Every finding on record at The Heights of League City

Based on interview and record review, the facility failed to ensure each resident has the right to be free from physical or mental abuse, neglect, misappropriation of resident property and exploitation for 1 of 2 (Resident #1) reviewed for abuse. The facility failed to protect Resident #1 from physical abuse when Resident #2 hit Resident #1 across the face on 07/28/26 at approximately 5:38pm. The facility failed to ensure Resident # 2 remained on 1:1 supervision after 1:1 supervision was initiated on 07/28/2026 at 9:43 am. These failures placed residents at risk of being in an unsafe environment causing residents to be vulnerable and unprotected. Findings included: 1.Record review of Resident #1's face sheet dated 08/18/2026 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included anxiety disorder (a mental health condition where every day worry or fear does not go away and is much stronger and lasts much longer than normal stress), Hypertension (the force of blood pushing against blood vessel walls is too high all the time) and age related cognitive decline (natural and gradual slowing of brain function that happens as people gets older). Record review of Resident #1's quarterly MDS assessment dated [DATE], section C0500 (Cognitive Patterns) revealed a BIMS score of 13 that indicated cognitive function was intact with normal memory and thinking. Record review of Resident #1's care dated 08/14/2026 indicated Resident #1 had self-care deficit (date initiated 02/14/2026) related to cognitive and physical limitation with interventions for care to be provided with 1 person assist for bathing, dressing, grooming, eating, drinking and a wheelchair for mobility. 2. Record review of Resident #2's face sheet dated 08/18/2026 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included impulse disorder (a mental health condition where a person cannot resist strong urges to do things that might hurt themselves or others), anxiety disorder (a mental health condition where every day worry or fear does not go away and is much stronger and lasts much longer than normal stress) and Diabetic Retinopathy without macular edema: left eye (an eye condition caused by high blood sugar that damages the tiny blood vessels in the back of the eye, but without causing swelling in the central part of your vision ) Record review of Resident #2's quarterly MDS assessment dated [DATE], section C0500 (Cognitive Patterns) revealed a BIMS score of 06 that indicated severe cognitive impairment. Section E0200 B (Behavior) indicated verbal behavioral symptoms directed towards others occurred 1 to 3 days. Record review of Resident #2's care plan dated 07/16/2026 indicated Resident #1 had vascular dementia, cognitive impairment, anoxic brain injury, and sequelae of CVA resulting in impaired cognition, poor judgment, impulsive behaviors, agitation, verbal aggression, mood disturbance, and dependence on caregivers with intervention to keep routine consistent to decrease confusion. Record review of Resident #2's progress noted 07/27/2026 at 5:25am revealed Resident #2 wanted to kill himself and stated he did not have a reason to live, was violent and tried to hit nurse. Phone call was made to on-call service who instructed nurse to send Resident #2 to hospital for evaluation. Progress note dated 07/27/2026 at 2:10 pm revealed Resident #2 returned from hospital without any new orders. Progress note dated 07/28/2026 at 9:43am read in part .ADON contacted Psychiatrist and notified of patient behavior and hospital transfer. Patient placed on 1:1 monitoring until the psychiatrist evaluates and states patient is safe. Further record review of Resident #2's progress notes revealed: - On 05/07/2026 at 08:16 pm - read in part .Resident #2 was aggressive and disruptive during shift, yelling, cursing at staff, and calling staff derogatory names including bitches, assholes and told nurse to kiss his ass. Resident continued argumentative and hostile behavior. On 05/12/2026 at 04:28am - read in part .Resident noted with continued aggressive, disruptive, and verbally abusive behavior toward staff throughout shift. Resident repeatedly yelling loudly from room, calling staff inappropriate names including bitches and demanding immediate attention from CNA staff in an aggressive manner. Resident continued yelling and making aggressive statements toward staff despite redirection and reassurance attempts. Roommate expressed fear and discomfort related to resident's ongoing aggressive behaviors and repeatedly requested room change due to feeling unsafe and unable to rest. On 06/10/2026 at 6:36 am - read in part .resident yelling and screaming.The resident stated, I am about to slap my roommate because he keeps talking to me. Writer removed and escorted him to the tv room to help him calm down. On 06/23/2026 at 11:15 pm - read in part .Resident became violent and combative with Nurse. Punched me three times in the chest after I tried to reeducate him on the importance of the life vest. While the bp cuff was on him he hit me 3 times, yelling profanities at me and telling me to get out of his room and get away from him. CNA stated he was yelling profanities at her and trying to take the vest off. On 08/18/2026 at 10:15am, Regional DON stated Resident #2 was sent to behavior hospital on 7/29 and has not returned. During a phone interview on 08/18/2026 at 12:52 pm, DA C stated he was coming out of the dining room into the hallway with the meal cart when Resident #1 was propelling herself in her wheelchair and was about to turn the corner when Resident #2 came fast in his wheelchair from behind and tried to past Resident #1 without waiting for Resident #1 to move aside. DA C stated both residents started arguing as to who was to go first. DA C stated Resident #2 hurled profanity towards Resident #1 and asked to move. Resident #1 stated she was stuck and was unable to move due to the tight spot. DA C stated Resident #2 tried to roll by Resident #1 and bumped into her w/c. Resident #1's right wheel and Resident #2's left wheel collided. DA C stated everything happened very fast when Resident #2 reached his left arm and hit the right side of Resident #1's face. DA C stated he immediately called for the nurse and they came to break it up. DA C stated he saw some red marks on Resident #2's face and nose right at that time. DA C stated he then left the area to deliver the meals cart to the halls. During an interview on 08/18/2026 at 1:15pm, Resident #1 stated she rolled out of the dining room like she always did and somehow Resident #2 who was in his wheelchair came very close to her and asked her to move. Resident # 1 stated she asked Resident #2 to stop so that she could get out of the way. Resident #2 used profanity and told her to get out of the way. Resident # 1 stated Resident #2 rammed into her wheelchair from behind, yelled at her and punched her on the right side of her nose before she knew it. Resident #1 stated a kitchen staff witnessed it and called the nurse. Resident #1 stated the police came and took her statement. Resident #1 stated the nurses came and hugged her and consoled her. Resident #1 stated she was shocked when it happened because no has hurt her since she lived at the facility. During a phone interview on 08/18/2026 at 2:05 pm, LVN S stated she was the nurse for Resident #1 on 07/28/2026. LVN S stated she was caring for another resident when the altercation occurred. LVN S stated Resident #1 was crying and was brought back to her room. LVN S stated she did a head-to-toe assessment and did not observe any redness or swelling on Resident #1's face. LVN S stated Resident #1 refused to go to the hospital for evaluation. LVN S stated she stayed with Resident #1 in her room until Resident #1 calmed down. During a phone interview on 08/18/2026 at 2:54 pm, LVN K stated she was the nurse for Resident #2 on 07/28/2026. LVN K stated she heard Resident #1 stating He hit me. LVN K asked Resident #1 who hit her. LVN K stated she saw Resident #2 rolling out in the hallway. LVN K asked Resident #2 if he hit Resident #1 and Resident #2 just looked at LVN K and rolled off in his wheelchair. LVN K stated she assessed Resident #2 and did not observe any injuries. LVN K stated the ADON took over and called 911. LVN K stated Resident #2 went outside to his usual place. LVN K stated Resident #2 did not have any other interaction with other residents. During an interview on 08/18/2026 at 3:32pm, the ADON stated that was the first time she heard Resident #2 was having a behavior and was surprised that he hit Resident #1. The ADON stated Resident #2 was not on her assignment, but she called 911 right away to send to hospital. The ADON stated Resident #2 refused to go to hospital and denied anything happened. The ADON stated both residents were immediately separated and both were assessed by EMS. ADON stated the facility called behavior hospital and got a bed placement for transfer. The ADON stated Resident #2 was not returning to the facility as the behavior hospital found a better placement for Resident #2 based on his behavior. During an interview on 08/18/2026 at 4:16pm, the Regional DON stated Resident #2 was normally calm but gets upset sometimes. The RDON stated they did 1:1 with Resident #2 after the incident and was transferred to behavior hospital on 7/29/2026. The RDON stated both residents were separated, completed head-to-toe assessment, informed family, informed the MD, and initiated referral for behavioral hospital for Resident #2. The RDON stated Resident #2 remained on 1:1 supervision until he was transferred to behavioral hospital on [DATE]. The RDON stated on 7/27/26 Resident #2 stated he wanted to kill himself; he was sent to hospital around 6am on 7/27/2026 and returned at 2:10pm. The RDON stated Resident #2 was on 1;1 supervision until psych evaluation and stated he was safe. The RDON stated Resident #1 was assessed and referred to psyche services to assess her emotional status after the incident. The RDON stated she was not sure if Resident #2 was coming back. The RDON stated her expectations are for nurse to immediately separate the residents, make sure all residents are safe, notify the MD, notify family and notify the ADM as he is the abuse coordinator. During an interview on 08/18/2026 at 6:00pm, the ADM stated Resident #2 was aggressive toward staff but not with other residents and was being seen by psych services. The ADM stated Resident #2 was pleasant and he was surprised that he hit Resident #1. The ADM stated Resident #2 was on 1;1 supervision the same day (07/28/2026) and the next day (07/29/2026). The ADM stated Resident #2 was sent to hospital on [DATE] because of statement about killing himself but was sent back to the facility after a few hours when it was determined by hospital MD that he was not a threat. The ADM stated he conducted a safe survey and nothing negative was indicated in the safe survey. The ADM stated Resident #1 stated she feels safe, did not voice any concerns and the family did not have any concerns. Record review of facility's policy titled Abuse Guidance: Preventing, Identifying and Reporting revised on January 2025 read in part .Every resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents should not be subjected to abuse by anyone, including, but not limited to, community team members, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Types of abuse: Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort for 1 of 4 residents (Resident #1) reviewed for PASRR. The facility failed to coordinate and submit a complete and accurate request for specialized services in the LTC Online Portal within 20 business days after the date of the IDT meeting for Resident #1 within the time frame set by PASARR or asked for guidance from PASARR support when the form was not accepted. This failure could place residents requiring PASRR services at risk of not receiving their specialized services and met by the facility. Findings;- Record review of Resident #1's face sheet dated 07/23/2026 indicated Resident #1 was a [AGE] year-old female admitted to the facility on 01/13//2026. Her diagnoses included thrombocytopenia (a medical condition where there is lower-than-normal number of platelets (tiny blood cells that stick together to form clots and stop bleeding) in the body), cerebral palsy (a lifelong condition that affect the body's movement, muscle control, balance and posture caused by damage in the brain) and aphasia (a brain related communication disorder causing trouble speaking, understanding speech, reading or writing). Record review of Resident #1's most recent quarterly MDS dated [DATE] indicated Resident #1 had unclear speech, was rarely/never understood and rarely/never understands most conversations. Resident #1 has a BIMS score of 7 indicating severe cognitive impairment and was dependent for all ADL's and care. Record review of a care plan last revised on 05/15/2026 indicated Resident #1 had a self-care deficit (date initiated 1/14/2026) related to cognitive and physical limitation with interventions for care to be provided with 1 person assist for bathing, bed mobility, turning and positioning, dressing, grooming. eating, drinking, incontinent care and personal hygiene. Resident #1 had a communication problem that needs time to gather thoughts/ words (date initiated 05/15/2026) with interventions to anticipate and meet her needs, ensure environment is suitable for adequate hearing and understanding. Resident #1 is considered PASRR positive for Development Disorder (date initiated 07/23/2026) with interventions to coordinate her plan of care with her Service Coordinator as indicated, and to report any need to re-evaluate specialized services and/or plan of care to service coordinator as indicated. Record review of Resident #1's physician orders dated July 2026 indicated Resident #1 had an order dated 03/23/2026 for PT to evaluate and treat as indicated under PASRR; PT clarification order: PT 2 times/week for 6 weeks. Treatment may include: therapeutic exercise, therapeutic activities and neuromuscular reeducation. Order dated 05/04/2026 for PT clarification order: PT 2 times/week for 6 weeks under PASSR services. Treatment may include: therapeutic exercise, therapeutic activities, neuromuscular re-education. Order dated 06/17/2026 for PT clarification order: PT 2 times/week for 6 weeks under PASSR services. Treatment may include: therapeutic exercise, therapeutic activities, neuromuscular re-education. Order dated 03/23/2026 for OT to Eval and treat as indicated for PASRR habilitative services; OT Clarification Orders for 3xwk x 6wks for ADL training, therapeutic exercise, therapeutic activities and neuromuscular reeducation. Order dated 05/04/2026 for OT Recertification orders for habilitative PASRR services for 3xwk x 6wks for ADL training, therapeutic exercise, therapeutic activities, neuromuscular re-education. Order dated 6/18/2026 for OT Recertification Orders for 3xwk x 6 wks for habilitative PASRR program for ADL training, therapeutic exercise, therapeutic activities and neuromuscular re-education. Review of Resident #1's medical records revealed Resident #1 had a PASRR Level 1 screening completed by the hospital RN on 01/09/2026 indicating a YES for Developmental Disability. Resident #1 had another PASRR Level 1 screening dated 01/13/2026 indicating a YES for Intellectual Disability and YES for Developmental Disability. Further review of Resident #1's medical record revealed a PASRR evaluation was completed by a PASRR Evaluator on 02/12/2026. Review of Resident #1's medical records revealed a PCSP form for an initial IDT/SPT meeting dated 03/20/2026. Attendees at the meeting were the Local Authority for Intellectual and Developmental Disability, the MDS nurse, the facility RN, the facility nursing staff, Resident #1 and her 2 responsible parties. The Nursing Facility Specialized Services indicated a Customized Manual Wheelchair, Specialized Assessment Occupational Therapy, Specialized Assessment Physical Therapy, Specialized Occupational Therapy and Specialized Physical Therapy. The IDD Specialized Services indicated Habilitation Coordination and Independent Living Skills Training. The LA-IDD Specialized Services comments indicated, All PASRR specialized services were offered and resident agreed to Hab Co., ILS, CMWC, OT and PT. Further record review revealed a second PCSP form for the Local Authority Update was held on 05/29/2026 and indicated, Hab Co, participated in LA Updated/Revision meeting by telephone due to COVID. MDS requested meeting to resubmit the NFSS form due to delay in obtaining physician signature. Resident agreed to ongoing services of Hab Co, ILS, OT, PT and ST. During an interview on 7/23/2026 at 11:35am the Regional MDS Nurse (RMN) stated when a new resident is admitted to the facility, the MDS nurse will look at the PASRR provided by the referring entity and compare it with the diagnosis of the resident. The RMN stated if there was a qualifying diagnosis the MDS nurse will enter it in the PASRR Level 1. The RMN stated the MDS nurse has 7 days to do a PL1. Then the MDS nurse will wait for the IDT meeting to take place to determine if the resident qualifies for specialized services. If the resident qualifies, the MDS nurse will submit a PCSP form in the SimpleLTC portal after the IDT meeting. The RMN stated if there were any recommendations indicated during the IDT meeting, the MDS nurse must submit a NFSS form within 20 days after the IDT meeting. The RMN stated after the NFSS form has been filed, the MDS nurse will follow through in the portal to address any further inquiries regarding the application. The RMN stated if the resident did not have a payor source and was a Medicaid-Pending resident, the facility will wait for the Medicaid approval for specialized services such as specialized wheelchair which the facility was unable to provide. The RMN stated a Medicaid-Pending resident will be provided with therapy services. The RMN stated if the resident was on Medicaid, the facility will follow the recommendations once the NFSS is approved and will start services per the recommendations. The RMN stated if the NFSS was rejected, the MDS nurse will find out what the rejection was about and will follow through with any corrections needed. The RMN stated she will need to review the RAI manual to confirm the time frame required to resubmit the paperwork. The RMN stated Resident #1 started the therapy services due to her Medicaid status pending approval. During an interview on 07/23/2026 at 1:09 pm, The RMN stated the MDS nurse that was working on Resident #1's application had abruptly quit and did not follow through with the PASRR process. The RMN stated the previous MDS nurse submitted the NFSS but did not follow through. The RMN stated another MDS nurse was hired but had also quit. The RMN stated she was currently helping the new MDS nurse that was hired a month ago. During an interview on 07/23/2026 at 4:13pm, The RMN stated Resident #1's PL1 was completed on 01/13/2026, the PE was completed on 02/12/2026 and the IDT meeting was completed on 03/20/2026. The RMN stated a NFSS form was not submitted because the previous MDS started the process but did not submit the form into the portal. The RMN stated the facility received an email on 05/20/2026 from HHSC stating they have not received the NFSS form. The RMN stated the facility rescheduled an IDT meeting on 05/28/2026 and uploaded the form into the portal but have not submitted it because it was not going through due to Resident #1's Medicaid-Pending status. The RMN stated Resident #1 was admitted to the facility in January 2026 as a skilled patient and received therapy services until 02/16/2026. The RMN stated the facility resumed therapy services on 03/23/2026 after the PCSP meeting. The RMN stated the facility had implemented a Plan of Correction on 07/10/2026 due to the missed PASRR guidelines and regulations. A phone call was placed to the MD on 07/23/2026 at 7:00pm with no answer. The facility's policy on PASRR guidelines and regulations were requested from the Administrator upon entrance on 07/23/2026 at 9:25am. A policy was not provided at exit. A policy on Specialized Rehabilitation Services was provided instead.

Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferencesfor 1 of 4 residents (Resident #1) reviewed for pain management. The facility failed to administer prescribed pain medication and adequately address Resident #1's complaints of pain. As a result, Resident #1 experienced unrelieved pain, and left the facility AMA on 3/28/2026 due to the facility's inability to provide pain management as requested. This failure could place the residents at risk of a decrease in quality of life due to pain. Findings included: Record review of a face sheet dated 4/23/26 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included multiple sclerosis (a condition where the body's defense system mistakenly attacks the protective coating around the nerves in the brain and spinal cord), chronic pain and acute respiratory failure (a sudden inability to breathe well enough to get oxygen into the body or remove carbon dioxide from it). Record review of Resident #1's BIMS score assessment dated [DATE] revealed resident had a BIMS summary score of a 15 (cognitively intact). Record review of Resident #1's care plan dated 4/23/26 indicated the resident had a risk of experiencing discomfort or pain. Intervention included to administer Resident #1's medication to relieve her pain as recommended by her doctor. Record review of Resident #1's physician orders revealed order dated 3/26/26 for Hydrocodone-Acetaminophen 10-325mg (medication to treat moderate to severe pain tablets to be given by mouth every 4 hours as needed for moderate pain. Baclofen 10 mg. Give 3 tablet by mouth three times a day for Muscle spasms. Gabapentin 600 mg by mouth three times a day for nerve pain Record review of Resident #1's MAR dated 4/23/26 revealed Resident #1 was administered one Hydrocodone-Acetaminophen 10-325mg tablet on 3/27/26 at 10:45 p.m. in response to a reported pain level of 5 out of 10. Further review indicated that no additional pain medication was administered prior to the resident leaving the facility AMA on 3/28/2026. During an interview with Resident #1 on 4/23/26 at 11:52 a.m., Resident #1 stated she left AMA due to dissatisfaction with pain management. Resident #1 stated the facility was unable to administer her pain medication as requested. She stated her established routine, including under hospice care, was to take her scheduled morning medications concurrently with her prescribed pain medication which was Hydrocodone - Acetaminophen 10-325mg. Resident #1 stated she informed LVN A her routine, however the nurse declined to administer the pain medication at that time, indicating that she had already received her morning medications and would need to wait several hours before receiving the pain medication. Resident #1 stated at that time, she was experiencing pain greater than 5 out of 10. She further stated the delay in her pain medication administration increased her pain and frustration. She stated due to unrelieved pain and inability to receive pain management consistent with her established routine, she elected to leave the facility AMA on 3/28/26 to manage her pain at home. She also stated she has a history of chronic pain managed through Hospice services and was just admitted to the facility for short time respite care on 3/26/26. During an interview with MA B on 4/24/26 at 1:48 p.m., she stated she administered Resident #1's scheduled medications on the morning of 03/28/2026. MA B stated when Resident #1 later requested PRN pain medication, she notified LVN A, as medication aides do not administer PRN medications. MA B stated she was unaware why LVN A did not administer the PRN pain medication to Resident #1. She expected LVN A to administer the PRN Hydrocodone to Resident #1 as ordered by the doctor. MA B said that the potential outcome of not administering prescribed pain medication as ordered by the doctor, would place the resident for increased pain, unmet pain management needs, and constitute substandard care. During an interview with LVN A on 4/24/26 at 1:55 p.m., she stated that she had two interactions with Resident #1 prior to the resident leaving AMA. She stated Resident #1 requested that her medications including Hydrocodone, Gabapentin (medication used to treat nerve pain) and Baclofen (medication use to treat muscle spasm - when muscles are tight or stiff), be administered together according to her home routine. LVN A stated she declined to administer Hydrocodone at that time, stating that Resident #1 had already received morning medications which included Gabapentin, and Baclofen. Resident #1 would need to wait for 2 to 4 hours to receive another pain medication to align with safe medication practice, as hydrocodone was ordered PRN every four hours. She stated she believed Gabapentin and Baclofen were pain medications and administering Hydrocodone would be excessive for Resident #1. She said that the last time Resident #1 received Hydrocodone was on 3/27/26 at 10:45 p.m. She stated the potential outcome of not administering prescribed pain medication as ordered could result in increased pain, failure to meet the resident's pain management needs, and substandard care. During an interview with DON on 4/24/26 at 2:20 p.m., she stated when she was notified that Resident #1 intended to leave the facility AMA, she immediately arrived at the facility to meet with the resident. Resident #1 reported she was leaving the facility due to LVN A's refusal to administer her prescribed pain medication, and the facility's inability to follow her establish pain management routine. The DON stated she attempted to intervene and offered to administer the PRN Hydrocodone, noting the last dose was given on 3/27/26 at 10:45 p.m., however Resident #1 declined and proceeded to leave the facility AMA. The DON stated LVN A could have administered the PRN medication as ordered or contacted the physician for further guidance. The DON stated failure to provide prescribed pain management constitutes substandard of care and it may result in continued, unrelieved pain for the resident. Review of the facility's policy Pain Management, dated 3/14/2019 and revised on January 2025, read in part .The goal of the community Pain Management Program is that pain is identified and treated timely, effectively and consistently.

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 4 residents reviewed for notification of changes. 1. On [DATE], LVN B and LVN C failed to notify the physician when CR#1 had a significant change in condition where he refused all meals, had increased drowsiness, and had hypotensive BP readings of 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m. 2. On [DATE], CR#1 was sent to the hospital due to unresponsiveness and was placed in ICU. He required several rounds of CPR and was diagnosed with a blood infection, septic shock, and suffered an acute stroke.On [DATE] at 1:47 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated and due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or infection, stroke, or death. Findings included:Record review of CR#1's face sheet, dated [DATE], documented a [AGE] year-old male, admitted [DATE]. His admitting diagnoses were Type 2 Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), presence of cardiac implants and grafts (cardiovascular surgery where artificial devices were inserted), morbid severe obesity due to excess calories, hypertension (high blood pressure), cerebral infarction (stroke), and he was a full code (a medical directive indicating that in the event of a cardiac or respiratory arrest, all possible life-saving interventions)Record review of CR#1's care plan, dated [DATE], documented CR#1 had chronic health issues and comorbid conditions that may further affect his quality of life. Interventions stated to monitor vital signs and report all changes in condition to a doctor.Record review of CR#1's vital signs on [DATE], MA B documented CR#1's BP was 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m. Record review of CR#1's CIC assessments documented no CIC assessment completed on [DATE]. Record review of CR#1's progress notes dated [DATE] revealed no documentation that CR#1's the physician had been notified regarding a change in condition. Record review of CR#1's progress note dated [DATE] at 10:53 a.m. created by LVN A, revealed that upon entering CR#1's room, he appeared asleep with minimal communication. CR#1 did not attempt to eat breakfast, he was barely responsive, and clammy to touch. Record review further revealed LVN A noted CR#1's BP to be low at 75/54 and he was unresponsive to a sternal rub. Record review revealed the resident was sent out due to an acute change in condition, hypotension (abnormally low blood pressure below 90/60 that indicates blood if not flowing adequately to the organs), increased work in breathing, and unresponsiveness. EMS was called, provider (a licensed person or organization that provides health care services such as doctor or NP) notified, DON notified, and family made aware of discharge.During an interview on [DATE] at 9:05 a.m., the PMD stated CR#1 was found unresponsive to a hard sternal rub (an emergency medical technique used to assess a patient's responsiveness by applying firm, grinding pressure with knuckles to the center of the chest or sternum) and his BP reading was low. The PMD stated CR#1 had vomit around his mouth and he looked like he had been deteriorating for hours. He stated that CR#1 technically passed away twice in the hospital but he was resuscitated.During an observation and interview on [DATE] at 9:35 a.m., CR#1 was seen intubated in the ICU. He could not open his eyes, but he raised his eyebrows when his name was called. The HRN stated CR#1 was admitted due to unresponsiveness and they had to do three rounds of CPR because his heart stopped. On [DATE], CT (an imaging test that helps healthcare providers detect diseases and injuries) and MRI (a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body) scans results showed that he had an infarct (presence indicates a disruption in blood flow to the brain, leading to cell death). The HRN stated cultures were also taken and results showed that he had an infection in the blood. The HRN stated CR #1 was currently sedated but was responsive to pain, tried to open his eyes to speech, and his pupils reacted to light. The FM, who was in the room, stated CR #1 wiggled his toes the day before. During an interview on [DATE] with HNP at 10:02 a.m., she stated that CR#1's hospital documentation revealed that he was found positive for a blood infection (still awaiting detailed results), septic shock, mucus in his lungs, and CT scans revealed he suffered an acute stroke. When they checked his blood sugar, it was 63 and the normal range should be above 70. The HNP stated she could not state which diagnosis was responsible for his unresponsiveness, but stated it was caused by many factors. During an interview on [DATE] at 10:06 a.m., CR#1's FM stated CR#1 suffered a stroke over a year ago that affected his mobility but his mind was very sharp. She stated she was grateful LVN A went back to check on him inside his room at the nursing facility and stated, LVN A probably saved CR#1's life. During an interview on [DATE] at 12:17 p.m., LVN A stated that she worked on [DATE] from 6:00 a.m.- 6:0 p.m. LVN A stated that when she arrived on shift LVN C informed her that CR#1 slept throughout the night and he would respond that he was ok but seemed really tired. LVN A stated when she on CR #1, she knew something was different because he was usually alert and oriented x3-4 (alert and oriented to person, place, time, and situation) and he was able to communicate his needs but he was drowsy and barely spoke. She stated his breakfast tray was untouched and that was unlike him. LVN A stated a medication aide and LVN A agreed CR #1 looked clammy, BP was low, and his blood sugar was 77. LVN A stated 911 was called and he was still unresponsive upon arrival of EMT. LVN A stated EMT replaced his CPAP (keeps your airways open while you sleep so you can receive the oxygen you need) with a non-rebreather mask (used for patients needing high-flow oxygen, such as in severe respiratory distress, trauma, or emergencies) and CR #1 was taken to the hospital. During an interview on [DATE] at 12:23 p.m., CNA D stated he worked from 6:00 a.m.- 2:00 p.m. on [DATE]. He stated CR#1 normally liked to play on his computer but he did not play on it on [DATE] and slept the majority of the day. CNA D described CR#1 as very sleepy and stated CR #1 did not eat breakfast or lunch aside from one cup of vanilla pudding. He stated he told the floor nurse but could not remember her name or if the floor nurse took action. During an interview on [DATE] at 12:59 p.m., the NP stated she did not receive a call directly on [DATE] because they have on call services where the providers in her group take turns answering. She stated that a BP reading of 86/57 or 89/59 was very concerning and staff nurses should not try to do anything without speaking to the doctor. She stated that if CR #1 had symptoms of not eating all day, tired, with low blood sugar, she would have sent him out to the emergency room. Additional questions were asked to the NP, but she refused to answer questions and stated she did not want to continue the interview with the surveyor. During an interview on [DATE] at 1:19 p.m., CNA E stated that she worked from 6:00 p.m. - 6:00 a.m. on [DATE]. She stated CR#1 was out of it on [DATE] and he barely said two words to her. She asked him if he was ok because he did not seem like himself because he slept the majority of her shift when he usually would stay up late and play on his computer. CNA E stated she communicated with LVN C about CR#1's condition and they checked on him several times throughout the night. CNA E stated she asked CR#1 if he was ok or if he needed water. CNA E stated CR#1 did not verbally communicate with her at all and only shook his head in response to questions. She stated CR #1's eyes were closed when she spoke to him and his breathing seemed heavy. CNA E stated that it was strange that CR#1 slept the majority of the night because he normally would not go to sleep until her shift was over (around 6 a.m.). During an interview on [DATE] at 1:33 p.m., MA A stated she worked from 6:00 a.m.- 2:00 p.m. on [DATE]. MA A stated when she took CR#1's BP that morning, his BP read 113/74 and he was fine. He took his medication without refusals and nothing seemed out of the normal. She explained that if his BP was outside the parameters of 110-120 systolic and 70-85 diastolic (Systolic blood pressure (top number) measures the maximum force against artery walls when the heart beats (contracts). Diastolic blood pressure (bottom number) measures the minimum pressure in arteries as the heart rests between beats), she would hold his medicine and tell the nurse. During an interview on [DATE] at 1:51 p.m., MA B stated he worked on [DATE] from 2:00 p.m.- 10:00 p.m. MA B state CR#1's BP was low on [DATE] and he had to hold his BP medicine. He stated that he told the nurse (unknown) but could not say which nurse or what their name was. MA B stated the nurse had no response when he informed her, restating that he was not sure what she said, then stating he did not know. MA B stated that CR#1 was sleeping and a little quite on [DATE], but otherwise no problems. During an interview on [DATE] at 3:03 p.m., LVN B stated she worked from 6:00 a.m. - 6:00 p.m. on [DATE]. She stated she did not receive any notifications from the CNAs or MA who worked [DATE] that CR#1 had low blood pressure and had not eaten. She stated she was very upset because if she would have known she would have called his provider to see what needed to be done. She stated that a systolic of 86 was very low and stated, Why would they not say anything!During an interview on [DATE] at 5:03 p.m., LVN C stated that she worked from 6 p.m.- 6 a.m. on [DATE]. LVN C stated that she checked on him several times throughout the night and she asked him if he was ok, he would say yes or nod his head. He was a very chatty person, but he did not talk during the night so she did not notice a change in his behavior. She stated that CNA D told her that CR#1 had not eaten breakfast or lunch but he stated that he told LVN B about his behavior. She had no knowledge of low BP readings from MA B. If she had known he had a low BP, she stated she would have reached out to the provider immediately.During an interview on [DATE] at 10:31 a.m., the DON stated when MA B identified CR#1 had low blood pressure on [DATE], he should have notified the nurse immediately and staff had been educated previously on what to do when there was a change in condition with a resident. The DON stated CNAs and MAs were expected to provide verbal updates to the nurses and nurses would notify the provider of changes, complete the documentation, and she would oversee it. She explained the chain of command went from CNAs/MA, to nurse, and to herself. The DON stated that per the policy, the provider should be informed of all significant changes. Record review of the facility's policy titled, Change in Resident Condition, revised 01/2023, documented when there was significant change in the resident's physical, mental, or psychosocial status, the medical provider should be contacted.This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:47 p.m. The Administrator, DON, and ADON were notified. The Administrator and DON was provided with the IJ templated [DATE] at 1:47 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 10:00 a.m. It was documented as follows:F 580 Notify of ChangesThe facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).Situation: Resident # 1 was discharged to the hospital on [DATE]. Director of Clinical Operations/ Regional Nurse identified medication aide #1 and immediately removed medication aide #1 from his assignment pending receiving of in serviced training regarding Medication Administration, Reporting of Abnormal vital signs to his charge nurse, Abuse/Neglect and Residents Rights -conducted by Director of Clinical Operations/ Regional Date Completed: [DATE] Director of Clinical Operations/ Regional and Administrator counseled medication aide #1 and a performance written action completed r/t medication aide #1's failure to ensure proper reporting of the low blood pressure readings to his charge nurse on [DATE]. Certified medication aide #1. Conducted by Director of Clinical Operations/ Regional and Administrator.Director of Clinical Operations/ Regional Nurses provided immediate re- education to all licensed nurses on the following: The expected process for: 1. Immediately evaluating/assessing resident upon a suspected or identified change in condition is noted. 2. Documenting nursing findings to include but not limited to evaluation of vital signs and utilizing the appropriate Change in Condition User Defined Assessment and/or Nursing Progress Note to ensure proper documentation is noted within the medical record. 3. Nurse to promptly report the identified change in condition (exception of usual baseline status) to the Medical Provider in order to ensure appropriate interventions are provided and carried out as ordered/recommended. 4. Nurse to ensure that appropriate notification is made to the resident's representative. 5. The Nurse is expected to ensure that all appropriate documentation to reflect 1-4 are noted with the electronic health record. 6. The Nurse should review the vital sign form (vital signs taken by certified medication aide) to ensure that any abnormal vital signs have been reviewed by the nurse with appropriate re-assessment and interventions to include the licensed nurse conducting the evaluation/assessment, notification to the Medical Provider, carrying out any recommended or prescribed medical interventions and notification to the resident's representative promptly, and ensuring all is documented within the electronic health record. 7. The nurse will ensure that all identified changes in condition or suspected changes in condition will be reported to the on-coming nurse to ensure appropriate 24-hour reporting at change of shift as per usual hand-off process. *No nursing staff full-time, part-time, PRN or nursing staff on leave will work their next assigned shift until all in-service training is completed. Date of completion: [DATE] Director of Clinical Operations/ Regional Nurses educated all certified medication aides on Medication Administration: 8. Right resident, right route, right dose, right time, right medication and right documentation. 9. Certified Medication Aides will also notify the charge nurse immediately of any abnormal vital signs.Date completed: [DATE] Director of Clinical Operations/ Regional Nurses educated all team members on the Stop and Watch process. 10. Stop and Watch is noted within the platform of the electronic health record and/or paper form - this process is expected to be utilized by nursing team members upon identification in subtle changes that could be indicative of a change in the resident's condition. Changes may include but not limited to increased sleepiness, not eating, not eating as much, not getting up as usual, not participating in usual activities, minimal or decreased communication (when they usually communicate often) are some changes that will warrant a Stop and Watch process. 11. This process should be completed in PCC/EMR and/or on paper form should be communicated to the nurse and paper form should be turned into the charge nurse upon completion and prior to end of shift to ensure nurse has conducted appropriate follow up to include proper assessment to be conducted. 12. The nurse should turn a copy of the paper form to the Director of Nursing Services. 13. Additionally, all nursing team members are to notify the Director of Nursing upon a change of condition identified along with information regarding the Stop and Watch process has been completed, assessment conducted and notifications to the Medical Provider and Representative have been made this is expected to take place immediately but not to exceed end of shift. 14. Blank copies of the Stop and Watch form will be readily available at the nurse's station for use. 15. A copy of the Stop and Watch form will be placed in the Plan of Removal binder available for State surveyor's review. *No nursing staff full-time, part-time, PRN or nursing staff on leave will work their next assigned shift until all in-service training is completed. Date completed: [DATE] Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents in the community to identify any residents with a change in condition. Outcome: 2 of 123 active residents were noted with an identified change in condition. The resident was on end-of-life care (hospice care) and the other resident noted with an acute condition that occurred at the time the audit was being conducted. Nurses conducted appropriate assessments, communication with the Medical Provider, orders received, change in condition was documented within the electronic health record and appropriate notifications to RP were made and the nursing 24-hour communication report was updated accordingly. Date completed: [DATE] Director of Clinical Operations/Director of Clinical Education provided education on Abuse/Neglect and Residents Rights to all nursing team members. Date of completion:[DATE]Community will ensure all nursing staff on leave/PRN nursing staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior to nursing team members working their next assigned shift. The facility will ensure all residents receive appropriate and immediate care after a change in condition.*No nursing staff full-time, part-time, PRN or nursing staff on leave will work their next assigned shift until all in-service training is completed. Risk Response:All residents who are currently reside in the community with a change in condition have the potential to be affected by the deficient practice.Systemic Response: Director of Clinical Operations/ Regional Nurses provided education to all licensed nurses on the following: The process to utilize immediately when a change in condition is noted. The Change in Condition User Defined Assessment is expected to be implemented in conjunction with an immediate assessment to include vital signs. This information will be immediately reported to the physician/NP so that interventions can be put in place to treat our patient. This will also include notifications to the party responsible for the resident. The Charge nurse will also complete a progress note to include documentation with notifications of the change in status to the MD/PCP and resident's representative accordingly. The Charge nurse will also review the Vital Sign form the certified medication aide will turn in at the end of the shift for review to the licensed nurse. The Charge nurse will review the vital sign form and address any abnormal vital signs. The Change in condition will be completed with a change in the resident's overall condition, after an assessment by the licensed nurse. All abnormal vital signs will warrant an assessment by the licensed nurse and notification to the physician/nurse practitioner and resident's representative, immediately. Date of completion: [DATE] Director of Clinical Operations/ Regional Nurses educated all certified medication aides on Medication Administration: Right resident, right route, right dose, right time, right medication and right documentation. Certified Medication Aides will also notify the charge nurse immediately of any abnormal vital signs. Certified Medication Aides will hand write all vital signs on the Vital sign form provided and turn into the charge nurse at the end of the shift. A copy of the Vital Sign form will be placed in the Abatement Plan Removal binder available for State surveyor's review. Date completed: [DATE] Director of Clinical Operations/ Regional Nurses educated all team members on the Stop and Watch process. This form will be used for all team members upon identification in a change in the resident's condition. Some of the changes may include increased sleepiness, not eating, not eating as much, not getting up as usual, minimal or decreased communication (when they usually communicate often) are some changes that will warrant a Stop and Watch form. This form will be completed and turned into the charge nurse. A copy of this form will be given to the Director of Nursing Services. In addition, all team members are to notify the Director of Nursing by phone when a Stop and Watch form is completed with notification of the change in condition, immediately. Blank copies of these forms will be available on the 600 hall on the wall in a secure compartment. Copies will also be at the nurse's station for access and use. A copy of the Stop and Watch form will be placed in the Abatement Plan Removal binder available for State surveyor's review. Date completed: [DATE] Director of Clinical Operations/ Regional Nurses completed a 100% audit on all residents in the community to identify any residents with a change in condition. Outcome: 2 of 123 active residents were noted with an identified change in condition. The resident was on end-of-life care (hospice care) and the other resident noted with an acute condition that occurred at the time the audit was being conducted. Nurses conducted appropriate assessments, communication with the Medical Provider, orders received, change in condition was documented within the electronic health record and appropriate notifications to RP were made and the nursing 24-hour communication report was updated accordingly. A copy of the change in condition forms will be placed in the binder for the incident and available for all state surveyors to review. Date completed: [DATE] Director of Clinical Operations/Regional Nurses provided immediate education on Abuse/Neglect and Residents Rights to all nursing team members. Date of completion: [DATE]Community will ensure all nursing staff on leave/PRN nursing staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior to nursing team members working their assigned shift. The facility will ensure all residents receive appropriate and immediate care after a change in condition.*No nursing staff full-time, part-time, PRN or nursing staff on leave will work their next assigned shift until all in-service training is completed. Ad Hoc Meeting was conducted on [DATE] Administrator, Director of Nursing Services and Medical Director discussed addressing the immediacy issue regarding:F 580 Notify of Changes---The facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications), and the plan of removal to lift the immediacy. Monitoring/Verification of Plan of removal: [DATE]Record review reflected that facility-wide in-services conducted between [DATE] and [DATE] were completed across all shifts. Staff were educated on abuse and neglect, including identification of abuse types such as neglect, exploitation, and misappropriation of property. Documentation reflected the Administrator was identified as the Abuse Coordinator.Record review reflected the facility's policy titled Notification of Change in Condition was reviewed with CNAs, CMAs, and nurses between [DATE] and [DATE].Record review that in-services was conducted on [DATE] and [DATE] under the direction of clinical leadership. The in-service reflected that the facility had implemented a Stop and Watch program utilized by all staff to report changes in resident conditions. Documentation indicated changes in condition included increased sleepiness, decreased appetite, decline in activity level, or deviation from baseline. Completed forms were submitted to the charge nurse, and the DON was to be notified immediately by phone for any identified change. Record review reflected that when a change in condition was identified, staff were expected to immediately assess the resident and document findings, including vital signs, change in condition assessments, and/or progress notes. Documentation indicated nurses were responsible for notifying the medical provider promptly and ensuring appropriate interventions were implemented. Nurses were also expected to review vital signs obtained by the medication aids for abnormalities and communicate all changes in condition during shift report to ensure continuity of care.Record review reflected that medication aides were educated on the five rights of medication administration (right patient, right medication, right dose, right time, and right documentation). Documentation indicated medication aides recorded vital signs on a designated log and submitted the documentation to the nurse daily.Record review reflected a conduct and workplace expectation notice issued to MA B for failure to follow protocol in notifying the charge nurse of a low blood pressure reading. Documentation indicated the staff member received verbal and written coaching and was re-educated on facility policy and procedures related to change in condition and notification requirements. Record review of the facility's Change in Condition audit tool reflected daily audits were conducted. Documentation dated [DATE] reflected four residents were reviewed, with compliance noted for all residents. Documentation indicated CIC forms were completed and corresponding progress notes were updated.Record review of the medication aide vital sign monitoring log reflected resident vital monitoring was completed daily from [DATE] through [DATE].Staff interviews:During interviews conducted on [DATE] between 1:14 p.m. and 3:18 p.m., LVN D, LVN E, and RN A, who worked the 6:00 a.m. - 6:00 p.m. and 8:00 a.m. - 5:00 p.m. shifts, stated they were in-serviced on abuse and neglect, including resident rights and the requirement to report allegations immediately to the Administrator, identified as the Abuse Coordinator. They reported that changes in condition were identified through assessment and staff reporting, followed by documentation in progress notes, completion of CIC assessments, and physician and family notification as applicable. Nurses indicated that CNAs and medication aides were expected to report changes immediately. Vital sign monitoring was reviewed for trends and Stop and Watch forms were maintained at the nurses' station and were utilized to communicate observed changes in resident condition. During interviews conducted on [DATE] between 3:31 p.m. and 3:33 p.m., RN B, RN C, and LVN C who worked the 6:00 p.m. - 6:00 a.m. shift, reported abuse and neglect training included identification of various types of abuse and immediate reporting to the Administrator. Nurses stated that changes in condition were identified as deviations from baseline (altered mental status, abnormal vital signs) and required completion of CIC assessments, documentation in progress notes, and physician notification. Nurses indicated reliance on CNAs and medication aides to report changes promptly and confirmed review of vital sign documentation for abnormalities. On [DATE] between 3:41 p.m. and 3:47 p.m., attempts were made to interview LVN B (PRN) and LVN A. No responses were received, and voicemail messages were left for returned calls. Call attempts were also made by the DON but were unsuccessful. During interviews conducted on [DATE] between 1:26 p.m. and 3:10 p.m., CNAs F, G, H, I, J, K, and X, who worked the 6:00 a.m. - 2:00 p.m. and 6:00 a.m. - 6:00 p.m. shifts, stated they were trained on abuse and neglect, including resident rights and the requirement to report immediately to the Administrator. CNAs identified types of abuse as physical, verbal, mental, sexual, and neglect. They reported that Stop and Watch forms were used to document and communicate changes in condition such as decreased intake, altered behavior, lethargy, abnormal vital signs, or skin changes. CNAs stated they notified the nurse immediately upon identifying a change and submitted completed forms to the nurse and/or DON. During interviews conducted on [DATE] between 3:26 p.m. and 4:07 p.m., CNAs L, M, N, O, P who worked the 2:00 p.m. - 10:00 p.m. and 6:00 p.m. - 6:00 a.m. shifts, stated they were trained to report abuse and neglect immediately to the Administrator. CNAs described Stop and Watch forms as tools used to report any observed change in resident condition, including behavioral changes, decreased appetite, abnormal vital signs, or signs of distress. CNAs reported they notified the charge nurse immediately and provided completed forms to the nurse and DON, with some indicating additional notification (e.g., calling or texting the DON). During interviews conducted on [DATE] between 2:36 p.m. and 3:10 p.m., CNAs Q, R, S, T, and U, who worked 6:00 a.m. - 6:00 p.m., 2:00 p.m. - 10:00 p.m., and PRN shifts, reported abuse and neglect training included immediate reporting to the Administrator. CNAs stated Stop and Watch forms were used to document changes in condition such as decreased intake, altered communication, lethargy, or decline in functional status, and were submitted to the nurse and DON. CNAs consistently reported that changes in condition were to be communicated to the nurse immediately upon observation. During an interview conducted on [DATE] at 1:42 p.m., MA C, who worked the 6:00 a.m. - 2:00 p.m. shift, reported abuse and neglect training included resident rights and immediate reporting to the Administrator. MA C stated vital signs were recorded and communicated to the nurse, and any abnormal findings or changes in condition (e.g., unresponsiveness, abnormal vitals) were reported immediately. Stop and Watch forms were used to document and communicate observed changes. During interviews conducted on [DATE] between 2:23 p.m. and 3:04 p.m., MAs B, D, and E, who worked the 2:00 p.m. - 10:00 p.m. shift, stated abuse and neglect training included identifying and reporting abuse immediately to the Administrator and/or DON. MAs reported they documented vital signs and notified nurses of abnormalities or changes in condition. Stop and Watch forms were described as tools used to report changes such as altered intake, vital sign abnormalities, or decline in condition, and were submitted to the nurse and DON. During an interview conducted on [DATE] at 10:40 a.m., LVN A, who worked the 6:00 a.m. - 6:00 p.m. shift, stated the Stop and Watch process was used by CNAs and medication aides to report changes in resident condition, including abnormal vital signs, changes in cognition, weakness, or any deviation from baseline. LVN A stated staff were expected to report changes immediately, and the nurse would assess the resident, document findings, and notify the physician or nurse practitioner as needed. She reported vital signs were reviewed daily and provided by medication aids. The Administrator and DON were informed the Immediate Jeopardy was removed on [DATE] at 7:14 p.m. The facility remained out of compliance at a severity level of minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective syst[TRUNCATED]

Based on observation, 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 (CR#1) of 4 residents reviewed for quality care. 1. MA B and CNA B failed to notify LVN B and LVN C on [DATE] when CR#1 refused all meals, had increased drowsiness, and had hypotensive BP readings of 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m. In result, LVN's failed to seek medical guidance from CR #1's physician related to the change in condition until 8:30 am on [DATE] when he became unresponsive and was sent out via EMT.2. CR#1 required several rounds of CPR and was diagnosed with a blood infection, septic shock, and suffered an acute stroke.On [DATE] at 1:47 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated and due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or infection, stroke, or death. Findings included:Record review of CR#1's face sheet, dated [DATE], documented a [AGE] year-old male, admitted [DATE]. His admitting diagnoses were Type 2 Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), presence of cardiac implants and grafts (cardiovascular surgery where artificial devices were inserted), morbid severe obesity due to excess calories, hypertension (high blood pressure), cerebral infarction (stroke), and he was a full code (a medical directive indicating that in the event of a cardiac or respiratory arrest, all possible life-saving interventions)Record review of CR#1's care plan, dated [DATE], documented CR#1 had chronic health issues and comorbid conditions that may further affect his quality of life. Interventions stated to monitor vital signs and report all changes in condition to a doctor.Record review of CR#1's vital signs on [DATE], MA B documented CR#1's BP was 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m. Record review of CR#1's CIC assessments documented no CIC assessment completed on [DATE].Record review of CR#1's progress note dated [DATE] at 10:53 a.m. created by LVN A, revealed that upon entering CR#1's room, he appeared asleep with minimal communication. CR#1 did not attempt to eat breakfast, he was barely responsive, and clammy to touch. Record review further revealed LVN A noted CR#1's BP to be low at 75/54 and he was unresponsive to a sternal rub. Record review revealed the resident was sent out due to an acute change in condition, hypotension (abnormally low blood pressure below 90/60 that indicates blood if not flowing adequately to the organs), increased work in breathing, and unresponsiveness. EMS was called, provider (a licensed person or organization that provides health care services such as doctor or NP) notified, DON notified, and family made aware of discharge.During an interview on [DATE] at 9:05 a.m., the PMD stated CR#1 was found unresponsive to a hard sternal rub (an emergency medical technique used to assess a patient's responsiveness by applying firm, grinding pressure with knuckles to the center of the chest or sternum) and his BP reading was low. The PMD stated CR#1 had vomit around his mouth and he looked like he had been deteriorating for hours. He stated that CR#1 technically passed away twice in the hospital but he was resuscitated.During an observation and interview on [DATE] at 9:35 a.m., CR#1 was seen intubated in the ICU. He could not open his eyes, but he raised his eyebrows when his name was called. The HRN stated CR#1 was admitted due to unresponsiveness and they had to do three rounds of CPR because his heart stopped. On [DATE], CT (an imaging test that helps healthcare providers detect diseases and injuries) and MRI (a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body) scans results showed that he had an infarct (presence indicates a disruption in blood flow to the brain, leading to cell death). The HRN stated cultures were also taken and results showed that he had an infection in the blood. The HRN stated CR #1 was currently sedated but was responsive to pain, tried to open his eyes to speech, and his pupils reacted to light. The FM, who was in the room, stated CR #1 wiggled his toes the day before. During an interview on [DATE] with HNP at 10:02 a.m., she stated that CR#1's hospital documentation revealed that he was found positive for a blood infection (still awaiting detailed results), septic shock, mucus in his lungs, and CT scans revealed he suffered an acute stroke. When they checked his blood sugar, it was 63 and the normal range should be above 70. The HNP stated she could not state which diagnosis was responsible for his unresponsiveness, but stated it was caused by many factors. During an interview on [DATE] at 10:06 a.m., CR#1's FM stated CR#1 suffered a stroke over a year ago that affected his mobility but his mind was very sharp. She stated she was grateful LVN A went back to check on him inside his room at the nursing facility and stated, LVN A probably saved CR#1's life. During an interview on [DATE] at 12:17 p.m., LVN A stated that she worked on [DATE] from 6:00 a.m.- 6:0 p.m. LVN A stated that when she arrived on shift LVN C informed her that CR#1 slept throughout the night and he would respond that he was ok but seemed really tired. LVN A stated when she on CR #1, she knew something was different because he was usually alert and oriented x3-4 (alert and oriented to person, place, time, and situation) and he was able to communicate his needs but he was drowsy and barely spoke. She stated his breakfast tray was untouched and that was unlike him. LVN A stated a medication aide and LVN A agreed CR #1 looked clammy, BP was low, and his blood sugar was 77. LVN A stated 911 was called and he was still unresponsive upon arrival of EMT. LVN A stated EMT replaced his CPAP (keeps your airways open while you sleep so you can receive the oxygen you need) with a non-rebreather mask (used for patients needing high-flow oxygen, such as in severe respiratory distress, trauma, or emergencies) and CR #1 was taken to the hospital. During an interview on [DATE] at 12:23 p.m., CNA D stated he worked from 6:00 a.m.- 2:00 p.m. on [DATE]. He stated CR#1 normally liked to play on his computer but he did not play on it on [DATE] and slept the majority of the day. CNA D described CR#1 as very sleepy and stated CR #1 did not eat breakfast or lunch aside from one cup of vanilla pudding. He stated he told the floor nurse but could not remember her name or if the floor nurse took action. During an interview on [DATE] at 12:59 p.m., the NP stated she did not receive a call directly on [DATE] because they have on call services where the providers in her group take turns answering. She stated that a BP reading of 86/57 or 89/59 was very concerning and staff nurses should not try to do anything without speaking to the doctor. She stated that if CR #1 had symptoms of not eating all day, tired, with low blood sugar, she would have sent him out to the emergency room. Additional questions were asked to the NP, but she refused to answer questions and stated she did not want to continue the interview with the surveyor. During an interview on [DATE] at 1:19 p.m., CNA E stated that she worked from 6:00 p.m. - 6:00 a.m. on [DATE]. She stated CR#1 was out of it on [DATE] and he barely said two words to her. She asked him if he was ok because he did not seem like himself because he slept the majority of her shift when he usually would stay up late and play on his computer. CNA E stated she communicated with LVN C about CR#1's condition and they checked on him several times throughout the night. CNA E stated she asked CR#1 if he was ok or if he needed water. CNA E stated CR#1 did not verbally communicate with her at all and only shook his head in response to questions. She stated CR #1's eyes were closed when she spoke to him and his breathing seemed heavy. CNA E stated that it was strange that CR#1 slept the majority of the night because he normally would not go to sleep until her shift was over (around 6 a.m.). During an interview on [DATE] at 1:33 p.m., MA A stated she worked from 6:00 a.m.- 2:00 p.m. on [DATE]. MA A stated when she took CR#1's BP that morning, his BP read 113/74 and he was fine. He took his medication without refusals and nothing seemed out of the normal. She explained that if his BP was outside the parameters of 110-120 systolic and 70-85 diastolic (Systolic blood pressure (top number) measures the maximum force against artery walls when the heart beats (contracts). Diastolic blood pressure (bottom number) measures the minimum pressure in arteries as the heart rests between beats), she would hold his medicine and tell the nurse. During an interview on [DATE] at 1:51 p.m., MA B stated he worked on [DATE] from 2:00 p.m.- 10:00 p.m. MA B state CR#1's BP was low on [DATE] and he had to hold his BP medicine. He stated that he told the nurse (unknown) but could not say which nurse or what their name was. MA B stated the nurse had no response when he informed her, restating that he was not sure what she said, then stating he did not know. MA B stated that CR#1 was sleeping and a little quite on [DATE], but otherwise no problems. During an interview on [DATE] at 3:03 p.m., LVN B stated she worked from 6:00 a.m. - 6:00 p.m. on [DATE]. She stated she did not receive any notifications from the CNAs or MA who worked [DATE] that CR#1 had low blood pressure and had not eaten. She stated she was very upset because if she would have known she would have called his provider to see what needed to be done. She stated that a systolic of 86 was very low and stated, Why would they not say anything!During an interview on [DATE] at 5:03 p.m., LVN C stated that she worked from 6 p.m.- 6 a.m. on [DATE]. LVN C stated that she checked on him several times throughout the night and she asked him if he was ok, he would say yes or nod his head. He was a very chatty person, but he did not talk during the night so she did not notice a change in his behavior. She stated that CNA D told her that CR#1 had not eaten breakfast or lunch but he stated that he told LVN B about his behavior. She had no knowledge of low BP readings from MA B. If she had known he had a low BP, she stated she would have reached out to the provider immediately.During an interview on [DATE] at 10:31 a.m., the DON stated when MA B identified CR#1 had low blood pressure on [DATE], he should have notified the nurse immediately and staff had been educated previously on what to do when there was a change in condition with a resident. The DON stated CNAs and MAs were expected to provide verbal updates to the nurses and nurses would notify the provider of changes, complete the documentation, and she would oversee it. She explained the chain of command went from CNAs/MA, to nurse, and to herself. The DON stated that per the policy, the provider should be informed of all significant changes. Record review of the facility's policy titled, Change in Resident Condition, revised 01/2023, documented when there was significant change in the resident's physical, mental, or psychosocial status, the medical provider should be contacted.This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:47 p.m. The Administrator, DON, and ADON were notified. The Administrator and DON was provided with the IJ templated [DATE] at 1:47 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 10:00 a.m. It was documented as follows:F 684 Quality of CareThe 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, in that:Situation: Resident # 1 was discharged to the hospital on [DATE]. Director of Clinical Operations/ Regional Nurse identified medication aide #1 and immediately removed medication aide #1 from his assignment pending receiving of in serviced training regarding Medication Administration, Reporting of Abnormal vital signs to his charge nurse, Abuse/Neglect and Residents Rights -conducted by Director of Clinical Operations/ Regional Date Completed: [DATE] Director of Clinical Operations/ Regional and Administrator counseled medication aide #1 and a performance written action completed r/t medication aide #1's failure to ensure proper reporting of the low blood pressure readings to his charge nurse on [DATE]. Certified medication aide #1. Conducted by Director of Clinical Operations/ Regional and Administrator.Director of Clinical Operations/ Regional Nurses provided immediate re- education to all licensed nurses on the following: The expected process for: 1. Immediately evaluating/assessing resident upon a suspected or identified change in condition is noted. 2. Documenting nursing findings to include but not limited to evaluation of vital signs and utilizing the appropriate Change in Condition User Defined Assessment and/or Nursing Progress Note to ensure proper documentation is noted within the medical record. 3. Nurse to promptly report the identified change in condition (exception of usual baseline status) to the Medical Provider in order to ensure appropriate interventions are provided and carried out as ordered/recommended. 4. Nurse to ensure that appropriate notification is made to the resident's representative. 5. The Nurse is expected to ensure that all appropriate documentation to reflect 1-4 are noted with the electronic health record. 6. The Nurse should review the vital sign form (vital signs taken by certified medication aide) to ensure that any abnormal vital signs have been reviewed by the nurse with appropriate re-assessment and interventions to include the licensed nurse conducting the evaluation/assessment, notification to the Medical Provider, carrying out any recommended or prescribed medical interventions and notification to the resident's representative promptly, and ensuring all is documented within the electronic health record. 7. The nurse will ensure that all identified changes in condition or suspected changes in condition will be reported to the on-coming nurse to ensure appropriate 24-hour reporting at change of shift as per usual hand-off process. *No nursing staff full-time, part-time, PRN or nursing staff on leave will work their next assigned shift until all in-service training is completed. Date of completion: [DATE] Director of Clinical Operations/ Regional Nurses educated all certified medication aides on Medication Administration: 8. Right resident, right route, right dose, right time, right medication and right documentation. 9. Certified Medication Aides will also notify the charge nurse immediately of any abnormal vital signs.Date completed: [DATE] Director of Clinical Operations/ Regional Nurses educated all team members on the Stop and Watch process. 10. Stop and Watch is noted within the platform of the electronic health record and/or paper form - this process is expected to be utilized by nursing team members upon identification in subtle changes that could be indicative of a change in the resident's condition. Changes may include but not limited to increased sleepiness, not eating, not eating as much, not getting up as usual, not participating in usual activities, minimal or decreased communication (when they usually communicate often) are some changes that will warrant a Stop and Watch process. 11. This process should be completed in PCC/EMR and/or on paper form should be communicated to the nurse and paper form should be turned into the charge nurse upon completion and prior to end of shift to ensure nurse has conducted appropriate follow up to include proper assessment to be conducted. 12. The nurse should turn a copy of the paper form to the Director of Nursing Services. 13. Additionally, all nursing team members are to notify the Director of Nursing upon a change of condition identified along with information regarding the Stop and Watch process has been completed, assessment conducted and notifications to the Medical Provider and Representative have been made this is expected to take place immediately but not to exceed end of shift. 14. Blank copies of the Stop and Watch form will be readily available at the nurse's station for use. 15. A copy of the Stop and Watch form will be placed in the Plan of Removal binder available for State surveyor's review. *No nursing staff full-time, part-time, PRN or nursing staff on leave will work their next assigned shift until all in-service training is completed. Date completed: [DATE] Director of Nursing Services/Assistant Director of Nursing Services completed a 100% audit on all residents in the community to identify any residents with a change in condition. Outcome: 2 of 123 active residents were noted with an identified change in condition. The resident was on end-of-life care (hospice care) and the other resident noted with an acute condition that occurred at the time the audit was being conducted. Nurses conducted appropriate assessments, communication with the Medical Provider, orders received, change in condition was documented within the electronic health record and appropriate notifications to RP were made and the nursing 24-hour communication report was updated accordingly. Date completed: [DATE] Director of Clinical Operations/Director of Clinical Education provided education on Abuse/Neglect and Residents Rights to all nursing team members. Date of completion:[DATE]Community will ensure all nursing staff on leave/PRN nursing staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior to nursing team members working their next assigned shift. The facility will ensure all residents receive appropriate and immediate care after a change in condition.*No nursing staff full-time, part-time, PRN or nursing staff on leave will work their next assigned shift until all in-service training is completed. Risk Response:All residents who are currently reside in the community with a change in condition have the potential to be affected by the deficient practice.Systemic Response: Director of Clinical Operations/ Regional Nurses provided education to all licensed nurses on the following: The process to utilize immediately when a change in condition is noted. The Change in Condition User Defined Assessment is expected to be implemented in conjunction with an immediate assessment to include vital signs. This information will be immediately reported to the physician/NP so that interventions can be put in place to treat our patient. This will also include notifications to the party responsible for the resident. The Charge nurse will also complete a progress note to include documentation with notifications of the change in status to the MD/PCP and resident's representative accordingly. The Charge nurse will also review the Vital Sign form the certified medication aide will turn in at the end of the shift for review to the licensed nurse. The Charge nurse will review the vital sign form and address any abnormal vital signs. The Change in condition will be completed with a change in the resident's overall condition, after an assessment by the licensed nurse. All abnormal vital signs will warrant an assessment by the licensed nurse and notification to the physician/nurse practitioner and resident's representative, immediately. Date of completion: [DATE] Director of Clinical Operations/ Regional Nurses educated all certified medication aides on Medication Administration: Right resident, right route, right dose, right time, right medication and right documentation. Certified Medication Aides will also notify the charge nurse immediately of any abnormal vital signs. Certified Medication Aides will hand write all vital signs on the Vital sign form provided and turn into the charge nurse at the end of the shift. A copy of the Vital Sign form will be placed in the Abatement Plan Removal binder available for State surveyor's review. Date completed: [DATE] Director of Clinical Operations/ Regional Nurses educated all team members on the Stop and Watch process. This form will be used for all team members upon identification in a change in the resident's condition. Some of the changes may include increased sleepiness, not eating, not eating as much, not getting up as usual, minimal or decreased communication (when they usually communicate often) are some changes that will warrant a Stop and Watch form. This form will be completed and turned into the charge nurse. A copy of this form will be given to the Director of Nursing Services. In addition, all team members are to notify the Director of Nursing by phone when a Stop and Watch form is completed with notification of the change in condition, immediately. Blank copies of these forms will be available on the 600 hall on the wall in a secure compartment. Copies will also be at the nurse's station for access and use. A copy of the Stop and Watch form will be placed in the Abatement Plan Removal binder available for State surveyor's review. Date completed: [DATE] Director of Clinical Operations/ Regional Nurses completed a 100% audit on all residents in the community to identify any residents with a change in condition. Outcome: 2 of 123 active residents were noted with an identified change in condition. The resident was on end-of-life care (hospice care) and the other resident noted with an acute condition that occurred at the time the audit was being conducted. Nurses conducted appropriate assessments, communication with the Medical Provider, orders received, change in condition was documented within the electronic health record and appropriate notifications to RP were made and the nursing 24-hour communication report was updated accordingly. A copy of the change in condition forms will be placed in the binder for the incident and available for all state surveyors to review. Date completed: [DATE] Director of Clinical Operations/Regional Nurses provided immediate education on Abuse/Neglect and Residents Rights to all nursing team members. Date of completion: [DATE]Community will ensure all nursing staff on leave/PRN nursing staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior to nursing team members working their assigned shift. The facility will ensure all residents receive appropriate and immediate care after a change in condition.*No nursing staff full-time, part-time, PRN or nursing staff on leave will work their next assigned shift until all in-service training is completed. Ad Hoc Meeting was conducted on [DATE] Administrator, Director of Nursing Services and Medical Director discussed addressing the immediacy issue regarding:F 684 Quality of Care-- 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. and the plan of removal to lift the immediacy. Monitoring/Verification of Plan of removal: [DATE]Record review reflected that facility-wide in-services conducted between [DATE] and [DATE] were completed across all shifts. Staff were educated on abuse and neglect, including identification of abuse types such as neglect, exploitation, and misappropriation of property. Documentation reflected the Administrator was identified as the Abuse Coordinator.Record review reflected the facility's policy titled Notification of Change in Condition was reviewed with CNAs, CMAs, and nurses between [DATE] and [DATE].Record review that in-services was conducted on [DATE] and [DATE] under the direction of clinical leadership. The in-service reflected that the facility had implemented a Stop and Watch program utilized by all staff to report changes in resident conditions. Documentation indicated changes in condition included increased sleepiness, decreased appetite, decline in activity level, or deviation from baseline. Completed forms were submitted to the charge nurse, and the DON was to be notified immediately by phone for any identified change. Record review reflected that when a change in condition was identified, staff were expected to immediately assess the resident and document findings, including vital signs, change in condition assessments, and/or progress notes. Documentation indicated nurses were responsible for notifying the medical provider promptly and ensuring appropriate interventions were implemented. Nurses were also expected to review vital signs obtained by the medication aids for abnormalities and communicate all changes in condition during shift report to ensure continuity of care.Record review reflected that medication aides were educated on the five rights of medication administration (right patient, right medication, right dose, right time, and right documentation). Documentation indicated medication aides recorded vital signs on a designated log and submitted the documentation to the nurse daily.Record review reflected a conduct and workplace expectation notice issued to MA B for failure to follow protocol in notifying the charge nurse of a low blood pressure reading. Documentation indicated the staff member received verbal and written coaching and was re-educated on facility policy and procedures related to change in condition and notification requirements. Record review of the facility's Change in Condition audit tool reflected daily audits were conducted. Documentation dated [DATE] reflected four residents were reviewed, with compliance noted for all residents. Documentation indicated CIC forms were completed and corresponding progress notes were updated.Record review of the medication aide vital sign monitoring log reflected resident vital monitoring was completed daily from [DATE] through [DATE].Staff interviews:During interviews conducted on [DATE] between 1:14 p.m. and 3:18 p.m., LVN D, LVN E, and RN A, who worked the 6:00 a.m. - 6:00 p.m. and 8:00 a.m. - 5:00 p.m. shifts, stated they were in-serviced on abuse and neglect, including resident rights and the requirement to report allegations immediately to the Administrator, identified as the Abuse Coordinator. They reported that changes in condition were identified through assessment and staff reporting, followed by documentation in progress notes, completion of CIC assessments, and physician and family notification as applicable. Nurses indicated that CNAs and medication aides were expected to report changes immediately. Vital sign monitoring was reviewed for trends and Stop and Watch forms were maintained at the nurses' station and were utilized to communicate observed changes in resident condition. During interviews conducted on [DATE] between 3:31 p.m. and 3:33 p.m., RN B, RN C, and LVN C who worked the 6:00 p.m. - 6:00 a.m. shift, reported abuse and neglect training included identification of various types of abuse and immediate reporting to the Administrator. Nurses stated that changes in condition were identified as deviations from baseline (altered mental status, abnormal vital signs) and required completion of CIC assessments, documentation in progress notes, and physician notification. Nurses indicated reliance on CNAs and medication aides to report changes promptly and confirmed review of vital sign documentation for abnormalities. On [DATE] between 3:41 p.m. and 3:47 p.m., attempts were made to interview LVN B (PRN) and LVN A. No responses were received, and voicemail messages were left for returned calls. Call attempts were also made by the DON but were unsuccessful. During interviews conducted on [DATE] between 1:26 p.m. and 3:10 p.m., CNAs F, G, H, I, J, K, and X, who worked the 6:00 a.m. - 2:00 p.m. and 6:00 a.m. - 6:00 p.m. shifts, stated they were trained on abuse and neglect, including resident rights and the requirement to report immediately to the Administrator. CNAs identified types of abuse as physical, verbal, mental, sexual, and neglect. They reported that Stop and Watch forms were used to document and communicate changes in condition such as decreased intake, altered behavior, lethargy, abnormal vital signs, or skin changes. CNAs stated they notified the nurse immediately upon identifying a change and submitted completed forms to the nurse and/or DON. During interviews conducted on [DATE] between 3:26 p.m. and 4:07 p.m., CNAs L, M, N, O, P who worked the 2:00 p.m. - 10:00 p.m. and 6:00 p.m. - 6:00 a.m. shifts, stated they were trained to report abuse and neglect immediately to the Administrator. CNAs described Stop and Watch forms as tools used to report any observed change in resident condition, including behavioral changes, decreased appetite, abnormal vital signs, or signs of distress. CNAs reported they notified the charge nurse immediately and provided completed forms to the nurse and DON, with some indicating additional notification (e.g., calling or texting the DON). During interviews conducted on [DATE] between 2:36 p.m. and 3:10 p.m., CNAs Q, R, S, T, and U, who worked 6:00 a.m. - 6:00 p.m., 2:00 p.m. - 10:00 p.m., and PRN shifts, reported abuse and neglect training included immediate reporting to the Administrator. CNAs stated Stop and Watch forms were used to document changes in condition such as decreased intake, altered communication, lethargy, or decline in functional status, and were submitted to the nurse and DON. CNAs consistently reported that changes in condition were to be communicated to the nurse immediately upon observation. During an interview conducted on [DATE] at 1:42 p.m., MA C, who worked the 6:00 a.m. - 2:00 p.m. shift, reported abuse and neglect training included resident rights and immediate reporting to the Administrator. MA C stated vital signs were recorded and communicated to the nurse, and any abnormal findings or changes in condition (e.g., unresponsiveness, abnormal vitals) were reported immediately. Stop and Watch forms were used to document and communicate observed changes. During interviews conducted on [DATE] between 2:23 p.m. and 3:04 p.m., MAs B, D, and E, who worked the 2:00 p.m. - 10:00 p.m. shift, stated abuse and neglect training included identifying and reporting abuse immediately to the Administrator and/or DON. MAs reported they documented vital signs and notified nurses of abnormalities or changes in condition. Stop and Watch forms were described as tools used to report changes such as altered intake, vital sign abnormalities, or decline in condition, and were submitted to the nurse and DON. During an interview conducted on [DATE] at 10:40 a.m., LVN A, who worked the 6:00 a.m. - 6:00 p.m. shift, stated the Stop and Watch process was used by CNAs and medication aides to report changes in resident condition, including abnormal vital signs, changes in cognition, weakness, or any deviation from baseline. LVN A stated staff were expected to report changes immediately, and the nurse would assess the resident, document findings, and notify the physician or nurse practitioner as needed. She reported vital signs were reviewed daily and provided by medication aids. The Administrator and DON were informed the Immediate Jeopardy was removed on [DATE] at 7:14 p.m. The facility remained out of compliance at a severity level of minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 4 (suction machine #1) suction machines reviewed for essential equipment. The facility failed to ensure the suction machine in CR #1's room was functioning correctly to suction oral secretions on 11/29/25, causing staff to get the suction machine from the crash cart.This failure could place residents at risk of not having their needs met due to a functional suction system not readily available.Findings included:Record review of CR #1's undated face sheet revealed she was an [AGE] year old female readmitted to the facility on [DATE] with diagnoses of Alzheimer's disease (brain disorder that destroys memory, thinking skills, and ability to carry out daily tasks), dysphagia (trouble swallowing), congestive heart failure (heart unable to pump effectively causing fluid in lungs), dementia significant decline in mental abilities), high blood pressure, Parkinson's disease (uncontrollable shaking), COPD (lung condition causing airflow obstruction), gastrostomy (tube in stomach for nutrition), pacemaker (controls heart rate), difficulty walking, and muscle wasting and atrophy (muscle shrinkage).Record review of CR #1's Significant Change MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15, which indicated significantly impaired cognition. The resident was dependent (helper does all of the effort and resident does none of the effort) with all ADLs. The assessment revealed CR #1 had shortness of breath with exertion (walking, bathing, transferring) and while lying flat. The resident had a PEG (tube into stomach for nutrition) tube and was receiving oxygen. Suctioning was not checked on the MDS.Record review of CR #1's Baseline Care Plan dated 11/27/25, revealed the following:There was no mention of oral suctioning.Focus: Resident had a self-care deficit r/t Parkinson's DiseaseGoal: Maintain/Improve ability to participate in ADLs through next review date.Interventions: 1 person assist with ADLsFocus: Resident required a feeding tube r/t NPO status and dysphagia.Goal: Resident will not experience any complications associated with feeding tube or enteral nutrition/hydration through review date.Interventions: HOB elevated when in bed, avoid flat while feeding was on/pump running. RD to evaluate PRN, report abnormal findings to MD. Provide local care to G-tube (tube into stomach for nutrition) site as ordered and monitor for s/sx of infection.Record review of a video provided by CR #1's RP, dated 11/29/25 and time stamped 7:08am, revealed the camera was at the head of the bed in CR #1's room. CR #1's head of bed was elevated, and RN W and CNA G were at the bedside. CNA G was on the left side of the bed and was heard saying, The machine's not working. RN W was on the rights side of the bed and was seen trying to suction CR #1's mouth. RN W was heard saying, It's not working. I'm not getting any suction.Record review of a video provided by CR #1's RP, dated 11/29/25 and time stamped 7:17am, revealed the camera was at the head of the bed in CR #1's room. CR #1's head of bed was elevated and LVN M and RN H came in with a new suction machine.Record review of CR #1's Record of Death revealed she passed on 11/29/25 at 7:45am, unrelated to the suction machine.Record review of CR #1's Discontinued Physician Orders as of 12/4/25 revealed the following orders from MD B:- Admit to [Hospice] under services of [doctor], admitting diagnosis Parkinsons Disease. Discontinued 10/24/25.- Suction orally per yankauer (type of suction tube for mouth) PRN Q6hr. Discontinued 10/18/25.Record review of CR #1's current Physician Orders as of 12/4/25 revealed the following orders from MD B:- DNR (code status). Ordered 10/31/25.- Oxygen at 2-3L per NC PRN for s/s of SOB/Comfort and to keep O2 sat 92%, as needed for shortness of breath. Ordered on 10/28/25.- Hyoscyamine Sulfate Tablet Sublingual 0.125mg (medication to decrease secretion), 1 tablet SL Q2hr PRN increased secretions, Do not exceed 1.5mg in 24hr. Ordered on 11/16/25.In an interview on 12/4/25 at 1:45pm, CR #1's RP said staff were attempting to suctions secretions from CR #1's mouth on 11/29/25, but the suction machine in the room was not working. She said there was no reason why the machine in the room should not have been working. The RP said staff had to go get the suction machine from the crash cart and it took them too long to get it.In an interview on 12/4/25 at 2:06pm, the DON said CR #1 was on hospice and had a suction machine in her room because all hospice residents had suction machines in their room as part of a bundle. The DON said the resident was removed from hospice, but the daughter wanted to keep the suction machine in her room, so they kept it in her room even though there was not an order for it. She said she was told by her staff that on 11/29/25 they attempted to use the suction in the room, and it did not work so they had to get the suction machine from the crash cart. The DON said it would have only taken 1-2 minutes to get the crash cart, and she would not have had a suction machine in her room normally, they just allowed CR #1 to keep hers in the room. The DON said she performed an audit of all three suction machines on 12/3/25, and they were functional.In an interview on 12/4/25 at 2:56pm, RN H said she tried to suction CR #1 on 11/29/25, but the machine in the room did not work, so she went and grabbed the crash cart. She said it took less than one minute to grab the crash cart.Record review performed on 12/19/25 revealed an in-service given by the DON completed on 12/1/25 regarding How to Properly Connect a Suction Machine-Return Demonstration. There were notes that stated, Back up suction machine located on the crash cart-100 hall time clock room. There was an Oral Suctioning Competency Checklist given to each nurse.In an interview on 12/19/25 at 1:19pm, RN W said, [CR #1] had a lot of blood tinged secretions so she went to use the suction machine, and it didn't work. She said another nurse brought the new suction machine in from the crash cart.In an interview on 12/19/25 at 1:45pm, the DON said they did not have a policy for checking the functioning of suction machines, and that whoever put the suction machine in the room should check it. She said if a suction machine did not work, they would get the crash cart and that would only delay treatment by a couple of minutes.In an interview on 12/19/25 at 3:50pm, the ADM said they did not have a policy on checking/maintaining equipment.Record review of the facility's policy and procedures on Suctioning (revised August 2014) read in part: The purpose of this procedure is to help prevent nosocomial infections associated with suctioning and to prevent transmission of such infections to residents and staff.Suction machines must be available at the bedside of residents who require suctioning because they cannot clear nasal, oral, and/or respiratory secretions by themselves and also at the bedside of all tracheostomy and ventilator residents.When suction machines are available for use, the following items should be available: Supply of exam gloves; Supply of sterile gloves, if tracheal suction is anticipated; Supply of suction catheters; Supply of sterile distilled water with which to flush suction catheters; and Appropriate trash receptacle for used catheters.Record review of the facility's policy and procedures on Physical Environment (revised January 2023) read in part: The community provides sufficient space and equipment to enable team members to provide residents with needed services as required by each resident's plan of care.The community is designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public.The community has a preventive maintenance program that ensures that all essential mechanical, electrical, and patient-care equipment is in safe operating condition. The preventive maintenance program is characterized by the following: It is ongoing and under the direction of a qualified and experienced maintenance director. Routine testing and maintenance of all equipment is scheduled, and records of the testing and maintenance are kept in an organized manner. Essential equipment.is kept in safe operating condition. Equipment is maintained according to manufacturer's recommendations. Nonoperating equipment is fixed or replaced in a timely manner. Nonoperating or damaged equipment is tagged and locked as soon as it is identified to prevent resident, visitor, or team member accident or injury.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 1 resident (CR #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to residents and adequate training of the staff regarding monitoring and documenting resident whereabouts (location) to mitigate accidents such as elopement when CR#1 eloped on 01/02/2025 and was found to have laceration to nose that required 3 sutures, a closed fracture to left wrist with splint in place, and a closed fracture to nasal bone. This noncompliance was identified as Past Non-Compliant Immediate Jeopardy (PNC IJ) was identified on 07/09/2025. The noncompliance began on 01/02/2025 and ended 01/31/2025. The facility corrected the noncompliance before the investigation began. The IJ began on 07/09/2025 and ended on 07/09/2025. The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to surveyor entrance. This deficiency failure exposed residents living in the facility to safety hazards.Findings included: Review of face sheet dated 08/04/2022 reflected CR #1 was an [AGE] year-old female who admitted to the facility on [DATE] and discharged to a secure facility on 01/08/2025. Record review of CR #1 was admitted with the following diagnosis Alzheimer disease, Major Depressive Disorder, Anxiety disorder, Psychotic disorders with delusions due to known physiological condition, Osteoarthritis, Dysphagia, Ataxic gait, Generalized anxiety disorder, Insomnia, Dementia mild with psychotic disturbance, Deficiency of specified B group vitamins, Unspecified abnormalities of Gait and Mobility, Pain. Review of CR #1's initial nursing evaluation indicated she was alert to person, displayed some cognitive and communication deficits RT DX Alzheimer Dementia. A BIMS score was conducted upon admission on [DATE]. The results were 6 out of 15 and on 11/14/2024 another BIMS score was conducted which indicated a 5 out of 15 which indicated severe cognitive impairment. CR #1 was ambulatory. Her initial wandering evaluation conducted on 08/04/2022 indicated she was not a wandering risk. Record review of closed chart for CR #1 on 12/21/2024 at 12:26 PM indicated CR# 1 had a change of condition reported Altered Mental Status suspected UTI. On 01/01/2025 indicated Urinalysis results were negative. Review of exit seeking tool on 1/2/2025 reflected it was completed indicating CR #1 was wondering and exit seeking behaviors and on 1 or more occasions attempted to exit or has exited the facility to wander away, whether intentionally or due to confusion. Record review of CR #1's nursing note dated 01/02/25 indicated during shift Resident was seen walking around nurses' station with a bag stating that she was looking for her mom. shortly after resident walked to front desk looking for her mother and was redirected back to her room x2. At 2:15PM I was notified that resident was down the street past the daycare. Another resident's family member came into the facility and ask the front desk if we had a resident by the name of CR#1, front desk agreed. witness stated that CR#1 was down the street past the daycare in the middle of the street on the ground. Front desk quickly rushed to scene with phone in had calling administrator. By the time she made it to scene EMS and ADNS was on site. She then returned to facility and notified Nurse of what had happened. Activity Director stated that while working front desk a lot of family and new hires were there and she did not see resident go out the door, after redirecting her x2. Resident was transported to ER for further evaluation. MD and RP were notified. Record review of progress notes of CR #1 dated 1/3/2025, nurse notes indicated CR #1 returned to facility via EMS on 01/02/25 at 7:21PM. RP, NP, and DON notified of return. Resident has no new orders. Resident vitals 130/79, 73, 94% O2, 18, 97.5. Resident has laceration to nose with 3 sutures, closed fracture to left wrist with splint in place, and closed fracture to nasal bone. Resident has no complaints of pain or discomfort at this time. Resident was put on 1:1 with CNA at CR #1 bedside and as CR #1 walked around facility. Record review of CR #1's nurses notes dated 1/3/2025 at 12:19AM indicated CR #1 Resident continues 1:1 service. Resident currently walking around facility with sitter. Resident states she is waiting on her mom to pick her up. Resident redirected to bed. Record review of nurse progress notes CR#1 revealed CR#1 was on 1:1 until discharge date of 01/08/2025. Interview on 07/08/2025 at 2:45PM with Activity Director who said around 1:30PM on 01/02/2025 CR #1 went out the front door like she does all the time to sit on the front porch, it was very busy that day there was new hires and trainings going on. CR #1 usually just sits in the front and then comes back into the building. That day a unidentified person came into the facility and reported that it was a lady sitting in the median that look like she was from the nursing home I went outside to check and it was CR #1 in the median and she was sitting on the ground. I came and got the charge nurse, and the administrator was called also, and the EMS was already there when we all arrived. CR #1 look like she had a cut on her forehead, and she was put into the ambulance. I know I saw CR #1 in the dining room when she had just come back from the therapy. If a resident was exit seeking and got out, they could get hurt or be lost and be in danger. Interview on 07/08/2025 at 4:30PM with the Unit manager who stated CR #1 had a history of looking for her mom. She would always have a bag with her stating she was looking for mom she would sit on the front porch all the time but would come back. Along with the receptionist and nursing staff it was our responsibility to check on all residents all the time while they are sitting outside in the front or the back of the facility. The receptionist should always call and ask if a resident was able to be outside by themselves. If a resident gets out it could be serious. Interview on 07/08/2025 at 5:30PM with previous Assistant Director of Nursing who said that day of 1/2/2025. I was working, and she was on the porch but was found at the car wash next door. When I got there the EMS was there and CR #1 was being accessed by the paramedics and was transported to the hospital for further evaluations. CR #1 had a laceration to her head, it had blood on it, and she was alert. When CR#1 came back that night, I called her FM who said she was received a call earlier. On 1/3/2025 (CR # 1) was put on a 1;1. She said the Activity Director, or the receptionist should have asked a nurse prior to letting CR #1 out of the building. It's something major if a resident that get out the building with memory issues because they can get hurt or worse. Interview on 07/08/2025 at 5:45PM with CNA A who said she saw CR #1 sitting outside around 11:30 am and tried to convince her to come inside because it was cold, and CR #1 resisted to return into the facility. CNA A said she tried to get another CNA to help to bring CR #1 to the facility, but she started to become aggressive. So, I let the front desk lady know, and I returned to the floor. Interview on 07/09/2025 at 11:30 AM with the regional nurse who stated that the facility conducted in-services on a quarterly basis prior to incident with CR #1 and after incident with CR #1 in-services were done monthly along with elopement drills which was done on 1/31/2025 with another drill planned for 7/31/2025. Elopement drills are done every 6 months per company policy. Record review of facility's Elopement policy dated Revised May 2024 revealed the Following: Review of the facilities meeting documentation reflected they completed an AD HOC QAPI on 01/03/25 which was attended by the Administrator, DON, and Medical Director. The following was discussed:1. Elopement wandering/leaving the facility training.2. Abuse/neglect training,3. Resident right rights training4. Updated the elopement book Performance improvement plan with immediate intervention which included: 1. Head count, 2. Resident returned to facility at 9:20 PM on the same day from the hospital ER3. Medical Director/RP notified.4. Head to assessment completed.5. Exit Seeking Tool was completed.6. Audit on all residents to identify residents at risk for elopement. 7. CR #1 was transferred to a secure facility.8. Elopement binder reviewed and updated.9. Residents' BIMS updated in binder. Review of Components of the PIP/QAPI dated 01/03/2025 were reviewed by the survey team. The QAPI recommendations were completed and included the following: The front door and all side/back doors are locked 24 hours a day. Residents are closely monitored that are seating in front porch area every 15 minutes by the receptionist. Facility is in the process of hiring hospitality aide to assist with the facility concierge program. Inservice was done the day of incident and every month after incident. Any residents that are at risk for elopement are evaluated upon admission and if necessary, will be placed on 1:1. Facility conducted elopement drill on 1/31/2025. Per company policy elopement drills are recurrence every 6 months. Record review of facility's elopement policy dated 01/03/2025 Record review of facility's grievance log did not reveal any concerns for potential elopement. Record review on 07/08/2025 of all elopement in-services and drills were conducted on 1/3/2025 and thereafter every 3 months. Completed with no concerns. Record review of incident and accidents did reveal resident with a potential to elope, resident was placed on 1:1 until discharged . Record review of facility's Reporting incidents and accidents in-service acknowledgement dated 05/24/2024 revealed nursing staff including RN and LVN's, MA's, and CNA's received training for how to investigate and follow up on incidents and accidents and completing incident and accident documentation. Record review of facility's Ensuring doors are locked behind staff entering and exiting facility in-service acknowledgement dated 7/31/2024 revealed nursing staff/nursing administration received education on alarms sounds and doors security. The signature page included Administration, DON, all nursing staff who was assigned for duty the afternoon of the elopement and thereafter education was provided for current and new staff. Record review of facility's Abuse and Neglect in-service acknowledgement dated 1/3/2025 revealed nursing staff received education on being expected to follow federal guidelines for ANE, prevention of ANE, reporting of ANE, and investigating allegations of ANE. The signature page included ADON, the nurse who was assigned to CR #1 on 1/31/2025 the afternoon of the elopement. On 07/09/2025 at 3:18 pm, facility administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the administrator via email with signature requested. The noncompliance began on 01/02/2025 and ended on 01/31/2025. The facility corrected the noncompliance before the investigation began.

Based on observations, interviews, and record review, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 77 residents (CR #1) reviewed for CPR. LVN A failed to call out a change in condition and obtain assistance from available staff when CR #1 was found unresponsive. This led to a delay of approximately 3 minutes before CPR was started on CR #1 on [DATE]. LVN B failed to enter CR #1's DNR code status at the time of admission which resulted in LVN A making multiple phone calls to determine code status prior to initiating CPR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:16 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level of potential harm that was not immediate jeopardy because all staff had not been trained on [DATE]. These failures placed residents at risk of experiencing worsening of condition, extended pain, and death from possible delays in the initiation of an emergency response and improper implementation of CPR. Findings included: Record review of CR #1's face sheet dated [DATE] revealed she was an [AGE] year-old female who was admitted to the facility originally on [DATE] and readmitted on [DATE] at 2:00 p.m. CR #1's diagnoses included Urinary tract infection, severe obesity, hypertension (high blood pressure), and diabetes (high blood sugar levels). Record review of CR #1's Entry MDS dated [DATE] was not completed and did not reveal a BIMS. Attempted record review of CR #1's care plan revealed it was not completed on [DATE]. Record review of CR #1's DNR code status reflected Resident #1 had a DNR dated [DATE]. Record review of progress notes dated [DATE] by LVN A revealed the following in part: Note Text: 3.00am: [CR #1] found unresponsive during rounds, no breath sounds or respirations, skin slightly warm to touch. Resident re admitted yesterday, no new code status entered in the system and no DNR in the folder noted. Progress notes states that resident was admitted under [Hospice]. Called [Hospice] and spoke to the [Hospice Nurse], notified her of change of condition and enquired on code status. They stated that resident was pending on their side, and they had no code status. Attempted to call [RP A] but call went to voicemail. Called the [ADMIN] and call went to voicemail. CPR started and 911 called. EMTs arrived to find CPR in progress, continued CPR and this nurse attempted to call [RP B] and he picked up, spoke to EMT who stated [RP B] requested to stop CPR and that they had signed a DNR at [Hospital]. CPR ceased and resident pronounced at 3.34am. 4.18am: [Hospice] nurse in the facility residents time of death is 3:34 a.m. Record review of advance directives for the facility census of 123 residents revealed there was 77 Full Code residents and 50 DNR residents. Interview on [DATE] at 2:41 p.m., the ADMIN and Reg. RN said the facility did not have a CPR policy. Reg. RN said the facility had a change in condition policy. Interview on [DATE] at 3:40 p.m., DON said she was notified on [DATE] (early morning hours) by voicemail that CR #1 had a change in condition and 911 was called. The DON said the facility did not have a CPR policy but had a CPR process. She said they did not have a documented policy of the CPR process. She said the CPR process should have been a team effort. The DON said she was told CNA A found CR #1 and notified LVN A. She said she later was informed LVN A left CR #1 after an initial pulse check, which CR #1 did not have a pulse, went to the nurses' station to check the code status. She said because LVN B had not put in CR #1's code status at admission ([DATE]), LVN A had to two separate locations, in the electronic record and a code status binder located at the nurses' station, before the attempted code status verification. Interview on [DATE] at 3:55 p.m., LVN B said she did not put in the code status for CR #1 at admission. She said when LVN A looked for the code status, it was not in the electronic health record or binder for hall 200. She said she was not working when CR #1 was found unresponsive. She said when the code status was unknown, the nurse should verify the code status and start CPR. She said she would leave the resident to check the code status and then tell the team (facility staff) to assist with calling 911 and assist with getting the crash cart. She said she was not trained by the facility staff on how to respond to an unresponsive resident but used her nursing school knowledge. She said she was not sure if there a risk to the resident if staff left an unresponsive resident to check the code status, rather than yell out, alerted staff for help with calling 911, getting the crash cart, and other staff verify the code status. Interview on [DATE] at 4:30 p.m., with LVN A said she was notified by CNA A, CR #1 was unresponsive. LVN A said she went to CR #1's room, attempted to arouse her and checked her pulse. She said CR #1 did not have a pulse. LVN A said she left CR #1 and went to the nurse's station to check CR #1's code status in the electronic health record. She said she told LVN C and LVN D that CR #1 did not have pulse. She said both, LVN A and LVN D looked in the binder and said there was not an advance directive for CR #1 and she should be treated as full code. LVN A said LVN D got the crash cart on the way to CR #1's room along with LVN C. LVN A said she stayed at the nurses' station and called hospice and the hospice representative said the code status was pending. LVN A said called the CR #1's RP and the ADMIN and the calls went to voicemail. LVN A called 911. LVN A said she after she left CR #1's room, looked for the code status, told LVN C and LVN D, and made the phone calls took approximately three minutes. She said she saw LVN C and LVN D perform CPR and EMS arrived in approximately ,d+[DATE] minutes after she called. She said EMS took over CPR. She said while EMS performed CPR for approximately 15 minutes, CR #1's RP was contacted and advised EMS to discontinue CPR because an out of hospital DNR was signed LVN A said she was not trained by the facility on how to respond to an unresponsive resident when CPR or 911 had to be called. LVN A said she responded as a prudent [acting with or showing care and thought for the future] nurse would do. She said she did not think there was a risk to CR #1 with her response to leave CR #1 and check for the code status herself. She said as a licensed nurse, she had to verify the CR #1's code status. She said she did not consider calling out for assistance. Interview on [DATE] at 4:49 p.m., with LVN C said he was near the nurses' station. LVN C said he saw LVN A at the nurses' station and she said CR #1 did not have a pulse. He said LVN A checked the electronic health record for CR #1's code status. He said LVN A did not find once in the electronic record and then looked in code status binder and there was not one. He said LVN A called multiple people to verify CR #1's code status unsuccessfully. He said LVN D and CNA (agency unknown) got the crash cart and went to CR #1's room. He said after LVN A found a code status for CR #1 from her February 2025 admission, which stated CR #1 was a full code. He said he went to CR #1's room. He said CNA (agency unknown) was holding the ambu bag (medical device that forces air into the lungs) and LVN D was in the process of connecting the oxygen. He said he started chest compressions. He said he was not able to recall how long he provided CPR before EMS arrived and they took over. He said he left out of the room immediately after EMS took over. He said he remembered LVN A was in the room with EMS. He said the CNA (agency unknown) and LVN D left out of the room after him too. He said the facility had not trained him on a code or protocol to follow when a resident was found unresponsive. He said he used his nurse knowledge on how to respond. He said there could have been a delay in responding to the resident when the code status was being verified in various ways before the CPR process was started. Interview on [DATE] at 1:36 p.m. with RN A said she was the weekend supervisor and duties included reviewing admissions and ensured they were accurate. She said the admissions process protocol was a checklist that included verification of code status. She said the facility had not trained her on the process after a resident was found unresponsive. Interview on [DATE] at 6:23 p.m. with CNA A said she went into CR #1's room, observed her and attempted to find a pulse. She said she left the room at a fast pace and notified LVN A that CR #1 was unresponsive. CNA A (agency staff) said LVN A went to CR #1's room and came back to the nurses' station to check CR #1's code status. She said when LVN A returned to the station she told another nurse (name unknown to CNA A) about CR #1. CNA A said both of the nurses looked through papers and tried to find the code status for CR #1. She said there was a male nurse at the nurses' station (name unknown to CNA A). She said LVN A told her to go and clean CR #1's face with CNA B. She said she went back to the room. She said LVN C and LVN D came into the room. She said she could not remember how long it was. She said CNA B assisted with the ambu bag. She said the male nurse (LVN C) did chest compressions and LVN D connected the oxygen. She said she did not assist. She said she had not been trained by the facility on how to assist with an unresponsive resident who needed CPR. Interview on [DATE] at 7:31 p.m. with LVN D said she was at the nurse's station and LVN A told her CR #1 was not breathing. LVN D said she flipped through the code status binder and did not see anything for [CR #1]. She said LVN A checked the electronic health record for CR #1 and did not see a code status for the resident. LVN D said she and LVN C went to the room where there was two cnas (CNA A and CNA B). LVN D said LVN C came to the room and assisted with chest compressions. LVN D said she connected the oxygen to the ambu bag that was help by CNA B. She said the event occurred at approximately between 3:00 a.m. and 3:30 a.m. She said she had been trained to check the code status books. She said there was one binder for each hall. She said the new company took over the facility and she had not been trained on a code or the protocol when a resident was found unresponsive. She said everything happened fast and she did not think there was a risk to the resident. Interview on [DATE]at 8:34 a.m. with CNA B said she saw LVN D get the crash cart and she followed her into CR #1's room. She said LVN C came in and assisted with chest compressions. She said she held the ambu bag. She said she was not able to recall how long CPR was performed. She said left after CNA A took over the ambu bag and she went back to her assigned hall. She said she was not trained on the CPR protocol. Record review of American Heart Association dated [DATE] (https://cpr.heart.org/en/resources/what-is-cpr) revealed the following in part: Check for responsiveness. Shout for nearby help Activate emergency response (via mobile device - if appropriate) Get AED and emergency equipment (send someone to do so) . Record review of the facility policy for Changes in Resident Condition (date implemented ,d+[DATE] and revised ,d+[DATE]) revealed the policy did not address what steps the facility staff should take when a resident is found unresponsive. Record review of the facility policy for Advanced Directive (date implemented ,d+[DATE] and revised ,d+[DATE]) revealed in part the following: .The medical record and resident plan of care should reflect the resident's wishes as well as the physician orders in order to meet the directives described . it is the community's responsibility. to ensure that it has current copies of all advance directives. Record review of facility in-service for Admissions/Re-Admissions dated [DATE] revealed the following in part: .Full-Code will be applied to all resident without a completed and signed OOH DNR . An IJ was identified on [DATE]. The IJ template was provided to the ADMIN on [DATE] at 12:16 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:32 a.m.: Allegation: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice. F678 CPR IJ Plan of Removal for F678 [DATE] [Facility Name]o f Removal F678 Cardiopulmonary Resuscitation Immediate Response: Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker on the expected practice of confirming all new admissions have advance directives elections indicated within the medical record. o 1. All residents should have a code status election physician's order in place upon admission. o 2. Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed timely, then uploaded into the electronic health record. o 3. Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN. Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed. o 4.The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will conduct an initial review of the admission/readmission orders to validate that the advanced directive election for code status is in place. This audit will take place the next business day during the morning meeting and the RN Supervisor on duty will conduct the audit on the weekends. In the absence of the RN Supervisor on duty, the Director of Nursing or Assistant Director of Nursing will be responsible for conducting the audit to validate code status election orders are in place. Any discrepancies will be immediately clarified with the resident, authorized representative and the appropriate order will be obtained by the attending physician. Date completed: [DATE] Corporate nurse educated the Administrator/Director of Nursing/Assistant Director of Nursing on response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate the CPR process, until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for a hospital transfer. Date completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record. o 1. All residents should have a code status election physician's order in place upon admission or re-admission. All licensed nurses will receive the education regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives. No nurse will be allowed to work until the in-service training has been completed. o 2. Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. o DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures timely (next business day, not to exceed 3 business days), then uploaded into the electronic health record. o Nurses are expected to validate the code status election within the electronic health record orders to determine code status ordered, upon identifying that a resident presents with altered signs of life, i.e. absence of detectable vital signs, no s/s of life. Nurse should immediately validate code status order in order to confirm advance directive/code status election prior to initiating CPR. After code status has been swiftly confirmed, the nurse should adhere to the code status election (Full Code = swiftly initiating CPR accordingly or DNR-do not resuscitate the nurse would swift proceed with notifications of no s/s of life to the physician and representative. If full code: The available licensed nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. If you find a resident is found unresponsive, the nurse must yell for help, and then proceed to validate the code status, if the cart with the computer is at the door of the room. In the event the cart is not at the door of the room, the charge nurse must also yell for a team member to bring the computer, the crash cart, and the AED machine. Nurses are expected to immediately review the code status orders within the electronic health record in order to identify the resident's code status. This should be immediately with the closest nurse's station computer or closest laptop available. The nurse should respond with urgency, immediately confirming code status and implementing resuscitative measures accordingly. o Nurses are expected to document findings, interventions/response and notifications within the medical record. o Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order. Date Completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses initially then re-education is provided to all licensed nurses regarding on response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate CPR until the code status is validated. The other present licensed nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for a hospital transfer. Date completed: [DATE] Director of Nursing/Assistant Director of Nursing conducted an audit to validate all orders have been entered into [facility electronic record system] accurately and timely from [DATE]-[DATE]. Outcome: 1 of 123 residents did not have designated advanced directive/code status orders in place. Issue was resolved, physician provided orders as per resident/representative's code status election. Date completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights. Date completed:[DATE] Going forward the identified trainings above will also be conducted with new hires accordingly. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Risk: All residents who currently admit or re-admit to the community have the potential to be affected by this practice. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Systemic Response: Director of Nursing/Assistant Director of Nursing conducted 100% re-education was extended to all nurses regarding the expected practice of confirming all new admissions have advance directives elections indicated within the medical record. The Administrator/Director of Nursing/Assistant Director of Nursing conduct re-education with the identified nurses as well as all other licensed nurses regarding the expected practice of confirming all new admissions, re-admissions have advance directives elections indicated within the medical record. o All residents should have a code status election physician's order in place upon admission or re-admission. All licensed nurses educated regarding the process of reconciling physician orders into the electronic health record accurately and timely to include but not limited to code status upon admission, re-admission and any changes in code status election/advanced directives. o Any resident who has an advance directive election change should have the election documented and a physician's order should be obtained at the time the election has been voiced. o DNR elections will be honored upon the resident/representative having voiced the advanced directive care election and if DNR the OOH-DNR form will be initiated and completed with physician's signatures timely (next business day, not to exceed 3 business days), then uploaded into the electronic health record. o Code Status Response: Upon a resident being identified with an acute change of condition; thus, presenting with no signs of life, the absence of vital signs the nurse will: Nurses are expected to validate the code status election prior to initiating CPR by revieing the code status order within the electronic health record. The nurse should immediately alert staff for assistance and all available nursing staff should immediately respond to that location. The nurse will alert staff by utilizing the call light system, phone and /or verbally calling for emergency response assistance to that location. Upon identifying the code status election via the physician's order, the nurse should then proceed with initiating CPR. If the person is designated as Full Code as per the code status order. The available nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and/or conducting proper notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. Should the resident be designated as DNR-do not resuscitate per physician's order and as per the resident's/representative's wishes, the nurse/nurses would proceed with conducting the proper notifications of no s/s of life to the physician and representative. In the event there is no identified code status / advanced directives CPR should be initiated. Resuscitative measures should then only be ceased upon the resident's representative's instruction to stop CPR, confirm the person wished to be DNR and as instructed by physician and/or EMS-medical response team. Director of Nurses/Assistant Director of Nurses will conduct training for licensed nurses, aids and medication aids regarding the process for confirming and implementing CPR. Nursing team members will not work until in-service training has been received. Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts. The DNS/ADNS will determine competency by evaluating the mock emergency drill. Mock code conducted on [DATE]. It was done correctly. All team members followed the Code Status Process with the Mock Code. Will conduct another mock code on [DATE] the day shift. This will be ongoing and monthly. Date to be completed: [DATE]. o Nurses are expected to document findings, interventions/response and notifications within the medical record. o Licensed Nurses both on-coming, and off-going nurses will review/audit the code status designation for any new admission, re-admission and new order or changes to code status during the 24-hour report. Any identified discrepancies or absence of code status will be reported to the attending MD, DNS and/or ADMIN. Should there not be an election of advanced directives or code status, will result in the individual being full code until otherwise directed. o Nurses are expected to notify the Administrator and/or Director of Nurses for all emergent events, deaths within the facility, significant changes in condition and any concerns regarding CPR emergent response as well as any resident without an identified code status election order. o All Staff: Any staff member should immediately respond to a code status response with the Crash Cart along with the AED to the bedside of identified resident accordingly. Date Completed: [DATE] The Administrator/Director of Nursing/Assistant Director of Nursing out of an abundance of caution, provided re-education to all team members on Abuse /Neglect and Residents Rights. Date completed:[DATE] Going forward the identified trainings above will also be conducted with new hires accordingly. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Going forward the identified trainings above will also be conducted with new hires accordingly. Monitoring: The Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will make weekly random audits validating the electronic health record for accurate code status orders as well as appropriate OOH-DNR form within the medical record. This audit will be conducted ,d+[DATE] days a week for the next 2 months. The findings will be reviewed and reported to the QAPI committee, to validate compliance or to identify additional training needs. The Director of nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry as well as interview nurses to review the expected practice of validating code status upon admission, validating code status order entry as well as expected process for an emergent response when a significant change in condition (absence of signs of life, no detectable vital signs) has been identified, as well as general interviews with all staff regarding expected response of responding with the crash cart to the designated room accordingly. This expected validation observations and interviews will take place ,d+[DATE] days a week for the next 2 months. Mock Code Drills: Director of Nurses/Assistant Director of Nurses will conduct monthly mock code response of both full code and DNR on various shifts at least once a month for the next 2 months. Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed as per required code status admission orders and will review all orders daily in the clinical meeting to validate compliance of code status election has the appropriate code status election physician's order in place. This expected validation observations and interviews will take place ,d+[DATE] days a week for the next 2 months. HR/Director of Nurses will conduct CPR certification audit at least once a month for the next 2 months. This corrective action plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months to establish compliance or identify additional trainings and oversight is required. All audits will be placed in a binder and kept for review by HHSC for the revisit to validate to compliance. The Administrator/Director of Nursing and Medical Director conducted a Ad Hoc QAPI meeting to review this situation, and the immediate corrective action plan implemented. Date of ADHOC : Monitoring of the plan of removal included the following: Record review of In-Service for Administrative Nurses on Advance Directives dated [DATE] revealed DON, ADON A, ADON B, MDS A, MDS B, MDS C, were provided education by Reg. RN regarding Advance Directives and CPR process. Record review of In-Service for Administrative Nurses on Response Times dated [DATE] revealed DON, ADON A, ADON B, MDS A, MDS B, MDS C, were provided education by Reg. RN. Licensed Nurses : Response times when performing immediate assessments/interventions for residents with changes in condition. Anytime a resident experiences a change in condition and it appears the heart has stopped, pulseless or not breathing, with a Full Code Order or No code status, you must immediately initiate CPR until the code status is validated. The other present license nurses in the community must assist with the change in condition by immediately verifying code status, calling 911, notifying MD and RP. As well as assisting with the required paperwork for a hospital transfer. Record review of In-Service for Administrative Nurses on Code Status Response dated [DATE] revealed ADMIN, DON, ADON A, MDS A, MDS B, MDS C were provided education by Reg. RN: Code Status Response: o Upon a resident being identified with an acute change of condition; thus, presenting with no signs of life, the absence of vital signs the nurse will: o 1. Nurses are expected to validate the code status election prior to initiating CPR by revieing the code status order within the electronic health record. The nurse should immediately alert staff for assistance and all available nursing staff should immediately respond to that location. The nurse will alert staff by utilizing the call light system, phone and /or verbally calling for emergency response assistance to that location. 2. Upon identifying the code status election via the physician's order, the nurse should then proceed with initiating CPR. If the person is designated as Full Code as per the code status order. The available nurses within the community should assist with the code status response by swiftly verifying the code status order, implementing CPR according to the physician's order, calling 911, and/or conducting proper notification to MD and RP, as well as assisting with the required paperwork for a hospital transfer. o Should the resident be designated as DNR-do not resuscitate per physician's order and as per the resident's/representative's wishes, the nurse/nurses would proceed with conducting the proper notifications of no sis of life to the physician and representative. o In the even [TRUNCATED]

Based on interviews, and record review the facility failed to immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 of 4 residents (CR #1) reviewed for notification of changes. The facility failed to ensure CR #1's physician was consulted when he was short of breath while receiving oxygen treatment. This failure could place residents at risk of respiratory distress or significant decline in physical or mental functioning. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of pattern because all staff had not been trained on notification of changes to the physician. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #1 had diagnoses included: heart failure, (heart cannot pulp enough blood and oxygen to the body's organ), morbid obesity (body mass index greater than 35 combined with other health issues), diabetes mellites (body does not manage blood sugar properly), and atrial fibrillation (irregular heartbeat). Record review of CR#1's admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 out of 15 which indicated intact cognition. Further review revealed Resident #1 needed moderate assistance with mobility. Record review of CR#1's care plan dated [DATE] revealed Resident #1 resident was at risk for shortness of breath. Intervention: alert my nurse for concentrator and/oxygen tank needs to be changed, provide oxygen as ordered by physician. Record review of CR#1's order summary report did not reveal that the resident had an order for oxygen administration. Record review of CR#1's NEMAR for [DATE] revealed there was no order found for Respiratory(oxygen). Record review of CR#1 progress notes from ,d+[DATE]/ 24 to [DATE] revealed there was no documentation that CR #1 was in any distress. Record review of CR #1 hospital discharge record printed [DATE] did not reveal any order for oxygen. During an interview on [DATE] at 2:07 p.m., RN G said CR #1 was on PRN oxygen. RN G said CR #1 would feel winded when he stood up for her during wound care and he would put his oxygen on. RN G said she was unsure if CR #1 had an order for oxygen. RN G said oxygen should be administered with a physician's order to ensure CR #1 received the appropriate liters of oxygen. RN G said if CR #1 did not receive adequate oxygen, he could go into respiratory distress. RN G said nurse managers monitored the nurses when they made random rounds. During a telephone interview on [DATE] at 4:15 p.m., LVN T said CR #1 had oxygen in his room and believed CR #1 had an order for oxygen. LVN T said CR #1 had an order for oxygen; the nurses would document it on the NEMAR. LVN T said CR #1 must have an order before oxygen would be administered because if CR #1 did not have an order, CR #1 may not receive the required liters of oxygen to prevent respiratory complications such as shortness of breath or a crisis. LVN T said she had an in-service on oxygen administration, and the nurse managers monitored the nurses during random rounds. During an interview on [DATE] at 5:27 p.m., LVN H said she verified the admission orders with the physician, and the physician gave an order for oxygen. LVN H was supposed to put the oxygen order in but did not know she did not put the oxygen order in the computer, and she could not remember how many liters of oxygen the physician prescribed for CR #1. LVN H said oxygen was a medication, and she should have put the order in the computer. LVN H also said if CR #1 did not get the prescribed liters of oxygen, CR #1 could have respiratory distress. LVN H said she had a skill- check off on the admission process, and the nurse manager should have checked the paperwork the day after admission. During an interview on [DATE] at 9:58 a.m., the OT said CR#1 could walk to the restroom and shower room, but he would need his oxygen. The OT said CR#1 kept his oxygen on with any activity, but he could take it off for a little while during the shower. During an interview on [DATE] at 10:38 a.m., PTA said she had worked with CR #1 during therapy and he wore an oxygen tank. She said they worked with him at his pace because of his size, he was mobility obese. She said he wore his oxygen at all times during therapy and he runs out of breath (SOB) and she would let him rest and continued again. She said that when the resident was able to walk to the bathroom in his room, and they told the resident he would have to have staff with him if he wants to walk past the bathroom in his room. During an interview on [DATE] at 10:57 a.m., the ADON said CR #1 did not have an order for oxygen from the hospital. The ADON said the nurse managers should have done chart checks and checked the orders to ensure CR #1's medication was correct the next day. The ADON said LVN H should have put in a PRN order because CR #1 had oxygen, but LVN H did not transcribe the oxygen order. The ADON said CR #1 should not have oxygen on without an order. The ADON said CR #1 could go into respiratory distress if he did not get adequate liters of oxygen, and if CR #1 got more than required, it could cause CR #1 to depend on oxygen. During an observation and interview on [DATE] at 1:55 p.m., the State Surveyor and the MDS Nurse reviewed CR #1's physician orders, and the MDS nurse said she did not see the order for oxygen. The MDS nurse said CR#1 should have an order for oxygen before the nurses could administer oxygen to him. The MDS nurse said it was a medication error because LVN H had to enter the physician's orders before nurses could administer oxygen to CR #1. The MDS nurse said there could be a negative effect on CR #1 if the nurse's administered oxygen to CR#1 without an order. The MDS nurse said the negative effect could cause CR #1 to depend on oxygen or could have an adverse respiratory crisis if he did not receive the recommended liters of oxygen. The MDS nurse said CR #1 was care planned by LVN H, not her. During an interview on [DATE] at 3:02 p.m., the Administrator said that for a resident to be on oxygen, the resident should have an order for oxygen. The Administrator said she was sure there could be some side effects, but she did not think it would be dangerous. The Administrator said the DON monitored the nurses to ensure the nurses transcribed the orders correctly. During an interview on [DATE] at 4:16 PM 4: 16 p.m., the DON said CR #l 's 02 was RPN the nurse would make the decision if the resident could take off the oxygen. The DON said the therapy dept did not tell her that CR#1 got winded during activity even with oxygen. During a telephone interview on [DATE] at4:37 p.m., the Physician said he gave intermitter oxygen order and he could not remember how many liters of oxygen he gave, but the nurse could titrate the liter for CR #1 to be comfortable. He said the resident used oxygen intermittently said CR #1 refused to use oxygen sometimes and he had experienced hypoxia and he was still comfortable. The physician said normal order for oxygen was between 2 to 3 liters. The Physician said the nursing or therapy did not communicate to him that CR #1 still has shortness of breath during activities even with oxygen. He said maybe the nursing staff spoke to the NP about the resident having SOB with oxygen during activity. He said it was his understanding that the resident was on oxygen while he was in the facility. During a telephone interview on [DATE] at 4:58 p.m., the NP refused to answer questions regarding CR #1. Record review of the facility oxygen administration dated [DATE], Revised [DATE] read in part . a resident receives oxygen therapy when there is an order by a physician. The resident's disease, physical condition, and age will help determine the most appropriate method of administration and should be reflected in the physician . The following Plan of Removal was accepted on [DATE] at 12:30 PM, PLAN OF REMOVAL: Abatement Plan Immediate Response: o The identified resident expired on [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE] . o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed: [DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] . Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Risk Response: All new admissions/readmissions have the potential to be affected by the deficient practice. Systemic Response: o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE] . o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed:[DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] . Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Monitoring Response: o The Director of Nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry for ,d+[DATE] nurses, ,d+[DATE] days a week for 2 months. o Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed per discharge orders for the reconciliation process for ,d+[DATE] days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting. A review of residents who are on oxygen will be reviewed with the rehabilitation representative. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with ,d+[DATE] random therapy team member ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with ,d+[DATE] random therapy team member ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services . o Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from ,d+[DATE] random licensed nurses ,d+[DATE] days a week for 2 months. o All the monitoring will be monitored by the Director of Nursing/Assistant Director of Nursing. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months. Medical Director notified of the Immediate Jeopardy on [DATE] @ 7:22pm per Director of Nursing Services. Surveyor monitored the plan of removal for effectiveness as follows: Observation and interviews starting from [DATE] to [DATE] revealed no concerns with oxygen therapy for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. There were no signs of shortness of breath or labored breathing, each resident received oxygen therapy within the parameters of their physician order. Record review of physician orders and care plans for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed no concerns, each resident had physician orders and were care planned for oxygen therapy. Record review of [DATE] to [DATE] oxygen saturations and MAR/TAR's for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed each resident was being monitored for oxygen therapy. Record review of the facility plan or removal training, skills check-off, and in-service revealed the facility had 12 residents on oxygen, and the DON reviewed and completed their clinical records on [DATE]. Record review of the facility training revealed that the corporate nurse trained the DON, nurse managers, and administrator on physician follow-up chart checks, completed on [DATE]. Record review of the facility training for the nurses on changes of condition and notifications to physicians completed on [DATE]. A record review of the facility's training revealed that the DON sent all staff training via Care Feed(electronic training system via telephone) on [DATE]. Record review of the facility's oxygen monitoring log revealed that the DON started monitoring on [DATE] and would be monitored 1 - 7 days/week for 1 - 2 months. Record review of the facility's clinical meeting dated [DATE] revealed daily oxygen review for nurse managers, administrators, and physical therapists would be present during morning meetings, residents on oxygen would be reviewed daily. A copy of this report will be given to the therapy representative at this time. Record review of the facility training dated from [DATE] - [DATE] on Kardex( quick reference to resident care) for all the nursing team revealed how to assess the care provided to the resident, how many staff, and equipment needed during care. Record review of the facility plan of removal training dated from [DATE] - [DATE] revealed the nurses had skills check off on change in condition for oxygen, and any general change in condition. Record review of the facility plan of removal revealed the facility had started monitoring on [DATE]. During interviews conducted on [DATE] between 9:31 a.m. and 2:31 p.m., with staff on shifts (4 CNAs: CNA A, CNA B, CNA D, and CNA E from 6:00 a.m. -to 2:00 p.m. and 4 LVN: LVN C, LVN D, LVN M, and LVN T from 6:00 a.m. -6:00 p.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During a telephone interview on [DATE] between 10:48 a.m. and 11:28 a.m., OT and PTA said the DON texted in service on change in condition of any resident during physical therapy. The OT or PTA would fill out stop and watch and sign the form, then give a copy to the nurse and the second copy to the DON. They said the DON called them on the phone and conducted the in-service. She said the physical therapist must report any change in condition, including the resident on oxygen, and the physical director had to attend morning meetings. During interviews conducted on [DATE] between 7:45 a.m., and 8:43 p.m., with staff on shifts (4 CNAs: CNAF, CNA G, CNA H, and CNA I from 2:00 p.m. -10:00 p.m., 3 CNAs: CNA J, CNA K, and CNA L from 6:00 p.m. - 6: 00a.m., and 3 LVN: LVN E, LVN F, and LVN G from 6:00p.m. -6 :00 a.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During an interview on [DATE] at 1:45 p.m., ADON L said the corporate nurse did an in-service for the nurse manager and the administrator. ADON L said the in-service and skills checkoff included change in condition, care plans, medication verification, and chart check after admission; Kardex and oxygen were part of the change in condition. During an interview on [DATE] at 1:57 p.m., the DON, corporate, and administrator were in the room. The DON said she had training from the corporate nurse on change in condition, oxygen, admission process, and the physical therapy director would come to the meetings. The DON said she would monitor the skills check-off and in-service progress for 1 to 7 days for 2 months. During an interview on [DATE] at 2:0 p.m., The Corporate Nurse said staff should report immediately when there was any change in condition, including shortness of breath. The Corporate Nurse said she validated the aide's competencies on Kardex. She also said she reviewed the removal plan with the administrator, DON, and the [NAME] President of operation. During an interview on [DATE] at 2:03 p.m., the Administrator said the Corporate Nurse trained her and the nurse managers on Kardex and change in condition. The Administrator said the DON would give the names of residents on oxygen to the therapy director so that they could communicate if any of those residents had shortness of breath to the floor nurse and the DON. The Administrator said the nurse manager would monitor the progress of the training for the next two months. During an interview on [DATE] at 2:13 p.m., the DON said the system broke when the LVN H missed entering the oxygen order in the computer, and ADON J, who did the chart check, did not realize LVN H did not enter the oxygen order in the computer. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated because all staff had not been trained on consulting the physician during a change of condition.

Based on interviews, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 4 residents (CR #1) reviewed for respiratory therapy. The facility failed to ensure CR #1 was provided with repiratory services to meet his needs. CR #1 ambulated with a walker approximately 30 feet without oxygen, slid out of a shower chair onto the floor and became unresponsive and later died . The facility failed to ensure CR #1 who was admitted with a verbal order for oxygen administration was documented, verified, and communicated to staff for proper implementation. This failure could place residents at risk of respiratory distress or dependency. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of pattern because all staff had not been trained on the process of medication reconciliation from the discharged facility with the physician during admission. The admitting nurse would enter the orders in PCC, and the nurse manager would conduct chart audits to validate accurate orders were entered into the computer using the discharge summary in collaboration with the admitting physician in the community. All staff trained on how to pull up residents care information from the Kardex, and change in condition. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #1 had diagnoses included: heart failure, (heart cannot pulp enough blood and oxygen to the body's organ), morbid obesity (body mass index greater than 35 combined with other health issues), diabetes mellites (body does not manage blood sugar properly), and atrial fibrillation (irregular heartbeat). Record review of CR#1's admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 out of 15 which indicated intact cognition. Further review revealed Resident #1 needed moderate assistance with mobility. Record review of CR#1's care plan dated [DATE] revealed Resident #1 resident was at risk for shortness of breath. Intervention: alert my nurse for concentrator and/oxygen tank needs to be changed, provide oxygen as ordered by physician. Record review of CR#1's order summary report did not reveal that the resident had an order for oxygen administration. Record review of CR#1's NEMAR for [DATE] revealed there was no order found for Respiratory(oxygen). Record review of CR#1 progress notes from ,d+[DATE]/ 24 to [DATE] revealed there was no documentation that CR #1 was in any distress. Record review of CR #1 hospital discharge record printed [DATE] did not reveal any order for oxygen. Record review of CR #1's Nurse Practitioner visit note dated [DATE] read, review of systems : Chief Complaint :seen today for admission visit .respiratory : chronically 02 dependent at 2L. Record review of CR #1's nursing progress note dated [DATE] at 5:45pm read in part, Around 3:40 p.m (CNA C) was in shower room with patient, as he was transfering to the shower chair he began sliding down, C.N.A assisted res to the floor. C.N.A notified this nurse of situation, this nurse observed res laying on bathroom/shower room floor supine. Res was alert and oriented, denied pain and discomfort at this time. Res skin color was within normal limits. Res stated to this nurse that we would need to call the fire department to get him up and that he needed oxygen. Res did not diplay any (signs or symptoms) of distress at this time. This nurse went across hallway to get res O2 concentrator. 45 seconds after returning to res with supplemental 02, res was unresponsive. lips where a purple coloration, unable to get readable (vital signs). Code blue was called, 911 was called and arrived on scene .Res was pronounced at (4:13pm). During an interview on [DATE] at 2:07 p.m., RN G said CR #1 was on PRN oxygen. RN G said CR #1 would feel winded when he stood up for her during wound care and he would put his oxygen on. RN G said she was unsure if CR #1 had an order for oxygen. RN G said oxygen should be administered with a physician's order to ensure CR #1 received the appropriate liters of oxygen. RN G said if CR #1 did not receive adequate oxygen, he could go into respiratory distress. RN G said nurse managers monitored the nurses when they made random rounds. During an interview on [DATE] at 2:45 p.m., the DON reviewed the discharge report from the hospital with the State Surveyor, and the DON said there was no oxygen order from the discharge summary hospital report. The DON said CR #1 was on oxygen PRN but could not see any order from the facility physician. The DON said CR #1 must have an order for oxygen to ensure the resident received the required liters of oxygen to prevent any respiratory distress for CR #1. During a telephone interview on [DATE] at 4:15 p.m., LVN T said CR #1 had oxygen in his room and believed CR #1 had an order for oxygen. LVN T said CR #1 had an order for oxygen; the nurses would document it on the NEMAR. LVN T said CR #1 must have an order before oxygen would be administered because if CR #1 did not have an order, CR #1 may not receive the required liters of oxygen to prevent respiratory complications such as shortness of breath or a crisis. LVN T said she had an in-service on oxygen administration, and the nurse managers monitored the nurses during random rounds. During an interview on [DATE] at 5:27 p.m., LVN H said she verified the admission orders with the physician, and the physician gave an order for oxygen. LVN H was supposed to put the oxygen order in but did not know she did not put the oxygen order in the computer, and she could not remember how many liters of oxygen the physician prescribed for CR #1. LVN H said oxygen was a medication, and she should have put the order in the computer. LVN H also said if CR #1 did not get the prescribed liters of oxygen, CR #1 could have respiratory distress. LVN H said she had a skill- check off on the admission process, and the nurse manager should have checked the paperwork the day after admission. During an interview on [DATE] at 9:58 a.m., the OT said CR#1 could walk to the restroom and shower room, but he would need his oxygen. The OT said CR#1 kept his oxygen on with any activity, but he could take it off for a little while during the shower. During an interview on [DATE] at 10:38 a.m., PTA said she had worked with CR #1 during therapy and he wore an oxygen tank. She said they worked with him at his pace because of his size, he was mobility obese. She said he wore his oxygen at all times during therapy and he runs out of breath (SOB) and she would let him rest and continued again. She said that when the resident was able to walk to the bathroom in his room, and they told the resident he would have to have staff with him if he wants to walk past the bathroom in his room. During an interview on [DATE] at 10:57 a.m., the ADON said CR #1 did not have an order for oxygen from the hospital. The ADON said the nurse managers should have done chart checks and checked the orders to ensure CR #1's medication was correct the next day. The ADON said LVN H should have put in a PRN order because CR #1 had oxygen, but LVN H did not transcribe the oxygen order. The ADON said CR #1 should not have oxygen on without an order. The ADON said CR #1 could go into respiratory distress if he did not get adequate liters of oxygen, and if CR #1 got more than required, it could cause CR #1 to depend on oxygen. During an observation and interview on [DATE] at 1:55 p.m., the State Surveyor and the MDS Nurse reviewed CR #1's physician orders, and the MDS nurse said she did not see the order for oxygen. The MDS nurse said CR#1 should have an order for oxygen before the nurses could administer oxygen to him. The MDS nurse said it was a medication error because LVN H had to enter the physician's orders before nurses could administer oxygen to CR #1. The MDS nurse said there could be a negative effect on CR #1 if the nurse's administered oxygen to CR#1 without an order. The MDS nurse said the negative effect could cause CR #1 to depend on oxygen or could have an adverse respiratory crisis if he did not receive the recommended liters of oxygen. The MDS nurse said CR #1 was care planned by LVN H, not her. During an interview on [DATE] at 3:02 p.m., the Administrator said that for a resident to be on oxygen, the resident should have an order for oxygen. The Administrator said she was sure there could be some side effects, but she did not think it would be dangerous. The Administrator said the DON monitored the nurses to ensure the nurses transcribed the orders correctly. During an interview on [DATE] at 4:16 PM 4: 16 p.m., the DON said CR #l 's 02 was RPN the nurse would make the decision if the resident could take off the oxygen. The DON said the therapy dept did not tell her that CR#1 got winded during activity even with oxygen. During a telephone interview on [DATE] at4:37 p.m., the Physician said he gave intermitter oxygen order and he could not remember how many liters of oxygen he gave, but the nurse could titrate the liter for CR #1 to be comfortable. He said the resident used oxygen intermittently said CR #1 refused to use oxygen sometimes and he had experienced hypoxia and he was still comfortable. The physician said normal order for oxygen was between 2 to 3 liters. The Physician said the nursing or therapy did not communicate to him that CR #1 still has shortness of breath during activities even with oxygen. Record review of the facility oxygen administration dated [DATE], Revised [DATE] read in part . a resident receives oxygen therapy when there is an order by a physician. The resident's disease, physical condition, and age will help determine the most appropriate method of administration and should be reflected in the physician . The following Plan of Removal was accepted on [DATE] at 12:30 PM, PLAN OF REMOVAL: Abatement Plan F695 Respiratory/Tracheostomy Care and Suctioning [DATE] at 7:11pm Immediate Response: o The identified resident expired on [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. The Director of Nursing Services/Assistant Director of Nursing will supervise this process and monitor ,d+[DATE] days a week for the next 2 months. Date completed:[DATE]. o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed: [DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the Kardex to be informed of the residents needs with activities of daily living prior to providing care of the resident. Date of completion: [DATE] o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with the admitting physician in the community. The RN supervisor will monitor this process on weekends, holidays, and when the Director of Nursing Services or Assistant Director of Nursing Services is not present in the community. Date completed: [DATE]. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Risk Response: All new admissions/readmissions have the potential to be affected by the deficient practice. Systemic Response: o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Date completed:[DATE]. o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed:[DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the Kardex to be informed of the residents needs with activities of daily living prior to providing care of the resident. o Date of completion: [DATE] o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with the admitting physician in the community. Date completed: [DATE]. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Monitoring Response: o The Director of Nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry for ,d+[DATE] nurses, ,d+[DATE] days a week for 2 months. o Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed per discharge orders for the reconciliation process for ,d+[DATE] days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting. A review of residents who are on oxygen will be reviewed with the rehabilitation representative. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with ,d+[DATE] random therapy team member ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with ,d+[DATE] random therapy team member ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing Services/Assistant Director of Nursing Services will validate the proper process of use/access of the Kardex by ,d+[DATE] direct care staff ,d+[DATE] days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from ,d+[DATE] random licensed nurses ,d+[DATE] days a week for 2 months. o All the monitoring will be monitored by the Director of Nursing/Assistant Director of Nursing. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months. Medical Director notified of the Immediate Jeopardy on [DATE] @ 7:22pm per Director of Nursing Services. Surveyor monitored the plan of removal for effectiveness as follows: Observation and interviews starting from [DATE] to [DATE] revealed no concerns with oxygen therapy for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. There were no signs of shortness of breath or labored breathing, each resident received oxygen therapy within the parameters of their physician order. Record review of physician orders and care plans for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed no concerns, each resident had physician orders and were care planned for oxygen therapy. Record review of [DATE] to [DATE] oxygen saturations and MAR/TAR's for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed each resident was being monitored for oxygen therapy. Record review of the facility plan or removal training, skills check-off, and in-service revealed the facility had 12 residents on oxygen, and the DON reviewed and completed their clinical records on [DATE]. Record review of the facility training revealed that the corporate nurse trained the DON, nurse managers, and administrator on physician follow-up chart checks, completed on [DATE]. Record review of the facility training for the nurses on medication reconciliation with the physician from discharged facility order summary report with MD/NP and entering the medication in the PCC. The nurse validated how to enter medication into PCC, completed on [DATE]. A record review of the facility's training revealed that the DON sent all staff training via Care Feed(electronic training system via telephone) on [DATE]. Record review of the facility's oxygen monitoring log revealed that the DON started monitoring on [DATE] and would be monitored 1 - 7 days/week for 1 - 2 months. Record review of the facility's clinical meeting dated [DATE] revealed daily oxygen review for nurse managers, administrators, and physical therapists would be present during morning meetings, residents on oxygen would be reviewed daily. A copy of this report will be given to the therapy representative at this time. Record review of the facility training dated from [DATE] - [DATE] on Kardex( quick reference to resident care) for all the nursing team revealed how to assess the care provided to the resident, how many staff, and equipment needed during care. Record review of the facility plan of removal training dated from [DATE] - [DATE] revealed the nurses had skills check off on change in condition for oxygen, and any general change in condition. Record review of the facility plan of removal revealed the facility had started monitoring on [DATE]. During interviews conducted on [DATE] between 9:31 a.m. and 2:31 p.m., with staff on shifts (4 CNAs: CNA A, CNA B, CNA D, and CNA E from 6:00 a.m. -to 2:00 p.m. and 4 LVN: LVN C, LVN D, LVN M, and LVN T from 6:00 a.m. -6:00 p.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During a telephone interview on [DATE] between 10:48 a.m. and 11:28 a.m., OT and PTA said the DON texted in service on change in condition of any resident during physical therapy. The OT or PTA would fill out stop and watch and sign the form, then give a copy to the nurse and the second copy to the DON. They said the DON called them on the phone and conducted the in-service. She said the physical therapist must report any change in condition, including the resident on oxygen, and the physical director had to attend morning meetings. During interviews conducted on [DATE] between 7:45 a.m., and 8:43 p.m., with staff on shifts (4 CNAs: CNAF, CNA G, CNA H, and CNA I from 2:00 p.m. -10:00 p.m., 3 CNAs: CNA J, CNA K, and CNA L from 6:00 p.m. - 6: 00a.m., and 3 LVN: LVN E, LVN F, and LVN G from 6:00p.m. -6 :00 a.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During an interview on [DATE] at 1:45 p.m., ADON L said the corporate nurse did an in-service for the nurse manager and the administrator. ADON L said the in-service and skills checkoff included change in condition, care plans, medication verification, and chart check after admission; Kardex and oxygen were part of the change in condition. During an interview on [DATE] at 1:57 p.m., the DON, corporate, and administrator were in the room. The DON said she had training from the corporate nurse on change in condition, oxygen, admission process, and the physical therapy director would come to the meetings. The DON said she would monitor the skills check-off and in-service progress for 1 to 7 days for 2 months. During an interview on [DATE] at 2:0 p.m., the Corporate Nurse said she conducted an in-service for the nurse managers, which included the administrator on verification of new resident medication with the physician, and any new order given by the physician would be entered into the computer by the admitting nurse. The Corporate Nurse said the nurse manager would verify the orders in the computer, cross-check them with the admitting orders, and verify from the nurse whether the physician gave an additional order on admission and if the nurse entered the order in the computer. The Corporate Nurse said residents on oxygen were transferred with portable oxygen when they were not in the room. The Corporate Nurse said staff should report immediately when there was any change in condition, including shortness of breath. The Corporate Nurse said she validated the aide's competencies on Kardex. She also said she reviewed the removal plan with the administrator, DON, and the [NAME] President of operation. During an interview on [DATE] at 2:03 p.m., the Administrator said the Corporate Nurse trained her and the nurse managers on verification of order from the discharged summary report from the transferring facility. The Administrator said the admitting nurse should verify the order with the physician upon admission and enter the order accurately into the computer. She also said if the nurse received any order, such as an oxygen order, the nurse should enter the order accurately in the computer. The Administrator said the next nurse would also check the order, and the ADON would do a chart check and ensure the admitting nurse entered all the orders correctly into the computer. The Administrator said she was also trained on Kardex and change in condition. The Administrator said the DON would give the names of residents on oxygen to the therapy director so that they could communicate if any of those residents had shortness of breath to the floor nurse and the DON. The Administrator said the nurse manager would monitor the progress of the training for the next two months. During an interview on [DATE] at 2:10 p.m., the Administrator said the error in the system happened when the physician gave an oxygen order for CR #1 and LVN H did not put the order in the computer. The Administrator said that ADON J did not completely check the chart because she did not realize CR #1 was supposed to be on oxygen. During an interview on [DATE] at 2:13 p.m., the DON said the system broke when the LVN H missed entering the oxygen order in the computer, and ADON J, who did the chart check, did not realize LVN H did not enter the oxygen order in the computer. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:11 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated because all staff had not been trained on the process of medication reconciliation from the discharged facility with the physician during admission. The admitting nurse would enter the orders in PCC, and the nurse manager would conduct chart audits to validate accurate orders were entered into the computer using the discharge summary in collaboration with the admitting physician in the community. All staff trained on how to pull up residents' care information from the Kardex, and change in condition.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (CR #1) of four residents reviewed for accidents, hazards, and supervision. -The facility failed to ensure CNA C followed CR#1's care plan when transferring CR#1 who required two staff for transfers. CR#1 slide out of shower chair onto the floor and became unresponsive and later died . -The facility failed to ensure CNA C followed CR#1's care plan when during ambulation. CR#1 ambulated with a walker instead of wheelchair as care planned. CR#1 slide out of shower chair onto the floor and became unresponsive and later died . These failures can place residents at risk of injury due to not being supervised properly. An IJ was identified on [DATE]. The IJ template was provided to the facility Administrator on [DATE] at 7:11 p.m. While the facility Administrator was informed that the IJ was removed on [DATE] at 2:58 PM, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated because all staff trained on how to pull up resident's care information from the Kardex, notifying the nurse regarding resident care and change in condition. Findings included: Record review of CR #1's face sheet dated [DATE]revealed a [AGE] year-old male was admitted to the facility on [DATE]. CR #1 had diagnoses included: heart failure (heart cannot pulp enough blood and oxygen to the body's organ), morbid obesity (body mass index greater than 35 combined with other health issues), diabetes mellites (body does not manage blood sugar properly), and atrial fibrillation (irregular heartbeat). Record review of CR #1's admission MDS assessment dated [DATE] revealed CR #1 had BIMS score of 15 out of 15 which indicated intact cognition. Further review revealed CR #1 needed moderate assistance with mobility. Record review of Resident #1's care plan dated [DATE] revealed CR#1 revealed resident had a self-care deficit. Interventions: mobility: I use a wheelchair, transfer: gait belt X2 team member CR#1 resident was at risk for shortness of breath. Intervention: alert my nurse for concentrator and/oxygen tank needs to be changed, provide oxygen as ordered by physician. During a telephone interview on [DATE] at 4:15 p.m., LVN T said CNA C called her to the shower room, he saw CR #1 was lying on his back, and CR #1 told him to call the fire department to come and pick him up off the floor. LVN T said he told CNA C to call LVN M, and he went across the hall and brought CR #1's concentrator into the shower room and applied the oxygen to CR #1. LVN T said CR #1 was unresponsive, and his lips and fingertips were blue. LVN T said he could get CR #1's pulse at first, and it was 92, and then there was no pulse. LVN T said all the nurses came and started CPR before the paramedics arrived, and when the paramedic came, they took over but CR #1 expired. During an interview on [DATE] at 4:37 p.m., CNA C said the day CR #1 fell in the shower room was her first time working with him. CNA C said she did not know how CR#1 ambulated or transferred, and she asked CR #1, and he said he walked with a walker. CNA C said CR #1 got up from the bed, took off his oxygen, and walked with his walker to the shower room from his room. CNA C said when CR#1 walked past the door, from the hallway to the shower room to the door in the shower room before the shower stall. CR #1 asked her to turn the shower chair to face him, while she went to turn the shower chair, CR #1 started to slide down and fell before, she could get to him. CNA C said CR #1 fell on his bottom, but he did not hit his head on floor. CNA C said she told CR #1 not to move because she was going to call LVN T. CNA C said she went and called LVN T, and both came back to the bathroom, and CR #1 was still sitting on his buttocks. Then, CNA C said that when she came back with LVN T, CR #1 asked LVN T to go and get his oxygen because he was short of breath. Then LVN T told her to call LVN M. CNA C said some minutes later, CR #1 became unresponsive. CNA C said she would not have ambulated CR #1 with a walker if she knew he was supposed to ambulate with a wheelchair or tried to transfer him by herself to the shower chair if she knew CR #1 was supposed to be transferred by two staff and a gait belt. CNA C said CR #1 would not have fallen if two staff had assisted with the transfer. CNA C said she did not know where to check for how many staff needed to provide care for CR #1. CNA C did not respond when asked about the Kardex or asking a nurse about care needs for CR#1 During a telephone interview on 01//,d+[DATE] at 9:21 a.m., LVN M said CNA C told him to go to the shower room, and when he got to the shower room, CR #1 was lying on his back on the floor, and he was still alive. LVN T went to the CR#1's room, brought the oxygen concentrator to the shower room, and applied the oxygen to CR #1, but CR #1 became unresponsive. LVN M said he called EMS, and a CODE was called. LVN M said other nurses came with a crash cart, and CPR was started. EMS came and took over CPR, but CR #1 expired. LVN M said CNA C should talk to the nurse or look through the Kardex to find out how CR #1 should be transferred or ambulate. If it was recommended for two staff, then two staff should have transferred CR #1, and maybe CR #1 would not have fallen. CR #1 said the nurse monitored the aides when the nurse made rounds, and the ADON monitored the nurses during random rounds. During an interview on [DATE] at 9:58 a.m., the OT said CR#1 could walk to the restroom and shower room, but he would need his oxygen. The OT said CR#1 kept his oxygen on with any activity, but he could take it off for a little while during the shower. The OT said CR #1 was a fall risk and should ambulate with a wheelchair and be assisted by staff when he ambulates with a walker. The OT said she did not tell the nursing staff to make any changes to CR #1's care plan. During an interview on [DATE] at 10:57 a.m., the ADON said CR #1 should be transferred by two staff and a gait belt because he weighed 554 LB. The ADON said CR #1 could have fallen and been injured if one staff member had transferred the resident. ADON said, one of the nurses called a code blue after the resident fell in the shower room and became unresponsive, but the staff and EMS could not revive CR #1, and he expired. The ADON and the therapist (OT), were responsible for telling the aides how many staff members were needed for transfer. The ADON said the charge nurse monitors the aides and staffing coordinator, and everybody monitors nurses because nursing was a revolving door. The ADON said CNA C should check the Kardex(a system nurses use to access resident care information) to see how CR #1 should be transferred if she had not previously worked with CR #1 or ask the nurse how to care for CR #1. During an interview on [DATE] at 1:31 p.m., the MDS nurse said any change in CR #1's condition would be changed in the care plan and during the quarterly assessment. The MDS nurse said the floor nurse and the DON initiated the care plan for CR#1 upon admission, and when there was a change, she would change the care plan. The MDS nurse said she had not changed CR #1's care plan. The MDS nurse said the therapist (OT), or nursing had not notified her that there were any changes in mobility and transfer for CR#1. The MDS nurse said if CNA C assisted CR #1 from walking to a shower chair, then it was an assisted transfer, and if CR #1 was supposed to be assisted by two staff, then two staff should have assisted. MDS nurse said if CR #1 was not transferred according to the plan of care, the resident could fall and sustain an injury or die. During an interview on [DATE] at 2:47 p.m., LVN T said CNA C could find out what type of care and how many staff were needed to provide care to CR #1 in the POC. LVN T said if CR #1 required two persons' assistance and CNA C transferred CR #1, then the resident could fall, which happened to CR #1. LVN T said the nurses monitored the aides, and the ADON and the DON monitored the nurses during random rounds. LVN T said he had an in-service on admission, transfer, oxygen, and supervision. During an interview on [DATE] at 3:09 p.m., the Administrator said if CR #1 was a two-person transfer, and if CNA C transferred CR #1 by herself, then CR #1 could fall and hurt himself. The Administrator said the nurse monitored the aides during rounds, and the ADON and the DON monitored the nurses during random rounds. During a telephone interview on [DATE] at4:37 p.m., the Physician said he gave intermitter oxygen order and he could not remember how many liters of oxygen he gave, but the nurse could titrate the liter for CR #1 to be comfortable. He said the resident used oxygen intermittently said CR #1 refused to use oxygen sometimes and he had experienced hypoxia and he was still comfortable. The physician said normal order for oxygen was between 2 to 3 liters. The Physician said the nursing or therapy did not communicate to him that CR #1 still has shortness of breath during activities even with oxygen. Record review of the facility accident prevention dated February 2017, Revised [DATE] read in part . adequate supervision and assistance devices to prevent accident .assessment and care plans are used to develop and implement procedures to prevent accidents . The Administrator was informed the following Plan of Removal was accepted on [DATE] at 12:30 PM, PLAN OF REMOVAL: Abatement Plan [DATE] at 7:11pm Immediate Response: o The identified resident expired on [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. The Director of Nursing Services/Assistant Director of Nursing will supervise this process and monitor ,d+[DATE] days a week for the next 2 months. Date completed:[DATE]. o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed: [DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the Kardex to be informed of the residents needs with activities of daily living prior to providing care of the resident. Date of completion: [DATE] o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with the admitting physician in the community. The RN supervisor will monitor this process on weekends, holidays, and when the Director of Nursing Services or Assistant Director of Nursing Services is not present in the community. Date completed: [DATE]. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Risk Response: All new admissions/readmissions have the potential to be affected by the deficient practice. Systemic Response: o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen. Date completed: [DATE]. o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Date completed:[DATE]. o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders. Date completed:[DATE]. o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completed: [DATE]. o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician. Date of completion: [DATE] o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the Kardex to be informed of the residents needs with activities of daily living prior to providing care of the resident. o Date of completion: [DATE] o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with the admitting physician in the community. Date completed: [DATE]. Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care. Monitoring Response: o The Director of Nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry for ,d+[DATE] nurses, ,d+[DATE] days a week for 2 months. o Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed per discharge orders for the reconciliation process for ,d+[DATE] days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting. A review of residents who are on oxygen will be reviewed with the rehabilitation representative. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with ,d+[DATE] random therapy team member ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with ,d+[DATE] random therapy team member ,d+[DATE] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services. o Director of Nursing Services/Assistant Director of Nursing Services will validate the proper process of use/access of the Kardex by ,d+[DATE] direct care staff ,d+[DATE] days a week for 2 months. o Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from ,d+[DATE] random licensed nurses ,d+[DATE] days a week for 2 months. o All the monitoring will be monitored by the Director of Nursing/Assistant Director of Nursing. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months. Medical Director notified of the Immediate Jeopardy on [DATE] @ 7:22pm per Director of Nursing Services. Surveyor monitored the plan of removal for effectiveness as follows: Observation and interviews starting from [DATE] to [DATE] revealed no concerns with oxygen therapy for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. There were no signs of shortness of breath or labored breathing, each resident received oxygen therapy within the parameters of their physician order. Record review of physician orders and care plans for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed no concerns, each resident had physician orders and were care planned for oxygen therapy. Record review of [DATE] to [DATE] oxygen saturations and MAR/TAR's for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed each resident was being monitored for oxygen therapy. Record review of the facility plan or removal training, skills check-off, and in-service revealed the facility had 12 residents on oxygen, and the DON reviewed and completed their clinical records on [DATE]. Record review of the facility training revealed that the corporate nurse trained the DON, nurse managers, and administrator on physician follow-up chart checks, completed on [DATE]. Record review of the facility training for the nurses on medication reconciliation with the physician from discharged facility order summary report with MD/NP and entering the medication in the PCC. The nurse validated how to enter medication into PCC, completed on [DATE]. A record review of the facility's training revealed that the DON sent all staff training via Care Feed(electronic training system via telephone) on [DATE]. Record review of the facility's oxygen monitoring log revealed that the DON started monitoring on [DATE] and would be monitored 1 - 7 days/week for 1 - 2 months. Record review of the facility's clinical meeting dated [DATE] revealed daily oxygen review for nurse managers, administrators, and physical therapists would be present during morning meetings, residents on oxygen would be reviewed daily. A copy of this report will be given to the therapy representative at this time. Record review of the facility training dated from [DATE] - [DATE] on Kardex( quick reference to resident care) for all the nursing team revealed how to assess the care provided to the resident, how many staff, and equipment needed during care. Record review of the facility plan of removal training dated from [DATE] - [DATE] revealed the nurses had skills check off on change in condition for oxygen, and any general change in condition. Record review of the facility plan of removal revealed the facility had started monitoring on [DATE]. During interviews conducted on [DATE] between 9:31 a.m. and 2:31 p.m., with staff on shifts (4 CNAs: CNA A, CNA B, CNA D, and CNA E from 6:00 a.m. -to 2:00 p.m. and 4 LVN: LVN C, LVN D, LVN M, and LVN T from 6:00 a.m. -6:00 p.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During a telephone interview on [DATE] between 10:48 a.m. and 11:28 a.m., OT and PTA said the DON texted in service on change in condition of any resident during physical therapy. The OT or PTA would fill out stop and watch and sign the form, then give a copy to the nurse and the second copy to the DON. They said the DON called them on the phone and conducted the in-service. She said the physical therapist must report any change in condition, including the resident on oxygen, and the physical director had to attend morning meetings. During interviews conducted on [DATE] between 7:45 a.m., and 8:43 p.m., with staff on shifts (4 CNAs: CNAF, CNA G, CNA H, and CNA I from 2:00 p.m. -10:00 p.m., 3 CNAs: CNA J, CNA K, and CNA L from 6:00 p.m. - 6: 00a.m., and 3 LVN: LVN E, LVN F, and LVN G from 6:00p.m. -6 :00 a.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident. During an interview on [DATE] at 1:45 p.m., ADON L said the corporate nurse did an in-service for the nurse manager and the administrator. ADON L said the in-service and skills checkoff included change in condition, care plans, medication verification, and chart check after admission; Kardex and oxygen were part of the change in condition. During an interview on [DATE] at 1:57 p.m., the DON, corporate, and administrator were in the room. The DON said she had training from the corporate nurse on change in condition, oxygen, admission process, and the physical therapy director would come to the meetings. The DON said she would monitor the skills check-off and in-service progress for 1 to 7 days for 2 months. During an interview on [DATE] at 2:0 p.m., the Corporate Nurse said she conducted an in-service for the nurse managers, which included the administrator on verification of new resident medication with the physician, and any new order given by the physician would be entered into the computer by the admitting nurse. The Corporate Nurse said the nurse manager would verify the orders in the computer, cross-check them with the admitting orders, and verify from the nurse whether the physician gave an additional order on admission and if the nurse entered the order in the computer. The Corporate Nurse said residents on oxygen were transferred with portable oxygen when they were not in the room. The Corporate Nurse said staff should report immediately when there was any change in condition, including shortness of breath. The Corporate Nurse said she validated the aide's competencies on Kardex. She also said she reviewed the removal plan with the administrator, DON, and the [NAME] President of operation. During an interview on [DATE] at 2:03 p.m., the Administrator said the Corporate Nurse trained her and the nurse managers on verification of order from the discharged summary report from the transferring facility. The Administrator said the admitting nurse should verify the order with the physician upon admission and enter the order accurately into the computer. She also said if the nurse received any order, such as an oxygen order, the nurse should enter the order accurately in the computer. The Administrator said the next nurse would also check the order, and the ADON would do a chart check and ensure the admitting nurse entered all the orders correctly into the computer. The Administrator said she was also trained on Kardex and change in condition. The Administrator said the DON would give the names of residents on oxygen to the therapy director so that they could communicate if any of those residents had shortness of breath to the floor nurse and the DON. The Administrator said the nurse manager would monitor the progress of the training for the next two months. During an interview on [DATE] at 2:10 p.m., the Administrator said the error in the system happened when the physician gave an oxygen order for CR #1 and LVN H did not put the order in the computer. The Administrator said that ADON J did not completely check the chart because she did not realize CR #1 was supposed to be on oxygen. During an interview on [DATE] at 2:13 p.m., the DON said the system broke when the LVN H missed entering the oxygen order in the computer, and ADON J, who did the chart check, did not realize LVN H did not enter the oxygen order in the computer. An IJ was identified on [DATE]. The IJ template was provided to the facility Administrator on [DATE] at 7:11 p.m. While the facility Administrator was informed that the IJ was removed on [DATE] at 2:58 PM, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated because all staff trained on how to pull up resident's care information from the Kardex, notifying the nurse regarding resident care and change in condition.

Based on interviews and record review, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for one of 5 residents (CR #1) reviewed for food and nutrition services. The facility failed to ensure CR#1's diet order was transcribed and administered as ordered by the physician for a cardiac (2 GM sodium, low fat, low cholesterol) diet. This failure put residents at risk for health complications related to nonadherence to diet order. Findings included: Record review of CR#1's face sheet dated [DATE]revealed a [AGE] year-old male was admitted to the facility on [DATE]. CR#1 had diagnoses included: heart failure, (heart cannot pulp enough blood and oxygen to the body's organ), morbid obesity (body mass index greater than 35 combined with other health issues) diabetes mellites (body does not manage blood sugar properly), and atrial fibrillation (irregular heartbeat). Record review of CR #1's admission MDS assessment dated [DATE] revealed CR #1 had BIMS score of 15 out of 15 which indicated intact cognition. Further review revealed CR #1 needed moderate assistance with mobility. Record review of CR #1's care plan dated [DATE] revealed CR #1 resident was at risk for shortness of breath. Intervention: alert my nurse for concentrator and/oxygen tank needs to be changed, provide oxygen as ordered by physician, further review revealed resident had a self-care deficit. Interventions: mobility: I use a wheelchair, transfer: gait belt X2 team member. It also revealed admission/readmission care plan: I may be at risk for nutritional/hydration concerns. Interventions: nutrition/hydration within prescribed diet. Record review of CR #1's order summary report dated [DATE] read in part . regular diet texture, thin/regular related to acute on chronic heart failure . Record review of diet order on the communication slip dated [DATE] revealed no added salt, cardiac with regular texture. Record review of CR#1's discharge summary report from the hospital dated [DATE] read diet instructions: cardiac (2 GM sodium, low fat, low cholesterol) diet texture: regular. During an interview on [DATE] at 1:40 p.m., the DON said CR #1 was on a regular diet, and she spoke to the Dietary manager. The DON said she transcribed the order in the kitchen computer as regular because that was what she saw in CR #1's order. The DON said LVN H wrote the diet order on the communication slip and could not remember if she had clarified the order with the physician. The DON said LVN H wrote no sodium, cardiac diet, and regular texture from the discharge summary report from the hospital. The DON said the Dietary Manager should have verified the order with her since she had a diet communication slip that read cardiac, no sodium, cardiac diet. The DON said she would have verified with CR #1 physician. During an interview on [DATE] at 5:27 p.m., LVN H said she wrote on CR #1 the diet communication slip: No sodium cardiac diet with regular texture. LVN H said she sent the communication slip to the kitchen but transcribed it incorrectly in the computer because she input a regular diet. LVN H said if CR #1 was not provided with the cardiac diet, it could cause CR #1's health condition to worsen. LVN H said she had a skill check-off on the new admission process, and the nurse managers should have checked the new admission paperwork the day after admission. During an interview on [DATE] at 10:57 a.m., the ADON said LVN H did not transcribe the correct order in the computer for CR #1. The ADON said CR #1 was given the wrong diet until he expired in the facility. The ADON said administering a different diet from what the physician said could cause life-threatening emergencies or death for CR #1. The ADON said LVN H, who admitted CR #1, should have verified the order with the physician and entered the correct order in the computer. Then, the nurse managers should have verified the CR #1's the next day, but the mistake was not caught in time. The ADON said she was not sure if the nursing staff were provided any in-service on the admission process after this incident, but the nursing staff was provided an in-service on the admission process before the incident. During an interview on [DATE] at 1:05 p.m., the Dietary Manager said nursing staff would write a diet communication form and send it to the kitchen. The Dietary Manager said she would cross-check the order on the slip with the physician's order on the computer. The Dietary Manager said she input a regular diet for the meal ticket because the physician's order on the computer was regular. The Dietary Manager said she could not remember what the diet communication read. The Dietary Manager said a regular diet could affect CR #1's medical health because he was not provided with a 2gm sodium cardiac diet. The Dietary Manager said she made a mistake, but now she takes the meal communication slip to the morning meeting and checks the order with the DON. The Dietary Manager said, if there were any differences, then the DON would call the physician for clarification. During an interview on [DATE] at 2:58 p.m., the Administrator said LVN H should have gone through the discharge order from the hospital for CR #1, written the diet order on the communication sheet, and given the slip to the kitchen. The Administrator said the Dietary Manager should also check the order on the computer. The Administrator said the dietary manager should have consulted with the nursing staff to see if there was a discrepancy when she checked the order. The Administrator CR #1 health would be at risk if CR #1 were given the wrong diet. Record review of the facility undated policy on therapeutic diets read in part . residents receive and consume foods and fluids in the appropriate form and appropriate nutritive content as prescribed .

Based on observation, interview and record review, the facility failed to ensure comprehensive resident centered care plans were reviewed and revised by the interdisciplinary team after each assessment for 7 residents reviewed for care plan accuracy (Residents #4, # 7, #10, #13, #48, #53, #70). -The facility failed to revise and update Resident #4's care plan to include her cognitive loss, dementia, mental illness of bipolar disorder, communication, and dental care that were triggered on her admission MDS assessment dated [DATE]. - Resident #7 care plan was not updated for cognitive function, visual Function, Psychosocial well-being and activities that were triggered on her annual MDS dated [DATE] -Resident #7's care plan was not updated to include her oral\dental care. --Resident #48's care plan was not updated to reflect DNR status. --Resident #13's care plan was not updated to reflect level of ADL care required. --Resident #48's care plan was not updated to reflect level of ADL care required. --Resident #53's care plan was not updated to reflect level of ADL care required. --Resident #10 order for brace/splint on in morning and removed at night in her record was not implemented. These failures placed residents at risk of not having their needs met and not receiving appropriate individualized care. Findings include: Resident # 4 Record review of Resident #4's electronic face sheet dated 08/19/24 revealed [AGE] year-old fe02/10 and readmitted on [DATE]. Her diagnoses included bipolar disorder, muscle weakness, unspecific dementia, muscle weakness and lack of coordination, anxiety disorder. Major depressive disorders, lack of coordination and difficulty in walking. Record review of Resident #4's comprehensive admission MDS assessment revealed assessment revealed Resident #4 had a BIMs score of 11 indicated she was moderately impaired on cognition. Record review of Resident # 4's care plan dated 07/12/24 revealed her care plan did not include her cognitive loss, dementia, communication, and dental care. Observation and interview on 08/18/24 at 10:30 AM indicated Resident #4 was in bed alert and oriented. In an interview Resident # 4 started saying she could not hear. A pen and paper were used for communication. She said her ears are blocked and was told that she had ear wax that prevent her from hearing. She said she was supposed to see an audiologist, but her appointment was canceled and re-scheduled. She said she has this problem from time to time and would have her ears cleaned out. She said it had been for a while. Resident # 7 Record review of Resident #7's electronic face sheet dated 08/19/24 revealed [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included neoplasm of colon (colon cancer) chronic pain, bipolar disorder, mood disorder, schizoaffective disorder, (a mental health condition that is marked symptoms, such as hallucinations and delusions, and mood disorder. Hallucinations involve seeing things or hearing voices that others don't observe. delusions involve believing things that are not real or not true) major depressive disorder, essential hypertension, and anxiety disorder. Record review of Resident #7's annual MDS dated [DATE] revealed she was coded having a BIMs score of 10 which indicated she was moderately impaired on cognition. Record review of section V CAAs revealed the following area were triggered, Cognitive function, Visual Function, Psychosocial well-being and activities. Record review of Resident # 7's care plan updated 07/29/24 reveal no evidence of care plan for Cognitive function, Visual Function, dental and falls. Observation and interview on 08/18/24 at 1:15 PM, revealed resident #7 was in bed alert and oriented. Observation revealed she was having her lunch. She said her lunch was alright, but she had pain in her gum from her teeth, and she can only eat soft food. She said 4 of her teeth had been pulled and she needed to see a dentist. She said the facility was aware and the social worker had to schedule the appointment. Resident #48 Record review of Resident #48's face sheet revealed admitted [DATE], with diagnoses including Alzheimer's disease (progressive disease that affects memory, thinking, behaviors), psychosis (mental disorder causing disconnection from reality), major depressive disorder (mood disturbance with delusions or hallucinations), chronic obstructive pulmonary disease (lung disease causing breathing problems), hypertension (high blood pressure), liver disease. Advanced Directives on the face sheet stated DNR. Record review of Resident #48's MDS dated [DATE] revealed Resident #48 was rarely or never understood, understands sometimes; has memory problems and moderately impaired cognitive skills; displays inattention and disorganized thinking; and is dependent on staff assistance for all ADLs. Observation of Resident #48 on 8/18/24 at 9:30 am revealed she was in her room, sitting in an easy chair inside her doorway. She appeared confused and not able to follow or answer questions. Interview with RN H on 8/18/24 at 9:45 am revealed Resident #48 was usually confused, and they helped her with cleaning her up, changing her briefs, showers and dressing, and bring her tray to her in her room so she could eat. She said they check on her about every 2 hours to see if she needed to be changed. Record review of Resident #48's progress note dated 7/24/24 revealed DNR was signed on that date. Record review of Resident #48's undated care plan revealed Resident is Full Code Status with start date of 7/13/24. Interventions included attempt to resuscitate should arrest occur. Resident # 13 Record review of Resident #13's face sheet revealed admitted [DATE] with diagnoses including acute kidney failure (inability of kidneys to filter waste), Diabetes (high blood glucose), cerebral infarction (blockage of blood flow to the brain), hypertension (high blood pressure). Record review of Resident # 13's MDS dated [DATE] revealed a BIMS score of 14, indicating no impairment of cognitive skills; physical impairment of upper and lower extremities on 1 side; dependent on staff assistance for toileting; maximum staff assistance for shower/bathing and dressing; and supervision by staff for hygiene. Observation of Resident #13 on 8/18/24 at 10:20 am revealed she was in bed, talking to her roommate. She said the staff will come help her when she pushes the call light, but sometimes she has to wait until they are finished with someone else. Record review of undated care plan for Resident #13 revealed will receive assistance as needed with ADL's daily. The interventions included assess for barriers to progress, encourage frequent rest periods, but did not include the level of assistance needed for ADL's. Resident #53 Record review of Resident #53's face sheet revealed admitted [DATE] with diagnoses including Dementia ((loss of cognitive functioning), diabetes (increased blood glucose), spinal stenosis (narrowing of the space around spinal cord), muscle wasting and atrophy (loss of skeletal muscle mass). Observation of resident #53 on 8/18/24 at 9:55 am revealed he was in bed and said the staff would come help him when he pushed the call light, and he said they were fast to answer the light and help with whatever he needed. Record review of Resident #53's MDS dated [DATE] revealed BIMS score of 11, indicating moderately impaired cognitive skills, dependent on staff assistance with ADL's (total assistance needed). Record review of Resident #53's undated care plan revealed Requires assistance with all ADL's. Interventions included assess barriers to progress, give verbal cues to help prompt, break tasks into smaller steps, but interventions did not include level of assistance required. Resident #74 Record review of Resident #74's face sheet revealed admitted [DATE] with diagnoses including Parkinsonism (brain condition causing slow movements, stiffness and tremors), hypertension (high blood pressure), Dementia (loss of cognitive functioning), psychotic disorder (mental disorder causing disconnection from reality), history of falling. In an interview with MDS Coordinator A on 8/20/24 at 12:40 pm, she said the ADL assistance levels should be on the care plan, and if it was not there, it was missed. She said she would update the care plans as needed with information from the team. She said the risk of not having accurate care plans would affect the resident by the CNA not knowing the proper care for the residents. In an interview with the Administrator and DON on 8/21/24 at 5:30 pm, they said the care plans should be accurate for the resident's care, and the risk of not having an accurate care plan would be the residents would not receive proper care. Resident#10 Record review of Resident #10's annual MDS assessment, dated 07/06/24, reflected a [AGE] year-old female with an admitted [DATE] and was readmitted on [DATE]. Her diagnoses included acute cystitis without hematuria (sudden inflammation of the bladder caused by a bacterial infection, also known as a urinary tract infection), cerebrovascular disease ( stroke, brain aneurysms and cerebral arteriovenous/blood clots) and lack of coordination due hemiplegia ( one-sided muscle paralysis or weakness). Record review of Resident #10's consolidated physician orders for 4/4/24 Brace/Splint: Apply to the Left foot on during the day and off @ HS ( Hour of sleep) for diagnosis left side foot drop QD ( every day). Chart refusals every morning and at bedtime related to Hemiplegia, affecting left dominant side. Record review of Resident #10's annual MDS dated [DATE] revealed she had a BIMS score of 11/15 (moderately cognitively intact) and diagnosis of hemiplegia. Record review of Resident #10's Care Plan dated 4/11/2024 revealed she had applied brace/splint to the left foot as ordered. She required extensive assistance of one-to-two-persons with all ADLs. Record review of Resident #10's medication administration record (MAR) dated 08/01/24 had nurses initialed as done for Brace/splint: Apply to the Left foot on during the day (at 9:00 AM) and off @ HS ( Hour of sleep at 9:00 PM) for diagnosis left side foot drop QD ( every day). Chart refusals every morning and at bedtime related to Hemiplegia, affecting left dominant side. There was no document reflecting resident #10's refusal of brace/splint to left foot. Observation on 8/20/24 at 9:29 AM, 11:00 AM, 2:00 PM, 4:00 PM Resident #10 did not have Brace/Splint to left side foot drop, she was lying in bed and there was no brace/splint at bedside. Interview on 8/20/24 at 4:00 PM with Resident #10 said she had not had any brace/splint on. Observation on 8/21/24 at 10:39AM, 11:00 AM, 2:00 PM, 4:00 PM, Resident #10 did not have Brace/Splint to left side foot drop. Interview on 8/21/24 at 2:00PM with Resident #10, she said she had never had any brace/splint on. In an interview with LVN KK on 08/21/24 at 2:00 PM regarding Resident #10's Brace/Splint to left side foot drop not being on the resident, she said Resident #10 did not have the brace /splint on her bedside. LVN KK said she did not receive any report about resident #10 using Brace/Splint to left side foot drop and she had not worked with the resident for a while. Interview on 8/21/2024 at 4:30 PM with the DON, she stated she was not aware residents were getting Brace/Splint to left side foot drop. The DON expected the staff to follow physician orders and care plans. The DON said Resident #10 always refused the Brace/Splint to left side foot drop. In an interview on 08/21/24 at 5:15 PM the DON stated the facility did not have a policy specifically for drop foot management. The DON did not have policy for following physician's order. Record review of the facility policy Care Plans - Comprehensive, undated, revealed, in part: . assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change .the Care Planning/Interdisciplinary team is responsible for the review and updating of care plans .

Based on observations, interviews, and record review the facility failed to conduct initial and periodical and comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 4 (Residents #4, #7, #34, & #97) of 16 residents reviewed for accuracy of resident assessments. -Residents #4 was not assessed for her mental diagnoses condition on her Admission MDS dated [DATE] MDS. -Resident # 4 was not accurately assessed for her hearing difficulty on her comprehensive MDS dated [DATE] and on her Quarterly MDS dated [DATE]. -Residents #7 was not assessed for her mental illness and her oral cavity on her annual comprehensive MDS assessment dated [DATE]. -Resident #34 was not assessed for her mental diagnoses. -Resident # 97 was not accurately assessed for he her oral cavity on her annual comprehensive assessment dated [DATE] These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being. Findings included: Resident # 4 Record review of Resident #4's electronic face sheet dated 08/19/24 revealed [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included bipolar disorder, muscle weakness, unspecific dementia, muscle weakness, lack of coordination, difficulty in walking, anxiety disorder, major depressive disorders. Record review of Resident #4's comprehensive admission MDS assessment dated [DATE] revealed Resident #4 had a BIMs score of 11 indicated she was moderately impaired on cognition. Review of section on hearing, she was assessed as adequate with no difficulty in normal conversation. Section on PASRR evaluation was coded as 0, serious mental illness condition was left blank. Section on hearing, was coded she was assessed as adequate. Record review of active diagnoses indicated she was as checked for bipolar disorder. Record review of Resident #4's quarterly MDS assessment dated [DATE] section on hearing was coded as adequate on hearing no difficulty in normal conversation. Record review of Resident # 4's PASRR assessment screening dated 03/13/24 indicated that Resident #4 was positive for mental illness. Record review of Nurse's note dated 8/12/2024 10:58 read in part Audiology appointment on 8/16/24 @ 1:45pm for hearing test @ ENT Appointment @ 4:15pm in same building and location. Transportation pick up has been set up with local EMS @ 12:45 pm in wheelchair r/p notified Observation and interview on 08/18/24 at 10:30 AM indicated Resident #4 was in bed alert and oriented. In an interview Resident # 4 started saying she could not hear. A pen and paper were used for communication. She said her ears are blocked and was told that she had ear wax that prevent her from hearing. She said she was supposed to see an audiologist, but her appointment was canceled and re-scheduled. She said she has this problem from time to time and would have her ears cleaned out. She said it had been for a while. In an interview with CNA L on 08/21/24 at 2:00PM, she said Resident # 4 has difficulty hearing. She said she had to speak very loud for her to hear. She said it has been going on for a while. In an interview with LVN E on 08/19/24 at 12:00PM, she said Resident #4 had difficulty hearing. She said Resident #4 had an audiology appointment but was canceled and rescheduled for the week of 08/22/24. She said does not know why the first appointment was cancelled. Resident # 7 Record review of Resident #7's electronic face sheet dated 08/19/24 revealed [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Her diagnoses included neoplasm of colon (colon cancer) chronic pain, bipolar disorder, mood disorder, schizoaffective disorder, (a mental health condition that is marked symptoms, such as hallucinations and delusions, and mood disorder. Hallucinations involve seeing things or hearing voices that others don't observe. delusions involve believing things that are not real or not true) major depressive disorder, essential hypertension, and anxiety disorder. Record review of Resident #7's annual MDS dated [DATE] revealed she was coded as having a BIMS score of 10 which indicated she was moderately impaired on cognition section on mental illness serious mental illness was left blank. Record review of section L Dental was marked as none of the above which indicated no problem on her oral cavity. Record review of Resident # 7's PASRR assessment screening dated 04/17/2023 indicated that Resident #7 was positive for mental illness. She was evaluated for services on 05/04/23 and did not qualify for PASRR services. Observation and interview on 08/18/24 at 1:15 AM, revealed resident #7 was in bed alert and oriented. Observation revealed she was having her lunch. She said her lunch was alright, but she had pain in her gum from her teeth, and she can only eat soft food. She said 4 of her teeth had been pulled and she need to see a dentist. She said the facility was aware and the social worker had to schedule the appointment. During an interview with the facility's social worker on 08/19/24 at 2:00 pm, she said she does not do section L of the MDS, but she would refer resident's for needed services. She said Resident #7 was schedule for dental appointment on the next visit. During an interview with MDS coordinator B on 08/20/24 at 2:00 PM, she looked at the MDS and said she was new to the MDS and was still learning the process. Resident # 34 Record review of Resident #34's electronic face sheet dated 08/19/24 revealed [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic respiratory failure, bipolar disorder, depression, anxiety disorder, mood disorder, Huntington's disease, lack of coordination, difficulty in walking. Record review of Resident #34's comprehensive annual MDS assessment dated [DATE] revealed Resident #34 had a BIMS score of 3 indicated she was severely impaired on cognition. Review of section on active diagnoses indicated she was checked for Huntington disease; bipolar disorder was left blank. Section on PASRR evaluation was coded as 0, serious mental illness condition was left blank. Record review of Resident # 34's diagnoses, indicated she was diagnosed with bipolar disorder on 02/11/2014. Observation on 08/18/24 at 11:00am revealed she was in bed, awake, alert. Attempt was made to communicate but she did not answer; She looked at surveyor. Resident was noncommunicative. She was on tube feeding at 60cc per hour jeverty 1.5, water flush 50cc per hour. During an interview with MDS coordinator A on 08/20/21 at 10:00AM, she looked at the MDS and said she did not do Resident #34's annual MDS assessment. Resident #34 was denied for PASRR services, but the MDS should have identified her mental diagnoses of mental illness. She said not identifying her condition may delay services. Resident # 97 Record review of Resident #97's electronic face sheet dated 08/19/24- revealed [AGE] year-old female admitted on [DATE]. Her diagnoses included disturbance in tooth formation, major depressive disorder, dementia, difficulty walking, lack of coordination, difficulty in walking. Record review of Resident #97's comprehensive annual MDS assessment dated [DATE] revealed Resident #97 had a BIMS score of 10 indicated she was moderately impaired on cognition. Review of section L oral dental indicated she had no problem on her oral cavity. Section was coded O. Observation and interview on 08/18/24 at 10:45AM, revealed Resident # 97 was in bed, alert and oriented. In an interview, she said she was worried about her dentures. She said she left them in the bathroom because they don't fit and cannot use them. She said she has been waiting for a call from the dentist but never got the call. She said the dentist had worked on them before. She said she does not remember how long ago. Observation revealed her dentures were in a cup in the bathroom. Observation and interview on 08/19/24 at 1:20PM, revealed Resident # 97 was served hamburger meat patty, mash potatoes and steamed\cooked cabbage. Resident #97 did not eat the served meal. In an interview she said she cannot eat the meat. LVN G asked resident #97 if she would like an alternative. Resident #97 requested for cottage cheese and fruits. During an interview with the facility's social worker on 08/19/24 at 2:00 pm, she said she does not do section L of the MDS, but she would refer all residents for needed services. She said Resident #7 was schedule for dental appointment on the next visit. She said Resident #97 was seen by the dentist and her dentures are being adjusted and she would follow up. Record review of Resident #97's clinical records revealed resident # 97 was seen by the dentist on 03/13/24, 04/10/24 and the last visit was 05/01/24. During an interview with the facility's Administrator and the DON on 08/21/24 at 5:00PM, both said the MDS staff are responsible for ensuring that all assessments reflected Resident's condition. The DON said inaccurate assessment may delay needed services and care. Record review of facility's provided undated policy on resident assessment read in part: Resident Assessment Instrument: Policy Statement A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. Policy Interpretation and Implementation 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident's admission to the facility; b. When there has been a significant change in the resident's condition; c. At least quarterly; and d. Once every twelve (12) months. 3 The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. 4 Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning.

Based on observation, interview, and record review the facility failed to ensure expired drugs were removed from the medication room used to store drugs and biologicals in accordance with currently accepted professional principles when applicable for 1 of 1 medication room, 4 of 7 medication carts observed for labeling and storage of drugs and biologicals. The facility failed to ensure expired medications stored in the medication storage room were removed and disposed according to facility procedures for drug destruction and drugs open were dated. This deficient practice could place residents who receive medications from the medication room at risk for receiving outdated medications and could result in residents not getting the intended therapeutic effects of their medications and worsening of residents' symptoms. Findings include: During observation on 08/20/24 at 1:30 PM, the following expired medications were found in the medication room with RN EE: 1. Meclizine Chewable 7 bottles 100 tablets expired 06/24 2. Prenatal for women before, during and after pregnancy 100 tablet multivitamin and mineral dietary supplement expired 6/24. 3. Optimum vitamin A 3,000 mcg 100 soft gel 3 bottles expired 4/24 4. Calcium 600 +D 5mcg 60 tablets 1 bottle expired 11/23. 5. Calcium 600 +D 5mcg 60 tablets 8 bottles expired 4/24 6. Enema saline laxative 1 4.5 Fl.oz expired 3/24 7. Sore throat spray ( Cherry Flavor) 6 Fl.oz expired 5/24 8. Docusate Calcium ( Stool softener) 100 softgels 240 mg each 7 bottles expired 4/24 Interview with RN EE on 8/20/24 at 1:55 PM, she said she was not sure who checks the medication room and she think it might be supply stock person. 600 Hall Medication cart. During observation on 08/20/24 at 2:05 PM, the following expired medications were found in the 600 Hall medication cart and medication open not dated with RN EE 1. Earache drops open not dated 2.Haloperidol con 2 mg /ml pen not dated 3 Lantus Solostar pen (3ml) open not dated 4. Famotidine tab 20 mg expired 4/24 5. Ammonium Lactate lotion 12% open not dated 6. Ammonium Lactate lotion 12% open not dated Interview with RN EE on 8/20/24 at 2:05 PM she was asked how often she checks the cart for expired medications. She said she just came back to work, she was off duty for1 month. Observation at 2:14 PM on 8/20/24 after showing RN EE the above expired medication and some opened not dated medications, RN EE said medication opened should be dated. 400 Hall Medication cart. During observation on 08/20/24 at 2:30 PM, the following expired medication were found in the 400 Hall medication cart with LVN AA 1. Triple antibiotic ointment 1oz expired 10/23. Interview with on 08/20/24 at 2:30 PM with LVN AA, she said she checks her medication cart whenever she works and she started working with the facility in 1/24. 100 Hall Medication cart During observation on 08/20/24 at 2:34 PM, the following nasal spray medication open and not dated were found in the 100 Hall medication cart with MA H 1. Fluticasone Propionate 50 mcg per spray open not dated 2. Fluticasone Propionate 50 mcg per spray for open not dated. 200 hall Medication cart. Levetiracetam oral solution 473ml open not dated Antacid Calcium Carbonate 750 mg 96 chewable tablets expired 2/2024 Interview with MA AA on 8/20/24 at 2:34 PM she said she works 2:00 pm to 10:00 pm and she checks her medication cart weekly or every 2 weeks. The following medication were taken in the morning and should have been dated when opened. During interview on 8/21/2024 at 11:27 PM, with the DON and the unit Managers, the DON stated the expired medications were supposed to be removed and kept in the designated area for expired drugs to be destroyed and the nurses were responsible for checking their medication cart. The DON stated this deficient practice could affect residents because the expired drugs could be mistakenly given to resident and would not be treating the symptoms it was supposed to treat. Residents could have GI (gastrointestinal) problem if they ingest expired drug. Interview with Administrator and DON, RN on 8/21/24 at 11:27 AM they both said, the nurses were responsible for checking the medication carts for expired medication. The pharmacist checks medication cart also, and was in the facility a couple of weeks ago. The managers were assigned to each medication carts weekly. They said central supply clerk checks the medication room., The DON said the central supply clerk was newly hired and was on vacation. Their expectation was managers were over medication carts and they did 100% audit on all medication on 8/20/24. The Nurse Managers will be checking medication cart weekly.

Based on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent a decline in range of motion for 1 (Resident #10) of 17 residents. The facility failed to ensure Resident #10 had interventions in place for her left side foot drop (difficulty lifting the front part of the foot) using the brace/splint to foot can help hold the foot in a normal position. This deficient practice placed residents at risk for decrease in mobility, range of motion, and could contribute to worsening of foot drop. Findings Include: Record review of Resident #10's annual MDS assessment, dated 07/06/24, reflected a [AGE] year-old female with an admitted [DATE] and was readmitted [DATE]. Her diagnoses included acute cystitis without hematuria (sudden inflammation of the bladder caused by a bacterial infection, also known as a urinary tract infection), cerebrovascular disease ( stroke, brain aneurysms and cerebral arteriovenous/blood clots) and lack of coordination due hemiplegia ( one-sided muscle paralysis or weakness). Record review of Resident #10's consolidated physician orders for 4/4/24 Brace/Splint: Apply to the Left foot on during the day and off @ HS (hour of sleep) for diagnosis left side foot drop QD ( every day). Chart refusals every morning and at bedtime related to Hemiplegia, affecting left dominant side. Record review of Resident #10's annual MDS dated [DATE] revealed she had a BIMS score of 11/15 (moderately cognitively intact) and diagnosis of hemiplegia. Record review of Resident #10's Care Plan dated 4/11/2024 revealed apply brace/splint to the left foot as ordered. She required extensive assistance of one-to-two-persons with all ADLs. Record review of Resident #10's recommendation from the Physical therapy Nursing Restorative Care Program dated 4/2/24 approaches and frequency. RNA ( Restorative Nurse Aide) to provide bilateral upper extremities exercises with TheraBand or exercise bike for 10-15 minutes . Left PROM exercises as needed. Observation on 8/20/24 at 9:29 AM, 11:00 AM, 2:00 PM, 4:00 PM Resident #10 did not have Brace/Splint to left side foot drop, she was lying in bed and there was no brace/splint at bedside. Interview on 8/20/24 at 4:00 PM with Resident #10 said she had not had any brace/splint on Observation on 8/21/24 at 10:39AM, 11:00 AM, 2:00 PM, 4:00 PM Resident #10 did not have Brace/Splint to left side foot drop. Interview on 8/21/24 at 2:00PM with Resident #10, she said she had never had any brace/splint on. Interview on 8/21/2024 at 1:55 PM with the RNA (Restorative Nurse Aide) she said works with Resident #10 on the bike exercise and TheraBand and Resident #10 always refuse brace/splint and the licensed nurse place the splint. Record review of Resident #10's Resident #10's RNA and TARs no documentation of Brace/Splint to left side foot drop refusal and restorative care was initiated since 4/2/24. In an interview with LVN KK on 08/21/24 at 2:00 PM regarding Resident #10's Brace/Splint to left side foot drop not on resident, she said Resident #10 did not have the brace /splint on her bedside. LVN KK said she did not receive any report about resident #10 using Brace/Splint to be left side foot drop and she had not worked with the resident for a while. Interview on 8/21/2024 at 4:30 PM with the DON, she stated she was not aware residents were getting Brace/Splint to left side foot drop. The DON expected the staff to follow physician order and care plan. DON said Resident #10 always refused the Brace/Splint to left side foot drop. In an interview on 08/21/24 at 5:15 PM the DON stated the facility did not have a policy specifically for drop foot management. DON did not have policy for following physician's order.

Based on record review and interviews, the facility failed to electronically transmit within 14 days after the facility completed a resident's assessment, encoded MDS data including a subset of items upon a resident's transfer, reentry, discharge, and death for 3 of 3 residents (CR #16, 44, and #114) reviewed for electronic transmission of MDS data to the CMS system. The facility failed to complete and transmit discharge MDS data to the CMS system for (CR #16, 44, and #114 residents within 14 days of Residents discharge from the facility. These failures could place residents at risk for not having their assessments transmitted timely and or having their long-term care nursing facility Medicaid payments and or services interrupted. Findings Include: CR #16 Record review of CR #16's Face Sheet dated 08/21/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of restlessness and agitation, respiratory failure, chronic kidney disease (long standing disease of the kidneys leading to kidney failure), pain, type 2 diabetes, and generalized anxiety. Record review of CR #16's nurses notes dated 4/2/2024 at 02:51read in part- Around 12:45am I was giving resident nebulizer treatment and his O2 saturation was 84% with O2 at 2L via n/c. Respiration 28 and labored, BP 143/93, HR 103 and temp 100.3. After 20min nebulizer treatment his respiratory rate continue to decline. While neb treatment going the 200 hall nurse gave me his x-ray result's from off the fax. Impression show subtle patchy opacity (appears as cloudy patches grey area) is seen in both lungs, new, this is likely secondary to pulmonary edema, and atelectasis. Resident O2 sat decline between 80-81 and I called 911. On shift report I was informed resident was having resp distress with hypoxia, hyperglycemia and was to be a direct admit to the hospital (waiting on a bed) to have surgery on his right lower leg distal tibia/fibula fracture. Residents remain hyperglycemic and blood sugar was 424. I called Resident's Physician on call staff and spoke to NP to report his change in condition and he sent 911 . sending him to ER. Record review of CR #16's clinical records revealed the last MDS assessment on his clinical record was dated 12/21/23 and coded as 5 days assessment. Record review revealed no discharge MDS assessment. CR #44 Record review of Resident #44's Face Sheet dated 08/21/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), muscle weakness, muscle wasting, sepsis (Sepsis is a life-threatening medical emergency caused by your body's overwhelming response to an infection), Record review of CR # 44's clinical records revealed no evidence of discharge MDS. The only MDS on CR #44's clinical record was an admission MDS dated [DATE]. Record review of Physician's discharge summary dated 03/28/24 revealed CR #44 was discharged home in stable condition. Record review of Nurse's note dated 03/29/24 read in part- CR 44's assessment :D\C from facility on 3/29/2024 06:11 . 3/28/2024 6p-6a: Patient was receiving skilled services due to renal failure. The patient was discharged today and left the facility around 0730. He was assisted by his family. He reviewed his inventory and verbally stated that he had all of his belongings. He was informed about his DME that was ordered along with the name and number to the facility to follow up. There were no c/o pain or discomfort when he left. He was escorted out by his wife, and his daughters returned the wheelchair that was used. CR #114 Record review of Resident #114's Face Sheet dated 08/21/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and discharge on 03/28/24 with diagnoses of lack of communication, lack of coordination, muscle weakness, muscle wasting, and age-related cognitive decline. Record review of Physician discharge orders dated 03/29/24 revealed CR #114 was admitted to the facility on [DATE] and discharged from the facility on 03/28/24 in stable condition. Record review of CR #114' clinical records revealed the last MDS on his clinical record was dated 03/08/24 coded 01-Admission 5 days. The MDS was not completed. Record review revealed no further information on CR #114 clinical records. In an interview on 08/21/24 at 2:51PM, MDS coordinator A looked at CR #4, #16 and #114's clinical records and said the MDS were not done. She did not give any answer why they were not done. She said she would close out the three identified clinical records and submit them to CMS as required. She said those three close records were overlooked. She said not closing out discharge resident's records may give false census. During an interview with the facility's DON and Administrator on 08/21/24 at 4:00PM, both the Administrator and the DON said they expect all discharged residents to have their records closed out as expected by regulation. The DON said not closing out the MDS may affect their staffing rating on PBJ report by not providing accurate census. Record review of CMS's RAI version 3.0 Manual dated October 2019 revealed the following: The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). Record review of undated facility's policy and procedure titled Resident Assessment Instrument revealed no information on completing and encoding resident's information into CMS system.

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #10) of two residents reviewed for incontinence care. -The facility failed to ensure CNA BB provided appropriate perineal care for Resident #10 after an incontinent episode when she failed to open and clean the labia. -The facility failed to ensure CNA BB cleaned and wiped around the resident's buttocks after an incontinent episode . These failures could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Findings include: Record review of Resident #10's annual MDS assessment, dated 07/06/24, reflected a [AGE] year-old female with an admitted [DATE] and was readmitted [DATE]. Her diagnoses included acute cystitis without hematuria (sudden inflammation of the bladder caused by a bacterial infection, also known as a urinary tract infection), cerebrovascular disease ( stroke, brain aneurysms and cerebral arteriovenous/blood clots), muscle wasting and atrophy, not elsewhere, right lower leg, bacteremia, adult failure to thrive, acute candidiasis ( fungal/yeast)of vulva and vagina, sepsis, non-pressure chronic ulcer of skin of other sites with fat layer exposed, pressure ulcer of right buttock, stage 4, type 2 , mellitus (a chronic disease that occurs when the body doesn't produce enough insulin or can't use insulin properly, causing blood sugar levels to rise) without complications, age-related nuclear cataract, bilateral, heart failure, lack of coordination due hemiplegia ( one-sided muscle paralysis or weakness). Resident #10 had a BIMS of 11, which indicated she was moderately cognitively impaired. She required extensive assistance of one-to-two-persons with all ADLs and was always incontinent of bowel and bladder. Record review of Resident #10's care plan, dated 3/31/24, reflected, . The resident has an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent An observation on 08/20/24 at 09:29 a.m. revealed CNA BB entered Resident #10's room preparing to provide incontinence care. CNA BB washed her hands and put on double gloves and unfastened Resident #10's brief soiled with urine and had large bowel movement. CNA BB took a peri-wipe and cleaned residents' perineal area; she did not open the labia to wipe. CNA BB assisted the resident to roll on her left side. CNA BB took a peri-wipe and wiped in-between residents' rectal area and did not wipe around the buttocks. With the same gloves, CNA BB applied barrier cream to a chafed area on the residents' right buttocks and then removed the soiled brief and placed a clean brief under the resident and assisted her to roll back onto her back and fastened the brief. CNA BB removed her gloves and washed her hands. Review of CNA BB's skill checks dated 07/29/24 reflected she was competent in performing peri-care and hand hygiene. In an interview with CNA BB on 08/20/24 at 10:15 a.m. she stated she was supposed to wash her hands before and after performing incontinent care and change her gloves when she finished. She stated she was supposed to open the labia to clean and around the buttocks. She stated she knew the importance of properly cleaning a resident and by not doing so, placed them a risk of infections. In an interview with the DON on 08/21/24 at 02:00 p.m., she stated staff were to open labia and clean around residents' buttocks. She stated by not following proper peri care it placed residents at risk of urinary tract infections. Record review of the facility's policy titled, Perineal care, revised October 2010, reflected, .Wash and dry hands thoroughly .put on gloves .wash perineal are, wiping from front to back .Separate labia and wash area downward from front to back . Assist the resident to turn on her side .Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .Rinse and dry thoroughly

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 14.28%, based on 4 errors out of 28 opportunities, which involved 1 of 4 residents (Resident #93), and 1 of 4 staff (Medication Aide DD) reviewed for medication errors. -Medication Aide DD failed to administer 4 medications Ferrous Sulfate Tab EC 325 MG (iron supplement used to treat or prevent low blood levels of iron), Cholecalciferol Tab 50 MCG (2000 Unit) (a fat-soluble vitamin that helps your body absorb calcium and phosphorus), Gabapentin Cap 100 MG (used to treat epilepsy. It's also taken for nerve pain, which can be caused by different conditions) and Carbamazepine Tab 200 MG (an anticonvulsant. It works by decreasing nerve impulses that cause seizures and nerve pain, such as trigeminal neuralgia and diabetic neuropathy) to Resident #93 according to physician orders. This failure could place residents at risk for not receiving therapeutic effects of their prescribed medications and possible adverse reactions. Finding include: Record review of the Admission Sheet (undated) for Resident #93reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #93 diagnosis included dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #93's Quarterly MDS, dated [DATE] reflected a BIMS score 09 out of 15 indicating moderately impaired cognition. Resident #93 was dependent on staff for personal hygiene, putting on/taking off footwear, shower/bathe self and toileting hygiene. Record review of Resident #93's Care Plan initiated 11/16/2022 and revised on 10/20/2023 reflected the following: Category: Seizures Goal: Will minimize risk for seizure activity daily and ongoing over the next 90 days. Intervention: levetiracetam, lacosamide and carbamazepine as ordered. Observation on 08/19/24 beginning 7:45am during med pass revealed MA DD prepared, dispensed, and administered 13 medications to Resident #93. The medications observed were: - Aspirin Tab Delayed Release 81MG Give 1 tablet orally one time a day related to Unspecified sequelae of cerebral infarction (I69.30) Give 1 tablet orally one time a day. -Lactulose (Encephalopathy)Solution 10 GM/15ML Give 30 ml by mouth one time a day related to epilepsy, unspecified, not intractable, without status epilepticus (G40.909) Give 30 ml by mouth one time a day. -Lisinopril Tab 5 MG Give 1 tablet orally one time a day related to Essential (primary) hypertension (I10) Give 1 tablet orally one time a day, (hold for sbp<110 or dbp<60) -Polyethylene Glycol 3350 Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 2 scoop orally one time a day related to Chronic idiopathic constipation (K59.04) Give 2 scoop orally one time a day. -Carbamazepine Tab 200 MG Give 2 tablet orally two times a day related to Epilepsy, unsp, notintractable, without statusepilepticus (G40.909) Give 2 tablet orally two times a day -Famotidine Tab 20 MG Give 1 tablet orally two times a day related to Unsp fx shaft of humerus, left arm, subs for fx w routn heal (S42.302D) Give 1 tablet orally two times a day -Levetiracetam Tab 1000 MG Give 1 tablet by mouth two times a day related to Other seizures (G40.89) Give 1 tablet by mouth two times a day. -Levetiracetam Tab 500 MG Give 1 tablet by mouth two times a day related to Other seizures (G40.89) Give 1 tablet by mouth two times daily -Magnesium Oxide Oral Tablet 250MG (Magnesium Oxide) Give 1 tablet by mouth two times a day related to Hypomagnesemia (E83.42) Give 1 tablet by mouth two times a day. -Memantine HCl Tab 5 MG Give 1 tablet by mouth two times a day related to gastroesophageal reflux disease without esophagitis (K21.9) Give 1 tablet by mouth two times a day. -Sertraline HCl Tab 50 MG Give 1 tablet orally one time a day related to Major depressive disorder, recurrent, mild (F33.0) Give 1 tablet orally one time a day. -Baclofen Tab 20 MG Give 1 tablet orally four times a day related to Epilepsy, unsp, not intractable, without status epilepticus (G40.909) Give 1 tablet orally four times a day. -Pantoprazole Sodium EC Tab 40 MG (Base Equiv) Give 1 tablet orally every 12 hours related to Nausea with vomiting, unspecified (R11.2) Give 1 tablet orally every 12 hours. Once MA DD indicated to Surveyor, she had completed Resident #93's medication administration for the scheduled 8am medications, further observation reflected MA DD failed to administer 4 prescribed medications as ordered. 1) Ferrous Sulfate Tab EC 325 MG (65 MG Fe Equivalent) Give 1 tablet orally one time a day related to Epilepsy, unsp, not intractable, without status epilepticus (G40.909) Give 1 tablet orally one time a day. 2) Cholecalciferol Tab 50 MCG (2000 Unit) Give 1 tablet orally one time a day related to Epilepsy, unsp, not intractable, without status epilepticus (G40.909) Give 1 tablet orally one time a day. 3) Gabapentin Cap 100 MG Give 1 tablet orally three times a day related to Unsp fx shaft of humerus, left arm, subs for fx w routn heal (S42.302D) Give 1 tablet orally three times a day. 4) Carbamazepine Tab 200 MG Give 2 tablet orally two times a day related to Epilepsy, unsp, notintractable, without status epilepticus (G40.909) Give 2 tablet orally two times a day. Administered 1 tablet instead of 2 tablets as ordered. Record review of Resident #93's MAR for August 19, 2024 revealed MA DD documented that Resident #93 was administered the following medications: Ferrous Sulfate Tab EC 325 MG (65 MG Fe Equivalent) Give 1 tablet orally one time a day related to Epilepsy, unsp, not intractable, without status epilepticus (G40.909) Give 1 tablet orally one time a day. Cholecalciferol Tab 50 MCG (2000 Unit) Give 1 tablet orally one time a day related to Epilepsy, unsp, not intractable, without status epilepticus (G40.909) Give 1 tablet orally one time a day. Gabapentin Cap 100 MG Give 1 tablet orally three times a day related to Unsp fx shaft of humerus, left arm, subs for fx w routn heal (S42.302D) Give 1 tablet orally three times a day. These medications were not observed being administered during med pass 8/19/24 beginning at 7:45a.m. Record review of Resident #93's nurse's notes for August 2024, reflected no documented evidence found that the doctor was notified of the missed doses on August 19, 2024 for the medications prescribed. In an interview on 8/19/24 at 10:37a.m., MA DD stated the medications were scheduled to be administered at 8 AM and she could have a grace of 1 hour prior and 1 hour post 8 AM to administer medications safely. MA DD stated she went down the list and documented that she administered the medications without looking at the name of the medication today (8/19/24) before moving to next resident for med pass. The surveyor reviewed med pass observation from earlier 8/19/24 beginning at 7:45 am and reviewed Resident #93's MAR with MA DD. MA DD stated, I forgot to give iron and D3 both were over the counter. MA DD stated Gabapentin Cap 100 MG was not available on the cart or in the overflow. She stated she faxed to the pharmacy for it to be delivered today. MA DD stated she remembered giving Carbamazepine Tab 200 MG it was a big white pill but I gave 1 instead of 2. When asked what could happened if resident missed dose of prescribed medication. MA DD stated, nothing would happen if missed one day. In an interview on 8/19/24 at 1:22p.m., the DON and the Administrator, the DON stated the expectation was for medications to be administered as ordered by the physician and standards of practice. The DON stated the risk to residents could have been a possible reduction in therapeutic efficacy of the medications. The DON stated iron could affect hemoglobin., D3 was supplement and gabapentin was to treat pain. She stated Medication Aide had their competency check off upon hire and annually. The DON stated gabapentin was in pyxis (an automated medication dispensing system). The DON stated MA DD did not have access to pyxis but she could let the nurse know to pull and administer. In an interview on 8/19/24 at 3:16p.m., with LVN E, she stated gabapentin 100mg and 300mg were available in the pyxis. She stated MA DD did not notify her of Resident#93 missed medications. Record review of facility's Competency Assessment Administering Oral Medications (not dated) revealed read in part: .A) Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. E) Steps in the Procedure: 6. Check 1he label on the medication and confirm 1he medication name and dose with the MAR. 8. Check the medication dose, Re-check to confirm the proper dose . Record review of facility's Administering Medications policy (not dated) revealed read in part: . Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Verifying/Identifying Resident/Medication: 6. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method of administration before giving the medication. Documentation of Medication: 12. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones .

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 Staff (CNA BB) reviewed for infection control. The facility failed to ensure CNA BB followed proper hand hygiene during incontinent. These deficient practices could affect residents and place them at risk for infection, and reinfection. Findings include: Record review of Resident #10''s annual MDS assessment, dated 07/06/24, reflected a [AGE] year-old female with an admitted [DATE] and was readmitted on [DATE]. Her diagnoses included acute cystitis without hematuria (sudden inflammation of the bladder caused by a bacterial infection, also known as a urinary tract infection), cerebrovascular disease ( stroke, brain aneurysms and cerebral arteriovenous/blood clots) and lack of coordination due hemiplegia ( one-sided muscle paralysis or weakness). Record review of Resident #10's annual MDS dated [DATE] revealed she had a BIMS score of 11/15 (moderately cognitively intact). She required extensive assistance of one-to-two-persons with all ADLs and was always incontinent of bowel and bladder. Record review of Resident #10's care plan, dated 3/31/24, reflected, . The resident has an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent An observation on 08/20/24 at 09:29 a.m. revealed CNA BB entered Resident #10's room preparing to provide incontinence care. CNA BB washed her hands and put on double gloves, she picked up Kleenex from the floor and discarded it in the trash, did not change gloves, using the same gloved hands, picked up the clean wipes from the container on the bedside table and unfastened Resident #10's brief soiled with urine and had large bowel movement, CNA BB assisted the resident to roll on her left side. CNA BB took a peri-wipe and wiped in-between residents' rectal area and did not wipe around the buttocks. With the same gloves, CNA BB applied barrier cream to a chafed area on the resident buttocks and then removed the soiled brief and placed a clean brief under the resident and assisted her to roll back onto her back and fastened the brief. CNA BB removed her gloves and washed her hands. Review of CNA BB's skill checks dated 07/29/24 reflected she was competent in performing peri-care and hand hygiene. In an interview with CNA BB on 08/20/24 at 10:15 a.m. she stated she was supposed to wash her hands before and after performing incontinent care and change her gloves when she finished. She stated she knew the importance of properly cleaning a resident and by not doing so, placed them a risk of infections. In an interview with DON on 08/21/24 at 02:00 p.m., the DON said CNA BB should wash or sanitize her hands when soiled and she should not use double gloves. The DON said CNA BB would be retrained before working with incontinent residents. Record review of the facility's policy titled Handwashing/Hand Hygiene (revised October of 2010) revealed: 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 hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; Or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a residence intact skin; 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.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one resident (CR #1) of five residents (CR #1) reviewed for pharmacy services. 1. The facility failed to ensure CR #1's discharge orders from a transferring hospital were transcribed to the facility orders. 2. The facility failed to ensure CR #1's two anti-rejection medications were obtained by the facility. 3. The facility failed to ensure CR #1 received daily anti-rejection medications as ordered by the hospital from 04/09/24 to 05/23/24, when she was re-hospitalized and admitted to the ICU. 4. The facility failed to ensure CR #1, who had a liver transplant, was provided with two anti-rejection medications. An Immediate Jeopardy (IJ) situation was identified on 05/29/24. While the IJ was removed on 05/30/24 at 5:13 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effective of the corrective systems. The deficient practice resulted in CR #1 exhibiting a change of condition that resulted in hospitalization . Findings include: Record review of CR #1's face sheet reflected a 73- year old female who was admitted to the facility on [DATE]. CR #1 had diagnoses which included, but were not limited to, unspecified cirrhosis of the liver, unspecified liver disease, and liver transplant status (July 2022). Record review of CR #1's Admission MDS assessment, dated 04/11/2024, reflected CR #1 had moderately impaired cognition. CR #1 had a feeding tube for nutrition and medications . Record review of the hospital Discharge Instructions, dated 04/08/24 , for CR #1 reflected the resident was to receive, in addition to her other medications, the following two anti-rejection medications related to her liver transplant: 1. Tactrolimus (Prograf) 0.5 mg/ml oral suspension, 2 ml (1mg) two times daily for 30 days. The Instructions read, in part, .This medication is very important: It prevents organ rejection. 2. Mycophenolate (Cellcept) 200mg/ml suspension, 2.5 ml (500 mg) two times daily for 360 days. The Instructions read, in part, .This medication is very important: It prevents organ rejection. Record review of CR #1's Physician's Order List (facility) reflected the two anti-rejection medications were not on the list. Record review of a Progress Note, dated 05/22/24 at 12:50 p.m., reflected CR #1 appeared jaundiced. The NP was notified and CBC, BMP, and Ammonia level labs were ordered . Record review of a Progress Note, dated 05/22/24 at 11:02 p.m., reflected the NP called the facility and ordered CR #1 be sent to the hospital due to elevated Ammonia level of 159 micromols per liter. Record review of a Progress Note, dated 05/23/24 at 3:24 a.m., reflected CR #1 was sent to the hospital via ambulance. In an interview on 05/24/24 at 5:10 p.m. the DON said she was notified this morning that CR #1 was sent to the hospital. She said the hospital asked if CR #1 received her anti-rejection medications. The DON said the anti-rejection medications were not entered into the facility order system when the resident was admitted on [DATE]. The DON said when CR #1 was admitted , her payor source was private pay. She said LVN A notified a family member that he needed to bring CR #1's anti-rejection medications. The medications never arrived at the facility. The resident was sent to the hospital yesterday (05/23/24) due to abnormal labs (high Ammonia level), and she appeared jaundiced. She was transferred to the hospital. There were no other residents in the facility that were status-post transplant. The DON said the admission nurse (LVN A) and the Unit Manager (RN B) were both suspended. She said LVN A informed RN B she had difficulty entering CR #1's orders. She said she has begun in-servicing nurses regarding family members bringing or not bringing medications. In an interview via telephone on 05/29/24 at 9:08 a.m., CR #1's family member said CR #1 was still in the hospital. He said the resident was going to have a biopsy conducted to see if the transplanted liver was still being rejected. He said CR #1 had the transplant in July of 2022. He said she was taking the anti-rejection medications prior to going to this facility. He said she was transferred from a hospital to the facility. The family never had the anti-rejection medications. He said he, nor any other family members received a call from the facility asking for medications. She was at a different facility prior to going to that hospital. In an interview via telephone on 05/29/24 at 12:00 p.m. the family member said CR #1 was transferred from the ICU to the transplant unit at the hospital . In an interview via telephone on 05/29/24 at 12:40 p.m. RN B said the protocol for new admissions at the facility was for the Charge Nurse (in this case it would be LVN A) to process the admission. She said the next day the ADON (RN B) would conduct a 'chart check.' RN B said when she conducted the chart check for CR #1 she noticed a couple of medications were not entered into the system . She said she informed the DON, and the DON said to see if the family could bring the medicine in. RN B said she called the family but could not recall whom she spoke with. She said she did not document the conversation with the DON or family member. She said she waited for the family to bring the medications in, but they did not. She said there was no additional follow-up regarding the medications. In an interview on 05/29/24 at 3:19 p.m., LVN A said she did not verify CR #1's admission orders with the physician or NP. She said she thought RN B had done that. LVN A said she had difficulty entering two medication orders. She said she called the family member and was told another family member had recently passed, and he (the family member) would 'figure it out.' She said she told RN B about the two medications . In an interview via telephone on 05/29/24 at 3:55 p.m. the NP said she was not aware CR #1 was not receiving the two anti-rejection medications. She said not administering the anti-rejection medications for a long period of time could cause organ failure . This was determined to be an Immediate Jeopardy (IJ) on 05/29/24 at 4:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 05/29/24 at 4:00 p.m. The following Plan of Removal submitted by the facility and was accepted on 05/30/26 at 2:00 p.m.: PLAN OF REMOVAL Name of facility: _____ [Facility] ID # _____ Date: 5/29/24 Immediate action: F-755 Pharmacy Services 5/24/24 Medication Error report was completed This was completed by _____ [DON] 5/24/24 5/24/24 Charge nurse _____ [LVN A] and ADON _____ [RN B] received disciplinary notice and suspended pending investigation. This was completed by _____ [DON] 5/24/24 5/24/24 Patient was assessed by charge nurse on 5/23/23 patient was noted to have jaundiced eyes and abdomen. Patient lab returned with abnormal values related to liver. MD was notified and was sent to _____ [Hospital] ER. This was completed by _____ [RN B], ADON 5/23/24 Facilities Plan to ensure compliance quickly 5/24/24 Facility reviewed the admission policy/ procedures. No changes were required. This was completed by _____ Administrator, _____DON 5/24/24 5/29/24 _____ [Medical Director] our medical director and _____ [Pharmacist], _____ [Pharmacy], _____ [Consultant Pharmacist 1], were notified about the plan of removal. This was completed by _____ DON 5/29/24 5/29/24 All licensed nurses will receive in-service on Reconciliations of medications to include faxing the hospital discharge medication list to pharmacy consultant (company name: _____ [Consultant Pharmacist 2], medication transcription on admission, home medication process, 24-hour chart check and follow-up routine. No nurse will report to duty until in-serviced. All new admissions will be reviewed in clinical meeting by ADON/Unit managers for medication reconciliation and availability utilizing the Admission audit tool that includes admissions orders completed and verified. (check for transcription errors), medication availability, and fax medication regimen review to _____ [Consultant Pharmacist 1] (our consultant company) for review. DON will spot check Admission audit tool & Review _____ [Consultant Pharmacist 1] Review Report for Recommendations. All new admissions will be reviewed by the Department head nursing on call for holidays and weekends utilizing a charge nurse in facility as the second person. This was completed by _____ DON 5/30/24 5/29/24 A root cause analysis was completed by IDT team This was completed by IDT 5/29/24 5/29/24 An audit will be completed on all admissions in the last 30 days for medication reconciliation accuracy. No other discrepancies were identified. This was completed by _____ DON 5/29/24 5/30/24 All new admissions will be reviewed in clinical meeting by ADON/Unit managers for medication reconciliation and availability utilizing the Admission audit tool that includes admissions orders completed and verified (check for transcription errors), medication availability, and fax medication regimen review to _____ [Consultant Pharmacist 1] (our consultant company) for review. ADON/Unit Manager in clinical meeting will completed medication reconciliation together (one will read off the hospital discharge orders and the other with review orders in the AHT system.) All new admissions will be reviewed by the Department head nursing on call for holidays and weekends utilizing a charge nurse in facility as the second person. DON will spot check Admission audit tool & Review _____ [Consultant Pharmacist 1] Review Report for Recommendations. Ongoing Monitoring of the Plan of Removal included the following: In an interview on 05/30/24 at 2:30 p.m. with the DON revealed she conducted a medication order audit for all of the facility admissions of the past 30 days. She said a Root Cause Analysis was completed. In an interview on 05/30/24 at 3:10 p.m. with LVN C revealed she received the in-service. She said the in-service was to introduce the new admissions packet that included new processes regarding medications. She said the medications were to be verified by the doctor and a copy of the list was to be faxed to the pharmacy. She said if the resident's family had the medications but did not provide them, order them from the pharmacy. In an interview on 05/30/24 at 3:15 p.m. LVN D said the in-service was about admissions. She said the orders were to be verified by the physician, then faxed to the pharmacy. She said if a family member had the medications, ask them to bring them. If they did not, call the DON and order from the pharmacy. For transplant medications she would call the transplant doctor's office to see where they were to be obtained. In an interview on 05/30/24 at 3:20 p.m., LVN E said the in-service was about admissions. She said the orders were to be verified with the physician and then faxed to the pharmacy. She said if a resident's family had the medications at home but did not provide them, call the pharmacy and order them. In an interview on 05/30/24 at 3:30 p.m., LVN A said there was a new form for medications upon admission. She said the other facility discharge orders were to be verified and faxed to the pharmacy. She said if medications were with the family, she was to call them, and follow-up to make sure the medications arrived. Call the pharmacy if not. In an interview on 05/30/24 at 3:40 p.m., LVN F said after the medication list was verified with the physician it was to be faxed to the pharmacy. If the family had the medications, call them. If the family did not bring them, call the DON and order from the pharmacy. In an interview on 05/30/24 at 4:20 p.m. RN B said the orders were to be faxed to the pharmacy after they were verified with the physician. She said if the family did not bring in home medications, she was to check the Pyxis and call the DON, then order from the pharmacy. She said she was re-training with the DON today and will be training at another facility next week. In an interview on 05/30/24 at 4:25 p.m. LVN G said after the medication orders were verified with the physician, the list was to be faxed to the pharmacy. If the family did not bring the medications, she would call the DON and order from the pharmacy. In an interview on 05/30/24 at 4:30 p.m., LVN H said after the orders were verified with the physician they were to be faxed to the pharmacy. If the family did not bring medications, call the DON, the Unit Manager, and let the incoming nurse know. Record review of Resident #2's admission orders, dated 04/26/24, and May 2024 MAR reflected no discrepancies. Record review of Resident #3's admission orders, dated 05/24/24, and May 2024 MAR reflected no discrepancies. Record review of Resident #4's admission orders, dated 05/14/24, and May 2024 MAR reflected no discrepancies. Record review of Resident #5's admission Audit Tool reflected it was completed with no errors noted. Record review of Resident #6's admission Audit Tool reflected it was completed with no errors noted. Record review of the Medication Error Report, dated 05/23/24, reflected it was completed. Record review of the Disciplinary Notices for LVN A and RN B was conducted . Record review of the facility's policy and procedures for new admissions was reviewed. Record review provided verification that the Medical Director and Pharmacist were notified. Record review of the in-services reflected all of the nurses onof the facility-provided staff list had been provided education . The facility implemented a medication reconciliation list of the hospital discharge medication orders form that was to be faxed to the pharmacy. Record review of the Admission Audit Tool did not reflect any concerns. The Administrator and the DON were informed the Immediate Jeopardy was removed on 05/03/24 at 5:13 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interview and record review, the facility failed to ensure the environment remained free of accident hazards and each resident received adequate supervision and assistance to prevent accidents for 1 of 6 residents (Resident#1) reviewed for accidents and hazards. The facility failed to ensure hot coffee was maintained at a temperature that prevented Resident #1 from sustaining a second-degree burn to his left groin. This failure could place residents at risk of second degree burns and a decline in quality of life. Findings Included Resident #1 Record review of Resident #1's admission face sheet, dated 8/25/2023, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included right eye cataract (blurry vision), dysphagia (difficulty swallowing), retinal hemorrhage left eye (bleeding from the blood vessel in the retina), sepsis (infection), dementia (memory loss), anxiety disorder (feeling of fear, dread and uneasiness), abnormalities of gait and mobility (unusual walking pattern and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating that the resident has cognitive issues. For Section B1000: Vision: Resident was coded as a 2 indicating the resident was moderately impaired- that is limited vision. For Functional Status G0110: Activities of Daily Living (ADL)assistance the resident was coded for Transfer and Toilet use as 2/2 indicating he was limited assistance with one-person physical assist. For bed mobility, dressing and personal hygiene the resident was coded 3/2 indicating he was extensive assistance with one-person physical assist. For eating he was coded as 1/1 indicating he needed supervision with set up only. For bowel he was coded as occasionally incontinent and for bladder he was coded as frequently incontinent. Record review of Resident #1's care plan dated 8/8/2023 revealed the care plan goal was to maintain adequate nutritional status and good oral hygiene daily and ongoing over the next 90 days. Interventions are to Monitor assistance needed with nutritional intake and notify the physician of changes and assist resident as needed. Record review of the incident report for Resident # 1 dated 8/23/2023 revealed CNA reported that patient stated to her that he had his coffee in his personal cup brought from home. He had the cup sitting in his lap and it spilled over into lap causing a burn 11/2 abrasion to upper left thigh and redness around the area. Record review of Resident #1's nurse's notes and the 24-hour report dated 8/22/2023 revealed no documentation of Resident #1's burn. Record review of the Bath Assignment Sheet (shower sheet) dated 8/22/2023 revealed When giving Resident #1 a shower, I asked about an open area. He told me his coffee spilled and burn him, but he did not tell anyone about it (upper left thigh). This sheet was sign by CNA B and Charge Nurse LVN A. During an interview with Resident #1 on 8/25/2023 at 10:30 a.m., he said he went to the dining room to get himself a cup of coffee in his coffee cup brought from home and was going outside to read the paper. He said, as habit he put the cup in his lap and did not realize the lid was not closed all the way. He then realized the coffee was burning him. He said he did not tell anyone about the burn because he did not think it was serious. Interview with the Dietary Manager on 8/25/2023 at 10:00 a.m., she said sometimes Resident #1 got his coffee by himself. She said she was not aware of the burn until 8/23/2023. She said when she heard about the burn, she checked the coffee machine, and the internal temperature on the thermometer was 170 degrees F and the actual coffee temperature in the cup was 149 degrees F. She said they did not know what the coffee temperature was when the resident got burned, because they never took coffee temperature, prior to the incident . Observation on 8/25/2023 at 10:00 a.m. revealed the internal temperature of the coffee machine was 140 degrees F and the coffee temperature in the cup was 135 degrees F. In an interview with Resident #1 on 08/25/2023 at 10:30 a.m., he said he went to the dining room to get himself a cup of coffee in his coffee cup and was going outside to read the paper. He said, as habit he put the cup in his lap and did not realize the lid was not closed all the way. Then the next thing he realized the coffee was burning him. He said he did not tell anyone about the burn because he did not think it was serious . During an interview with the DON on 8/25/2023 at 11:00 a.m., she said CNA B asked her on 8/23/2023 about 3:30 p.m. what they were doing about Resident #1's burn and she told her she was not aware of Resident #1 having a burn. She said the CNA told herwhen she was giving Resident #1 a shower on 8/22/2023 around 7:00 p.m. she noticed the area on his groin and asked him what happened and he told her he had his coffee cup in his lap with coffee he got from the coffee machine last night (8/21/2022) and he forgot to close the opening on the lid, and it spilled over and burned him and he did not tell anyone. She said the CNA B told her she reported it to the charge nurse and documented the burn on the shower sheet. The DON said she assessed the resident and notified the physician and an order was given for treatment. Further interview with the DON revealed the resident sustained a second degree burn to the left groin area. Interview with CNA B on 8/25/2023 at 1:30 p.m. via telephone, she said she was giving Resident #1 a shower on 8/22/2023 around 7:00p.m. and noticed the area on Resident #1's left groin and asked him what happened. CNA B said, Resident #1 told her last night (8/21/2023) that he had his coffee cup in his lap, and he forgot to close the opening on the lid of the cup, and it spilled over and burned him, and he did not report it to anyone. She said he told her he just went back to his room and changed his clothes. She said she reported it LVN A and documented it on the shower sheet. She said she did not report it to the DON because she reported it to LVN A. Observation on 8/28/2023 at 11:45 a.m. the internal temperature of the coffee was 145 degrees F, and the actual coffee temperature in the cup was 135 degrees F. During an interview on 8/28/2023 at 11:45 a.m. with the Dietary Manager, she said she was going to have the company who in-serviced the coffee machine adjust the internal temperature coffee machine to 140 degrees F. She said she was going to ensure it won't get higher than 140 degrees Fahrenheit and residents would get their coffee at a safe temperature level. Observation on 08/30/2023 at 4:15 pm. of the internal temperature of the coffee machine revealed it was set at 140 degrees F. and the temperature of the coffee was 138 degrees F. In an interview with the Dietary Manager on 8/30/2023 at 4:15 p.m., she said they were dispensing coffee from the coffee machine to the Eco Air pot where they could monitor the coffee temperature better. She said staff were supposed to take the temperature of the coffee before it was sent to the dining room and document on the temperature log. Record review of facility policy and procedure on Safety of Hot Liquids, dated 06/2017, read in part . Maintaining hot liquid serving temperature of not more than 140 degrees Fahrenheit'.

Based on observation, record review and interview, the facility failed to provide 1 of 9 sampled residents (Resident #1) and 2 of six random residents with wheelchair alarms(Resident #10 and #11) with the supervision required to ensure the resident's safety and well-being. ----Resident #1's floor mats were not in proper place, bed alarm was not activated, and bed was not in low position when resident was found bleeding from her head on the floor. ----Residents #10 and #11 were in dining room during lunch meal without wheelchair alarms properly affixed from chair to resident. This failure caused actual harm to Resident #1 who sustained a head injury and subsequently died in the hospital. This failure affected 2 residents and placed 13 other residents at risk for sustaining injuries related to falls. Incident # 4 Finding include: Resident # 1 Record review of Resident #1's medical record (face sheet chart) revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was transferred from the facility on [DATE]. A list of the resident's medications included: Aspirin, Plavix, Zoloft and Lipitor. Record review of the resident's Admission MAR dated [DATE] revealed the resident had difficulty communicating some words or finishing thoughts, but was able to make herself understood if prompted or given time. She was identified as having the ability to understand others if prompted or given enough time. The resident was identified as being wheelchair dependent and required the assistance of one person to transfer out of bed. She was identified as incontinent of bowel and bladder. Record review of the resident's Care Plan dated [DATE] revealed she had the following "Problem/Need:" Resident plays with electric bed controller; Approaches: 1) reorient resident to proper use of bed controller, 2) staff to make Q2 hrs and prn room checks. "Potential for injuries from falls due to recent history of falls 'Actual Fall [DATE]"; Approaches: 7) add chair alarm when in wheelchair. Three additional approaches were handwritten at the bottom: *bed in lowest position, *W/C alarm, *fall mats. "Potential for injuries from falls due to high risk for falls on Fall Risk Assessment" - Approaches were same as "recent history of falls" above, however, "bed in lowest position, w/c alarm, and fall mats" were not on this one. An added approach was for "Therapy to eval and treat as indicated." "Potential for falls *Risk for falls will be r/t (related to) impulsiveness and minimized poor safety awareness - Approaches... 8) Lap buddy for wheel chair for positioning and as a reminder not to get up unassisted...12) Keep bed in lowest position." "Resident has a history of falling - Approaches...7) Resident uses a Tab alarm while in the chair...8) Resident uses a Tab alarm while in bed...10) Monitor for changes in Resident's condition that may warrant increased supervision/assistance and notify the physician..." Record review of Resident #1's physician admission orders [REDACTED]. Record review of Resident #1"s nurses notes dated [DATE]; 11:30 PM revealed an entry by LVN A. This entry in part read: "this writer (nurse) heard someone calling for 'Help'. I observed resident lying prone on floor next to bed with right side of head against nightstand leg and left upper extremity twisted behind her back. Upon turning resident onto back significant amount of bleeding noted on floor and coming from right temporal area of head." Resident alert and conversing coherently at this time. Neurological vital signs began and unremarkable except resident not oriented to place or time, but this is not unusual for resident. Followed all commands, moves all extremities well. Left hand grip greater than right hand grip but this is not unusual for this resident. Pupils equal and reactive to light." Record review of Resident's #1's nurses notes dated [DATE]; 12:05 AM revealed the resident was discovered nonresponsive by LVN A. The nurses' notes further indicated LVN A dialed 911 and the resident was transported to a local hospital. During an interview on [DATE] at 1:18 PM, LVN A stated that she was working the 10 to 6 shift and clocked in about 10:10 PM. There was discussion regarding hall assignments when she heard someone scream for help. When she entered Room 502 Resident #1 was lying on the floor. She ran out of the room and screamed for help. CNA B came to help, along with 2 other staff. Resident was bleeding from her right temporal area; she was alert and talking. She and the other staff got resident back into bed to assess vital signs. Resident was alert and oriented to her name. Resident followed commands appropriately, did not see doubles, moved both legs and arms. She applied pressure to wounds as bleeding had started again bleeding then stopped. She went to get treatment cart to treat wounds and when she arrived in the room again, the resident was unresponsive. She called 911 at 12:10 AM and EMS arrived at 12:25 AM. LVN A further stated at this time that when resident was found, her mats were not in proper place, the bed was waist high, not in position, and bed alarm was clipped to the bed (instead of the resident) and the magnet (triggering mechanism) was clipped to the alarm. Interview with CNA B on [DATE] at 1:29 PM revealed that after she helped LVN A with resident, she noticed that "the bed was high," the bed alarm was not attached. She stated that she had been assigned the back half of the 500 hall, resident rooms 516 - 520. There was confusion that night about what the assignments were for the staff. Interview with DON on [DATE] at 11:17 AM, she stated that CNA C took over at 10:00 PM. CNA D had been responsible for resident on 2P-10P shift, and put resident to bed. The floor mats were in place on both sides of the bed, and bed alarm was in place at 2200 (10:00 PM). Record review of an Incident Investigation report conducted by the facility dated [DATE]. This report indicated "Resident #1 was found lying on the floor her bed was in the high position; bed alarm not on resident." This report was signed by LVN A on [DATE]. Record review of the resident's ICU medical record revealed a document dated [DATE]; 6:42 AM (name of Hospital). "Transferred from (name of Hospital) with large left SDH (Subdural Hematoma-blood clot). Daughter request DNR (Do not resuscitate)." This document further revealed under heading; HPI: "[AGE] year old female status [REDACTED]. The patient was intubated for airway protection and was then transferred to (name of Hospital) for a higher level of care. Per discussion with daughter, the patient did not have a good quality of life prior to her fall. The family requested a DNR on the chart and consented to intubation only until patient's disposition could be clarified by neurosurgery. After talking to the neurosurgery resident, they do not want extraordinary measures taken if her quality of life will not return to where it was at the SNF (Skilled Nursing Facility). This document revealed under heading Plan: "comfort measures only. After discussion with the family, they do not want to proceed with surgical intervention given that the patient would very unlikely regain a good quality of life. No surgical intervention at this time." An interview was conducted with the facility's DON on [DATE] at 9:00 AM. She stated "after interviewing staff that work the 10 PM to 6 AM shift to gather information regarding Resident #1's fall; I don't think any staff on the 10PM to 6 AM shift observed Resident #1 before she fell because after my interview with the staff, I've come to the conclusion that the 10 PM to 6 AM Charge nurse did not give them their assignments until after the resident fell ." Resident #10 and #11 Observation in the main dining room on [DATE] at 11:58 AM revealed that Resident #10's wheelchair had an alarm on it, but it was not clipped to his shirt. Resident #11's wheelchair alarm was hanging down over back of wheelchair, almost touching the floor. Interview with CNA C on [DATE] at 12:41 PM, CNA C stated that yes, the chair alarm is "supposed to be hooked to the resident's shirt," and then she attached it appropriately. The facility's DON listed 15 residents with physician orders [REDACTED].