. Per the report at 7:01pm, Pt was found to have an increased respiratory effort. Lung sounds were found to be diminished in the lower lobes bilaterally and rhonchi [continuous gurgling/bubbling sounds heard during inhalation and exhalation] in the apexes [very top] bilaterally. At 7:05pm EMS placed a non-rebreather mask on the resident and increased his oxygen to 10LPM and Pt respiratory effort improved once on the non-rebreather mask. According to the EMS narrative report taken by EMS #1 They found the patient sitting upright in his bed with a nebulizer mask on in the process of finishing a treatment. The patient was awake, alert, and appeared to have an increased effort for respirations. The patient's [family] reported she arrived to the facility about 4:00pm today. She stated she found him having difficulty breathing. She stated he could only get one word out at a time. The patient's [family] stated she had to make a scene to have the nursing staff come in to treat him. The [family] stated he was supposed to be getting nebulizer treatments throughout the day and they had not done one until she arrived. She stated he did not appear to be getting any better and the facility staff did not want to call for EMS . In an interview with family at the hospital on 8/6/23 at 3:44pm, she revealed staff were not listening to CR #1's lungs regularly on 8/5/23, to know if he needed his neb treatments. She said that CR #1 had bad COPD and was not getting his PRN neb treatments regularly throughout the day on 8/5/23. She said that CR #1 knew when his COPD was flaring up and when he needed his neb treatments, but staff were not giving them to him, so when she got to the facility on [DATE] at around 4:00pm he was gasping for air, pale, and making guggling sounds. LVN B, a nurse from another hall came in the room to assess him, and the family member asked her to have an MD come assess CR #1 or to send him to the hospital. The family member stated LVN B told them that he did not need to go to the hospital. CR #1 tried to explain how he was feeling and LVN B cut him off and said, Listen to me! The family member said she was very rude, demanding, and did not want to listen to anything they had to say. The family member also said that LVN B told them he was having problems from drinking/eating lying down. The family member said that was ridiculous and they were never sent to the hospital. The family member said finally RN A nurse came and listened to what they were saying and called the MD for an ER transfer order, and they were sent to the hospital. The family member stated RN A was the only one who listened to them. In an interview on 8/6/23 at 4:30pm with the Charge Nurse at the hospital, she said the admitting diagnosis for CR #1 was shortness of breath and he would be there for a few days, getting diuretics (water pills), neb treatments, steroids (helps with inflammation), and antibiotics. In an interview on 8/6/23 at 6:27pm with RN A she said she was the nurse who came on shift at 6pm on 8/5/23. She took report from LVN A and he said that CR #1 had been requesting to go to the hospital all day, so she saw him first at about 6:30pm. She said she took his vital signs, and they were ok, but he appeared to be physically having a hard time breathing. She stated he was using his accessory muscles to breathe, and he looked uncomfortable. She said she gave him some neb treatments, but they did not work, so she called the MD and told her that CR #1 had been breathing like that all day. The MD said to send CR #1 to the hospital. RN A was not sure why LVN A did not send CR #1 to the hospital. She said if the resident/family requests to go to the hospital, they do not tell them no, but staff would perform a nursing assessment first to see what was wrong and if the resident really needed to go to the hospital. She said, then they call the MD with the assessment findings, and it was up to the MD if they wanted to send the resident or not. RN A stated the family had mentioned to her that no one was helping them (CR #1 and family) the whole day until she arrived, and she was the first one to help them. Record review of CR #1's medical record on 8/5/23 revealed no documentation from LVN A that he contacted the MD or the NP. There was no documentation of an assessment of CR #1's lungs, or vitals taken around the time CR #1 complained of increased shortness of breath. In an interview on 8/6/23 at 3:12pm with EMS A he revealed when he arrived in CR #1's room it was evident he was struggling to breathe. He said CR #1 had increased respirations, belly breathing, and could only say a few words at a time without stopping to catch his breath. He stated the family member had told him she got there at about 4:00pm and had to really fight for CR #1 to get neb treatments. CR #1 was on his 2nd neb treatment when EMS arrived. In an interview on 8/17/23 at 10:23am LVN A stated CR #1 was congested when he assessed his lungs in the morning. He remembered that CNA A came and told him that CR #1 had eaten something, and it went in the wrong tube. He said CR #1 started complaining of increased SOB around 5:00pm and when he assessed his lungs he was still just as congested as he was in the morning, and his vitals were normal. He stated the family wanted him to go to the hospital, so he called the MD. He said the MD called back and said he was not taking care of the resident and for him to call his NP. He said he then called the NP and she said to send the resident to the hospital. LVN A said by the time the NP said to send the resident to the hospital, it was shift change already. He stated CR #1 did not appear to be working harder to breathe and looked the same. He said he did not remember if he gave the resident neb treatments but knew he was already on Levaquin (antibiotic) and had other meds ordered. LVN A also did not remember if he had documented his phone call, assessment, or vitals. He did not know why he did not document them, he said he must have forgotten. According to LVN A, he considered a change in condition was worsening vital signs, worsening condition from baseline, change in mental status, or unresponsiveness. In an interview on 8/17/23 at 2:10pm with NP A she stated she was notified about CR #1's condition by the nurse via text at 6:23pm and she replied via text to send him to the hospital at 6:27pm. She said she did not talk to anyone else regarding CR #1 prior to that date/time. A message was left for MD A on 8/17/23 at 11:09am, but he did not call back. In an interview with the DON on 8/17/23 at 3:06pm he revealed it was his expectation of staff to assess the resident, give PRN meds, and reach out to the MD when a resident came to the facility, newly discharged from the hospital with COPD exacerbation, and had shortness of breath.The DON said he oversaw the staff's trainings/competencies and assessed the nurses for competency. He said he provided yearly competencies as well as in-services/trainings, and the staff complete online trainings continuously. He stated that LVN A was PRN, new to the facility, and worked at a couple other places as well. The DON stated that a change in condition would be anything outside of the normal for the resident. He said if the resident had COPD, then it would be anything that was not normal for him, which would include increased shortness of breath. He also stated it was his expectation that if there was a change in condition that a progress note be filled out, an assessment of the resident, vitals, what treatment was given, and when the provider was spoken to and what they said should also be documented. The DON stated he expected the nurses to provide a focused assessment for the particular concern at hand. He said if the resident complained of being SOB, he expected a focused respiratory assessment, to give any medications available for that concern, and then call the MD if the resident did not improve. He stated the same would apply if the resident complained but everything was normal with the resident. The DON stated the nurse should contact the MD immediately if the meds did not help. He also stated the 5:00pm nurse should have evaluated, provided treatment, and called the MD before change of shift, and this incident would not be something to hand off to the next shift. Record Review of LVN A's Training Transcript dated 8/17/2023 revealed no documented training for significant change of condition. Record review of the facility's Policy and Procedure on Acute Condition Changes- Clinical Protocol (Revised March 2018) read in part: .2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs .d. Level of consciousness .g. Onset, duration, severity .3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident .and how to communicate these changes to the Nurse .5. The physician and nursing staff will review the details of any recent hospitalization s and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having addition complications .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician .8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or practitioner) will respond in a timely manner to notification of problems or changes in condition and status .10. The nurse and physician will discuss and evaluate the situation .1. The physician will help identify and authorize appropriate treatments .3. If it is decided .the physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting .1. The staff will monitor and document the resident's progress and responses to treatment . Record review of the facility's Policy and Procedure for Chronic Obstructive Pulmonary Disease (COPD)- Clinical Protocol (Revised November 2018) read in part: .2. In addition, the nurse shall assess and document/report the following: a. Vital signs (including detailed descriptions of respirations) b. Full lung assessment (including sounds of wheezing, sputum production) .d. Pulse oximetry result e. Onset, duration, frequency, severity . 3. The physician and staff will identify individuals with risk factors for developing COPD or for exacerbation of existing COPD .7. The physician will identify individuals with complications of COPD; for example, cor pulmonale [alteration in structure/function of the right ventricle of the heart caused by respiratory system, causing pulmonary hypertension], arrhythmia [irregular heart rhythm] or lethargy [very tired and hard to wake up], or confusion due to hypoxia .3. The physician and staff will identify relevant elements of the care plan; for example, what symptoms to expect (dyspnea, cough, fever, progressive activity intolerance, etc.), how often and what to monitor, when to report findings to the physician .4. Key objectives of COPD management include: a. Minimize disease progression b. Relieve symptoms .e. Prevent and treat exacerbations .11. The physician and staff will identify and manage complications of COPD, such as acute infections, hypoxia .and respiratory failure .12. The staff and physician will identify and treat acute exacerbations of COPD; for example, recognizing and reporting when an individual with COPD has a change in function or activity tolerance, increased dyspnea [trouble breathing], additional sputum production, cough, increasing lethargy or confusion, increased wheezing, increased respiratory or heart rates .1. The staff and physician will monitor the progress of individuals with COPD, including ongoing evaluation and documentation of signs and symptoms and condition changes . Record review of the facility's Policy and Procedure for Change in a Resident's Condition or Status (Revised February 2021) read in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician of physician on call when there has been a(n): .d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly .i. Specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions .3. Prior to notifying the physician or healthcare provider, the nurse will make details observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . On 9/15/2023 9:10 a.m. an Immediate Jeopardy (IJ) was identified. The Administrator was notified and provided the IJ template on 9/15/2023 9:10 a.m.; and a POR was requested at that time. After several revisions, the POR submitted by the Administrator was accepted on 9/19/2023 at 3:30 pm. PLAN OF REMOVAL The DON, ADON in-serviced all licensed staff, via live in-service, on observing for changes of condition on September 15th, continuing through September 18, 2023. The training included when to notify MD of a change of condition. All nurses should inform the MD after the following steps have been taken. 1. A nursing assessment has been completed. 2. PRN medications are administered as ordered. 3. A reassessment is completed and determined that interventions were not effective. 4. Call MD with information obtained and carry out any new orders provided. In the instance a patient or family member was requesting to go to the hospital the following steps should be taken: 1. Reassure patient and family 2. Follow nursing process and complete a nursing assessment 3. Provide PRN medications as ordered 4. Reassess patient and determine if interventions are effective 5. Call MD with information and carry out any new orders provided In the instance when the MD does not answer in a prompt manner, (within 2 calls), the nurse should call the Medical Director for further instructions. If the patient was unstable the nurse should call 911 immediately. This would include abnormal vital signs outside of the patients previously assessed normal, for example a sustained oxygen saturation of 85% or lower with no success increasing after oxygen therapy. On 9/15/2023, a chart audit for recent significant changes of condition was completed by management nurses. All changes were reported to the MD's. Current patients with the above conditions were assessed by licensed nurses. Assessments included blood pressure, pulse, respirations at rest, respirations with activity, temperature, lung sounds and oxygen saturations. In addition, return demonstrations were observed by the assigned nurse managers to ensure competency. There were no incidents when prn respiratory treatments were required, based on nursing assessment. Those assessments were placed in the appropriate medical chart upon completion. All non-PRN licensed nurses were trained by September 19th, 2023. Staff will have had training before their next scheduled shift or will not be allowed to work the floor until said training is completed. MONITORING During IJ implementation dates 9/15/2023-9/19/2023, investigation, interview and monitoring for Notify of Changes, this surveyor observed nursing staff doing their work, interviewed nurses on day and night shift, interviewed other staff members regarding and new and recent trainings by, computer, licensed in person in-service. 12 of 12 nursing staff were able to verbalize and verify new and reinforced training regarding changes of condition, SBAR documentation, Oxygen therapy, respiratory medication, following orders, PRN medications and documentation of refusal of medications. Record review of Training between 9/15/2023-9/19/2023 included: call the doctor or the nurse practitioner, and if the doctor or nurse practitioner do not respond timely or appropriately when the patients change of condition is reported- they should report to DON/ADON and the Medical Director if ADON/DON not available. The training consisted of specifically observing acute changes in patients with COPD, respiratory infections and other diseases of the lungs. Patients were assessed with COPD, respiratory infections by licensed nurses. Assessments included blood pressure, pulse, respiration at rest, respiration with activity, temperature, lung sounds and, oxygen saturation. Nurses report in the event family member or resident request to be sent to hospital, they will inquire as to why, perform assessment, SBAR, contact medical doctor or nurse practitioner, explain to the doctor/nurse practitioner what the resident is requesting, the vital signs, signs and symptoms they observed, receive orders, follow orders, in the event no new orders are given, DON will be contacted and medical director may be contacted. Interviews between 9/15/2023-9/19/2023, 12 of 12 Nurses were able to verbalize: signs and symptoms of COPD, signs and symptoms of COPD, ineffective breathing pattern assessment, ineffective breathing pattern interventions, activity intolerance assessment, activity intolerance interventions, deficient knowledge assessment, deficient knowledge interventions, respiratory assessment, oxygen administration, nebulizer therapy, small volume, and proper documentation. Record Reviews between 9/15/2023-9/19/2023, were performed regarding the training and monitoring to be done by management when and found to be compliant with standards of care. Residents were interviewed between 9/15/2023-9/19/2023 and were pleased with the care received by all staff members in the facility and reported they got their medications timely and when they asked for prn medications, the prn medications were given timely. The Administrator, DON were informed the Immediate Jeopardy (IJ) was removed on 09/19/2023 at 1:09 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet resident's medical, nursing and mental and psychosocial needs which were identified in the comprehensive assessment for 1 of 5 residents(Resident #1) reviewed for care plans. -The facility failed to complete a comprehensive care plan that addressed the assessed needs and documented diagnoses for Resident #1 This failure could place residents at risk of not having their needs met, decreased quality of life or injury. Findings included: Record review of Resident #1's Face Sheet dated 11/09/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: acute kidney failure, COPD (a group of diseases that cause airflow blockage and breathing-related problems) high blood pressure, high cholesterol, anxiety disorder, insomnia, low platelet count, anemia, GERD (acid reflux), lung cancer, bladder disorder, shortness of breath, prediabetes, constipation and a history of stroke. Record review of Resident #1's Admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score on 00 out of 15, extensive assistance to total dependence for most ADLs. Diagnoses of: cancer, anemia, coronary artery disease, high blood pressure, GERD, kidney failure, high cholesterol, anxiety disorder, depression, COPD, insomnia and low platelet count. Record review of Resident #1's undated Care Plan revealed, focus areas of: advance directives, functional performance, nutritional status. The care plan did not address any of Resident #1 listed and treated diagnoses. An observation and interview on 11/02/23 at 11:20 AM revealed, Resident #1 lying in bed, well groomed, well dressed, in no immediate distress, receiving oxygen via nasal cannula at 4 LPM. She said her breathing was doing well, she had not had any recent COPD exacerbation and she had no issues/concerns with her nursing care. In an interview on 11/09/23 at 11:00 AM, the ADON said she was responsible for ensuring care plans were up to date and accurate. She said a resident's comprehensive care plan must represent a complete picture of the residents health/disease and set goals/interventions to address the resident's care. The ADON said the comprehensive care plan should address all of a resident's diagnoses and chronic conditions. The ADON said she did not know why Resident #1's care plan was not accurate and failure to complete care plans could place residents at risk for miscommunication about the resident's care, delay in care and adverse reactions. In an interview on 11/09/23 at 11:24 AM, the ADON said the facility just missed completing Resident #1's care plan. She said it was an oversight. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered revised 03/2022 revealed, The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet resident's medical, nursing and mental and psychosocial needs which were identified in the comprehensive assessment for 1 of 5 residents(Resident #1) reviewed for care plans. -The facility failed to complete a comprehensive care plan that addressed the assessed needs and documented diagnoses for Resident #1 This failure could place residents at risk of not having their needs met, decreased quality of life or injury. Findings included: Record review of Resident #1's Face Sheet dated 11/09/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: acute kidney failure, COPD (a group of diseases that cause airflow blockage and breathing-related problems) high blood pressure, high cholesterol, anxiety disorder, insomnia, low platelet count, anemia, GERD (acid reflux), lung cancer, bladder disorder, shortness of breath, prediabetes, constipation and a history of stroke. Record review of Resident #1's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score on 00 out of 15, extensive assistance to total dependence for most ADLs. Diagnoses of: cancer, anemia, coronary artery disease, high blood pressure, GERD, kidney failure, high cholesterol, anxiety disorder, depression, COPD, insomnia and low platelet count. Record review of Resident #1's undated Care Plan revealed, focus areas of: advance directives, functional performance, nutritional status. The care plan did not address any of Resident #1 listed and treated diagnoses. An observation and interview on 11/02/23 at 11:20 AM revealed, Resident #1 lying in bed, well groomed, well dressed, in no immediate distress, receiving oxygen via nasal cannula at 4 LPM. She said her breathing was doing well, she had not had any recent COPD exacerbation and she had no issues/concerns with her nursing care. In an interview on 11/09/23 at 11:00 AM, the ADON said she was responsible for ensuring care plans were up to date and accurate. She said a resident's comprehensive care plan must represent a complete picture of the residents health/disease and set goals/interventions to address the resident's care. The ADON said the comprehensive care plan should address all of a resident's diagnoses and chronic conditions. The ADON said she did not know why Resident #1's care plan was not accurate and failure to complete care plans could place residents at risk for miscommunication about the resident's care, delay in care and adverse reactions. In an interview on 11/09/23 at 11:24 AM, the ADON said the facility just missed completing Resident #1's care plan. She said it was an oversight. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered revised 03/2022 revealed, The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 5 residents (Residents #1) for professional standards. - The facility failed to immediately transport Resident #1 to the hospital after the NP diagnosed the resident with a suspected pulmonary embolism( a blockage caused by a blood clot in the lungs). Resident #1 was sent by non-emergent transport over 2 hours after the order was given. This failure could place residents at risk of delay in treatment, adverse reactions and harm. Findings included: Record review of Resident #2's Face Sheet dated 11/09/23 revealed, a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD, pneumonia, Afib (an irregular heartbeat that puts you at risk of developing blood clots), hypertension, heart failure and the presence of a pacemaker. Record review of Resident #2's Admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, occasionally incontinent of bladder and frequently incontinent of bowel. Record review of Resident #2's Progress Note dated 10/09/23 at 01:05 PM revealed, Resident #2 suffered from SOB, a dry cough, edema in both feet, swelling in both upper extremities. The NP ordered antibiotics, breathing treatments, a diuretic, a chest x-ray, venous doppler of upper and lower extremities to rule out DVT (blood clot), an antibiotic for 5 days and a potassium supplement. Record review of Resident #2's Provider Note dated 10/09/23 at 6:11 PM revealed, Assessment plan: Labs were ordered on 10/09/23 and the resident was started on an antibiotic for 7 days, order for stat chest xray and venous of both upper and lower extremities to rule out DVT for worsening swelling. Resume Diuretic. Record review of Resident #2's Progress Note dated 10/12/23 at 08:13 PM, signed by LVN A revealed, Patient complaining of dizziness, shortness of breath, and edema (fluid buildup) observed to bilateral lower extremities and arms. PRN Oxygen applied at 2L via nasal cannula and O2 went up to 98%. The NP was notified, and she gave orders to do stat chest x-ray and stat EKG, orders carried out by National mobile, pending results. The NP also gave orders for one time Lasix 80mg, Prednisone 40mg, and Budesonide neb treatment, which was all administered. NP gave order to place foley catheter in patient, patient refused, stating she does not want it, NP made aware. NP also gave orders for Lasix 80 mg BID, Prednisone (a steroid) 40mg daily, and Budesonide neb treatment BID, orders carried out and in system. Patient currently in bed, oxygen applied, no complaints of pain. Will continue to monitor throughout the shift for any changes. Record review of Resident #2's Provider Note dated 10/13/23 at 06:24 PM revealed, Subjective: complaint of worsening SOB with chest pain on minimum activity (moving from bed to bedside commode) on 2.5 L of oxygen via nasal canula and O2 saturation at 96% but currently resting in bed but she still feels sob. Improved hand and legs swelling, denied n/v, abdominal pain, chills, fever, constipation and diarrhea. Assessment Plan: 10/13/23- Lasix has been increased to 80 mg twice daily, chest xray revealed no pleural effusion (a build up of fluid between layers of tissue that line the lungs and chest cavity usually found in HF or infection), right lower lobe small atelectasis (partial collapse of a section of the lung), and permanent pacemaker in position. Labs reviewed unremarkable. No change. Send pt to hospital for suspected PE workup. Record review of Resident #2's Progress Note dated 10/13/23 at 08:45 PM signed by LVN A revealed, upon coming on shift receiving report, The NP, gave order to send patient to the hospital at 1807 (06:07 PM) due to suspected PE and patient kept complaining of worsening shortness of breath and some chest pain despite unremarkable CXR and high dose of Lasix and breathing TX. [Transport Company] was called Patient picked up at 08:22 PM and taken to the hospital. Record review of Resident #2's EMS Record revealed, Resident #2 was transferred to the hospital on 10/13/23 via non-emergent transport. The transport company was contacted by the facility on 10/13/23 at 06:31: PM, an ambulance was assigned at 6:58 PM, enroute at 8:10 PM, , Resident #2 departed the facility at 8:16 PM, the transport mode was non-emergent, with neither lights or sirens used and Resident #2 arrived at the hospital at 8:34 PM. Record review of Resident #2's Hospital Records dated 10/16/23 revealed, the resident admitted altered mental status, chest pain and shortness of breath. History of Present Illness: Concern for possible PE vs CHF per EMS. The Hospital performed a CT of Resident #2's chest due to high probability suspected PE but the results yielded no evidence of PE, and the resident was diagnoses with pneumonia. Record review of Resident #2's Order Summary revealed, - Lasix (a diuretic) give 3 tablets by mouth one time only for swelling. The Order started on 10/09/23 and ended on 10/09/23 at 12:00 PM. - Lasix 40 mg 1 tablet 2 times a day for swelling related to acute CHF, do not hold call NP or MD. The order was started on 10/09/23. - Stat Venous Doppler for upper and lower extremities. The order was started on 10/09/23. - Stat Chest Xray for shortness of Breath- Ordered on 10/12/23 - Budesonide 0.25mg/2mL inhale 1 vial orally one time only for shortness of breath for 1 day. The order was started on 10/12/23 and ended on 10/13/23. - Budesonide 0.25mg/2mL inhale 1 vial orally one time only for shortness of breath for 1 day. The order was started on 10/13/23. - Apixaban (a blood thinner) 5 mg give 1 tablet by mouth every 12 hours related to Afib. - Send Patient to Hospital for suspected PE. Ordered on 10/13/23. Record review of Resident #2's October MAR revealed, Resident #2's her blood thinner, Apixaban, was on hold from the evening of 10/11/23 to 10/13/23. Record review of a Pulmonary Consultant Note present by the facility and dated on 11/09/23 revealed. Pulmonary Embolism (PE) is a sudden change of condition with signs and symptoms that DO NOT resemble Pneumonia. Early warning signs of PE are shortness of breath that appears suddenly, chest pain that become worse when breathing (may feel like a heart attack), lightheadedness, dizziness, sudden loss of blood pressure, cough which may contain blood. An observation and interview on 11/02/23 at 11:36 AM revealed, Resident #2 sitting in a wheelchair in her room. The resident appeared to be well dressed, well fed and in no immediate distress. She said last month she got up and could not use her left leg, had shortness of breath, chest pain, and swelling. Resident #2 said these symptoms persisted for several days and the facility tried to treat it but eventually they sent her to the hospital where she was diagnosed with pneumonia and some blood issues. Resident #1 said she had been in and out of the hospital recently, and had never declined or rejected transportation to the hospital via 911 ambulance. In an interview on11/02/23 at 12:06 PM, the NP said she ordered Resident #2 be transferred to the hospital because she suspected the resident might have a PE. She said Resident #2's Apixaban (a blood thinner) was stopped prior to her hospitalization due to reported nose bleeds, the resident was experiencing SOB which was treated with a diuretic, but it was not effective, her symptoms seemed to be worsening and she did not seem to be stable. The NP said since all treatments rendered had yielded no improvement and Resident #2 appeared to be worsening as well as the stopped use of her blood thinner she suspected the resident might have a PE. The NP said she did not remember if she told the nurse explicitly to send the resident to the hospital via 911 but that was her expectation since a PE requires emergency treatment. She said failure to get immediate treatment for a PE could result in increased difficulty breathing and altered mental status. In an interview on 11/02/23 at 12:13 PM, the MD said she remembered Resident #2 suffered from HF/volume overload and was sent to the hospital last month that was handled by the NP. She said a PE should be treated as an emergency situation and failure to transport a resident emergently could result in worsening of condition, stoke and a mortality risk. In an interview on 11/02/23 at 12:35 PM, LVN A said she was responsible for sending Resident #2 to the hospital. She said the resident had SOB, was sweating and could barely breathe so the NP said the resident should be transferred to the hospital. She said she did not send the resident via emergency transport because the resident was stable at that time. She said the resident had suffered from worsening of symptoms over 2 days, experienced some swelling, SOB that the facility tried to treat but the resident was not improving. When asked if chest pain, SOB and a suspected PE were considered an emergency she said, the resident was not experiencing chest pain at that moment and per her nursing judgment it was not an emergency. When asked if a suspected PE was an emergency, LVN A said yes, a suspected PE was an emergency and failure to transport a resident suffering from a PE could result in loss of consciousness, SOB and death unfortunately. In an interview on 11/02/23 at 01:17 PM, the interim DON said she had been at the facility for only 1 week. She said she had reviewed Resident #1's change of condition and the resident suffered from chronic Anemia and the NP decided to transfer the resident to the hospital. When asked if how a resident suspected of a PE should be transferred to the hospital she said, I want her sent 911. The interim DON said failure to transfer a resident with a suspected PE out timely to the hospital could place the resident at risk of negative outcomes such as respiratory failure. In an interview on 11/09/23 at 11:11 AM, the ADON said a PE results from a blood clot that develops in some other part of the body and migrates to the lungs. She said symptoms of a blood clot in areas leg the leg included increased swelling, warmed and redness and symptoms of a PE included: increased shortness of breath, decreased O2 saturations, chest pain, increased pulse and increased respirations. The ADON said delay in care/transfer to the hospital for a patient with a PE could place the resident at risk for worsening of symptoms, stroke and cardiac arrest. In an interview on 11/02/23 at 11:00 AM, RN A said if a provider requested a resident be sent out to the hospital due to a suspected PE she would send the resident out emergently by calling 911. She said the provider would not have to give her specific instructions to send the resident out via 911 because per her nursing judgment a PE is an emergency. In an interview on 11/02/23 at 11:05 AM, RN B said symptoms of a PE include chest pain, and hypoxia (low oxygen) or difficulty breathing and if a resident was suspected of having a PE they should be sent out via emergency 911 transport. In an interview on 11/02/23 at 11:10 AM, RN C said if a resident showed signs of or were diagnosed with a suspected PE and the residents symptoms have not improved regardless of treatment they should be sent out via 911 emergency transport. She said failure to send the resident out promptly could result in worsening of breathing. In an interview on 11/02/23 at 11:35 AM, LVN B said if a resident had a suspected of a PE they should be sent out via 911 not through the facility contracted non-emergent transportation because it would take too long. She said failure to transport a resident with a suspected PE immediately could place them at risk for worsening of symptoms, cardiac arrest and death. In an interview on 11/02/23 at 11:55 AM, LVN C said if it was suspected that a resident had a PE they should be sent out via 911 and failure to do so could result in worsening of condition or death. Record review of the facility policy titled Transfer or Discharge, Emergency revised 08/2018 revealed, the policy did not address what method of transport should be used to transfer residents to the hospital. Record review of the facility policy titled Physician Services revised 02/2021 revealed, 3- supervising the medical care of residents includes (but is not limited to): b- monitoring changes in resident's medical status, e- ordering transfers to the hospital if necessary.

Based on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 5 residents (Residents #1) for professional standards. - The facility failed to immediately transport Resident #1 to the hospital after the NP diagnosed the resident with a suspected pulmonary embolism( a blockage caused by a blood clot in the lungs). Resident #1 was sent by non-emergent transport over 2 hours after the order was given. This failure could place residents at risk of delay in treatment, adverse reactions and harm. Findings included: Record review of Resident #2's Face Sheet dated 11/09/23 revealed, a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: COPD, pneumonia, Afib (an irregular heartbeat that puts you at risk of developing blood clots), hypertension, heart failure and the presence of a pacemaker. Record review of Resident #2's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, occasionally incontinent of bladder and frequently incontinent of bowel. Record review of Resident #2's Progress Note dated 10/09/23 at 01:05 PM revealed, Resident #2 suffered from SOB, a dry cough, edema in both feet, swelling in both upper extremities. The NP ordered antibiotics, breathing treatments, a diuretic, a chest x-ray, venous doppler of upper and lower extremities to rule out DVT (blood clot), an antibiotic for 5 days and a potassium supplement. Record review of Resident #2's Provider Note dated 10/09/23 at 6:11 PM revealed, Assessment plan: Labs were ordered on 10/09/23 and the resident was started on an antibiotic for 7 days, order for stat chest xray and venous of both upper and lower extremities to rule out DVT for worsening swelling. Resume Diuretic. Record review of Resident #2's Progress Note dated 10/12/23 at 08:13 PM, signed by LVN A revealed, Patient complaining of dizziness, shortness of breath, and edema (fluid buildup) observed to bilateral lower extremities and arms. PRN Oxygen applied at 2L via nasal cannula and O2 went up to 98%. The NP was notified, and she gave orders to do stat chest x-ray and stat EKG, orders carried out by National mobile, pending results. The NP also gave orders for one time Lasix 80mg, Prednisone 40mg, and Budesonide neb treatment, which was all administered. NP gave order to place foley catheter in patient, patient refused, stating she does not want it, NP made aware. NP also gave orders for Lasix 80 mg BID, Prednisone (a steroid) 40mg daily, and Budesonide neb treatment BID, orders carried out and in system. Patient currently in bed, oxygen applied, no complaints of pain. Will continue to monitor throughout the shift for any changes. Record review of Resident #2's Provider Note dated 10/13/23 at 06:24 PM revealed, Subjective: complaint of worsening SOB with chest pain on minimum activity (moving from bed to bedside commode) on 2.5 L of oxygen via nasal canula and O2 saturation at 96% but currently resting in bed but she still feels sob. Improved hand and legs swelling, denied n/v, abdominal pain, chills, fever, constipation and diarrhea. Assessment Plan: 10/13/23- Lasix has been increased to 80 mg twice daily, chest xray revealed no pleural effusion (a build up of fluid between layers of tissue that line the lungs and chest cavity usually found in HF or infection), right lower lobe small atelectasis (partial collapse of a section of the lung), and permanent pacemaker in position. Labs reviewed unremarkable. No change. Send pt to hospital for suspected PE workup. Record review of Resident #2's Progress Note dated 10/13/23 at 08:45 PM signed by LVN A revealed, upon coming on shift receiving report, The NP, gave order to send patient to the hospital at 1807 (06:07 PM) due to suspected PE and patient kept complaining of worsening shortness of breath and some chest pain despite unremarkable CXR and high dose of Lasix and breathing TX. [Transport Company] was called Patient picked up at 08:22 PM and taken to the hospital. Record review of Resident #2's EMS Record revealed, Resident #2 was transferred to the hospital on [DATE] via non-emergent transport. The transport company was contacted by the facility on 10/13/23 at 06:31: PM, an ambulance was assigned at 6:58 PM, enroute at 8:10 PM, , Resident #2 departed the facility at 8:16 PM, the transport mode was non-emergent, with neither lights or sirens used and Resident #2 arrived at the hospital at 8:34 PM. Record review of Resident #2's Hospital Records dated 10/16/23 revealed, the resident admitted altered mental status, chest pain and shortness of breath. History of Present Illness: Concern for possible PE vs CHF per EMS. The Hospital performed a CT of Resident #2's chest due to high probability suspected PE but the results yielded no evidence of PE, and the resident was diagnoses with pneumonia. Record review of Resident #2's Order Summary revealed, - Lasix (a diuretic) give 3 tablets by mouth one time only for swelling. The Order started on 10/09/23 and ended on 10/09/23 at 12:00 PM. - Lasix 40 mg 1 tablet 2 times a day for swelling related to acute CHF, do not hold call NP or MD. The order was started on 10/09/23. - Stat Venous Doppler for upper and lower extremities. The order was started on 10/09/23. - Stat Chest Xray for shortness of Breath- Ordered on 10/12/23 - Budesonide 0.25mg/2mL inhale 1 vial orally one time only for shortness of breath for 1 day. The order was started on 10/12/23 and ended on 10/13/23. - Budesonide 0.25mg/2mL inhale 1 vial orally one time only for shortness of breath for 1 day. The order was started on 10/13/23. - Apixaban (a blood thinner) 5 mg give 1 tablet by mouth every 12 hours related to Afib. - Send Patient to Hospital for suspected PE. Ordered on 10/13/23. Record review of Resident #2's October MAR revealed, Resident #2's her blood thinner, Apixaban, was on hold from the evening of 10/11/23 to 10/13/23. Record review of a Pulmonary Consultant Note present by the facility and dated on 11/09/23 revealed. Pulmonary Embolism (PE) is a sudden change of condition with signs and symptoms that DO NOT resemble Pneumonia. Early warning signs of PE are shortness of breath that appears suddenly, chest pain that become worse when breathing (may feel like a heart attack), lightheadedness, dizziness, sudden loss of blood pressure, cough which may contain blood. An observation and interview on 11/02/23 at 11:36 AM revealed, Resident #2 sitting in a wheelchair in her room. The resident appeared to be well dressed, well fed and in no immediate distress. She said last month she got up and could not use her left leg, had shortness of breath, chest pain, and swelling. Resident #2 said these symptoms persisted for several days and the facility tried to treat it but eventually they sent her to the hospital where she was diagnosed with pneumonia and some blood issues. Resident #1 said she had been in and out of the hospital recently, and had never declined or rejected transportation to the hospital via 911 ambulance. In an interview on11/02/23 at 12:06 PM, the NP said she ordered Resident #2 be transferred to the hospital because she suspected the resident might have a PE. She said Resident #2's Apixaban (a blood thinner) was stopped prior to her hospitalization due to reported nose bleeds, the resident was experiencing SOB which was treated with a diuretic, but it was not effective, her symptoms seemed to be worsening and she did not seem to be stable. The NP said since all treatments rendered had yielded no improvement and Resident #2 appeared to be worsening as well as the stopped use of her blood thinner she suspected the resident might have a PE. The NP said she did not remember if she told the nurse explicitly to send the resident to the hospital via 911 but that was her expectation since a PE requires emergency treatment. She said failure to get immediate treatment for a PE could result in increased difficulty breathing and altered mental status. In an interview on 11/02/23 at 12:13 PM, the MD said she remembered Resident #2 suffered from HF/volume overload and was sent to the hospital last month that was handled by the NP. She said a PE should be treated as an emergency situation and failure to transport a resident emergently could result in worsening of condition, stoke and a mortality risk. In an interview on 11/02/23 at 12:35 PM, LVN A said she was responsible for sending Resident #2 to the hospital. She said the resident had SOB, was sweating and could barely breathe so the NP said the resident should be transferred to the hospital. She said she did not send the resident via emergency transport because the resident was stable at that time. She said the resident had suffered from worsening of symptoms over 2 days, experienced some swelling, SOB that the facility tried to treat but the resident was not improving. When asked if chest pain, SOB and a suspected PE were considered an emergency she said, the resident was not experiencing chest pain at that moment and per her nursing judgment it was not an emergency. When asked if a suspected PE was an emergency, LVN A said yes, a suspected PE was an emergency and failure to transport a resident suffering from a PE could result in loss of consciousness, SOB and death unfortunately. In an interview on 11/02/23 at 01:17 PM, the interim DON said she had been at the facility for only 1 week. She said she had reviewed Resident #1's change of condition and the resident suffered from chronic Anemia and the NP decided to transfer the resident to the hospital. When asked if how a resident suspected of a PE should be transferred to the hospital she said, I want her sent 911. The interim DON said failure to transfer a resident with a suspected PE out timely to the hospital could place the resident at risk of negative outcomes such as respiratory failure. In an interview on 11/09/23 at 11:11 AM, the ADON said a PE results from a blood clot that develops in some other part of the body and migrates to the lungs. She said symptoms of a blood clot in areas leg the leg included increased swelling, warmed and redness and symptoms of a PE included: increased shortness of breath, decreased O2 saturations, chest pain, increased pulse and increased respirations. The ADON said delay in care/transfer to the hospital for a patient with a PE could place the resident at risk for worsening of symptoms, stroke and cardiac arrest. In an interview on 11/02/23 at 11:00 AM, RN A said if a provider requested a resident be sent out to the hospital due to a suspected PE she would send the resident out emergently by calling 911. She said the provider would not have to give her specific instructions to send the resident out via 911 because per her nursing judgment a PE is an emergency. In an interview on 11/02/23 at 11:05 AM, RN B said symptoms of a PE include chest pain, and hypoxia (low oxygen) or difficulty breathing and if a resident was suspected of having a PE they should be sent out via emergency 911 transport. In an interview on 11/02/23 at 11:10 AM, RN C said if a resident showed signs of or were diagnosed with a suspected PE and the residents symptoms have not improved regardless of treatment they should be sent out via 911 emergency transport. She said failure to send the resident out promptly could result in worsening of breathing. In an interview on 11/02/23 at 11:35 AM, LVN B said if a resident had a suspected of a PE they should be sent out via 911 not through the facility contracted non-emergent transportation because it would take too long. She said failure to transport a resident with a suspected PE immediately could place them at risk for worsening of symptoms, cardiac arrest and death. In an interview on 11/02/23 at 11:55 AM, LVN C said if it was suspected that a resident had a PE they should be sent out via 911 and failure to do so could result in worsening of condition or death. Record review of the facility policy titled Transfer or Discharge, Emergency revised 08/2018 revealed, the policy did not address what method of transport should be used to transfer residents to the hospital. Record review of the facility policy titled Physician Services revised 02/2021 revealed, 3- supervising the medical care of residents includes (but is not limited to): b- monitoring changes in resident's medical status, e- ordering transfers to the hospital if necessary.

Based on observation, interview, and record review the facility failed to make sure its medication error rate was not less than 5% of 2 of 25 residents reviewed for medication administration. 1. The facility's medication error rate was 8%. 2. The facility failed to order medications for medication administration at designated time. These deficient practices could place residents at risk of severe consequences leading to declining health, harm, or hospitalization due to missed medications. Findings: Resident # 212 Record review of Resident #212's face sheet revealed an [AGE] year-old female admitted [DATE] with a diagnosis of Wedge Compression Fracture of T-11 Vertebra (When front of lower spinal column collapses but back side does not), Subsequent Encounter for Fracture for Routine Healing (active treatment and routine care for the fracture). Record review of Resident #212's Care Plan dated 3/7/2023 revealed the resident communicates easily and understands staff. She required one-person physical assistance with personal hygiene, toilet use, dressing, bathing, bed mobility and transfers. Record review of Resident #212's physician order revealed Hydroxyzine HCL 10mg 1 PO Q12H for allergies: start date 3/4/2023. Record review of Resident #212's MAR dated, 3/1/2023-3/31/2023 revealed nurses entered Code 9 (Not available) on medication (Hydroxyzine)totaling 5 doses for the following dates and times: 3/4/2023 8:00pm, 3/5/2023 8:00pm, 3/6/2023 8:00am, 3/6/2023 8:00pm, 3/7/2023 8:00am. Record review of Resident #212's MAR dated, 3/1/2023 to 3/31/2023 revealed blank spaces on the MAR on 3/7/2023 at 8:00pm and on 3/8/2023 at 8:00am meaning the Hydroxyzine had not been addressed or administered. Observation/Interview on 3/8/2023 at 7:25am during medication administration of RN#1 revealed her going to administer a dose of Hydroxyzine to Resident #212, she looked through the medication cart and she could not locate Resident #212's Hydroxyzine. She said they were out of Hydroxyzine and the medication had to be ordered. She said they could not administer the Hydroxyzine until the facility filled resident #212's order for Hydroxyzine. Resident #7 Record review of Resident #7 revealed a [AGE] year-old female with a diagnosis of Cerebral Infarction, Unspecified (Occurs because of disrupted blood flow to the brain). Heart Failure Unspecified (Heart cannot pump enough blood to support other organs). Record review of Resident #7's Care Plan dated 1/20/2023 revealed the resident had impaired cognitive function related to Dementia and was dependent on bathing, bed mobility, bedfast, dressing, eating, personal hygiene, toileting, and transfers. Record review of Resident #7's physician order dated 3/4/2023 revealed Potassium Chloride ER Oral Tablet Extended Release 10meq (Potassium Chloride) Give 1 tablet by mouth one time a day for Supplement. Record review of Resident #7's MAR dated, 3/1/2023-3/31/2023 revealed Code 9 (Not Available) was entered on the Potassium totaling 2 doses for the following dates and times: 3/8/2023 at 9:00am and 3/9/2023 at 9:00am. Observation of LVN #1 on 3/8/2023 at 7:56am revealed she looked at Resident #7's MAR and did not administer the potassium because she said she could not crush the medication so she would have to call hospice for an order. In an interview on 3/8/2023 at 7:56am LVN #1 said Resident #7 could not have the potassium because the resident could not swallow the pill and the medication could not be crushed. She said she called hospice on Sunday 3/5/23 for a new order, and she had not heard back from them. Surveyor pointed out that today was Wednesday 3/8/2023 and asked LVN #1 if she had followed up with hospice and she said no. In an interview on 3/8/2023 at 11:12am with NP#3, she said if a person does not get potassium their potassium could go low or if they have a cardiac condition their cardiac muscle could be affected. She said residents could go into A-fib (Fluttering of the Heart muscle) if they had A-fib previously. In an interview on 3/9/2023 at 12:16pm LVN#1 said she ordered the potassium on 3/5/23 but forgot to document in the nurse's notes. In an interview on 3/8/2023 at 12:30pm Chief Clinical Officer, he said the pharmacy makes three deliveries a day. He said the nurses were supposed to report to him if they did not get their medications. He said he in-serviced nursing staff in February on what to do if a medication was not available. He said the expectation for any medication was that he ordered that day by 9pm and the medications would be received by 5am the next morning. He said if the medication was not received the nurse was supposed to escalate to management so that it could be delivered as soon as possible. He said he was unaware the resident #212 had not received Hydralazine for 5 days and resident #7 had not received Potassium on 3/8/2023 and 3/9/2023 had missed medications due to physician orders not being filled timely. He said if this was not done it was a failure of communication from the nurses. He said that he became lax in his auditing of Code 9 which was what they use to see when medications were not administered. He said, Code 9 was what the nurses used to chart when a medication was missed. Record review of facility in-service titled, Charting Requirements, dated 2/8/2023 read in part . Educate staff on procedure if medication not available and To ensure medication are available for patients . Record review of facility's medication policy titled, Administering Medication, dated 2019, read in part . Medications are administered in accordance with prescriber orders, including any required time frame . Record review of facility's medication policy titled, Administering Medication, dated 2019, read in part . Medication administration times are determined by resident need and benefit, not staff convenience .

Based on observation, interview, and record review, the facility failed to ensure residents received medications in accordance with doctor's orders for 1 of 5 residents (Resident #1) reviewed for pharmaceutical services. 1.The facility failed to ensure Resident #1 received Modafinil 100 mg as ordered by her physician related to Traumatic Subdural Hemorrage (traumatic head injury) with loss of consciousness. 2.The facility failed to notify Resident #1's PCP that a new order for Modafinil 100 mg was necessary. 3.The facility failed to ensure their procedure of ordering a controlled substance medication from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand. These failures placed residents whose medications were administered by facility staff at risk of experiencing adverse effects of not receiving medications. Findings included: Record review of Resident #1's face sheet, dated 2/7/2023, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] from an acute hospital. She was diagnosed with traumatic subdural hemorrhage (traumatic head injury) with loss of consciousness, Hemiplegia and Hemiaparesis (paralysis of one side of the body) following other nontraumatic intracranial hemorrhage (bleeding of the brain nonrelated to trauma or surgery) affecting the left dominant side, Compression of the brain (pressure of the brain which deteriorates levels of consciousness), muscle weakness, unspecified abnormalities of gait and mobility, and Recurrent Major Depressive Disorder with Psychotic Symptoms. Record review of Resident #1's MDS, dated ,d+[DATE] revealed she had a BIMS score of 13 (cognitively intact); she required extensive assistance from staff with bed mobility, transfers, ambulation via wheelchair, dressing, toilet use, personal hygiene and bathing. Record review of Resident #1's care plan, revised on 01/19/2022, revealed she had an altered neurological statue due to a head injury; she had an ADL self-care performance deficit due to activity intolerance, fatigue, hemiplegia, impaired balance, limited mobility and trauma; she was at risk for adverse reactions due to Polypharmacy and was to be monitored for fatigue. Record review of Resident #1's Medication Administration Record for January and February 2023 revealed the following: Provigil Tablet 100 mg (Modanifil) Give 1 tablet by mouth one time a day. No medication given documented on 1/1/23 and 1/2/23 at 6:00 am. Medication administered documented at 6:00 am on 1/3/23 and 1/4/23. Medication documented as administered at 8:00 am on 1/5/23 and 1/6/23. Medication documented as administered at 9:00 am 1/6/23 - 1/31/23 Provigil Tablet 100 mg (Modanifil) Give 1 tablet by mouth one time a day. No medication given documented at 9:00 am on 2/1/23, 2/2/23, 2/4/23, 2/5/23, 2/6/23 and 2/7/23. Record review of Resident #1's physician's orders for January and February 2023 revealed the following: Ordered Date: 1/16/2023 Ordered Medication Name: modanifiL 100 mg tablet (ProvigiL) Pharmacy Directions: Take 1 tablet (100 mg total) by mouth for 15 days. Qty Ordered: 15 # of Refills: 000 PRN Only: N Ordering Physician: Madhavi Machineni Controlled Substance Approved: Yes Further review of Resident #1's pharmacy orders revealed no additional orders for Mondanifil 100 mg after 1/16/2023. In a telephone interview with Resident #1's PCP on 02/07/2023 at 1:45 PM, she stated that she was unsure of the last order of Modafinil for Resident #1 as she did not have access to her medical information at that time. The PCP stated that the reason she orders 15 day prescriptions of Modafinil was because the medication was a controlled substance. The PCP stated that most of the residents she cares for at this facility are there for short periods of time and to reduce the risk of having a surplus of this type of medication, she prefers to order 15 day prescriptions. The PCP stated that the potential harm associated with Resident #1 not receiving Modafinil 100 mg daily was nothing more than experiencing more sleepiness or fatigue during the day, than usual. The PCP stated that in order for the medication to be refilled, a nurse from the facility notifies her via a messaging system or phone call, she submits an order to the pharmacy and the medication is sent directly to the facility. The PCP stated that she was not aware that Resident #1 was completely out of her Modafinil medication and was unsure as to how a lapse in ensuring the facility had an adequate supply on hand. In an interview with the DON on 2/7/23 at 1:00 PM, he stated that he was unaware as to how or why a lapse in Resident #1's Modafinil 100 mg medication occurred. The DON stated that he was not made aware of Resident #1 being out of Modafinil 100 mg and having not received the medication for 7 days, including today. He stated that he would have to look the medication up, a well as, take a look at Resident #1's chart in order to identify her medical necessity for the medication and the adverse implications of her not receiving the medication. He stated that a possible mix up or breakdown in communication between either the nurse that ordered the medication and the PCP, or the between PCP and the pharmacy could have been the reason for the facility not having the medication on hand. The DON stated that it is the responsibility of the nurse's that administer medications to identify low quantities and contact either the pharmacy or physician to obtain refills in a timely manner. The DON stated that the nurses are supposed to notify him and the administrator of medication errors. He stated that this situation had not been reported to him or the administrator, however, he would conduct an investigation to assess the situation. Observation of Resident #1 on 2/7/2023 at 10:15 AM revealed the following: Resident #1 observed to be awake, alert, sitting upright in a chair to the side of her bed. Her room was clean and she appeared to be well groomed. Resident #1 seemed to be in good spirits and enjoying video content on a tablet device. Observation of 2 of the facility's hall 200 medication passes on 02/7/2023, at 10:30 a.m. revealed there was no Modafinil 100 mg tablet on the hall 200 medication cart, or in the medication storage room for Resident #1. In an interview with Resident #1 on 2/7/2023 at 1:25 PM, she stated that she hadn't been at the facility long. She stated that she recently had surgery and was sent to this facility to build up her strength. She stated that the staff treat her pretty well. Resident #1 stated that she felt pretty good today, enjoyed her breakfast and now was just relaxing and watching television. She stated that she did not feel tired or fatigued today. Resident #1 stated that she did not recall feeling tired, more tired than usual or fatigued over the last several days either. She stated that always gets her medications on time. She stated that she's never had an issue with receiving medications late, not receiving certain medications, or not receiving medications at all. In an interview with LVN A on 2/7/2023 at 1:35 PM, she stated that she was not aware that Resident #1 was out of Modafinil 100 mg. LVN A stated that she was responsible for administering medications on the 200 hall during the day shift, Monday through Friday. LVN A stated that she was aware that Resident #1 was out of the medication, but she believed she (LVN A) had already submitted a new order to the doctor and just needed to follow up. LVN A stated, usually, once a nurse noticed a resident was running low on a medication, without surplus in their e-kits, a refill would need to be requested. LVN A stated an e-kit was the facility's overflow of medications. LVN A stated depending on the type of medication, the facility may not keep an overflow on hand in the e-kit. LVN A stated the facility utilized a messaging system that allowed for instant communication with the physicians associated with the facility, regarding residents' medical needs. LVN A stated she would have submitted her most recent order of Modafinil 100 mg for Resident #1 via the messaging system. LVN A demonstrated use of the messaging system. LVN A stated the last message she could find regarding Resident #1's Modafinil 100 mg was around 1/16/23. LVN A stated she would not have submitted a refill request any other way. LVN A stated nobody else would have submitted a refill request for Resident #1. LVN A stated she was not sure of the implications of Resident #1 not receiving the medication for seven days and she would have to do a little research to be sure of her response. LVN A stated that she thought she already submitted a refill request for the medication. LVN A stated she (LVN A) had gotten busy, and she did not remember to check on the request. Record review of the undated facility policy, titled, Policy/Procedure - Medication Ordering and Receiving From Pharmacy Provider; Ordering and Receiving Controlled Medications, revealed the following: Medications included in the Drug Enforcement Administration classification as controlled substances .are subject to special ordering, receipt, and record keeping requirements in the nursing care center, in accordance with federal and state laws and regulations .refills requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand. Further review of the policy revealed, in an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order .

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, for 3 of 3 medication carts ( 100 North Med Cart, 200 North Med Cart and 200 West Med Cart) reviewed for medication storage. The facility failed to ensure 100 North Med Cart did not contain Insulin vials and pens without open dates. The facility failed to ensure 200 North Med Cart did not contain loose, unlabeled pills The facility failed to ensure 200 West Med Cart did not contain an insulin pens without open dates. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings include: 100 North Med Cart In an observation and interview on [DATE] at 08:43 AM, inventory of the 100 North Med Cart drawers with LVN A revealed: -1 open and in use vial of [MEDICATION(S)] insulin with no labeled open date. -2 open Insulin [MEDICATION(S)] pens with no labeled open date. -1 loose pill LVN A said that all multi-dose insulin containers must be labeled upon opening or once they are taken out of the refrigerator. She said that each type of insulin has a specific beyond use date once open and by labeling the container with an open date staff can track their expiration. LVN A said since the insulin vial and pens were not labeled it was impossible to determine the expiration date and they could no longer be used. She said once insulin expires it can lose efficacy or be contaminated. LVN A said nursing staff are expected to check their carts once a week for loose pills, expired and inappropriately labeled medications. She said since the insulin containers could not be used, they must be discarded in the sharps container. In an observation and interview on [DATE] at 08:55 AM, inventory of the 200 North Med Cart drawers with LVN B revealed: -17 loose pills. LVN B said nursing staff are expected to check their carts once a week for loose pills, expired and inappropriately labeled medications. He said all medication should be in their original dispensing containers and since the pills were no longer in their original containers they could not be used and they must be discarded in the sharps container. LVN B said the risk of having unidentified loose pills was theft, contamination or adverse reactions if the wrong medications are administered to a resident. In an observation and interview on [DATE] at 09:00 AM, inventory of the 200 North Med Cart drawers with LVN C revealed: - 1 open and in use Insulin [MEDICATION(S)] pen with no open date. LVN C said insulin has a specified beyond use date once opened, so nursing staff must label insulin containers once opened in order to track the expiration date. She said since the insulin pen didn't have an open date it could not be used because it might be expired and once expired it can become ineffective or contaminated. She said that nursing staff are expected to check their carts daily as used for loose pills, expired or inappropriately labeled medications and since the pens were not labeled, they must be discarded in the sharps container. In an interview on [DATE] at 11:10 AM, the DON said that all multidose insulin containers are to be labeled with an open date and staff initials when taken out of the refrigerator. She said Insulin has specific beyond use dates and staff label the containers with the open date to their expiration. The DON said that when Insulin containers are not labeled appropriately the expiration date can not be determined and that once insulin expires it could lose its efficacy and can become contaminated. She said that using expired insulin places resident's at risk of infection and exacerbation of chronic issues. The DON said that nursing staff are expected to check their carts once a week for loose pills, expired and inappropriately labeled medications. She said all medications must be stored in their original dispensing container which contain both resident and drug identifiers and all loose pills must be discarded in the drug disposal bin. The DON said that loose pills place resident's at risk for adverse drug reactions from administration of incorrect medications and misappropriation. Record review of the facility policy titled Medications and Medication Labels revised ,d+[DATE], revealed 1. Each prescription medication will be labeled to include a. Resident's name, b. Specific directions for use, including route of administration, c. Medication name . h. expiration or end-of-use date. 2. Multi-dose vials shall be labeled to assure product integrity, considering the manufacturers' specifications. (Example: Modified expiration dates upon opening the multi-dose vial.) Nursing staff should document the date opened on multi-dose vials on the attached auxiliary labels. 8. Medication containers having soiled, damaged, incomplete, illegible or makeshift labels are returned to the dispensing pharmacy for re-labeling or destroyed in accordance with the medication destruction policy. Record review of the facility policy titled Medication Packaging revised ,d+[DATE] revealed, 1. Solid oral medications forms (tablets and capsules) are supplied by the provider pharmacy using the agreed upon distribution system. (This may take the form of unit-dose packaging, punch cards, cassettes or other packaging.) Record review of the facility policy titled Storage of Medication revised ,d+[DATE] revealed, .12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may by stored in refrigerator or at room temperature. Opened insulin pens must be stored at room temperature. Do not freeze insulin .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. Record review of the facility policy titled Discarding and Destroying Medications revised ,d+[DATE] revealed, .2. Non-controlled and Schedule V (non-hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications.

Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal in that the facility dumpster lids and door were not secured. This failure could place residents, staff, and visitors at risk of infection from improperly disposed garbage. Findings include: Observation on 12-14-21 at 9:00 a.m. revealed the facility's dumpster area, which was in the lot behind the dietary department the contained commercial -size dumpster lids and door were open. There were bags of trash in the dumpster mostly from the kitchen Interview on 12-14-21 at 9:00 a.m. with the Dietary Manager, she stated the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. Any staff dumping garbage should close the dumpster lids after each use. Interview on 12-15-21 at 10:00 Am with the Dietary Manager where she stated that she will be checking and monitoring and ensuring the dumpster lids are close. She will check first thing in the morning, then after lunch services and at the end of her shift. Record review of facility's in-service dated 12-14-21 Purpose: Properly disposing waste to maintain on-going pest control and to keep facility free of rodents, pests and other unwanted creatures. Test included when is lid of dumpster allowed to be open? Only when throwing out garbage. If you have an excess amount of garbage that requires more than one trip to the dumpster, is it ok to walk away and leave dumpster open. False Record review on 12-15-21 of the facility policy and procedure on Pest Control / Waste Disposal revealed, Trash will be deposited into a sealed container outside the premises to keep facility free of rodents/pests and other unwanted creatures.

Based on observation, interview and record review, the facility failed to establish an infection prevention and control program that included hand hygiene procedures to be followed by staff involved in direct resident contact for one of one residents (Resident #45) reviewed for incontinent care and one of two nursing staff (RNA) reviewed for infection control. -RNA failed to wash or sanitize her hands in between glove changes during Resident #45's incontinent care and performed inadequate hand washing after the care. These failures could affect residents requiring incontinent care placing them at risk for cross contamination and infection. Findings included: Record review of Resident # 45's face sheet revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #45's Admission Minimum Data Set ((MDS) dated [DATE] revealed, she was severely impaired when making decisions regarding tasks of daily life. She required extensive one-person physical assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. She was incontinent of bowel and bladder. Record review of Resident # 45's care plan, with start date 08/27/2020 revealed in part; -Problem: Resident requires assistance with (activities of daily living) ADLs related to (r/t) impaired mobility, impaired cognition, right [MEDICAL CONDITION] and [DEVICE] status. Goal: ADL approaches will meet resident's needs. Interventions: .toileting-dependent . -Problem: Resident is at risk for skin breakdown r/t non-verbal, right side paralysis, immobility, decreased sensory perception, incontinence and Percutaneous endoscopic gastrostomy (PEG) tube status. Goal: Resident's skin will remain intact. Interventions: provide incontinence care after each incontinent episode . Observation on 09/25/2020 at 6:35 AM, revealed Resident #45 was awake, laying in bed on her back. The nurse entered room and turned off the tube feeding and disconnected from [DEVICE]. RNA assembled supplies, preparing for incontinent care. RNA put on clean gloves, untaped Resident #45's brief and rolled it aside. She then cleansed Resident #45's front peri area with wet wash cloth and disposable wipes. She assisted Resident #45 to her left side, removed the soiled brief and removed used gloves placing them in trash bin. Without sanitizing her hands, RNA then put on gloves that she removed from her pocket, cleansed Resident #45's peri-anal and buttocks area with wet wash cloth and disposable wipes. She removed used gloves and placed in trash bin. Without sanitizing her hands, she put on gloves that she removed from her pocket and using a dry towel, dried off Resident#45's peri-anal area. She positioned the clean adult brief beneath Resident #45 and secured it. She then adjusted the incontinent pad beneath Resident #45 and adjusted bed linen. She removed used gloves and placed in trash bin in the resident bathroom. At the sink she washed her hands with soap and water for 6 seconds. She put on gloves, cleaned up used supplies, removed used gloves and washed her hands at the sink for 2 seconds. In an interview on 09/25/2020 at 7:00 AM, when asked to describe the policy and procedure for glove changes, RNA said they should wash their hands after removing old gloves and before donning new gloves. When asked why she did not wash her hands, she said she got thrown off this morning and had to keep going back to get more supplies. She said she worked as CNA when extra help was needed. She usually worked on the other hall and was not familiar with Resident #45. When asked why it was important to wash hands after glove removal, she said to prevent cross contamination. When asked how do you wash hands, she said wash for 20 seconds. She said she did not do this the last time she washed her hands. In an interview on 09/25/2020 at 8:10 AM, DON stated she expected the nursing staff to wash their hands before donning gloves and to wash hands when removing gloves after performing dirty task. She expected remove gloves and wash their hands when done. She stated hand washing should take 20 seconds. She stated RNA has been one of the longest working staff members. She has been here for 7 years. She probably just forgot. Record review of the facility's policy and procedure Handwashing/Hand Hygiene, Infection Control Policy and Procedure Manual 2001 MED-PASS. Inc (Revised August 2015) revealed in part; .Policy Statement, this facility considers hand hygiene the primary means to prevent the spread of infections Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .Use an alcohol based hand rub or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. after removing gloves; .8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .Procedure: .Washing Hands-1. Vigorously lather hands with soap and rub them together .for a minimum of 20 seconds (or longer) under moderate stream of running water .Applying and removing gloves-1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time .3. When removing gloves 4. Hold the removed glove .5. Perform hand hygiene. Record review of the facility's policy and procedure Perineal Care, Nursing Services Policy and Procedure Manual for Long-Term Care, 2001 MED-PASS, Inc. (Revised October 2010) revealed in part; Purpose-The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation .Steps in the Procedure- .1. Place the equipment on the bedside stand .2. Wash and dry your hands thoroughly .7. Put on gloves .9. For female resident: B. Wash perineal area 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13. Reposition the bed covers .16. Clean bedside stand. 17. Wash and dry your hands thoroughly . Record review of the website, (http://www.cdc.gov/), Hand Hygiene in Healthcare Settings, Hand Hygiene Guidance, accessed on 09/30/2020 revealed in part: The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient -Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices -Before moving from work on a soiled body site to a clean body site on the same patient -After touching a patient or the patient's immediate environment -After contact with blood, body fluids, or contaminated surfaces -Immediately after glove removal

Based on observation, interview and record review, the facility failed to provide safe environment for 1 of 6 (Resident #118) reviewed for safe environment. The facility failed to ensure scissors, metal nail filer and nail clippers in Resident #118's room were properly secured. This failure placed one resident at risk of injuries and potential environment hazards. The findings include: Resident #118 Record review of Resident # 118's face sheet revealed that she was [AGE] years old. She was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Observation of Resident #118 on 4/24/2019 at 2:20 p.m. revealed resident in bed sleeping. In a rectangular container on her night stand there was scissors and a metal nail file in the container. Observation of Resident #118 on 4/25/2019 at 9:30 a.m. revealed resident was not in her room. The door to her room was open. The open blue rectangular container was still on her night stand which had scissors, metal nail file, and nail clippers in the container. In an interview with the Administrator on 04/25/2019 at 9:42 a.m. revealed that any items that would be a hazard for the resident or the building was not permitted in residents rooms. He said scissors should not be in the resident room. He did not say anything about the nail file or the clippers. Record review of the facility's admission agreement with a revised date of 7/31/2016 revealed in part .The following is a brief list of some restricted items: medications, food, safety hazards, refrigerators, and electrical appliances. Record review of the facilities policy titled Hazardous Area, Devices, and Equipment with a revised date (MONTH) (YEAR) revealed in part .A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to: sharp objects that are accessible to vulnerable residents.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (CR #1) reviewed for supervision. -The facility failed to have a lock or an alarm on an exit door to an outside patio on the second floor and failed to supervise CR #1 who had a [MEDICAL CONDITION], confusion and wandering behaviors and intervene when he sat outside on that patio during 90+ degree heat on 9/16/18. - CR # 1 was on the patio at least one hour and had to be admitted to the local hospital with heat exhaustion/stroke. This was determined to be an Immediate Jeopardy (IJ) that occured inthe past due to the facility having impletmented actions pior to the beginning of the investigation. An Immediate Jeopardy ( IJ) was determined to have existed from 09/16/18 through 09/18/18. The IJ was removed on 09/18/18 because residents no longer had access to the second floor balcony. The facility remained out of compliance at a pattern of actual harm but not immediate jeopardy. This failure affected one former resident and could affect three additional residents who wander placing them at risk for sun burn, dehydration, heat exhaustion and heat stroke. Findings include: Intake # ; Record review of CR # 1's medical records revealed he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR # 1's quarterly MDS assessment dated [DATE] revealed his BIMS was 03 indicating he had severe cognitive impairment. He required extensive one-person assistance for transfers, locomotion on and off unit, dressing, eating, toileting and personal hygiene. He had range of motion impairment on one side, upper and lower extremity. Record review of CR # 1's Care Plans revealed a care plan dated 4/14/18 for Behavioral Symptoms read Resident has poor safety awareness and may be harmful to self r/t hx of TBI, [MEDICAL CONDITION] and cerebral infarction with Approach Remove resident from other residents' rooms and unsafe situations. Record Review of CR#1's care plan dated 4/15/18 for Psychosocial Well-being read, Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs, visual hallucination. An updated care plan on 9/16/18 read, Resident found on balcony alone, unresponsive to verbal stimuli. Abrasion noted to top of head. 911 called, transferred to hosp. The Approach read, Administer medications: [REDACTED]. Monitor and record effectiveness .Maintain a calm environment and approach to the resident .Remove resident form other resident's rooms and unsafe situations. Record review of CR # 1's Progress Notes written by LVN A revealed a note dated 9/16/18 at 6:15 PM which read: Around 2:15p-2:20pm resident observed in TV room. 5pm During meals service, notified by certified staff member (CNA C) resident not in tv area. Instructed aide to look in residents room, she states he wasn't in room. This writer began looking for resident, went to dining room large amount of family from another resident present in dining room. At approximately 5:10 pm-5:15 pm looked outside on balcony observed resident with head leaning against wall face flush unresponsive to verbal stimuli, respirations uneven, with abrasion noted to top of head. Resident transported in and transferred to bed by this writer and certified staff. 5:20 pm assessment initiated blood pressure 116/75 pulse 112 respirations 21, O2 sat 96 on 2 liters per nasal cannula. Residents skin red and warm to touch, respirations rapid equal rise and fall of chest wall, O2 initiated @ 2 liters per nasal cannula, vital signs obtained by staff nurse. Shoes and socks removed cool towels applied to head and feet 911 called with staff CNA prior to assessment this writer took over call to give appropriate report with staff nurse and CNA at bedside. Head. (sic) 911 called information given to dispatch 5:45 pm-5:50 911 arrived treatment by EMT's [MEDICATION NAME] approximately 10-15 minutes. 6:15 pm 911 exited facility. Record Review of the Incident detail report from the EMS dated 09/16/18 revealed that they received the call on 09/16/18 at 17:49 from the facility regarding CR#1. Record review of the hospital Emergency Department Record revealed CR # 1 arrived at theER on [DATE] at 6:33 PM with Chief Complaint of Heat Exhaustion/Stroke. The report further read, EMS reports Pt found by staff in parking lot of facility. Staff unable to report how long Pt was in heat. Pt found with altered mental status and fever. Vital signs read, Temperature F: 104.1, Temperature source: Axillary, Pulse: 51, Respiratory rate: 24, Blood pressure: 114/72. The Glasgow Coma Scale (assessment of alertness and responsiveness) read the Glasgow Coma score was Severe. The report further read CR # 1 was intubated on 9/16/18 at 6:59 PM. The Emergency Notes read, Patient unresponsive; skin hot and dry, breathing even and unlabored. Diaper on Patient soaked with enormous amount of urine and feces. MD made aware. Ice packs applied to patient's body. Body temperature lowered from initial 104 to 102F. Patient prepared to intubation. Skin cleaned . Record review of the accuweather.com website revealed the outside high temperature in Conroe Texas on 9/16/18 was 94 degrees Fahrenheit. Record review of the weather history posted on timeanddate.com/weather/usa/Conroe/historic revealed on 9/16/18 the temperature outside at the facility at 4:53 PM was 92 degrees Fahrenheit. Observation and Interview on 9/18/18 at 12:02 PM of the porch on the second floor of the facility where CR # 1 resided revealed it was a large porch that was accessed through a heavy steel door at the end of one hall. There was no awning or cover of any kind, or shade trees over the porch. There were no windows for staff on the second floor to be able to view the porch from the inside. In an interview with the Administrator at this time he stated that he does not know how CR # 1 got out on the porch. He stated CR # 1 had a stroke and was very weak on one side and he does not see how he could've opened that heavy steel door by himself and wheeled his chair through it. He stated they found CR # 1 sitting in the corner of the porch leaning over with his head against the wall of the building. He stated they started keeping the porch door locked since this incident so no one can go out there without their knowledge. In an interview with LVN A on 9/18/18 at 1:26 PM she stated she was the charge nurse on the 2nd floor on Sunday 9/16/18. She stated it was around 5:00-5:15 PM when she looked outside on the porch and found CR # 1 out there. She stated they brought him in at about 5:20 PM. She stated as soon as they got CR # 1 back to his room and in bed they called 911. She stated he was warm and unresponsive. She stated EMS arrived at 5:45 PM and they left with CR # 1 at 6:15 PM. In an interview with LVN S on 9/18/18 at 2:36 PM she stated she was working on the 1st floor on Sunday 9/16/18. She stated she was summoned upstairs to CR # 1's room around 6:30 PM. Surveyor asked if she was sure about the time. She stated she knows it was at least 6:00 PM because her relief had come in and she was working on her report. She stated it had to be between 6:00 and 6:30 PM when she went up to assist them. She stated CR # 1 felt very warm and she took his blood pressure. She stated she assisted the CNA to get towels on his neck, feet and head. She stated his heart rate was a little high. When asked if she took his temperature, she said she did not take his temperature because she couldn't find a thermometer. She stated she told them to find a thermometer and take his temperature. In an interview with CNA C on 9/18/18 at 2:47 PM she stated on 9/16/18 the last time she saw CR # 1 was in the television room between 2:30-3:00 PM. She stated at dinnertime between 4:30-6:30 PM she couldn't find him and she went downstairs and searched and didn't find him. She stated when she went back upstairs LVN A was bringing CR # 1 back inside from the porch. She stated when she went into CR # 1's room LVN A was taking CR # 1's temperature. She stated she and CNA B and MA W were all working on the hall where all of the resident's rooms are and would not have been able to see CR # 1 go down the hall the porch door. She stated LVN A was sitting at the nurse's station where she could see down that hall and should have been able to see him go outside. In an interview with the Director of Environmental on 9/18/18 at 10:41 AM, he stated that he wasn't there when the incident happened since it happened on Sunday when he was off. He stated the door to the porch on the second floor has always been unlocked. He stated they had alarms on the exit doors that have a mag lock ( magnetic), but that door does not have a mag lock and has no alarm to let staff know if someone has opened it and gone outside. He stated since this incident as far as he knows they are to keep that door locked at all times now. He stated he had seen CR # 1 open that door by himself and go out. He stated that he always comes back in. He stated his office is on that hall so he had seen residents go out on that porch. In an interview with LVN A on 9/18/18 at 12:17 PM she stated she did not see CR # 1 go outside on Sunday (09/16/18). She stated she was not at the nurse's station all afternoon before dinner that day. LVN A stated they make rounds every two hours to check on the residents. She stated the CNAs also make rounds every two hours, but at a different time so the residents are seen and monitored all of the time. In an interview with MA W on 9/18/18 at 11:16 AM she stated she last saw CR # 1 on Sunday 9/16/18 sometime between 3:45 PM and 4:15 PM when she gave him his eye drops. She stated she had never seen him go outside before. In an interview with CNA B on 9/20/18 at 11:30 AM she stated she saw CR # 1 on 9/16/18 at 2:30 PM sitting in the television room. Then she went to do her rounds. She stated at supper time she went downstairs to the kitchen to get something for a resident and when she came back up on the elevator LVN A came up and asked her to help take CR # 1 to his room. She stated she helped them get him into his room and put him in bed. She stated he had blood on his head and on his hand and coming out of his nose. She stated his eyes were closed and he was breathing, but he looked hot. She stated there were two nurses in his room and they told her to call 911 so she did. She stated then LVN A took over the call with 911. She stated she left the room because she had to answer other resident's call lights on the hall. In an interview with LVN J on 9/19/18 at 12:56 PM she stated CR # 1 was confused and wandered. She stated he was able to wheel his wheelchair around with his one good hand and foot. She stated they would find him trying to push doors open and go in the offices and other resident rooms. She stated he would be very confused and talk like he was at work. She stated , He has really bad audio/visual hallucinations. She stated they have a Wandering Book at the nurse's station with each resident who wanders photo and face sheet in it so the nurse's will know who the wanderers are. She stated CR # 1 was in the Wandering Book while he was there. She stated they do not use wanderguards and they have no bed or chair alarms or anything like that. She stated they just have to monitor the confused wanderers more closely. LVN J stated CR # 1 was very weak and she did not think he could open the porch door by himself. She stated that door is very heavy and it opens inward and she did not think he was strong enough to open it and pull his chair around the door onto the porch. She stated she was not there that day and she did not know how he got outside. She stated another resident or a family member may have opened the door. LVN J stated there were currently two additional residents in the facility who wander that they were monitoring more closely. In an interview with Resident # 7 on 9/19/18 at 1:59 PM he stated he sits in the television room for several hours every day with CR # 1. He stated CR # 1 is very confused. He stated he wanders in and out of the television room all day moving his wheelchair with his one good foot. He stated he sometimes will do things like go up into the corner of the room by the television and start knocking on the walls. He stated he thought CR # 1 needed to be in memory care. In an interview with RN A on 9/19/18 at 2:07 PM she stated CR # 1 used to roll around up and down the halls. She stated during the last couple of weeks he's been staying more around the nurse's station. She stated she never saw him go into other resident's rooms. She stated she never saw him try to open doors and she didn't think he could open a door. She stated he would come behind the nurse's station and then could not get himself back out from behind it. Observation of CR # 1 in the ICU unit of a local hospital on [DATE] at 10:18 AM, revealed he was sleeping calmly with his mouth open. The head of the bed was up. He had sensors on his left hand. The monitor above his head read that his blood pressure was 114/89, heart rate was 80, O2 SAT was 99, and respirations were 20. In an interview with ICU RN B at this time, he stated CR # 1 was doing much better and he was ready to be moved out of ICU and into the regular hospital room. In an interview with the DON on 9/20/18 at 1:46 PM she stated they can't provide one on one supervision to the residents in the nursing home. She stated if a resident wants to go outside and stay out there they can't make the resident come back in because they have rights. She stated she didn't feel it was their fault that CR # 1 got heat exhaustion. The DON stated We didn't intentionally hurt (CR # 1). She stated they took immediate steps to prevent something like that from happening again by locking that porch door. Record review of the facility's policy titled Wandering Resident, dated 2001 Med-Pass, Inc., Revised (MONTH) 2014, revealed, The facility will strive to prevent wandering outside facility while maintaining the least restrictive environment for residents who are at risk for elopement .The staff will identify residents who are at risk for harm because of wandering (including elopement). Record review of the Elopement Book at the 2nd floor nurse's station revealed there was information for three residents who wander in the book for monitoring. Record review of the facility's policy titled Routine Resident Checks, dated 2001, revised (MONTH) 2013, revealed, Staff shall make routine resident checks to help maintain resident safety and well-being .1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8-hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 3. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs. 4. The Nursing Supervisor/Charge Nurse shall document any changes in condition reported, including the time, staff that reported the checks, any outcomes of each check and any follow-up assessment completed due to the result of the outcomes reported during the routine check. (Note: CNAs may also record this information and provide it to the Nurse Supervisor/Charge Nurse.) An IJ was determined to have existed from 09/16/18 through 09/18/18. The IJ was removed on 09/18/18 because residents no longer had access to the second floor balcony. The facility remianed out of complaince at a pattern of actual harm that was not an immediate jeopardy. The facility Administrator was notified on 10/02/18 at 4:40 PM that an IJ had occured in the past due to the above failures. Monitoring by surveyor revealed: Observation on 10/02/18 at 9:00 AM revealed the door to the second floor porch was locked and a new keypad lock had been installed on the door. Record review of facility in-service training records revealed an in-service was conducted on 9/17/18-9/19/18 on Resident's Rights, Abuse and Neglect, When to Report and to Whom; an in-service was conducted on 9/18/18-9/19/18 with all RN's and LVN's covering documentation of all vital signs, completing all documentation for a resident discharging to the hospital, and daily shift documentation for all events; and an in-service was conducted on 9/25/18 on Accidents and Supervision: who must record and report accidents; when to report accidents to Administrator, family and MD, Routine checks on residents: who makes rounds, how often, and why; Residents not leaving unit unattended; and State regulations. Interview with LVN J on 10/02/18 at 9:05 AM revealed she stated they had an all-staff meeting she believed on 9/25/18 and covered behavior monitoring. She stated she taught the behavior monitoring piece of the in-service. She stated they covered updating the monitoring book kept at the nurse's station and routine checks and monitoring of resident's who wander. She stated they also covered areas of safety, i.e. the doors to the patio's, both upstairs and downstairs, the stairwells, and the elevators. She stated they also talked about reporting of incidents. She stated the two doors in the dining room downstairs that go out onto the patio are unlocked during daylight hours and locked at night. She stated the door to the patio upstairs is to remain locked at all times. She stated there were currently three residents with wandering behavior in the facility. In an interview with RN C on 10/02/18 at 9:17 AM she stated she was a new employee. She stated she received training on monitoring resident's who wander during orientation when she first started. She stated they had an in-service a little over a week ago regarding monitoring wandering residents and doing a room to room search if they did not immediately find them. She stated they also talked about trying to keep resident's from going out in the heat and if they insist on going out, checking on them frequently and providing water to keep them hydrated. In an interview with LVN G on 10/02/18 at 9:25 AM she stated she usually worked on the 1st floor and they didn't have any residents who wander on that floor. She stated they had in-services on monitoring wandering residents. She stated they were instructed to monitor routinely and keep an eye on their whereabouts and know where they are at and on the security of the doors. In an interview with LVN B on 10/02/18 at 9:34 AM she stated she attended an in-service on wandering residents. She stated they gave them a list of the current wanderers and where to find the binder with their information, the facility protocol, and monitoring residents closely who go outside. In an interview with the Administrator and DON on 10/02/18 at 9:41 AM they stated that they have always monitored their residents and that they cannot provide one on one supervison. They said that they do 2 hour checks on all the residents. When asked how they were monitoring residents that wander and go outside, they said that they are supposed to keep an eye on them. They explained they cannot keep an eye on the residents on the second floor patio if they don't know that they are out there because there are no windows. However, since this incident they are keeping the door to the upstairs patio locked at all times and have put a keypad lock on it. They stated only the Administrator, DON, and Maintenance man have the code to open that door. They stated they are not going to use the upstairs patio anymore. If people ask to go out on that patio they will only allow it with supervision. They stated they have in-serviced staff on supervision, accident prevention, falls, and abuse/neglect including elopement. They stated the receptionist downstairs can see directly out onto the downstairs patio and if she sees someone go out there she is to go out and check on them every 10-15 minutes and see if they are okay and need water etc. In an interview with the MDS Coordinator on 10/02/18 at 11:33 AM she was asked about CR # 1's (MONTH) (YEAR)'s quarterly MDS that read he required extensive one-person assistance with locomotion on and off unit even though staff stated he could self-propel in his wheelchair with one arm and one foot. She stated based on her personal experience with CR # 1, he could use that one hand and one leg to move, but at times he needed help and would ask for assistance. She stated he would have periods when he couldn't move himself or he would not be able to get over the rubber strip across the doorway. She stated she was gone from the facility for a period and another MDS nurse who was no longer there did the (MONTH) quarterly assessment. She stated they take the functional status on the MDS from the P[NAME] documentation from the CNAs. She stated they had in-services on wandering and elopement. She stated when someone wants to elope or wander they just want to get out and get away from everything. She stated a resident who wanders is confused and usually just needs redirection. In an interview with CNA K on 10/02/18 at 11:45 AM she stated she didn't know CR # 1 as she had just been moved to work on the second floor of the facility. She stated she attended in-services regarding residents wandering. She stated they are to watch them closely and redirect them. She stated they instructed them to try to talk them out of going outside when it's hot or bring them back in. In an interview with MA W on 10/02/18 at 11:53 AM she stated they had in-services on residents who wander and talked about checking on them frequently. She stated the in-services did help. She stated CR # 1 only wandered a little of the time off and on, not a lot. MA W was observed at this time walking the hall with Resident # 8 who wanders, had anxiety, and was wheeling herself back and forth up and down the hall. Interviews with five nursing staff on 10/02/18 concerning the effectiveness with recent training's revealed the staff were very knowledgeable concerning the process for supervision and monitoring of residents with confusion and wandering behavior, monitoring and supervision of residents going outside during hot weather, and when to report incidents to the Administrator, DON, family and the attending physician. In an interview with the Administrator on 10/02/18 at 2:07 PM he stated they have QA meetings once a month. He stated they had one scheduled on 9/19/18, but cancelled it because the surveyor was in the building. He stated they usually discuss any incidents like this during their morning meetings. He stated they did have a meeting about this incident and conducted training about monitoring residents who wander and monitoring residents who go outside during hot weather. Record review of an Abaqis document on Adequate Assessment/Supervision provided by the Administrator revealed meeting notes dated 9/17-10/02/18 to discuss Accidents and Adequate Assessment/Supervision, To ensure staff assess and monitor patients location in the facility per the center's policy and procedure and follow the plan of care set forth by the IDT team without infringing on the rights of the resident. The document further read the IDT team was to meet weekly with members: Administrator, Director of Nurses, Medical Director, Department Heads, and Therapists with target date of 11/21/18. Interventions read that the main door to 2nd floor balcony would remain locked at all times, a weekly audit of unplanned discharges to the hospital, a weekly audit of events, status change, and in-service on Assessment/Supervision with all licensed nurses. Meeting notes dated 10/02/18 read, Immediate discussions of assessment and monitoring concerns that could possibly be for patients at risk for wandering currently were discussed again with a possibility of adding them to the MAR indicated [REDACTED]. According to the DON there were 3 residents that were wanderers currently in the facility.