Every finding on record at The Willows at Springhurst

Based on observation, interview and review of facility policy, the facility failed to prepare, store, and serve food under sanitary conditions for 51 of 52 residents who received food from the kitchen. The findings include: Review of the facility's Hair Restraint Policy' revised date 07/09/2025, revealed all dining service employees were required to wear hair restraints as required by the Federal Food Code, Hair Restraints 2-402.11. Review of the Federal Food Code dated 2009, revealed food employees shall wear hair restraints such as hats, hair covering or nets that are designed and worn to effectively keep their hair from contacting exposed food. Observation, on 09/16/2025 at 2:14 PM, revealed the Cook's hair net was not covering the side or back of her hair. There was approximately eight inches of hair without covering.During interview with the [NAME] at the time of the observation, she stated employees were to wear a hair net that covered all the hair when they were in the kitchen and around food. She further stated, I have a lot of hair. She also stated the facility discussed the importance of covering hair about once a week.During interview with the Director of Food Services (DFS) on 09/16/2025 at 2:15 PM, he stated the staff should wear hairnets or hats that covered the hair. He stated he just now saw the Cook's hair out of the hair net.During interview with the Executive Director on 09/19/2025 at 2:03 PM, she stated she expected staff to follow the policies. She rounded periodically to assure policies are followed.

Based on interview and record review, the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II Pre-admission screening and resident review (PASRR) evaluation for 1 of 1 sampled resident (Resident (R) 5).The findings include: The facility did not provide a policy specific to PASRR evaluation. Review of Resident (R) 5's, Face Sheet revealed the facility originally admitted the resident on 07/01/2022 with the most recent re-admission date of 11/25/2024 with diagnoses including acute and chronic respiratory failure, bipolar disorder, dementia, major depressive disorder, generalized anxiety disorder, and paranoid personality disorder. Review of R5's, Pre-admission Screening and Resident Review (PASRR), dated 07/01/2022 revealed diagnoses of major depressive disorder, generalized anxiety disorder, and dementia. Further review revealed a Level II referral was not indicated at that time. Review of R5's Comprehensive Care Plan (CCP) revised 08/05/2025 revealed the resident demonstrated altered behaviors including delusions and received medication for bipolar disorder. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/18/2025 revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) exam score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed bipolar disorder was coded as an active diagnosis. Review R5's Resident Progress Notes, dated 11/14/2024 revealed the resident was sent out of the facility to an outside hospital for psychiatric evaluation. Review of R5's hospital Discharge summary dated [DATE] revealed the resident was hospitalized for bipolar disorder with recent mania and psychosis. Review of R5's Resident Progress Notes, dated 11/25/2024 revealed the resident returned to the facility with diagnoses of bipolar 1, psychosis, and paranoia. Surveyor attempts to interview R5 on 09/16/2025 at 2:11 PM were unsuccessful as R5 refused interview. During an interview with the Social Services Director (SSD) on 09/19/2025 at 9:41 AM, she stated the Admissions Department was responsible for initial PASRR screenings. She stated she helped some but did not have access to the Kentucky Level of Care System (KLOCS). The SSD further stated if a resident developed a new diagnosis after the initial screen, the Minimum Data Set (MDS) Coordinator submitted that information to KLOCS. During an interview with the MDS Coordinator on 09/19/2025 at 9:49 AM, she stated if a resident had a new qualifying diagnosis after the Level I PASRR was completed, the diagnoses was submitted through the KLOCS system. She further stated the system determined if Level II services were needed. The State Survey Agency (SSA) Surveyor observed the MDS Coordinator as she accessed the KLOCS system; however, there were no new diagnoses listed for R5. The MDS Coordinator stated R5's new diagnoses should have been submitted. Additionally, she stated it was important new diagnoses were submitted to KLOCS so the facility provided newly identified care and services to the resident. During a follow up interview with the MDS Coordinator on 09/19/2025 at 12:16 PM, she stated she contacted and spoke to someone at KLOCS and found R5's new diagnoses information was not submitted as required. During an interview with the Director of Health Services (DHS) on 09/19/2025 at 1:34 PM, she stated R5 should have been referred for a Level II evaluation when the resident received new qualifying diagnoses. The DHS stated it was important referrals were made when indicated because the resident may need services the facility was not equipped to provide. During an interview with the Executive Director on 09/19/2025 at 1:46 PM, she stated the facility did not have a specific policy related to PASRR screenings, but rather the facility followed the Centers for Medicare and Medicaid Services (CMS) and the State guidelines for PASRR screenings. She stated it was her expectation the facility followed those guidelines so residents received appropriate care and services.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free of any significant medication errors and that medications were received at the right time for 1 of 8 sampled residents (Resident (R) 6).The findings include: Review of the facility policy titled, Medication Administration Times Procedural Guidelines, revised 12/01/2021 and reviewed 12/17/2024 revealed guidelines for determination of medication administration times based on a resident's preference unless a specific time is designated by the attending physician. Review of the facility policy titled, Specific Medication Administration Procedures/Injectable Medication Administration, revised 11/2018 revealed the procedure included guidelines to check the five rights (right patient, right drug, right route, right dose, right time) when medication selected, as dose is prepared, after dose prepared, before medication is put away, and before injection is administered. Review of Resident (R) 6's, Face Sheet revealed the facility admitted the resident on 02/20/2025 with diagnoses including type II diabetes and congestive heart failure (CHF). Review of R6's Comprehensive Care Plan (CCP) dated 02/21/2025 revealed a risk for hypoglycemia/hyperglycemia (low/high blood glucose) related to a diagnosis of diabetes mellitus. Review of R6's blood glucose readings for 09/17/2025 revealed the following: 123 at 9:37 AM, 255 at 10:27 AM, and 124 at 4:17 PM. Review of R6's orders revealed insulin lispro was ordered for administration before meals at 6:30 AM - 9:00 AM, 10:00 AM - 12:30 PM, and 3:30 PM - 6:30 PM. Review of R6's electronic Medication Administration Record (eMAR) revealed Registered Nurse (RN) 2 documented administration of 6 units lispro insulin to R6 on 09/17/2025 at the 10:00 AM - 12:30 PM timeframe. Observation on 09/17/2025 at 2:27 PM revealed RN2 entered R6's room and administered 6 units of lispro insulin via subcutaneous route. During an interview with RN2 on 09/17/2025 at 3:55 PM when asked about the administration time of R6's insulin, he stated that was when he got to her to administer the insulin. The State Survey Agency (SSA) Surveyor asked RN2 if he saw a concern with giving insulin when the resident's blood glucose was checked at 10:27 AM and after she had finished her lunch, he stated R6 was typically stable with her blood glucose readings, but if it had been low, he would have addressed it earlier.During an interview with Certified Resident Care Associate (CRCA) 1on 09/19/2025 at 7:53 AM revealed she was also a Certified Residential Medication Aide (CRMA). She stated she checked residents' blood glucose levels typically around 11:00 AM for the lunch meal, and any needed insulin was administered before they ate.During an interview with Licensed Practical Nurse (LPN) 4 on 09/19/2025 at 12:45 PM, she stated before she administered insulin to a resident, she verified the order, and the amount of insulin needed based on the resident's glucose check reading. She stated insulin was important insulin to be administered at the right time because if too much time passed after their glucose check, their sugar could have either increased or dropped. During an interview with LPN1 on 09/19/2025 at 1:05 PM, she stated she used the five rights when she administered medications and that included insulin. She stated it was important insulin was given at the right time because if a resident experienced a change in their blood glucose level, they possibly received the wrong dose of insulin. During an interview with the Director of Health Services (DHS) on 09/19/2025 at 1:34 PM, she stated it was her expectation staff followed the facility's medication administration policies. She further stated she expected staff adhered to the five rights of medication administration. The DHS stated it was important insulin was administered at the right time based on blood glucose readings, so the resident did not have either an increase or drop in their blood glucose. The DHS stated if too much time passed before insulin was administered, a resident's blood glucose was potentially two to three times higher than the initial reading. During an interview with the Executive Director on 09/19/2025 at 1:46 PM, she stated it was her expectation staff administered medications at the right time as ordered by the physician, so that the facility provided the appropriate care and services each resident needed.

Based on observation, interview, record review, and review of facility policies, the facility failed to follow infection prevention and control practices to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident observed for subcutaneous injection administration. (Resident (R) 6.The findings include: Review of facility policy, Infection Prevention and Control Program, revised 11/15/2021 and reviewed 12/17/2024 revealed its purpose was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections. Review of the facility policy, Specific Medication Administration Procedures/Injectable Medication Administration, revised 11/2018 revealed examination gloves were part of the equipment required for injectable medication administration. Further review revealed procedures for subcutaneous injections included to sanitize hands with approved hand sanitizer and put on gloves prior to administration. Review of the facility's policy titled, Guideline for Handwashing/Hand Hygiene, dated 03/20/2017 revealed all health care workers shall utilize hand hygiene frequently and appropriately and health care workers shall use hand hygiene before/after having direct physical contact with residents. Review of Resident (R) 6's, Face Sheet revealed the facility admitted the resident on 02/20/2025 with diagnoses including type II diabetes and congestive heart failure (CHF). Review of R6's Comprehensive Care Plan (CCP) dated 02/21/2025 revealed a risk for hypoglycemia/hyperglycemia related to a diagnosis of diabetes mellitus. Observation on 09/17/2025 at 2:27 PM revealed Registered Nurse (RN) 2 entered R6's room and administered insulin subcutaneously to the resident. Observation additionally revealed R6 did not sanitize hands while in the room and administered the injection without gloves.During an interview with Licensed Practical Nurse (LPN) 4 on 09/19/2025 at 12:45 PM, she stated prior to administration of any type of injection, she performed hand hygiene and put on gloves. She stated it was important to follow proper infection control procedures when she administered medication to help prevent transmission of germs.During an interview with Registered Nurse (RN) 2 on 09/19/2025 at 12:56 PM, he stated he performed hand hygiene before he entered R6's room when he administered her insulin on 09/17/2025. However, he further stated he administered the insulin to R6 without gloves. RN2 stated it was important gloves were worn when injections were administered so cross contamination was controlled. During an interview with the Infection Preventionist (IP) on 09/19/2025 at 1:15 PM, she stated infection prevention/control education was continual and ongoing. She stated she performed weekly audits and alternated between different areas of infection control, which included administration of injections. The IP stated it was her expectation staff used hand hygiene and put on gloves before they administered an injection so the exposure to infection was decreased. She further stated the facility was the residents' living environment and staff were responsible for them and their safety.During an interview with the Director of Health Services (DHS) on 09/19/2025 at 1:34 PM, she stated she expected staff to follow all infection control/prevention policies and procedures. She further stated the expectation was staff performed hand hygiene and put on gloves prior to administration of an injection. The DHS stated it was important gloves were worn because of the potential for bacterial transfer to a resident, as well the possibility of a needle stick to staff. During an interview with the Executive Director on 09/19/2025 at 1:46 PM, she stated she expected staff followed facility guidelines when they gave injections. She further stated it was her expectation staff adhered to infection prevention and control policies during medication administration, so residents were kept safe from any blood borne pathogens.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and distribute food under sanitary conditions and in accordance with professional standards for food safety. Initial tour of the facility revealed undated and opened containers of salad dressing, and in the freezer unopened vegan trays, and meat and cheese packages. Additional observation of the freezer revealed a container of strawberries covered with a gray substance. Further observations revealed the freezer temperature log was incomplete for the dates of 08/20/2021 through 08/30/2021. The findings include: Review of the facility's policy, Food Labeling and Dating, dated March 2019, revealed any food product removed from its original container, or with a broken seal, or had been processed in any way, would be labeled. Per review, the label was to include the item's name, the date and time the food was labeled, the used by date, and initials of the person labeling the item. Review of the facility's policy titled, Refrigerators, dated May 2017, revealed refrigerators would have a functioning thermometer present in a visible location, which were monitored daily. Per review, the temperature checks were documented on the refrigerator monitoring log, and there was documentation of follow up for any out of range readings noted. Tour of the facility's kitchen area, on 08/30/2021 at 6:18 AM, with the Dining Services Assistant, revealed observations of a Caesar dressing container which was opened but not labeled and dated. Continued observations revealed a package of lunch meat and package of cheese in the refrigerator which had been opened, but not dated. Per observation, the refrigerator also contained strawberries with a gray, fuzzy material on them, moldy in appearance. Further observation revealed two (2) Styrofoam containers with food items stored in them in the freezer, which had not been dated or labeled as per facility policy. Observation further revealed the facility's temperature log for the freezer contained documentation noting the latest entry completed on 08/20/2021. Interview with the Kitchen Director, on 08/30/2021 at 6:35 AM, revealed all temperature logs were to be filled out every morning and evening because if something was not working right, the facility needed to know and have it repaired or replaced. He stated the strawberries should have been thrown away as they were moldy. Per interview, the Styrofoam containers contained vegan meals and should have been labeled as per policy. According to the Kitchen Director, the Caesar dressing which was open and not dated should have been dated. He stated the importance of having food items labeled and dated gave kitchen staff an idea of when they could discard those items. He revealed if the food was in the cooler too long it could make a resident sick. Further interview revealed the Kitchen Director acknowledged, after reviewing the freezer log, it had not been filled out since 08/20/2021; however, the Kitchen Director stated it should have been completed daily. In addition, he stated if the freezer log was not completed as required staff would not be able to tell if the freezer was operating as it was supposed to. Interview with the Director of Health Services (DHS), on 09/03/2021 at 10:56 AM, revealed if the facility's refrigerator contained food which was moldy or had undated opened food it could affect the residents negatively. She stated the persons responsible for labeling and dating items were the ones who opened the items. Per interview, if someone opened food items they were to label and date the items. According to the DHS, the kitchen staff were ultimately responsible for ensuring opened food items were labeled and dated as per facility policy. She stated the temperature log for the refrigerators and freezers was used to ensure staff determined equipment was running at the right temperature. Further interview revealed if the refrigerator or freezer temperatures were out of range it could cause food to thaw. She further revealed the kitchen staff was responsible for making sure the refrigerator and freezer temperature logs were completed every day. Interview with the Area Executive Director (ED), on 09/03/2021 at 1:32 PM, revealed there was a potential for using an outdated item if containers were not date and labeled when opened. Per interview, whoever put away the food in the kitchen area was responsible for dating it. She stated the purpose of the refrigerator and freezer temperature logs was to ensure food was maintained at the correct temperature and everything was working properly. According to the Area ED, the potential problem with a temperature log not being filled out completely was food might not be stored at the proper and safe temperature. Further interview revealed the facility's cook was the one responsible for keeping the refrigerator and freezer logs up to date. She revealed the morning cook made sure the morning temperatures were completed and noted, and the evening cook made sure the evening temperatures were noted.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure performance reviews were completed every twelve (12) months, for six (6) of six (6) nurse aides personnel files reviewed. The findings include: Review of the facility's policy, Quarterly Wage Investment Timeline, undated, revealed employee eligibility for increases was dependent on disciplinary actions incurred resulting from performance and performance improvement plans, etc. Review of the facility's Skills Check-Off sheets revealed the facility evaluated employees on Hand Washing, and Guidelines for Donning and Doffing Personal Protective Equipment (PPE). The facility did not provide a policy specific to Nurse Aid performance evaluation. The facility failed to provide documented evidence of performance evaluations of nurse aides for six (6) of six (6) nurse aide files sampled. Interview, on 09/03/2021 at 9:40 AM, with the Staff Development Coordinator (SDC) revealed the nurse aide employment anniversary was utilized to meet training and educational timeframe's. She stated the nurse aides were educated to ensure they were competent to do their job, in order for residents to receive the care they required and deserved. Per interview, she provided input into the nurse aides' annual and other evaluations, although she did not conduct the evaluations herself. According to the SDC, the Director of Health Services (DHS) or Executive Director (ED) completed the nurse aide evaluations. She stated the evaluations determined if the aide performed their duties properly, and in order to identify anything necessary areas of improvement for the aide. Further interview revealed the only skills check off the facility used was for hand washing, and donning and doffing PPE. On 09/03/2021 at 10:56 AM, interview with the DHS revealed the facility had not performed annual nurse aide evaluations as per the regulation. She stated the facility completed staff competencies and check offs of staff regarding hand washing and PPE, with infection control as the focus. She stated the purpose of the nurse aide evaluations was to ensure the aides knew the tasks they were responsible to perform. The DHS further revealed if the nurse aide evaluations were not completed the aides could perform tasks improperly which could lead to other issues, such as improper skin integrity or infection for a resident. Interview with the Area Executive Director (ED), on 09/03/2021 at 1:32 PM, revealed the facility's corporate policy for nurse aide evaluations was the quarterly wage increases with a focus on positive reinforcement. Per interview, she addressed any concerns regarding an employee's performance. The ED stated prior to receiving the quarterly pay increase, employee personnel files were reviewed for counseling and coaching needs. According to the ED, the facility used non-certified nurse aides to provide resident care. Continued interview revealed the non-certified nurse aides received a lot of hands on monitoring on the floor by the DHS and Assistant Director of Health Services (ADHS); however, there was no documentation of the nurse aide evaluations. Further interview revealed the purpose of the nurse aide evaluations, per the regulation, was to ensure staff were competent and capable to care for residents, and for the residents to receive the care they deserved and required. She further revealed the facility's Quality Assurance (QA) Committee had not discussed how the new corporate policy for quarterly wage increases met the regulatory requirement for nurse aide evaluations.

Based on observation, interview, record review and facility policy review it was determined the facility failed to ensure resident care plans were implemented for one (1) of nineteen (19) sampled residents, Resident #14, related to use of a palm guard. Observations from 08/30/3031 through 09/03/2021, revealed no palm guard in place to the resident's right hand as per the Comprehensive Care Plan. The findings include: Review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, dated October 2019, revealed the Comprehensive Care Plan was an interdisciplinary communication tool. Per review, the Comprehensive Care Plan described the services provided to a resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. In addition, review revealed the Comprehensive Care Plan was to reflect the care a resident received. Review of the facility's policy, Splints and Orthotic Devices, undated, revealed an orthotic device was used to support a joint or body part, reduce pain, or position the joint in a functional position. Per review, the rationale for use of orthotics included joint range of motion, reduced pain, reduced effects of disease, and reduced risk for skin breakdown or joint deformity. Review of the clinical record for Resident #14 revealed the facility readmitted the resident on 04/09/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/09/2021 revealed the facility assessed Resident #14 as severely cognitively impaired. Continued review of the MDS revealed the facility assessed the resident with impairment of functional ROM in his/her upper extremities. Review of Resident #14's Comprehensive Care Plan revealed the facility care planned the resident for safety, dated 07/02/2019. Per review of the safety care plan Resident #14 had limited range of motion (ROM) due to contractures and the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed goals included for Resident #14's joint contractures to be free from injury and skin breakdown. Further review revealed the interventions included the following: therapy evaluation and treatment as needed; staff were to follow Physical Therapy (PT) and Occupational Therapy (OT) recommendations as indicated; and for staff to place a palm guard to his/her right hand. In addition, review revealed the nurse aides and nurses were responsible for ensuring the listed interventions on the Comprehensive Care Plan for Resident #14 were implemented. Review of an OT Therapist Progress Note, dated 03/12/2021, revealed Resident #14's goal was upgraded on 03/12/2021, for the resident to tolerate upper extremity splints for six (6) hours with the use of a palm guard. Per review, this goal was to enhance maximum ROM and joint alignment to prevent deformity and pain for Resident #14. Continued revealed Resident #14's prior level of function, on 02/26/2021, was four (4) hours, and his/her current level of function on the 03/12/2021 Note, was documented as four (4) to five (5) hours. Further review revealed the OT noted Resident #14's caregiver was educated on putting on and taking off his/her palm guards. Review of the OT Therapist Progress and Discharge Summary, dated 07/23/2021, revealed the goal for the caregiver to put on and take off Resident #14's palm guard was met on 07/23/2021. Per review, the caregiver was educated on how to put on and take off the palm guard splint, as the resident required assistance with the splint. Further review revealed the OT noted Resident #14's caregiver was aware of his/her need for assistance with the palm guard splint, and understood the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's Nurse Aide Care Sheet, dated 08/31/2021, for Resident #14 revealed the resident was to have a splint to his/her right upper extremity at all times, which could be removed for bathing. Observations of Resident #14, on 08/30/2021 at 6:21 AM, and at 12:45 PM; on 08/31/2021 at 12:05 PM, at 2:10 PM, and at 4:04 PM; on 09/01/2021 at 8:27 AM, at 10:13 AM, at 10:54 AM, at 1:40 PM, and at 2:05 PM, revealed the resident's hands were contracted. In addition, the observations revealed no visual evidence Resident #14 of his/her OT recommended and care planned palm guard in place to his/her right hand. Interview with Certified Nurse Aide (CNA) #1, on 09/01/2021 at 3:29 PM, revealed Resident #14 was unable to do anything for himself/herself. Per interview, Resident #14 did not have anything for his/her hands. The CNA revealed Resident #14's hands were tight, and therapy was responsible for providing range of motion (ROM) exercises, and for placing anything in the resident's hands. Further interview revealed the CNA had access to Resident #14's care plan and was supposed to anticipate the resident's care needs. In addition, she stated if there were any changes in Resident #14's condition, she reported it to the nurse. Continued observations of Resident #14, on 09/01/2021 at 3:33 PM and 09/02/2021 at 8:28 AM, revealed the resident continued to have no visual evidence of his/her palm guard in place as per the care plan interventions. Interview, on 09/02/2021 at 11:33 AM, with Licensed Practical Nurse (LPN) #1 revealed therapy worked with Resident #14's contractures. She stated Resident #14 did not have anything scheduled to be placed on the resident's hand, and she had not seen the resident with a palm guard in his/her hand. However, she stated as the nurse she was responsible for ensuring Resident #14's palm guard was in place. Per interview, she had not seen Resident #14 with a palm guard in place to his/her hands since she had been employed at the facility, which had been about ten (10) months. The LPN stated the Comprehensive Care Plan intervention for the palm guard to the resident's right hand was to protect his/her skin integrity. Further interview revealed if the care plan intervention for the palm guard was not followed, the resident's palm could be cut by the resident's fingernails. Observation during the interview, revealed Resident #14's hands were contracted, and his/her right hand fingers were folded and tightly closed to the palm. Additional observation of Resident #14, on 09/02/2021 at 2:13 PM, revealed no visual evidence of the palm guard in place to his/her right hand as per the care plan interventions. On 09/03/2021 at 8:35 AM, interview with the Therapy Program Director revealed Resident #14's care plan included an intervention for a palm guard. She stated the palm guard was a type of splint which wrapped around the hand and was held in place with a Velcro strap. Per interview, therapy evaluated Resident #14 and made recommendations. The Therapy Director stated therapy turned over care of Resident #14's palm guard to the nursing department when the resident was discharged from therapy on 07/23/2021. Continued interview revealed the resident tolerated four (4) hours of use of the palm guard. She stated the nursing department was responsible to set up the actual schedule of when to use Resident #14's palm guard once the resident had been discharged from therapy. According to the Therapy Director, if Resident #14 was not assisted to wear the palm guard as per the care plan, the resident could experience skin breakdown, risk of infection. She stated Resident #14 could also experience becoming septic and possibly hospitalized if his/her nails were not cut and allowed to pierce the skin on his/her palms. The Therapy Director revealed the Comprehensive Care Plan was to ensure the facility provided good care and prevented hospitalization of a resident. Additionally, the Director stated if Resident #14's care plan interventions were not provided, it could lead to further functional decline in the resident. She stated staff were educated to follow residents' Comprehensive Care Plans and to perform the interventions. An additional observation on 09/03/2021 at 8:59 AM, revealed Resident #14 had no visual evidence the palm guard was in use as per the care plan interventions. Interview with the Director of Health Services (DHS), on 09/03/2021 at 10:56 AM, revealed therapy was responsible for entering the order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, the palm guard noted on Resident #14's Comprehensive Care Plan was also be entered as an order to ensure the intervention was provided. The DHS stated if it was placed as an order it carried over to Resident #14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated however, the Comprehensive Care Plan intervention was not entered in the computer separately. The DHS revealed the purpose of the palm guard care plan intervention for Resident #14 was to maintain his/her skin integrity. Further interview revealed the purpose of Comprehensive Care Plans was to note care an individual resident required and interventions for staff to follow. Per the DHS, if staff did not provide the care Resident #14 required, it could result in the resident experiencing skin breakdown. Interview, on 09/03/2021 at 1:32 PM, with the Area Executive Director (ED) revealed the nurse aide or the nurse was responsible for ensuring Resident #14's palm guard were applied as per the resident's Comprehensive Care Plan interventions. She stated there should be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, the ED revealed the facility had not identified communication issues between therapy services and the nursing department regarding the use of therapeutic devices.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure quality of care for one (1) of nineteen (19) sampled residents, Resident #14, related to use of a palm guard. Observations each day of the survey revealed no palm guard present on the resident per care plan intervention and therapy recommendation. The findings include: Review of the facility policy Splints and Orthotic Devices, undated, revealed orthotic devices were used to support a joint or body part, inhibit abnormal tone, reduce pain, or position the joint in a functional position. Orthotic devices were used for joint range of motion, to reduce pain, reduce effects of disease, and reduce risk for skin breakdown or joint deformity. Review of the Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, dated October 2019, revealed the comprehensive care plan (CP) was an interdisciplinary communication tool that described the services provided to a resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The CP should reflect the care a resident received. Review of the clinical record for Resident #14 revealed the facility readmitted the resident on 04/09/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's comprehensive care plan (CP), dated 07/02/2019, revealed the resident with limited range of motion (ROM) due to contractures and [CONDITION(S)]. Interventions included therapy evaluation and treatment as needed, follow physical therapy (PT)/ occupational therapy (OT) recommendations, and a palm guard to his/her right hand with the nurse aides and nurses responsible for the intervention. Review of an OT Therapist Progress note, dated 03/12/2021, revealed Resident #14's goal was upgraded on 03/12/2021 to tolerate upper extremity splints for six (6) hours with use of a palmer guard to enhance maximum ROM and joint alignment to prevent deformity and pain. The caregiver was educated to put on and take off the palm guards. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #14 as severely cognitively impaired. The resident had impairment with functional ROM in his/her upper extremities. Review of the OT-Therapist Progress and Discharge Summary, dated 07/23/2021, revealed the resident required assistance to put on and remove the splint and the caregiver was educated how to put on and take off the palmer guard splint. Review of the nurse aide care sheet, dated 08/31/2021, revealed Resident #14 had a splint to his/her right upper extremity at all times and may be removed for bathing. Observations of Resident #14, on 08/30/2021 at 6:21 AM, 08/30/2021 at 12:45 PM, 08/31/2021 at 12:05 PM, 08/31/2021 at 2:10 PM, 08/31/2021 at 4:04 PM revealed no palm guard in place and the resident's hand contracted. Continued observations on 09/01/2021 at 8:27 AM, 09/01/2021 at 10:13 AM, 09/01/2021 at 10:54 AM, 09/01/2021 at 1:40 PM, and 09/01/2021 at 2:05 PM, on 09/01/2021 at 3:33 PM revealed the resident's hand contracted and no palm guard in place. Further observations on 09/02/2021 at 8:28 AM, on 09/02/2021 at 2:13 PM, on 09/03/2021 at 8:59 AM revealed his/her hands contracted, and the resident did not have a palm guard in place. Interview, on 09/01/2021 at 3:20 PM, with Certified Nurse Aide (CNA) #1 revealed Resident #14 did not have anything for his/her hands. The CNA stated the resident could not do anything for him/herself and staff had to anticipate the resident's needs. She revealed the resident's hands were tight, and therapy was responsible to provide ROM and put anything in place for the resident's hands. She revealed she had access to the resident's care plan and if there were any changes to the resident, she reported the changes to the nurse. Interview with Licensed Practical Nurse (LPN) #1, on 09/02/2021 at 11:33 AM, revealed therapy worked with Resident #14's contractures. She stated the resident did not have anything scheduled for his/her hand and she had not seen the resident with a palm guard, although as the nurse she was responsible for ensuring the resident had his/her palm guard in place. The nurse revealed she had not seen the resident with a palm guard since she was employed at the facility, about ten (10) months. The LPN stated without the palm guard, the resident's nails could cut his/her palm. Observation during the interview, revealed the Resident #14's hands were contracted with his/her fingers folded closed to the palm. On 09/03/2021 at 8:35 AM, interview with the Therapy Program Director revealed therapy evaluated Resident #14 and then turned over care of the palm guard to the nursing department when therapy discharged the resident on 07/23/2021. She stated the nursing department was responsible to set up the actual schedule when to use the palm guard. She revealed if the resident did not wear the palm guard he/she could have skin breakdown, risk of infection, or if the resident's nails were not cut, the resident could get wounds which could lead to becoming septic and hospitalization . Additionally, the Director stated if the resident did not have the palm guard care provided, he/she could have further functional decline. She revealed staff were educated regarding positioning related to the palm guard. Interview, on 09/03/2021 at 10:56 AM, with the Director of Health Services (DHS) revealed when therapy discharged Resident #14 from therapy services, the therapy department was responsible to enter an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DHS revealed the purpose of the palm guard for Resident #14 was for skin integrity and not providing the care could lead the resident to have skin breakdown. Interview with the Area Executive Director (ED), on 09/03/2021 at 1:32 PM, revealed the nurse aide or the nurse was responsible to apply Resident #14's palm guard. She stated there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ED revealed the facility had not identified communication issues between therapy and nursing related to use of therapeutic devices.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure unused kitchen equipment was removed and disposed of when no longer in use. Observation revealed the outside delivery area of the facility contained six (6) commercial coffee makers/dispensers, two (2) commercial beverage dispensers, an ice chest, a commercial toaster, a countertop microwave, three (3) empty milk crates, a portable gate, a mop and bucket full of liquid, and a wood pallet. The findings include: Review of the facility's policy entitled, Garbage and Refuse, dated 05/31/2016, revealed all garbage and refuse was stored and disposed of daily. Observation, on 09/01/2021 at 8:49 AM, revealed the facility's outside delivery area contained the following: a mop bucket filled with liquid and a mop; six (6) commercial coffee makers/dispensers; two (2) commercial beverage dispensers; three (3) black, empty milk crates; a countertop microwave oven; a blender base; a yellow rolling [MEDICATION(S)] gate; a horizontal ice chest; a commercial toaster with rust on the top; a hose sprayer; and two (2) black rubber mats. Continued observation revealed there were brown leaves and pine cones located in the spaces between all the equipment and in the corners of the area. Further observation revealed a wood pallet with rough edges observed leaning against the exterior wall by the delivery door. An additional observation, on 09/02/2021 at 1:59 PM, revealed the following items still present in the same area: a mop and bucket full of liquid; three (3) empty, black milk crates; six (6) commercial coffee makers/dispensers; two (2) commercial beverage dispensers; a commercial toaster; horizontal ice chest; and wood pallet. Interview, on 09/02/2021 at 2:54 PM, with the Director of Food Services (DFS) revealed most of the kitchen equipment stored outside the delivery door had been there before he started employment at the facility one (1) year and eleven (11) months ago. Per interview, nothing had been added to that area with the rest of the equipment in the last six (6) months. The DFS revealed the facility used the delivery door for the vendors delivering food or other items to the facility. According to the DFS, he was aware the outside area had coffee machines, tea machines, and a cooler stored there. He stated it was not the time of the year or season for brown leaves or pinecones to be there. Further interview revealed it was his understanding the vendors who supplied the equipment, which was stored outside the delivery door, had been contacted to come pick up the equipment. The DFS revealed however, the vendors had not came to pick the unused equipment up and remove it from the facility's premises. He further revealed he was not aware of who the vendors were that needed to come pick the unused equipment up. In addition, the DFS stated the unused equipment left outside could be a potential trip hazard and was an invitation for pests to be located there. Interview on 09/03/2021 at 10:56 AM, with the Director of Health Services (DHS) revealed she was not aware of unused kitchen equipment being stored outside the delivery area until yesterday (09/02/2021). She stated the maintenance department was responsible for the equipment. Per interview, staff in the facility's morning meeting had not previously discussed the unused kitchen equipment stored outside the delivery door. The DHS revealed she was unsure how long the equipment had been stored outside the delivery door. Further interview revealed the equipment left outside the delivery door could be in the way of people making deliveries or in facility staff's way. Interview with the Maintenance Director, on 09/03/2021 at 11:19 AM, revealed the unused kitchen equipment stored outside the delivery door had been there since he began his employment at the facility two (2) years ago. The Maintenance Director revealed he was unsure who was responsible for ensuring the equipment was removed from that area. Per interview, he had been told the previous company which had operated the facility had been contacted prior to his employment regarding removal of the equipment. The Maintenance Director revealed he was unsure if there were any potential issues with the equipment being stored outside the delivery door, as the equipment was stationary and there was a clear path for people to walk through. Interview, on 09/03/2021 at 1:32 PM, with the Area Executive Director (ED) revealed she had noticed the unused kitchen equipment stored outside the delivery door after she started working at the facility. Per interview, the previous facility operator had used different vendors for equipment supplies than the facility currently used. The ED revealed the facility had been waiting for the equipment to be picked up by the previous vendors. Further interview revealed the equipment was visible through the window and was an eyesore. The ED further stated she did not want the facility's residents to see it.

Based on interview, record review, review of the facility-wide assessment, CMS Form 672, and policy review it was determined the facility failed to accurately determine the number of residents in the facility with respiratory diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's assessment found the facility failed to include the residents for the determination of the competent care to meet the needs of the resident population. The findings included: Review of the Facility Assessment Tool, dated 08/18/2017, revealed Long Term Care (LTC) facilities conducted the assessment to document and annually review a facility-wide assessment, which included both their resident population and the resources the facility needed to care for their residents. The purpose included to determine the necessary resources to care for residents competently with day-to-day operations and emergencies. The facility used the assessment to make decisions about scheduling the proper staff to provide the required care for the required residents. The intent of the facility assessment included to evaluate the LTC resident population and identify the resources needed to provide the necessary person-centered care and services. The use of the competency-based approach ensured the focus allowed the facility to provide resident care, which allowed the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The facility did not provide a facility assessment policy or procedure guide. Review of the Resident Census and Condition of Residents Form CMS-672, dated 03/02/2021, revealed under section E, Special Care, the facility included [CONDITION(S)] for three (3) residents. Review of the Facility Matrix, dated 03/02/2021, revealed the facility noted ten (10) residents in the facility who required a closed unit and private rooms to provide transmission based precautions (TBP) with dedicated staff for residents with or under surveillance for COVID-19. Review of the Quality Assurance and Performance Improvement (QAPI) attendance record, dated 01/13/2021, revealed two (2) Directors of Health Services (DHS), two individual (2) Executive Directors (ED), one Assistant DHS, and the Clinical Support Nurse. The Medical Director (MD) area did not include a name. Review of the Facility Assessment, dated 12/01/2020, revealed the facility's QAPI team reviewed the assessment on 01/13/2021. Review of the Assessment revealed the persons involved with review and completion of the assessment included the ED, DHS, and MD. Review of section 1.3, Diseases, Conditions, Physical, and Cognitive Disabilities, of which the facility could accept residents, included respiratory and infectious disease. The facility identified Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, and Asthma. The facility did not identify residents with [CONDITION(S)] or COVID-19. Review of Section 2.1, revealed the facility indicated the ability to care for residents included [CONDITION(S)]. However, the facility marked the numeric percentage as zero (0) percent. Review of Resident #29's clinical record revealed the facility admitted the resident on 02/13/2021 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's clinical record revealed the facility admitted the resident on 04/23/2015 with respiratory failure. Further review revealed Resident #4's Minimum Data Set (MDS) dated [DATE], revealed the facility's assessment included [CONDITION(S)] status. Review of Resident #142's clinical record revealed the facility admitted the resident on 07/30/2014 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #124's MDS, dated [DATE], revealed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility listed the resident's condition as a medically complex for the resident's primary medical condition category. Interview with the MD, on 03/04/2021, at 1:15 PM, revealed the facility accepted residents with [CONDITION(S)] care requirements. He stated the facility required competent staff to care for tracheostomies because of the higher level of risk and the acuity of the resident. He stated the facility housed residents on a closed unit with active COVID-19. The MD stated he did not participate in the development of the facility's assessment, but the facility did review it with him. However, he stated the facility's assessment should include [CONDITION(S)] residents and COVID-19 resident care. Interview with the DNS (Director of Nursing), on 03/04/2021 at 1:20 PM, revealed the facility's assessment reflected the resident population. She stated the facility determined the type of residents to include based on their review of clinical documentation, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the facility assessment for respiratory care should include [CONDITION(S)] and COVID-19. The DNS stated on 01/13/2021, the facility held a QAPI meeting at which time she and the ED reviewed the assessment for accuracy and the review deemed the assessment was accurate. However, she stated the assessment needed to be accurate to show what care the facility could provide competently. She stated the ED's and DHS's responsibility included to ensure the assessment remained accurate. Interview with the ED, on 03/05/2021 at 9:16 AM, revealed the facility's process for completion of the assessment included to gather facts about the facility's population and care capabilities. She stated the facility's QAPI team reviewed the information, then forwarded to the corporate office for review by corporate level staff, who returned the assessment to the facility if revision was necessary. She stated the facility obtained information for the assessment through medical review of the residents and the facility involved the ED, DHS, MD, MDS, and interviews with staff to obtain an accurate assessment. The ED stated the facility did not have a policy for facility assessment and further stated an accurate assessment to ensure care, resources, and staffing needs were met to provide the necessary care of the resident. She stated the ED responsibilities included to ensure an accurate facility assessment reflected the resident population and the assessment needed to be updated.

Based on observation, interview and policy review, it was determined the facility failed to ensure safe, operating conditions of the fryer and freezer in the kitchen. Observation on 03/02/2021 at 8:28 AM, revealed two (2) boxes in close proximity to the ceiling of the walk-in freezer. Observation on 03/03/2021 at 1:35 PM, revealed liquid substance on the floor under fryer and four (4) boxes in the walk in freezer within close proximity to the ceiling. The findings include: Review of the document titled, Emergency Operations Plan, Hazardous Materials or Chemical Spills, undated, revealed hazardous materials included substances which were flammable and combustible. The policy revealed the proper steps for facility staff members during a hazardous materials emergency. Review of the document titled, Fryer, undated, revealed the cleaning process for the fryer which included draining the fryer, using cleaning solution, rinsing the fryer twice after cleansing solution, and replacement of oil after the fryer has dried. Review of the documents titled, Aides Cleaning List, dated December 2020 through March 2021, revealed daily and weekly tasks for work areas, equipment, and cleanliness of the kitchen. Review of the documents titled, Cooks Cleaning List, dated January through March 2021, revealed daily and weekly cleaning schedule with staff initials for sanitation, equipment, and the kitchen environment. The records revealed the cook swept and mopped the kitchen daily. The weekly tasks included changing the oil in the fryer, dated completed on 03/02/2021. Review of the policy titled, Storage Guidelines, undated, revealed the guidelines used for storage of dry goods and food in the refrigerator and freezer. The facility did not provide the requested policy for oil disposal. Observation on 03/02/2021 at 8:28 AM, revealed two (2) boxes in close proximity to the ceiling of the walk-in freezer. Observation on 03/03/2021 at 1:35 PM, revealed liquid substance on the floor under fryer and four (4) boxes in the walk in freezer within close proximity to the ceiling. Interview with the Director of Food Services (DFS), on 03/03/2021 at 1:35 PM, revealed the liquid substance on the floor behind the fryer was either water or oil. He stated he was unaware there was liquid on the floor prior to the identification by the State surveyors. The DFS stated there was no schedule for cleaning under or behind the fryer. He stated staff used a lift or [NAME] to move the stove in order to clean behind it. Upon further interview, the DFS revealed the assisted living DFS assisted him with delivery of food to the walk-in freezer and placed smaller boxes on the top shelf. The DFS stated adding the task to clean behind the fryer would be an important addition to the cleaning schedule. Interview with the assisted living DFS, on 03/02/2021 at 2:00 PM, revealed boxes in the walk-in freezer were to be at least eighteen (18) inches from the ceiling to prevent a fire hazard and ensure the sprinkler system to cover items if triggered. He stated if there was a fryer fire, the oil on the floor would make it difficult to extinguish and it created a fall hazard. The DFS stated the facility did not have an oil disposal policy. Interview with the Cook, on 03/03/2021 at 2:15 PM, revealed she was educated during training regarding the process used to change fryer oil. She stated she changed the oil out yesterday, did not spill the oil, and did not notice any oil on the floor upon completion of the task. The Cook stated she mopped the floor daily and had not noticed oil on the floor. She stated oil on the floor could make the floor slick. Interview with the Chief Engineer, on 03/05/2021 at 9:08 AM, revealed he performed daily rounds throughout the facility that included assessment of the kitchen to check for leaks, proper storage of flammables, and to ensure the sprinkler system was free from obstructions. The Chief Engineer stated he did not have a checklist for the kitchen assessment. He stated boxes stored in close proximity to the ceiling created a fire hazard. The Chief Engineer stated he was not aware of oil under the fryer in the kitchen floor until the DFS notified him during the survey. Interview with the Executive Director (ED), on 03/05/2021 at 9:53 AM, revealed she performed daily rounds to ensure safety of the residents and staff, and to identify possible regulatory violations. She stated she would speak to staff at that moment, follow up later, and/or discuss the issue in the morning meeting. The ED stated an assessment of the issue would reveal if the incident was isolated or systemic, required immediate intervention, and whether staff required further education. The ED stated boxes close to the ceiling could interfere with the effectiveness of the sprinkler system. She stated the facility needed to ensure proper cleaning schedules to address oil under the fryer in the kitchen. The ED stated she had been to the kitchen once in the two (2) weeks of employment at the facility.

Based on interview, record review, and policy review, it was determined the facility failed to maintain accurate documentation of the freezer and refrigerator temperatures for one (1) of one (1) walk in cooler; one (1) of one (1) walk in freezer; and two (2) of two (2) reach in coolers. The findings include:: Review of the facility's policy titled, Storage, and dated 05/31/16, revealed refrigerated storage temperatures will be recorded on the Refrigerator Log at least twice daily and frozen storage temperatures will be recorded on the Freezer Temperature Log at least twice a day. Review of the, Cooler/Freezer Temp Log, dated September 2020 revealed on 09/29/2020 at 9:19 AM, the Temp Log had already been completed in entirety through 09/30/2020. Interview with Cook #18 on 09/29/2020 at 9:22 AM revealed he had documented the temperatures of the coolers, and freezer this morning, 09/29/2020, and he must have just mixed up the dates. Interview with the Dietary Director, on 10/02/2020 at 10:00 AM, revealed his expectation of the Cooks were to monitor and accurately log the refrigerators, and freezer temperatures twice a day. He stated Management reviewed the Temp Log daily. Further interview revealed the purpose of checking the temperatures of the refrigerators and freezer was to ensure the equipment was in working order, and all of the food products were stored within safe temperatures zones. He stated if the refrigerators and freezer were not monitored appropriately the food products could spoil and possible make residents ill.

Based on interview, record review, and policy review, it was determined the facility failed to provide adequate notice of discharge, or specific reasons for discharge from the facility for one (1) of twenty-one (21) sampled residents (Resident #343). Resident #343 was discharged from the facility while the resident was an inpatient in an acute care facility. However, the facility failed to document specific reasons for the resident's discharge. The facility also failed to provide the resident or a family member a written notice of the discharge. The findings include: Review of the facility's policy and procedure titled, Guidelines for Transfer and Discharge, dated 05/03/17, revealed procedures should include for non-emergency transfers or discharges to record the reasons for, the effective date of transfer or discharge, and the location to which the resident is being discharged in the medical record and on a discharge form or a letter. Give a copy of the discharge notice to the resident and his/her legal representative. Provide the resident with a statement of the right to appeal the action to the state agency designated for such appeals, along with the name, address, and phone number of the State Long-term Care Ombudsman. Assist the resident with such appeal, and the Ombudsman, representative, consultations, as desired. The physician should document the medical reasons for transfer or discharge in the medical record, when the reason for transfer or discharge is for any reason other than nonpayment of the stay or the facility ceasing to operate. A copy of the physician's orders [REDACTED]. Record review revealed the facility admitted Resident #343 on 04/15/15. Current [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), signed and dated 10/04/19, revealed the facility assessed Resident #343's Brief Interview of Mental Status (BIMS) as fifteen (15), and determined the resident was interviewable. Continued review of the MDS revealed the facility assessed Resident #343 to require the extensive assistance of two plus (2+) persons with bed mobility, transfers, dressing, and toilet use, and the resident was totally dependent on one (1) person for bathing. Review of the Resident Progress Notes, dated 11/05/19 at 6:49 PM, revealed the results of the resident's urine culture indicated two (2) organism growths. The Physician was notified and orders were received to transfer Resident #343 to a local Emergency Department (ED). Continued review of the Resident Progress Notes dated 11/05/19 at 7:31 PM revealed Resident #343 was transferred to the ED via the Emergency Medical Services (EMS), and the transfer/discharge/bed hold forms were sent with the resident. Review of the Resident Progress Notes, dated 11/05/19 at 11:20 PM, revealed Resident #343 had been admitted to the hospital with [REDACTED]. Continued review of the Resident Progress Notes, dated 11/07/19 at 1:36 PM, revealed Discharge Planning Communication with Resident #343 to inform the resident of the intent of the facility to discharge him/her. Telephonic interview with Physician #12, on 10/01/2020 at 2:52 PM, revealed he did not recall anything about Resident #343. Review of the clinical record revealed no documented evidence by the physician for Resident #343's discharge, or an order for [REDACTED].>Review of the clinical record revealed no documented evidence that a written Notice of Discharge was sent to Resident #343, or the resident's Emergency Contact/Responsible Party (RP). Further review revealed no specific reasons listed as to what resident needs could not be met. Telephonic interview with Resident #343, on 10/01/2020 at 10:08 AM, revealed he/she received a call from a social worker at the facility, who stated, She hated to tell me this, but you are not going to be able to return to the facility. I told her I had only been in the hospital for two (2) days with a UTI. When I asked her why, she told me she did not know why. Further interview revealed with Resident #343 revealed, The Assistant Director of Nursing (ADON) had been with the Social Worker when she called me, so I asked her why as well. She told me the facility could no longer meet my clinical needs, and I asked, what clinical needs? The ADON could not give me an answer. The resident stated that he/she had not received any paperwork or a written notice of discharge. Interview with ADON #13, on 10/02/2020 at 8:13 AM, revealed she did not recall anything about Resident #343, or the resident's discharge from the facility. Review of the Discharge Summary and Recapitulation of Stay, dated and signed on 11/19/19 at 10:56 AM, by Social Worker #10, revealed the reason for discharge was met skilled care goals. Telephonic interview with Social Worker #10, on 10/01/2020 at 10:47 AM, revealed she would not disclose or acknowledge any information about Resident #343's case due to the Social Worker Code of Ethics. Telephonic interview with Resident #343's Emergency Contact/RP, on 09/30/2020 at 2:47 PM, revealed the facility phoned him and stated the facility could no longer meet his family member's needs. However, the facility did not identify the specific needs. He stated he had not received any paperwork in regards to Resident #343's discharge from the facility. Interview with Clinical Support Registered Nurse #8, on 09/30/2020 at 4:02 PM, revealed the Chief Nursing Officer (CNO) assessed Resident #343's care at the time of discharge, and decided the facility could not provide the care the resident needed. However, she was unsure what care the resident needed. Interview with the facility's Administrator- In-Training, on 10/01/2020 at 9:00 AM, revealed the CNO was not available for interview. Interview with the Assistant Vice President of Clinical Quality, on 10/01/2020 at 8:58 AM, on 10/02/2020 at 9:39 AM; and, on 10/02/2020 at 1:56 PM, revealed the facility made some decisions in regards to not being able to meet Resident #343's medical and psychosocial needs. He stated the specific needs the facility could not meet should have been documented in the resident's clinical record. He stated the facility had not given the resident a thirty (30) day notice because it had been determined the facility could not meet the resident's needs. He was unable to state whether or not the physician should have been involved in Resident #343's discharge. Telephonic interview with the previous Executive Director revealed Resident #343 had an unplanned discharge from the facility. He stated the facility could not meet the resident's needs because of staffing challenges at the time and that the resident required a two (2) to three (3) person staff assist with his/her Activities of Daily Living (ADLs). He stated Resident #343 should have received a discharge notice when the facility discharged him/her. Interview with the Interim Executive Director, on 10/02/2020 at 2:58 PM, revealed when a resident was discharged from the facility, a discharge notice had to be given; a copy given to the resident; and, a copy of the notice was kept on file in the resident's Electronic Medical Record (EMR).

Based on observation, interview, record review, and facility policy review it was determined the facility failed to develop and implement the care plan for two (2) of twenty-one (21) sampled residents (Residents #27 and #37). The findings include: 1. Review of the facility's policy Comprehensive Care Plan Guideline, revised 05/22/18, revealed the purpose of the policy was to ensure appropriateness of services that would meet the resident's needs, severity and stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. The policy revealed a comprehensive care plan would be developed within seven (7) days of completion of the admission comprehensive assessment. Care Plan problem areas should identify the relative concerns; goals should be measurable and attainable; and interventions should be reflective of the individual's needs and risk influence as well as the resident's strengths. The policy further revealed pertinent care plan approaches were communicated to the nursing staff, per the assignment sheet or Care Tracker profile dependent on the campus' preference. Review of the clinical record revealed the facility admitted Resident #27 on 12/24/18 with [DIAGNOSES REDACTED]. Review of the Care Plan, revised 09/29/2020, revealed the plan stated the resident would safely wander around the facility and remain safe from any harm. Review of interventions revealed the resident would wear a wander guard device and nursing staff would collaborate with each other to help monitor the resident. Observation, on 09/29/2020 at 9:14 AM, revealed Resident #27 seated on the side of the bed. Further observation and interview with Licensed Practical Nurse (LPN) #2 revealed a wander guard bracelet should be attached to the resident's wheelchair; however, she could not locate a bracelet on the wheelchair or the resident. Observation, on 09/29/2020 at 12:25 PM, revealed Resident #27 exited the restorative dining room unsupervised and propelled to the opposite end of the South Hall. Further observation, on 09/29/20 at 12:29 PM, revealed the resident propelled back down the South Hall towards the dining room. Interview with Certified Nursing Assistant (CNA) #3, on 10/01/2020 at 2:01 PM, revealed it was important to supervise residents to ensure their safety. He further revealed the purpose of the wander guard bracelet was to protect a resident from elopement. Interview with Licensed Practical Nurse (LPN) #3, on 10/01/2020 at 2:57 PM, revealed care plans were individualized to include interventions to meet a resident's preferences and care needs. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 10:25 AM, revealed the care plan was a systematic intervention to meet a resident's needs. She stated Resident #27's care plan was not implemented if the interventions were not followed. Interview with the Minimum Data Set (MDS) Coordinator, on 10/02/2020 at 3:07 PM, revealed care plans were resident centered to address any issues and ensure interventions were in place to prevent potential harm. She stated the interdisciplinary team (IDT) reviewed progress notes, new orders, falls, and behaviors during the daily clinical care meeting (CCM) and she revised the care plan as needed. The MDS Coordinator revealed Resident #27 exhibited behaviors, including crying and wandering. Interview with the Interim Director of Health Services (DHS), on 10/02/2020 at 1:17 PM, revealed the MDS Coordinator or Social Services Director (SSD) was responsible for developing care plans to ensure interventions were individualized to resident care needs. She stated the IDT reviewed clinical records in the daily CCM and revised care plans as needed. The DHS revealed she was not aware of any issues related to care plan development or implementation. Interview with the Interim Executive Director (ED), on 10/02/2020 at 4:31 PM, revealed staff should follow and update care plans as needed to provide for residents' psychosocial, emotional, and physical needs. The ED revealed the goal of the facility was to make the care plan individualized and least intrusive as possible. He further stated the facility tried to find creative ways to provide a safe environment for certain residents. The ED stated he was not aware of any concerns related to care plans. 2. Review of the facility's policy, CCP guideline, revised 05/22/18, revealed CCPs were to remain accurate, current, and updated. The facility was to ensure the approach met the resident care needs to meet the resident's level of condition, impairment, disability, or disease according to Federal and State guidelines. Review of the clinical record revealed the facility admitted Resident #37 on 04/23/15 with the [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident with severe cognition, total dependence with two (2) staff for all activities of daily living (ADL) needs including transfers and mobility. Further review revealed the resident had a [MEDICAL CONDITION]. Review of the facility's resident posted information, undated, revealed Resident #37 liked listening to music; liked being outdoors when the weather allowed; and, liked going to the activity room at 1:00 PM on Monday, Wednesday, and Friday for Mindful Moments. Review of the CCP, reviewed 09/22/2020, revealed the care plan for Resident #37 included Activities, which included to seat resident with younger residents, outdoors when the weather allowed, coordination of care with staff on attendance of activity, provide 1:1 as needed, and provide transport to activity. Further interventions included to attend music, spiritual, outdoor activity, social special events, animal, and sensory activity. Staff responsibilities included the transfer of the resident into the wheelchair on Monday, Wednesday, and Friday, and take to activities. The ADL care focus included interventions for transfers included the use of the specialty chair as ordered, and mechanical lift with total assist for all transfers. Review of the Resident First Meeting notes, dated 03/06/2020 at 10:09 AM, revealed a goal included to have staff dress the resident and transfer to the wheelchair at least every Monday, Wednesday, and Friday to socialize, and watch television (TV). Record review revealed on 06/12/2020, the TV required appropriate placement in order to allow the resident to watch TV. Further review revealed, on 09/17/2020, the facility removed the resident from isolation, but they had not changed the position of the TV. Observations, on Tuesday, 09/29/2020 at 9:40 AM and 3:30 PM; on Wednesday, 09/30/2020 at 8:43 AM, 10:40 AM, 12: 14 PM, 2:00 PM, AND 3:35 PM; on Thursday, 10/01/2020 at 10:59 AM, and 2:30 PM; and, on Friday, 10/02/2020 at 9:30 AM and 2:35 PM revealed Resident #37 in bed, staff did not have the TV or radio on for activities or stimulation, and the resident was not transferred into the wheelchair. Review of Physician Summary Orders revealed the physician ordered for Resident #37, [MEDICAL CONDITION] (trach) care every shift, change humidifier water three (3) times a week with distilled water, oxygen saturation level check weekly while off oxygen, number four (4) SHILEY 4 (type [MEDICAL CONDITION]) change monthly and PRN; change the inner cannula daily; change dressing [MEDICAL CONDITION]; oxygen at three (3) liters per minute per collar;[MEDICAL CONDITION] as needed and after breathing treatment; and, oxygen monitoring per respiratory contracted orders. Continued review of the CCP for Resident #37 revealed the facility did not develop a focus care plan for the presence of the resident's [MEDICAL CONDITION]. Interview with Certified Nursing Aide (CNA) #3, on 10/02/2020 at 3:03 PM, revealed care plans explained the care required for each resident. He stated the care plan should be specific to the resident and the tasks necessary to care for the resident came from the care plan. CNA #3 stated the facility expected staff to follow the care plan. He stated the resident could decline if the care plan did not address the resident needs or staff did not follow. In addition he stated staff did not implement the care plan because the resident remained in bed, was not engaged in activity, and staff did not initiate activity in the room with music or TV. Interview with Licensed Practical Nurse (LPN) #3, on 10/02/2020 at 2:39 PM, revealed staffs' responsibilities included to follow resident care plans daily. She stated this ensured residents remained safe with the interventions specific for the resident. She stated when staff did not follow care plans ,the resident may become depressed or decline. LPN #3 stated the facility initiated a CCP upon a resident's admission and the MDS staff ensured the care plan interventions reflected the resident's care needs. She stated residents may suffer if staff did not follow the care plan or the interventions did not reflect specific care interventions for the resident. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 2:35 PM, revealed the facility prepared care plans with admissions and upon review and all resident care plans required specific interventions to meet the care needs of the residents. RN #1 stated the facility expected staff to follow the care plan at all times. She further stated staff did not initiate sensory activities and the resident remained in bed, therefore staff did not implement the resident's care plan. Interview with MDS Coordinator, on 10/02/2020 at 3:08 PM, revealed she obtained a resident's information to develop and revise the resident's CCP through observation, interview of staff and residents, review of orders, new treatments and review of clinical data. She stated the CCP focused on interventions to prevent harm and to implement care which spelled out the care the resident required to meet their goal. The MDS Coordinator stated residents with trachs required interventions specific to the resident because not every resident with [MEDICAL CONDITION] the same. She stated upon review, the CCP needed to provide specific interventions, such as emergency supplies, and the size of [MEDICAL CONDITION] to use which would provide the individuated components for each resident. She stated the facility expected staff to follow residents' care plans for ADL care and all the components required specific indicators for each resident. She stated the care plan provided directions for resident care to maintain physical, mental, and emotional health for dependent residents and if care needs were not specific and not implemented the resident may require hospitalization or die. Interview with the Director of Health Services (DHS), on 10/02/2020 at 4:06 PM, revealed she expected staff to provide the care plan interventions to ensure cognitive impaired residents received the appropriate care, services, and staff were to help provide activities. She stated the facility provided individualized care plans to meet each individual need for safe care. Further interview revealed she had not initiated care plan audits but, she expected staff to follow the care plan and MDS Coordinator should ensure the care plan reflected the resident's individual care needs. She stated residents could decline when care plans were not followed. Interview with the Executive Director, on 10/02/20 at 4:36 PM, revealed he ensured staff met the resident care needs with monthly review by the department supervisor. He stated he expected staff to follow resident care guides and orders to meet the needs of the resident. He further stated his responsibilities included to ensure staff provided the care ordered.

Based on observation, interview, record review, and facility policy it was determined the facility failed to provide Activity of Daily Living (ADL) transfers for dependent residents for one (1) of two (2) bedfast residents of a total resident sample of twenty-one (21) (Resident #37). Observations revealed the resident remained in bed during times ordered by the physician to be out of bed. The findings include: The facility did not provide an ADL policy or a policy for transfers upon request. Review of the clinical record revealed the facility admitted Resident #37, on 04/23/15 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with severe cognition, total dependence for transfers and bed mobility with two (2) person assist, impaired functional range of motion to both sides of the arms and legs, and used a wheelchair. Review of the Physician Order's, dated September 2020, revealed an order for [REDACTED]. Observation, on Tuesday, 09/29/2020 at 2:39 PM; Wednesday, 09/30/2020 at 2:00 PM, 2:50 PM, and 3:40 PM; Thursday, 10/01/2020 at 3:01 PM, and on Friday, 10/02/2020 at 2:35 PM, revealed Resident #37 in bed in his/her room. Review of the Progress Notes, dated 03/04/2020 at 2:45 PM, revealed the care plan meeting note included discussion of the resident's goal to have staff dress the resident, and transfer him/her to the wheelchair at least every Monday, Wednesday, and Friday. Interview with Certified Nursing Aide (CNA) #3 on, 10/02/2020 at 3:03 PM, revealed Resident #37 required a mechanical lift with two (2) staff to transfer into the wheelchair and the resident was dependent for all required ADL care. He stated he could not think of a reason why the resident could not be out of bed daily. CNA #3 stated staff used to get him/her up for activities, but this had not occurred for several months. He stated the transfer to the wheelchair provided pressure relief to areas affected while in bed, allowed for a change of scenery; and, getting out of the bed was good for the resident's emotional wellbeing. CNA #3 stated his care task listed getting the resident up once a week. Additionally, CNA #3 stated he had not transferred the resident to the wheel chair today. Review of CNA Task List, dated 09/28/2020, revealed Resident #37's documented ADL care needs included nothing by mouth, check and change, elbow brace, heel protectors, turn every two (2) hours, and a mechanical lift for transfer. The CNA tasks did not include when to transfer the resident into the wheelchair. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 2:35 PM, revealed Resident #37's care included physician orders [REDACTED]. She stated the resident's care included to be up a couple times a week. Continued interview revealed the resident required a transfer to another surface for socialization, relief from pressure points in bed, respiratory status, and it was good for the residents to be out of bed. RN #1 stated being in bed all the time could cause depression and change of skin status. She stated staffs' responsibilities included to follow physician orders [REDACTED]. She stated staff did not follow physician orders [REDACTED]. Interview with the MDS Coordinator, on 10/02/2020 at 3:08 PM, revealed residents who were dependent on all ADL care needs required staff to complete the related task. She stated when residents required full assist with transfers, the facility's expectations of staff included to transfer the resident as ordered. She stated the importance of staff to follow the order to transfer a resident from one area to another included prevention of skin breakdown, to move the resident to a different location for social and emotional care, and to ensure the staff completed the order. She stated when dependent residents' care plans were not followed the resident may end up in the hospital. She stated the facility assessed the resident as dependent with two (2) staff required for transfer by a lift. She stated staffs' expectations included to transfer the resident when the physician or family requested. Interview with the Nurse Executive, on 10/02/2020 at 4:06 PM, revealed when she cared for Resident #37 the resident's care included transfer to the wheelchair for activity. She stated the transfer to the wheelchair helped Resident #37 decrease the risk of skin integrity issues, changed his/her venue, and provided activity for the resident. She stated she audited resident care, how staff followed care plans or orders, with walking rounds, and she had not identified issues with Resident #37's care. She stated she expected staff to transfer the resident into the wheelchair as ordered. Interview with the Executive Director, on 10/02/2020 at 4:36 PM, revealed he ensured staff met the resident care needs with monthly reviews conducted by the Department Supervisor. He stated he expected staff to follow resident care guides and orders to meet the needs of the resident, which included transfer of the resident. He further stated his responsibilities included to ensure staff provided the care ordered.

Based on observation, interview, record review, and facility policy, it was determined the facility failed to ensure individualized activities were implemented for one (1) of twenty-one (21) sampled residents (Resident #37). Observations revealed signage in Resident #37's room that stated he/she enjoyed music. However, the resident's environment was silence. The findings include: Review of the facility's policy, Individual Program Planning, dated 06/02/16, revealed programs were provided to residents who were not able to attend group programs. The program included interventions to meet the resident's social, emotional, physical, and cognitive functioning needs and ensured the resident had consistent recreation opportunities. Review of the clinical record revealed the facility admitted Resident #37, on 04/23/15 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with severe cognition impairment, extended or total dependent care needs, required oxygen seven (7) days a week, and received treatment for [REDACTED]. Review of the facility's resident posted information, undated, revealed the resident liked listening to music; liked being outdoors when the weather allowed; and, liked going to the activity room at 1:00 PM on Monday, Wednesday, and Friday for Mindful Moments. Review of the Resident First Meeting notes, dated 03/06/2020 at 10:09 AM, revealed the notes included to dress the resident daily, socialize, and watch television (TV). On 6/12/2020, the facility notes for the meeting included concern over the location of the TV in regard to the resident's bed because the resident could not see the TV. Observations, on Tuesday, 09/29/2020 at 9:40 AM and 3:30 PM; on Wednesday, 09/30/2020 at 8:43 AM, 10:40 AM, 12: 14 PM, 2:00 PM, and 3:35 PM; on Thursday, 10/01/2020 at 10:59 AM, and 2:30 P; and, on Friday, 10/02/2020 at 9:30 AM and 2:35 PM revealed Resident #37 in bed and the TV and radio were turned off. Review of Progress Note, dated 09/17/2020 at 2:39 PM, revealed the resident was off isolation, and the facility's maintenance staff needed to change the TV placement. Interview with Certified Nursing Aide (CNA) #3, on 10/02/2020 3:03 PM, revealed Resident #37 liked music and to watch TV. He stated staffs' responsibilities included to turn on the TV or radio to provide stimulation, and to ensure the resident did not feel alone. CNA #3 stated this should be done daily and turned off later in the evening, which would give Resident #37 a sense of day and night. He further stated the CNA's task card did not specify to turn on the TV or music. However, CNA #3 stated all staff should be mindful and ensure either the TV or radio was on during the day. He stated the activity personnel could not be in the resident's room all the time so it was up to the staff to initiate the activity. CNA #3 stated without stimulation the resident could become depressed. Review of the CNA Task List, dated 09/28/2020, revealed Resident #37 documented care needs included nothing by mouth, [MEDICAL CONDITION] (trach mask), perimeter mattress, elbow brace, heel protectors, and turn every two (2) hours. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 2:35 PM, revealed Resident #37's care included for staff to stimulate and socialize the resident. She stated the resident had access to a TV to watch and listen; and, a radio for music for his/her enjoyment. She further stated staff were expected to ensure the resident was stimulated and not in an isolated environment. RN #1 stated lying in a quiet environment listening to himself/herself breathe would make anyone depressed. Interview with the Life Enrichment Director (LED), on 10/02/2020 at 3:47 PM, revealed activities for cognitive impaired residents included sensory stimulation of music, smells, and sensory bins. The LED stated Resident #37 had a smart TV to ensure staff used the unit for music as well for TV shows and movies. He stated staff were expected to turn on the radio and TV daily to ensure the resident was stimulated and felt involved. The LED further stated the reason activities were included with resident care was to enrich the resident's life, wellbeing and provide personal contact with interests. He further stated if the resident did not have the TV or music on in the room the resident could become sensory deprived. Interview with the Nurse Executive, on 10/02/2020 at 4:06 PM, revealed resident activity information was located on the resident's wall by the door. She stated staff were to implement the activity or care listed and she expected staff to use the information to provide stimulation to prevent isolation. The Nurse Executive stated without stimulation the resident could become depressed and may further impair the resident. Interview with the Executive Director, on 10/02/2020 at 4:36 PM, revealed he expected staff to follow the activity plan for the residents when residents were unable to attend activities, when possible. He stated the activity provided to the resident helped to meet the psychosocial needs for the resident.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to supervise and ensure placement of a wander guard bracelet for one (1) of two (2) sampled residents (Resident #27), at risk for elopement, of a total resident sample of twenty-one (21). The findings include: Review of the facility's policy Elopement Risk Assessment and Prevention, revised 05/01/17, revealed the policies assisted to define the mechanisms and procedures for monitoring and managing residents at risk for elopement and help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision. Wandering referred to a cognitively-impaired resident's ability to move about inside the facility aimlessly and without an appreciation of personal safety needs and who may enter into a dangerous situation. Further review of the policy revealed facilities with wander alert detection systems should place a wander alert bracelet on the resident. Activity programs should include plans for diversion and redirection during periods of increased wandering and exit seeking. Review of the facility's policy General Safety Practices, undated, revealed it was the policy of the facility to promote safety first when performing maintenance tasks. Review of the clinical record revealed the facility admitted Resident #27 on 12/24/18 with [DIAGNOSES REDACTED]. Observation on 09/29/2020 at 9:10 AM revealed Resident #27 beating on the North Hall exit door, pushed the handle until the door alarmed, and asked to open the door. Interview with Licensed Practical Nurse (LPN) #2, during the observation, revealed Resident #27 was an elopement risk and occasionally went to the doors and tried to get out. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #27 exhibited the behavior of wandering. Review of the Quarterly Elopement Risk Review, dated 06/11/2020, revealed Resident #27 had a history of [REDACTED]. Approaches to prevent elopement included observing for elopement attempts. Review of the clinical record revealed a physician's orders [REDACTED]. The order stated the bracelet was located on the right back bottom of the wheelchair. Observation, on 09/29/2020 at 9:14 AM, revealed Resident #27 seated on the side of the bed with a wheelchair at bedside. Further observation and interview with LPN #2 revealed a wander guard bracelet should be attached to the resident's wheelchair; however, she could not locate a bracelet on the wheelchair or the resident. Observation, on 09/29/2020 at 12:25 PM, revealed Resident #27 exited the restorative dining room unsupervised and propelled to an office at the end of the South Hall. Further observation, on 09/29/2020 at 12:29 PM, revealed the resident propelled back down the South Hall in the direction of the dining room. Observation of Resident #27, on 09/30/2020 at 2:35 PM, revealed the resident propelled to an exit door at the end of the North Hall and pushed on the handle to exit. Observation of the South Hall, on 10/01/2020 at 2:32 PM, revealed an unsecured utility closet located across from the beauty shop containing two (2) breaker boxes and a transformer. Further observation revealed an unsecured utility closet adjacent to room [ROOM NUMBER] which contained a fire alarm system panel. Interview with the Chief Engineer, on 10/01/2020 at 4:03 PM, revealed he accidentally left the utility room doors unsecured. He stated the rooms should be secured to prevent access to residents. Interview with Certified Nursing Assistant (CNA) #3, on 10/01/2020 at 2:01 PM, revealed it was important to supervise residents at risk of elopement because they could potentially fall or leave the building. He further revealed the purpose of the wander guard bracelet was to protect a resident from elopement. Interview with the Certified Medication Technician (CMT), on 10/02/2020, at 10:03 AM, revealed staff kept an eye on Resident #27 because he/she wandered around the building. The CMT stated she supervised the resident by checking on him/her every 15 or 20 minutes. Interview with Licensed Practical Nurse (LPN) #3, on 10/01/2020 at 2:57 PM, revealed nursing staff was responsible for verifying placement/function of wander guard bracelets. She stated it was important to verify placement because a resident could potentially elope and be injured. The LPN stated it took a village to keep an eye on Resident #27 because he/she roamed the building. Interview with Registered Nurse (RN) #1, on 10/02/2020 at 10:25 AM, revealed staff kept a close eye on Resident #27 because he/she was a wanderer. RN #1 stated it was not okay for the resident to be unsupervised on the South Hall because he/she could easily follow someone who did not know him/her out of the building. Interview with the Interim Director of Health Services (DHS), on 10/02/2020 at 1:17 PM, revealed all staff were responsible for room rounds and supervision of residents to ensure their safety. She stated she was not aware of any issues related to the wander guard bracelets or supervision of residents. Interview with the Interim Executive Director (ED), on 10/02/2020 at 4:31 PM, revealed staff were expected to check on residents every two (2) hours. Further interview revealed the level of supervision would depend upon the resident's needs. The Director stated he was not aware of any issues related to wander guard bracelets, supervision of residents, or unsecured utility rooms. The ED revealed the ultimate goal of the facility was resident safety.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to provide [MEDICAL CONDITION] care and services for one (1) of two (2) sampled residents (Resident #37) with [MEDICAL CONDITION] (trach) care needs, of a total resident sample of twenty-one (21). Observations revealed the facility did not have an AMBU (Artificial Manual Breathing Unit) at the resident's bedside. The findings include: Review of the facility's policy, [MEDICAL CONDITION] Care, revised 05/11/16, revealed the staff were to return the oxygen delivery device to the [MEDICAL CONDITION] (trach) after each portion of [MEDICAL CONDITION] session which required access to the device. Staff were to educate and prepare the resident for the care to be provided. Review of LinCare [MEDICAL CONDITION] Care, undated, included to educate and explain the procedure to the resident, suction the airway per the facility artificial airway procedure, and maintain a resuscitative bag for immediate use. The facility did not provide policies for emergency care, assessment of a resident with a trach, [MEDICAL CONDITION] procedures. Review of Lippincott Nursing [MEDICAL CONDITION] Care, dated 10/2018, revealed an artificial manual resuscitation bag at the resident's bedside for immediate use, as part of the listed equipment to be at the bedside at all times. Suctioning of the resident included to ensure correct suction depth to prevent trauma, insert slowly, remove the catheter slowly with the suction activated, and less than ten (10) seconds for the total procedure. Review of the clinical record revealed the facility admitted Resident #37, on 04/23/15 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with severe cognitive impairment, extended or total dependent care needs, required oxygen seven (7) days a week, and received treatment for [REDACTED]. Observation, on 09/29/2020 at 2:39 PM; 09/30/2020 at 8:49 AM; 10/01/20 3:01 PM and, 10/02/20 at 10:02 AM, revealed the facility did not have a AMBU bag in or at the bedside of Resident #37's room. Interview with Licensed Practical Nurse (LPN) #2, on 09/30/2020 at 8:49 AM, revealed she could not locate an AMBU in Resident #37's room. She stated the room previously had one at the bedside and the other resident in the room, who also had a trach, had an AMBU at his/her bedside. She stated she did not know if a resident with [MEDICAL CONDITION] an AMBU at the bedside at all times. However, LPN #2 stated staff used the AMBU to give resident air and provide respiratory support when indicated. Interview with Registered Nurse (RN) #1, on 10/02/2010 at 2:35 PM, revealed staff interactions with Resident #37 included to talk to the resident to ensure he/she felt as a part of the care process and that he/she mattered. She stated she observed Resident #37's room to be without an AMBU bag. She stated the resident should have an AMBU at the bedside. RN #1 stated if the resident's oxygen went low and equipment was not immediately available, then the resident might not recover. Interview with the Nurse Executive (NE), on 09/30/2020 at 9:05 AM, revealed the facility did not follow standards of care from Lippincott Nursing Care, which the Nurse Executive cited was used as the facility's procedures for their standard of care. In addition, the NE stated education provided by the contracted respiratory company included an AMBU for immediate use at the residents' bedsides. Interview with the Executive Director, on 10/02/2020 at 4:36 PM, revealed observations [MEDICAL CONDITION] was done by the NE. He stated the observations were reviewed monthly by the head of the department and this ensured residents care and services were met. He further stated he did not receive any reported care issues for resident with [MEDICAL CONDITION] care needs.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to provide training and ensure competent nursing staff for the provision of [MEDICAL CONDITION] care and emergency interventions for two (2) of twenty-one (21) sampled residents (Residents #36 and #37). The findings include: 1. Review of the Lippincott Nursing [MEDICAL CONDITION] Care, dated 10/2018, revealed suctioning of a [MEDICAL CONDITION] (trach) included to ensure correct suction depth to prevent trauma, to insert catheter slowly, and remove slowly with suction activated while using less than ten (10) seconds for the total procedure. Furthermore, the oxygen mask was to be replaced to the [MEDICAL CONDITION] at all times except when care required access to the stoma or when [MEDICAL CONDITION] removed. The resident was to be monitored to ensure oxygen levels were maintained, not in distress, and that emergency supplies were available to treat the resident. Review of the LinCare [MEDICAL CONDITION] Care, undated, revealed staff were to monitor the resident during the procedure, assess the respiratory status before and after the session, to suction the airway per the artificial airway procedure, and maintain a resuscitative bag for immediate use. The facility did not provide policies for emergency care, assessment of a resident with of a trach, [MEDICAL CONDITION] procedures. Review of the clinical record revealed the facility admitted Resident #37, on 04/23/15, with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with oxygen requirements seven (7) days a week. Observation, on 10/01/2020 at 11:00 AM, revealed Licensed Practical Nurse (LPN) #2 set up a sterile tray [MEDICAL CONDITION] and suctioning with her back to the resident and table in front of her. The LPN reached over the sterile field several times to obtain supplies on the dresser. The LPN was observed providing care with her body turned away from the resident and rotated her upper body back and forth to provide care. The LPN removed the [MEDICAL CONDITION] and pinned it to the side of the bed. Continued observations revealed with one (1) hand, the LPN repeatedly pulled the gauze dressing placed under [MEDICAL CONDITION] she twisted around to the resident, and dislodged [MEDICAL CONDITION] the edge of the stoma. LPN #2 did not reach in and clean the edges of the stoma, instead swiped around the edge of the face plate. The LPN did not inform the resident, proceeded to push the suction catheter into the resident'[MEDICAL CONDITION], the resident gagged and began a long episode of coughing. Further observation revealed the resident turned a deep red to purple color while his/her tongue protruded. The LPN did not replace the oxygen mask to the resident, did not attempt to sooth the resident at this time and resumed one (1) other suction episode in the same manner. LPN #2 removed one side of [MEDICAL CONDITION], did not hold the face plate, and [MEDICAL CONDITION] to the tip of the stoma. The LPN did not monitor the resident's oxygen level throughout the procedure and did not complete a respiratory assessment after the procedure. Interview with LPN #2, on 10/01/2020 at 11:30 AM, revealed she provided care and treatment for [REDACTED]. She stated she attended an in-service education provided by the respiratory service provider [MEDICAL CONDITION]. LPN #2 stated Resident #37 did not appear distressed with the procedure and she did not self-identify concerns for the provided care with the exception of not ensuring [MEDICAL CONDITION] was held down. The LPN stated she had access to a pulse oximeter. She stated she did know the facility's policy [MEDICAL CONDITION] and services. 2. Review of the facility's policy, [MEDICAL CONDITION] Change, revised 05/11/16, revealed the resident should be assessed for the following indications that the [MEDICAL CONDITION] change was needed: abnormal breath sounds, reduced airflow through the tube, and/or respiratory distress,[MEDICAL CONDITION] out. Explain the procedure to the resident; perform hand washing and put on gloves; put on a mask and protective eyewear as indicated. Assist the resident to Fowler's or semi-Fowlers position; and hyperextend the neck by putting a pillow under the shoulders (if resident can tolerate). Check the cuff on the [MEDICAL CONDITION] inserting air with syringe, to make sure it inflates, and listen for air leaks. Then deflate cuff entirely. Undo [MEDICAL CONDITION], holding on to trach; remove [MEDICAL CONDITION]; insert the [MEDICAL CONDITION] immediately as the patient is inhaling; remove obturator immediately while holding the tube in place with your fingers; insert the inner cannula ([MEDICAL CONDITION] has one); inflate the cuff with syringe; [MEDICAL CONDITION]; and suction as needed. Apply split sponge dressing; assess lung sounds; discard supplies in appropriate receptacles and wash hands. Document the size [MEDICAL CONDITION], color and amount of secretions, resident's response to procedure, and any abnormalities noted, if any. Review of the clinical record revealed the facility readmitted Resident #36 on 12/13/19 with [DIAGNOSES REDACTED]. Further review of the clinical record revealed a physician's orders [REDACTED].#5 Shiley (type of cannula) [MEDICAL CONDITION] with obturator to be kept at bedside - taped to wall in a bag at all times for emergency replacement purposes as needed for [MEDICAL CONDITION] dislodgement. Interview with Licensed Practical Nurse (LPN) #2, on 09/29/2020 at 2:26 PM, revealed the facility's respiratory provider changed [MEDICAL CONDITION] every 30 days. Interview with Registered Nurse (RN) #1, on 09/30/2020 at 9:00 AM, revealed in the event of an accidental decannulation she would ensure the stoma was patent, check the resident's oxygen saturation, and insert a [MEDICAL CONDITION] in the stoma; however, she could not describe the procedure for insertion of the tube or use of the obturator. The nurse revealed she was new to the facility and was not trained on accidental decannulation. Review of the Respiratory Services Inservice, dated 02/13/2020, revealed RN #1 did not attend the training. Further review of the training material revealed no content related to accidental decannulation. Interview with the Interim Director of Health Services (DHS), on 10/02/2020 at 1:17 PM, revealed the facility trained staff upon hire, to include skills competency. She stated the facility and the respiratory services provider trained and assessed staff for competency of [MEDICAL CONDITION] care and skill(s) in February. However, RN #1 was hired in March and missed the inservice. She stated she had no concerns with the care RN #1 provided and stated there were resources and other staff available in the event of an emergency. Interview with the Interim Executive Director (ED), on 10/02/2020 at 4:31 PM, revealed he was not aware of any concerns related to staff education/competency.

Based on observation, interview, and facility policy review it was determined the facility failed to implement an effective infection control program related to hand hygiene (HH), unlabeled personal hygiene products, and storage of clean linens in one (1) of one (1) shower room on the North Hall. In addition, the facility failed to implement an effective infection control program to prevent the spread of bacteria and communicable diseases, which includes COVID-19 infection control guidelines in relation to maintain clean equipment used for multiple residents and HH. Observations revealed staff did not wash hands after contact with residents, and failed to sanitize the equipment used to obtain vital signs, and the pulse oximeter. The findings include: 1. Review of the facility's policy Infection Prevention and Control Program (IPCP), revised 11/10/17, revealed the purpose of the policy was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy revealed the campus shall designate a member of the clinical team to monitor the campus IPCP program to perform surveillance to identify, investigate, control, and prevent the spread of infection and reporting for the IPCP. The policy revealed designee responsibilities included monitoring compliance with infection control practices and procedures; and ensuring timely infection control education and training at orientation, regularly scheduled in-services, and as needed in response to identified problems. Review of the facility's policy Guideline for Handwashing/Hand Hygiene, revised 03/12/2020, revealed handwashing was the single most important factor in preventing transmission of infections. The policy stated HH was a general term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Health Care Workers shall use HH at times such as: reporting to work; before/after eating; after smoking, toileting, blowing nose, coughing, sneezing, etc; before/after preparing/serving meals, drinks, tube feedings, etc; before/after having direct physical contact with residents; and after removing gloves, worn per Standard precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc. Review of the facility's policy, Medication Administration-General Guidelines, revised 1/17, revealed when administering medications staff washed or sanitized their hands at the beginning of the medication pass, prior to handing medications, after contact with the resident. Review of Centers for Disease Control and Prevention (CDC), and the COVID-19 Standard Infection Control Practices, 2019, revealed standard infection control practices to decrease the transfer of the COVID-19 virus included to clean and disinfect equipment used between residents with an approved agent for [MEDICAL CONDITION] pathogens prior to use on another resident Observation of the North Hall Shower Room, on 09/29/2020 at 9:53 AM, revealed a stack of clean towels/washcloths stored in a handwashing sink and a white uniform jacket lying on top of the linens. There were soiled towels on top of the trash can and a soiled washcloth on the floor. Further observation revealed the following opened, unlabeled personal hygiene items stored on top of a heating unit: one (1) 30 oz. bottle of hair conditioner, two (2) 1.5 oz. cans of shaving cream, one (1) 700 ml bottle of hair conditioner, one (1) 8 oz. bottle of shampoo and body wash, one (1) 21 oz. bottle of lotion, one (1) 2.6 oz. tube of deodorant, one (1) 13 oz. bottle shea moisture conditioner, one (1) 16.8 oz. bottle of lotion, one (1) 16 oz. bottle of lotion, one (1) bottle of cocoa butter lotion. Further observation of the shower room revealed one (1) 3 oz. bottle of antifungal body powder, one (1) 5.6 oz. tube of protective ointment, and one (1) 3.4 oz. tube of deodorant stored on a shelf. In addition, there was one (1) unlabeled tube of protective ointment on top of the toilet tank and two (2) unlabeled brushes containing hair on the sink. Interview with the Certified Medication Technician (CMT) Preceptor during observation revealed personal hygiene items should not be shared and should be labeled with the resident's name/room number. She further revealed clean linens should not be stored in the handwashing sink due to infection control issues. The CMT stated sharing personal hygiene items and improper storage of clean linens could spread germs. Observation of Registered Nurse (RN) #1, on 09/30/2020 at 8:34 AM, revealed the nurse entered room [ROOM NUMBER] and assisted a resident with his/her sweater. The RN failed to perform HH, exited the room, and walked to the nurses' station. The nurse collected papers at the nurses' station, pulled a cell phone from her pocket, made a phone call, and placed the phone back in her pocket. She used the computer at the desk, left the nurses' station, failed to perform HH, entered room [ROOM NUMBER], and closed the door. Observation of Restorative Dining, on 09/29/2020 at 11:57 AM, revealed the CMT pushed Resident #27's wheelchair to the dining room, failed to perform HH, removed clothing protectors from a storage cabinet, and passed them out to seven (7) residents. The CMT placed a clothing protector on Resident #21, failed to perform HH, removed Resident #39's facemask, and performed HH. Further observation of dining revealed the CMT placed a clothing protector on a resident, removed his/her facemask, failed to perform HH, and passed out silverware/napkins to resident tables. Interview with Certified Nursing Assistant (CNA) #3, on 10/01/2020 at 2:01 PM, revealed personal hygiene items should be labeled with the resident's name and stored in their room. However, staff forgot to return them to the resident's room once in a while. He stated personal hygiene items should not be shared because it was an infection control issue. Further interview with CNA #3, on 10/01/2020 at 2:49 PM, revealed HH should be performed before/after leaving a resident's room, before and after contact with a resident, and between each tray during tray pass. He stated it was important to perform HH to prevent the spread of germs and infection. Interview with Licensed Practical Nurse (LPN) #3, on 10/01/2020 at 2:57 PM, revealed staff should perform HH before/after resident care, after touching anything dirty or soiled, and after contact with resident equipment. She stated HH was the first line to prevent the spread of infection. The LPN revealed she constantly reminded CNA's to make sure they performed HH. LPN #3 stated she was not aware of any issues. Further interview with LPN #3 revealed she noticed personal hygiene items left in the shower room every once in a while. She stated the purpose of labeling hygiene items was to ensure they were not used for another resident because of the potential for passing germs and infection. Interview with Registered Nurse #1, on 10/02/2020 at 10:25 AM, revealed she noticed personal hygiene items lined up on top of the air conditioning unit in the shower room. She further revealed staff were responsible for ensuring the items were labeled with the resident's name. According to RN #1, personal hygiene items should not be shared because of the potential for cross contamination with skin infections. Interview with the Interim Director of Health Services (DHS)/Infection Preventionist, on 10/02/2020 at 1:17 PM, revealed personal hygiene items should be labeled with the resident's name and stored in the resident's room. She stated she monitored the shower room once or twice a week and had not identified any concerns. Further interview with the DHS revealed she monitored restorative dining at least weekly to ensure staff were performing HH and ensure residents received the correct diet/adaptive equipment. She stated every once in a while she had to remind someone about HH but it was not a huge issue. Interview with the Interim Executive Director (ED), on 10/02/2020 at 4:31 PM, revealed the facility conducted random audits for infection control to ensure staff donned/doffed personal protective equipment (PPE) and performed HH appropriately. The ED stated he was not aware of any concerns related to infection control. 2. Observations, on 10/2/2020 at 8:00 AM, revealed observations of medication pass with Registered Nurse (RN) #2, revealed staff did not wash or sanitize hands before initiation of medication preparation and before entering resident rooms after handling equipment on the medication cart. Equipment included drawers to the cart, medication packages, containers, computer keyboard, and computer mouse. Furthermore, observations revealed staff held water cups by the lip of the cup and handed the residents the cup of water to drink. In addition, staff obtained vital signs for multiple residents with the assigned vital sign machine and pulse oximeter. Continued observation revealed staff did not clean the devices with a disinfectant agent after use with a resident and used the devices with the next resident. Review of the policy, Medication Administration-General Guidelines, revised 1/17, revealed when administering medications staff washed or sanitized their hands at the beginning of the medication pass, prior to handing medications, after contact with the resident. Interview with RN #2, on 10/02/2020 at 8:00 AM, revealed the facility provided and the RN completed education for general infection control and to prevent the spread of COVID-19 virus. The RN stated staff's responsibilities included to wipe the vital sign unit and pulse oximeter with the disinfection wipe after each resident. The RN stated the disinfection process was to prevent the spread of [MEDICAL CONDITION] and any other bacteria to other residents. RN #2 stated the facility expected all staff to follow standard infection control practices. Further interview revealed proper HH included to sanitize or wash hands before medication prep, and when staff entered and exited resident room. The RN stated the facility expected staff to follow proper HH practices because HH prevented the transmission of infections more than any other practice for infection control. RN #2 stated they forgot to clean the equipment between residents. The RN stated when staff did not follow infection control (disinfection and proper HH) staff put residents at risk for infection which could lead to a risk of loss of life. The RN further stated they did not follow the facility's policy for infection control. Interview with the Nurse Executive, on 10/02/2020 at 4:06 PM, revealed she expected staff to clean all equipment after each use with a resident to prevent the spread of infection. She stated she expected staff to follow the infection control practice for HH to prevent the spread of infection. The Nurse Executive stated when staff did not follow HH or ensure the disinfection of equipment used for residents, it could result in the spread of the COVID-19 virus. She stated the facility audited medication pass which had not identified infection control issues with HH and equipment cleaning. She stated she expected staff to follow policy and when they did not follow policy the residents were not safe. She stated her responsibilities included to make sure residents remained safe. Interview with the Executive Director, on 10/02/2020 at 4:36 PM, revealed that the staff who cared for the residents should consider the need for good infection control.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system to ensure the Physician was notified when there was a need to alter treatment for [REDACTED].#2, #3, #5, #7 #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30). Review of twenty-three (23) resident records to include the Electronic Medication Administration Records (eMAR) dated 04/07/19, and the correlating Administration Compliance Report, dated 04/07/19, revealed documentation by Licensed Practical Nurse (LPN) #1, stating Not administered: not adequately staffed, management aware for medications scheduled on 04/07/19, between 2:00 PM and 10:00 PM, on the Therapy Lodge Unit. Interview with LPN #1, revealed he was unable to perform duties as assigned including medication administration on 04/07/19 between the hours of 2:00 PM to 10:00 PM, related to insufficient staffing. Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, and #28 missed significant medications to include: Insulin; Anti-Hypertensive Medications; Anticoagulant Medications; Antibiotics; Anti-[MEDICAL CONDITION] Medications; [MEDICATION NAME]; and Anti-arrhythmic Medications. However, there was no documented evidence the Attending Physicians/Providers were notified on 04/07/19, in order to seek guidance related to the need for possible adjustment in medications times or guidance related to the delivery of care, by either LPN #1, or by LPN #2, who was the oncoming nurse relieving LPN #1 at 10:00 PM. Furthermore, there was no documented evidence the Attending Physicians/Providers were notified of the missed medications until 04/09/19. This affected Residents #2, #3, #5, #7, #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30. (Refer to F-600, F-725 and F-760) The facility's failure to have an effective system in place to ensure the Physician was notified when medications were not administered as ordered caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate jeopardy (IJ) was identified on 05/23/19 and determined to exist on 04/07/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 alleging removal of the Immediate Jeopardy on 06/06/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/06/19, prior to exit on 06/07/19 with remaining non-compliance at a Scope and Severity of a [NAME] while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility Change in Condition Process Policy, effective 04/25/13, revealed the purpose of the policy is to ensure the facility promptly informs the resident's physician when there is a change requiring notification. Review of Resident #2, #3, #5, #7, #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30's eMARs dated 04/07/19, and the correlating Administration Compliance Report, dated 04/07/19, revealed documentation by LPN #1 stating Not administered: not adequately staffed, management aware for medications, scheduled on 04/07/19, between 2:00 PM and 10:00 PM, on the Therapy Lodge Unit. Further review of the eMARs dated 04/07/19, revealed Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, and #28 missed significant medications to include: Insulin; Anti-Hypertensive Medications; Anticoagulant Medications; Antibiotics; Anti-[MEDICAL CONDITION] Medications; [MEDICATION NAME]; and Anti-arrhythmic Medications. However, review of Resident #2, #3, #5, #7 #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30's Nurse's Notes, for the month of (MONTH) 2019, revealed there was no documented evidence the residents' Attending Physician's were notified of the failure to administer the scheduled medications, as per the eMARs, dated 04/07/19. Review of the Medication Error Reports, revealed Resident #2, #3, #5, #7 #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30's Physicians were notified the medication was not administered on 04/07/19 on the evening shift (2:00 PM to 10:00 PM). However, further review of the Reports, revealed the Physicians were not notified of the missed medications, until 04/09/19, between 8:00 AM and 11:00 AM. Interview with LPN #1, on 05/14/19 at 3:30 PM, revealed he worked as the only nurse on the Therapy Lodge Unit, on 04/07/19 from 6:00 AM until 10:00 PM. He stated the Certified Medication Technician (CMT) left at 2:00 PM, which left just him and a State Registered Nursing Assistant (SRNA) to provide care for twenty-nine (29) residents from 2:00 PM until 4:00 PM. He revealed there was insufficient staff the evening of 04/07/19, as the Unit did not have the minimum required number of staff, and he was unable to administer medications to all twenty-nine (29) residents. Therefore, per interview, some residents did not receive significant medications including Insulin, [MEDICATION NAME], anti-hypertensive medications and other cardiac medications, as well as antibiotics. Additional interview revealed he did not ensure the Physician was notified of the missed medications in order to seek guidance related to missed dosages. Interview with LPN #2, on 05/16/19 at 3:45 PM, revealed when she arrived at the Therapy Lodge Unit at 10:00 PM, on 04/07/19, to relieve LPN #1, he did inform her he was unable to pass all the medications due to lack of staff and he had notified the DON and the Administrator of the staffing situation. Further interview revealed it did not occur to her to notify the Physician of the medications not being administered as prescribed as she was mainly concerned about assessing the residents' vital signs and ensuring none of them were in pain or had complaints. Per interview, she should have notified the Physician to find out if the medications could be administered late as some residents missed significant medications including Insulin, blood pressure medications, cardiac medications, [MEDICATION NAME] and antibiotics. Interview with Physician #1, on 05/22/19 at 4:15 PM, and on 05/22/19 at 4:30 PM, revealed it was his expectation medications be administered as prescribed, as there was the potential for serious consequences when the residents did not receive medications as scheduled. Per interview, he was not notified of the residents missing their medications on 04/07/19, until a few days later. Further interview revealed LPN #2, who came on shift at 10:00 PM on 04/07/19, should have contacted him regarding the missed medications. He stated if he had been contacted on 04/07/19, he could have given new orders to administer the missed medications late. Further interview revealed it was his expectation staff notify him if residents miss their medications. Interview with Physician #2 on 05/22/19 at 9:30 AM revealed medications were ordered for a reason and it was important to administer medications as prescribed for the wellbeing of the residents. Further interview revealed he was notified during a Quality Assurance Performance Improvement (QAPI) meeting that residents missed their medications on 04/07/19; however, he could not recall the date of the meeting. He stated he wished LPN #2, who came on duty to relieve LPN #1 on 04/07/19, had notified him the evening/night time medications had not been administered. He stated if he had been contacted on 04/07/19 of the residents not receiving their medications as scheduled, he could have given orders for LPN #2 to administer the medications late, as this would have ensured the residents at least received their needed medications. He stated he expected timely notification when residents did not receive their medications. Interview with the Director of Nursing (DON) on 05/23/19 at 3:49 PM, revealed there was the potential for adverse consequences for residents who did not receive their prescribed medications on 04/07/19, due to LPN #1 not administering the medications as scheduled. When questioned if the Physicians should have been notified on 04/07/19 related to the missed medications in order for staff to seek guidance, she stated she could not speak for what LPN #2 should have done when the nurse was informed the medications were not passed. Further interview with the DON, revealed after the administrative staff learned of the missed medications on 04/08/19, they failed to contact the Physicians and the Advanced Registered Nurse Practitioner, until 04/09/19. Interview with the Administrator, on 05/23/19 at 3:11 PM, revealed it would have been nice, if LPN #2 had contacted the physicians when she came on shift and was informed by LPN #1 the residents did not receive their scheduled medications, as the Physician's may have wanted to give new orders related to the missed medications. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 that alleged removal of the Immediate Jeopardy (IJ) on 06/06/19. Review of the AoC revealed the facility implemented the following. 1. The Administrator was provided counseling and assistance on 05/29/19 by the President and Chief Executive Officer (CEO) of the facility's minimum staffing standards and the steps to take when the daily schedule did not meet the standards. On 06/05/19, the CEO and Administrator met again and the CEO re-emphasized with the Administrator that it was the Administrator's responsibility to ensure care and services were provided for the residents, twenty-four (24) hours a day. 2. On 05/30/19, the Administrator educated/reviewed with the Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UM) the actions to take if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to the residents. 3. On 6/05/19, the Administrator and the Social Services Director visited all interviewable residents and asked if they have been receiving medications, treatments and services to their satisfaction. They were also asked if they knew who to report to if they had issues. The Administrator and Social Services Director will continue to interview the residents two (2) times a week for one (1) month. The Quality Assurance (QA) team will determine ongoing frequency based on findings after the first month. 4. On 04/09/19, the Director of Nursing (DON) notified the Physician/Advanced Registered Nurse Practitioner (ARNP) of the missed medications on 04/07/19 with follow-up orders implemented as indicated for Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30. Additionally the DON assessed the residents to determine if there was any adverse effects to the residents that missed their medications with no adverse effects noted. 5. The Resident Representatives were notified of the missed medications on 04/11/19 and 04/12/19 by the DON and Registered Nurse (RN) #2 for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30. 6. Licensed Practical Nurse (LPN) #2, who did not report the previous nurse's missed medication administration, was provided education related to the facility's policies related to notification on 04/14/19 and again on 05/31/19 by the Staff Development Director (SDD). 7. Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25, and #28 and all other current in-house residents, will be administered their medications and treatments in accordance with the Medical Doctor's (MD)/ARNP's orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) will be checked, by the Administrator and/or DON for late and due medication administrations. The MARS and TARS will be checked twice daily for two (2) weeks, then once daily for one (1) month and will then be re-evaluated by the Quality Assurance Performance Improvement (QAPI) committee to determine ongoing frequency. 8. The facility had employed twenty-eight (28) new staff, ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN) and twelve (12) State Registered Nurses Aides (SRNA), since 04/01/19. This was done to fill positions on the nursing schedule to provide staffing and to provide nursing and related services. This will assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house resident. 9. To assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house residents, care observations of six (6) residents will be completed, two (2) residents will be observed per wing. These observations will be performed by the Administrative Nursing Staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors weekly for two (2) months and will then be re-evaluated by the QAPI committee to determine ongoing frequency using the Care Observation tool. The first observation occurred on 06/03/19. 10. The CEO, Administrator and DON developed facility Minimum staffing standards, and procedures to take when the daily schedule did not meet the established facility staffing standards. The procedures included: a) when there was a call in at the last minute, the designated staffing person will try to find a replacement. If a replacement could not be found, the designated staffing person will look at moving staff around if there is extra staff available on another unit; b) There may be times when the staff member was a no-call, no-show. In this case, a nurse at the facility must call the designated staffing person to inform them of the no-show. c) If the staffing person could not be reached, the nurse will call the DON. If the DON could not be reached, the nurse will call the Administrator. If the staffing level on any day falls below the minimum staff level, one (1) of the administrative staff will be asked to come in to support the staff currently working. d) Due to weekends being more difficult to staff, the Unit Managers and other Nursing Directors agreed to a weekend on call schedule and will be available to come in on the weekends if staff drops below the minimum staffing level. 11. Resident #1 is no longer on [MEDICATION NAME]. The facility currently had three (3) Residents including Resident #2, which were required to have [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) labs, and have their PT/INR labs obtained/followed-up in accordance with their Physician/ARNP orders and their care plan as determined by PT/INR monitoring. The DON will track [MEDICATION NAME] labs and follow-up orders. Three (3) times a week on weekdays, a binder that contains a lab log page for each resident will be brought to the morning meeting. The DON will initial she reviewed the labs, including the PT/INR, to check that labs were collected and reported timely to the Physicians/ARNPs. The DON or Unit Managers (UM) will also check with the lab to ensure the lab is in a Pending status, which indicates the lab work is in process. Lab tracking sheets are now being used and will be brought to the morning meeting. [MEDICATION NAME] tracking sheets were implemented for each resident on [MEDICATION NAME]. The DON will initial that she has reviewed labs and the [MEDICATION NAME] tracking sheets to verify that they have been obtained and reported to the attending Physician/APRN in a timely manner. 12. Facility licensed nursing staff were provided in-service education on 05/30/29; 05/31/19; 06/01/19; 06/02/19; 06/03/19; and, 06/04/19 by the DON and SDC on the following: the requirement to administer resident medications in accordance with the Medical Doctor (MD)/ARNP orders and the resident care plan; the need to notify a fell ow charge nurse, their Unit Manager, the QA Nurse, the SDC, or the DON if they were unable to complete medication administration for their assigned residents in accordance with the /ARNP orders and the resident care plan so that assistance would be provided; the requirement to perform PT/INR labs in accordance with MD/APRN orders and the resident care plan; the requirement to notify the MD/APRN and the Resident Representative if medications were not administered to the resident in accordance with their orders, care plan and facility policy; and, the components of the facility's Abuse/Neglect Policy, including what constitutes abuse/neglect and the reporting aspects if a staff has neglected to provide medications or treatments to residents, and the disciplinary action that will be implemented for failure to follow the requirements, which is disciplinary action up to termination, was addressed in this training. 13. A review of the facility's staffing, as compared to the established staffing standards, will be provided to the Board of Directors at their monthly meeting. This will include, but not be limited to, the protocol steps taken by the facility when the daily schedule did not meet the established staffing standards. 14. The DON and Administrator have and will continue to monitor staffing levels based on census and acuity levels. The facility developed a Minimum Staffing Target worksheet that established a minimum staffing level for all three units for all three shifts. The instructions on the sheet indicated what the Managers were to do in the case of a call-in or shortage and what to do if a replacement could not be found. It listed the DON's and Administrator's phone number for assistance. The State Survey Agency validated the implementation of the facility's A[NAME] as follows: 1. Record Review confirmed the President and CEO of the facility provided counseling and assistance to the Administrator, on 05/29/19, related to the minimum staffing standards and the steps to take when the daily schedule did not meet the established standards. Record Review of the document titled, Minimum Staffing Targets, 2019, dated 05/29/19, confirmed the Administrator was educated by the President and CEO of the facility on minimum staffing standards and steps to take when the daily schedule did not meet the established standards. Further review confirmed the Administrator reviewed Scoring Rules for staffing and ratings with the President and CEO. Continued review confirmed, the President and CEO again met with the Administrator to ensure care and services were provided for the residents, twenty-four (24) hours a day. Interview with the Administrator on 06/07/19 at 1:10 PM revealed he received counseling related to ensure minimum staffing standards and the steps to take when the daily schedule did not meet the standard. Continued interview revealed he was also educated that it was the Administrator's responsibility Interview with the President and CEO of the facility, on 06/07/19 at 2:01 PM, confirmed he met with the Administrator several times about staffing concerns and the need for the facility to make the resident's care a priority. Further interview revealed, the administrator was educated on facility staffing standards, and the administrator's responsibility twenty-four (24) hours a day to ensure care and services are provided. 2. Review of the Chain of Command, dated 06/06/19, validated the administrator educated/reviewed with the DON, SDC, and Unit Managers about what they would need to do if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to our residents. Interview with the DON on 06/06/19 at 1:49 PM, confirmed she had received education related to the facility's Chain of Command, staffing standards Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking and Notification of Change. Interview with South Wing Unit Manager, on 06/07/19 at 12:00 PM and the Staff Development Coordinator (SDC), at 1:00 PM, confirmed they were educated on the Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking, Notification of Change, Chain of Command and Staffing Standards. 3. Review of the Midnight Census Worksheet utilized 06/05/19 with resident statements confirmed, revealed the Administrator and the Social Services Director (SSD) visited all interviewable residents and asked if they had been receiving care, medications, treatments and services and if care was to their satisfaction. They were also questioned related to who they should report issues to, regarding care provided. Interview with the Administrator, on 06/07/19, confirmed interviewable residents were asked if they were receiving their medications, treatments, and care to their satisfaction. Per interview, the interviewable residents were also asked if they were aware of how to report problems concerning their care, and who they should notify if there was a concern related to care. Further interview revealed the SSD and Administrator were able to interview fifty (50) residents. Per interview, interviews were scheduled to continue two (2) times weekly for one (1) month and then the Quality Assurance team would determine the ongoing frequency based on the findings. 4. Review of the Medication Error Report Sheets, dated 04/09/19, revealed notification was made by the Director of Nursing (DON) to the Physician/Advanced Practice Registered Nurse (APRN) for each of Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29 and #30 from 04/08/19 to 04/09/19. The Physicians/APRN was notified the residents listed above, on the Therapy Unit, did not received their medications on 04/07/19 from the time of 3:00 PM to 10:00 PM. Interview with the DON, on 06/06/19 at 3:39 PM, confirmed she had informed the Physician/APRN and the Resident Representative of medications not being administered to Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30 on 04/07/19. Continued interview revealed she assessed all of the residents by observation, clinical review, such as monitoring blood pressure and blood sugars, and record review for any adverse effects of missing their medications and there were no adverse effects on any of the residents. Interview with Physician #1, on 05/22/19 at 9:30 AM, confirmed he was notified the residents on the Therapy Unit had not received their evening medications on 04/07/19. He reported he had been informed of this immediately after the facility became aware of the situation on 04/08/19 but could not recall the time. Further interview revealed, there were plans for ongoing monitoring of vital signs, pain or any changes related to medications missed to assure there are no adverse effects. Interview with Physician #2, on 05/22/19 at 8:30 PM, confirmed he was informed on 04/08/19 the residents on the Therapy Unit did not receive their medications the night of 04/07/19. Physician #2 also confirmed during the interview, the DON and his Nurse Practitioner discussed the incident prior to him having knowledge. Further interview confirmed he was uncertain of when he was informed. Physician #2 requested the Residents effected have their vital signs monitored and the nursing staff alert the Physician of any adverse changes. 5. Review of the Medication Error Report Sheets, dated 04/09/19, revealed notification was made by the DON and RN # 2 to the Resident Representatives between 04/11/19 and 04/12/19 informing them medications had not been administered for Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29 and #30. The Resident Representatives were also informed the Resident's Physician/APRN had been informed of the missed medications. Interview with RN #2, on 06/06/19, confirmed he did notified six (6) to seven (7) of the Resident Representative to inform them the residents did not receive their medications the evening of 04/07/19 on the Therapy Unit. Interview with the DON, on 06/06/19, confirmed she and RN #2 did notify the Resident Representatives of the residents not receiving medications on the evening of 04/07/19.3 6. Review of the Education Sign-In Roster, dated 04/14/19 and 05/31/19, revealed Licensed Practical Nurse (LPN) #2, who did not report the previous nurses' missed medication administration, was provided education by the Staff Development Director (SDD). Continued review revealed education included the Scope of Practice, High Risk Medication, Medication Administration, Abuse and Change in Condition Process, Interview with LPN #2, on 06/06/19 at 7:35 PM, confirmed education was received over the last few weeks. LPN #2 stated the physician should have been notified at the time she received the information. The previous nurse, LPN #1, had not informed the physician the medications had not been given the evening of 04/07/19, but informed LPN #2 when giving report. 7. Review of the Medication Administration Checks, initiated on 06/01/19, validated Resident #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25 and #28, and all other current in-house residents, were administered their medications and treatments in accordance with the Medical Doctor's (MD)/APRN orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) were checked twice daily by the Administrator of DON. The MARS and TARS checks were initiated twice daily beginning 06/01/19 to present. Interview with the DON, on 06/07/19 at 1:49 PM, confirmed the MAR and TAR have been monitored twice daily by herself or the Administrator. Interview with the Administrator, on 06/07/19 at 1:08 PM, confirmed the MARs and TARS are monitored and reviewed for any missed or past due medications. The Administrator confirmed the MARS and TARS are check twice daily and will continue to be check twice each day for two (2) weeks, then once daily for one (1) month and then will be evaluated by QAPI committee to determine ongoing frequency. Per interview, if any issues are found, the DON will be contacted to follow-up with the floor nurse during the week and on the weekends. 8. Review of the facility's Human Resources records, New Hire list, dated 04/01/19 to present, validated the facility had employed twenty-eight (28) new staff. Continued review revealed ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN), and twelve (12) State Registered Nurses Aides (SRNA) were hired by the facility since 04/01/19. Interview with the DON, on 06/06/19 at 1:49 PM, confirmed the facility has hired many new nurses and aides and had increased the staffing level. This facility has joined with a corporation that will assist with staffing. Further interview confirmed the facility is following the Minimum Staffing Target, 2019. Continued interview revealed if they did not meet the minimum level of staffing, Managers had been educated to call the Unit Managers and they can work the carts and they are able to contact an agency nursing staff. Interview with the Administrator, on 06/07/19 at 1:08 PM, confirmed if the facility's minimum staffing level was not achieved, the DON and or Administrator was notified. Continued interview revealed staff may be moved around to provide coverage to each unit. Further interview revealed on the weekends, administrative staff will come in to support staff working if staffing levels fall below the minimum staffing level. 9. Review of the Resident Observation Tool validated care observations of six (6) residents weekly was initiated as of 06/03/19. Continued review revealed the Resident Observation Tool confirmed two residents were observed per wing. Further review revealed the observations were performed by the administrative nursing staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors. Interview with the North Hall Unit Manager, on 06/07/19 at 11:15 AM, confirmed the administrative staff was responsible to complete resident observations for six (6) residents, two (2) from each unit using the Resident Observation Tool. Interview with the Quality Nurse (QA) nurse, on 06/07/19 at 2:07 PM, revealed the DON, Administrator or herself would utilize the Resident Observation Tool for six (6) Residents. Continued interview revealed two (2) residents on each unit would be observed using the tool for two (2) months, then it would be re-evaluated to make a decision if they were going to do it once a week. Interview with the DON, on 06/06/19 at 1:49 PM, revealed she and the Quality Assurance (QA) Nurse use the Resident Observation Tool. Per interview, two (2) residents are selected from every unit to observe the care. Further interview revealed this tool is utilized weekly for a total of two (2) months. Per interview, the tool will assist the facility to ensure residents are receiving good care and things are going well. She stated they look at shower care, nail care, hair care, and general overall care and have not identified any issues with the observations. Interview with the Administrator, on 06/07/19 at 1:08 PM, revealed the facility was utilizing the Resident Observation Tool. Per interview, the tool looks at how residents are dressed, it covers dignity, privacy, the resident mood/behavior, and any accident or hazards in the room, call lights and functioning for safety. Further interview confirmed the tool also assesses areas to ensure the resident is receiving good care. He stated, the Resident Observation Tool is utilized weekly for two months on six (6) residents, two (2) from each wing. 10. Review of the Minimum Staffing Targets, 2019 validated the Chief Executive Officer (CEO) the Administrator and DON developed facility Minimum Staffing Standards, and steps to take when the daily schedule does not meet the established facility staffing standards. Further review revealed, the minimum staffing was established using the Scoring Rules Table 3: of the National Star Cut Points for Staffing Measures Based on adjusted hours per Resident Day, updated (MONTH) 2019 and Table 4: Staffing and Rating, updated, (MONTH) 2019. This method was used for both RN Staffing and total staffing; a rating of 1 to 5 stars is assigned. Continued review revealed the facility initiated protocols on 05/29/19, for last minute call-in by staff. The designated staffing person works toward to finding a replacement. If a replacement cannot be found, the designated staffing person will look at moving staff around if there is extra staff available on another unit. Interview with the Therapy Unit Manager, on 06/07/19 at 11:35 AM, revealed the policy of the facility when a staff member is a no-show, no-call is to notify the staffing coordinator so they can began to work on staffing. Per interview, the staffing coordinator had previously been responsible for staffing. She stated, the new policy designate this responsibility to all managers. If the staffing coordinator cannot be reached, then the DON is called, if the DON is unavailable, it is the responsibility of the nurse to contact the Administrator. Continued interview revealed if staffing levels fall below minimum staff, the UMs are to cover. She stated, if the UM is not available it will be any of the other nurses in administration. This will include t

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents were free from neglect for twenty-four (24) of thirty-eight (38) sampled residents (Residents #2, #3, #4, #5, #7, #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30). Staff interviews revealed on 04/07/19, Licensed Practical Nurse (LPN) #1 was assigned to work 6:00 AM to 6:00 PM on the Therapy Lodge Unit; however, LPN #1 was informed by the Staffing Coordinator there was no licensed staff to relieve him and he would need to stay over and work until 10:00 PM. Staff interviews and review of the facility time punch cards, revealed LPN #1 was the only licensed nurse on the Unit for twenty-nine (29) residents to perform treatments as well as deliver other care to be performed by a licensed nurse as prescribed, from 6:00 AM until 10:00 PM. In addition, after Certified Medication Technician (CMT) left the Unit at 2:00 PM, LPN #1 was left to administer medications to twenty-nine (29) residents. Staff interviews and review of the screen shots of LPN #1's phone related to outgoing phone calls and text messages on 04/07/19, revealed LPN #1 notified the Director of Nursing (DON), Administrator, and the Staffing Coordinator, there was inadequate staff and he could not get all assigned tasks completed that evening. However, the facility failed to take action and make certain there was sufficient staffing available between the hours of 2:00 PM and 6:00 PM, when staffing was below the required minimum. As a result, record review revealed twenty-four (24) residents did not receive their medications and/or treatments and/or other care as scheduled from 2:00 PM until 10:00 PM. This affected Residents #2, #3, #4, #5, #7,#8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30). (Refer to F-580, F-656, F-725, and F-760) The facility's failure to have an effective system in place to ensure residents were free from neglect has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 05/23/19 and determined to exist on 04/07/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 alleging removal of the Immediate Jeopardy on 06/06/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/06/19, prior to exit on 06/07/19 with remaining non-compliance at a Scope and Severity of a [NAME] while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Resident Abuse, Neglect and Misappropriation of Property Policy dated (MONTH) (YEAR), revealed Springhurst Health and Rehabilitation strives to maintain the highest level of resident care. Our goal is for every resident to be free from abuse, neglect and misappropriation of property. All employees must follow this policy; failure to do so will result in immediate termination. Continued review reveals the definition of neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Further review of the Policy, revealed employees will be trained as part of orientation and in ongoing sessions regarding issues how to recognize signs of burnout, frustration and stress that may lead to abuse; and what constitutes abuse, neglect and misappropriation of resident property. Additional review of the Policy, revealed staff will monitor for situations in which abuse, neglect and misappropriation of resident property may occur and identify, correct and intervene when necessary. As necessary, nursing management will modify staffing assignments and resident to staff ratios to assure optional care to prevent situations that might lead to abuse or neglect. Review of the facility's Licensed Practical Nurse Job Description, undated, revealed a Licensed Practical Nurse (LPN) has the primary responsibility for providing necessary medical services, supervision and care plan implementation to residents. The LPN is also responsible for supervision of Certified Nursing Assistants (CNA)/{State Registered Nurse Assistants (SRNA)} and Certified Medication Technicians (CMT). Further review of the Job Description, revealed the LPN's general responsibilities include: following all related policies and procedures; completing skin treatment per Physician/Advanced Registered Nurse Practitioner (ARNP) orders; supervising and/or providing personal care to residents to include bathing, dressing, toileting, grooming and feeding; delivering resident care as directed by the Physician or ARNP; and administering medication via oral, intramuscular (IM), subcutaneous (SQ), gastrostomy tube ([DEVICE]), or intravenous (IV) piggyback route in accordance with Physician/ARNP orders. Review of LPN #1's personnel record, revealed he signed as acknowledging receipt and understanding of the Springhurst Health and Rehab Policies related to the LPN Job Description, on 08/05/16. Further review revealed he received verbal coaching, on 05/12/18, related to not completing assigned skin assessments on 04/28/18 and 05/05/18. Review of the facility's Staffing Guidelines Policy, dated 01/31/14, revealed the facility must have adequate staffing to ensure appropriate care is provided to the residents in accordance with accepted professional standards and practices. Further review revealed the Therapy Lodge Unit required two (2) Nurses or one (1) Nurse and one (1) CMT 6:00 AM to 6:00 PM, and one (1) Nurse on the 6:00 PM to 6:00 AM Shift. Further review revealed the Unit required two (2) to four (4) State Registered Nurse Assistants (SRNA) on the 6:00 AM to 6:00 PM shift and two (2) SRNAs on the 6:00 PM to 6:00 AM shift. Review of the facility's Time Punches and interviews with staff, revealed on the Therapy Lodge Unit on 04/09/19, from 6:00 AM to 2:00 PM, there was one (1) LPN, one (1) CMT and two (2) SRNAs. However, from 2:00 PM to 4:00 PM, there was only one (1) LPN and one (1) SRNA; from 4:00 PM to 6:00 PM, there was only one (1) LPN, one (1) CMT working as a SRNA, and one (1) SRNA; and, from 6:00 PM to 10:00 PM there was one (1) LPN and two (2) SRNAs. Therefore, the unit did not meet the minimum requirement of staff according to the facility's Policy on 04/07/19, as the unit was short two (2) staff from 2:00 PM to 4:00 PM and the unit was short one (1) staff from 4:00 PM to 6:00 PM. The following are examples from record review related to medications, treatments, and other delivery of care not being administered on the Therapy Lodge Unit on 04/07/19 by LPN #1. 1. Review of Resident #15's clinical record revealed the facility admitted the resident on 10/13/17, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].(ml), 10 units subcutaneous (SQ) with meals at 4:00 PM; and, [MEDICATION NAME] 25 mg, one (1) tablet (medication used to treat high blood pressure and heart failure) to be administered at 4:00 PM. In addition, review of the physician's orders [REDACTED]. Review of the Electronic Medication Administration Record [REDACTED]. In addition, the following medications were scheduled 7:00 PM to 10:00 PM: [MEDICATION NAME] tablet 5 mg, one (1) tablet; Atorvastatin 40 mg, one (1) tablet; [MEDICATION NAME] (HCL) tablet 0.1 mg, one (1) tablet; [MEDICATION NAME] 100 mg, one (1) capsule; Donepezil 10 mg, one (1) tablet; Eliquis 5 mg, one (1) tablet; [MEDICATION NAME] 100 mg, one (1) tablet; Montelukast 10 mg, one (1) tablet; Trazadone 50 mg, one (1) tablet; [MEDICATION NAME] aerosol inhaler 160-4.5 micrograms (mcg) inhalation two (2) puffs; and [MEDICATION NAME] 75 mg, one (1) capsule. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report dated 04/07/19, revealed under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for medications scheduled at 4:00 PM; medications scheduled from 3:00 PM to 6:00 PM; and medications scheduled 7:00 PM to 10:00 PM. Further review of the physician's orders [REDACTED]. However, review of the Electronic Treatment Administration Record (eTAR) dated 04/07/19 and review of the Administration Compliance Report, dated 04/07/19 revealed the interventions for oxygen saturation every shift for the evening shift, and accuchecks at 4:30 PM and 9:00 PM were not documented as completed. Under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware. 2. Review of Resident #13's clinical record revealed the facility admitted the resident on 12/20/18 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. orally twice daily (medication used for treating high triglycerides); and, [MEDICATION NAME] powder 17 grams/dose orally (laxative). Review of the eMAR, dated (MONTH) 2019, revealed the following medications were scheduled at 7:00 PM to 10:00 PM: Klonopin 0.5 mg, one (1) tablet, [MEDICATION NAME] 100 unit/mL administer 14 units, [MEDICATION NAME] 1 gram, and [MEDICATION NAME] powder 17 grams. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for all medications scheduled for 7:00 PM to 10:00 PM. Review of the physician's orders [REDACTED]. However, review of the eTAR, dated 04/07/19, and the Administration Compliance Report, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware. 3. Review of Resident #2's clinical record revealed the facility admitted the resident on 10/14/18 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. orally (medication to treat high blood pressure); [MEDICATION NAME] 25 mg tablet, ½ tablet to equal 12.5 mg orally (medication used to treat high blood pressure); and, [MEDICATION NAME] 0.25 mg, one (1) tablet orally (medication used for anxiety). Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 5.5 mg, one (1) tablet and [MEDICATION NAME] 100 mg, one (1) capsule were scheduled at 5:00 PM and the following medications were scheduled 7:00 PM to 10:00 PM: [MEDICATION NAME] 100 mg, one (1) capsule; [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg tablet; [MEDICATION NAME] 10 mg, one (1) tablet; Losartan 50 mg, one (1) tablet; [MEDICATION NAME] 25 mg tablet ½ tablet to equal 12.5 mg; and [MEDICATION NAME] 0.25 mg, one (1) tablet. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for the [MEDICATION NAME] 5.5 mg, one (1) tablet and [MEDICATION NAME] 100 mg, one (1) capsule scheduled at 5:00 PM and for all medications scheduled for 7:00 PM to 10:00 PM. 4. Review of Resident #21's clinical record revealed the facility admitted the resident on 03/28/19, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 2 mg, one (1) tablet was scheduled at 5:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for the [MEDICATION NAME] 2 mg scheduled at 5:00 PM. 5. Review of Resident #23's clinical record revealed the facility admitted the resident on 05/03/17, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 0.25 mg, one (1) tablet was scheduled to be administered 3:00 PM to 4:00 PM and [MEDICATION NAME][MEDICATION NAME] liquid 12.5 mg/5 ml was scheduled to be administered at 4:30 PM. In addition, the following medications were scheduled to be administered 7:00 PM to 10:00 PM: [MEDICATION NAME] 10 mg, one (1) tablet; [MEDICATION NAME] tablet 10 mg, one (1) tablet; Levetiracetam solution 100 mg/ml, administer 10 ml; [MEDICATION NAME] 25 mg, one (1) tablet; [MEDICATION NAME] 20 mg (1) capsule; and [MEDICATION NAME] tablet 0.25 mg. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for [MEDICATION NAME] tablet 0.25 mg, one (1) tablet scheduled 3:00 PM to 4:00 PM; [MEDICATION NAME][MEDICATION NAME] liquid 12.5 mg/5 ml scheduled for 4:30 PM; and all medications scheduled for 7:00 PM to 10:00 PM. Further review of the physician's orders [REDACTED]. However, review of the eTAR and review of the Administration Compliance Report, dated 04/07/19 from 2:00 PM to 10:00 PM, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware. 6. Review of Resident #25's clinical record revealed the facility admitted the resident on 04/17/15, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] 650 mg scheduled to be administered at 3:00 PM and also at 7:00 PM (medication used to treat pain); [MEDICATION NAME] tablet 0.25 mg, one (1) tablet scheduled 3:00 PM to 4:00 PM (medication used to treat anxiety); and, Xarelto 10 mg, one (1) tablet scheduled at 5:00 PM (anticoagulant medication). Further review of the physician's orders [REDACTED]. eye including [MEDICAL CONDITION]); Preparation H ointment 0.25-14-74.9%, rectal (medication used in the treatment of [REDACTED]. In addition, review of physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 650 mg was scheduled to be administered at 3:00 PM and again at 7:00 PM; [MEDICATION NAME] tablet 0.25 mg was scheduled 3:00 PM to 4:00 PM; and Xarelto tablet 10 mg was scheduled to be administered at 5:00 PM. In addition, the following medications were scheduled to be administered between 7:00 PM and 10:00 PM including: [MEDICATION NAME] tablet 0.25 mg; [MEDICATION NAME] solution 100 mg/ml; administer 5 ml; [MEDICATION NAME] drops 0.01%, one (1) drop each eye; Preparation H ointment 0.25-14-74.9%, rectal; and [MEDICATION NAME] tablet 75 mg. In addition, the following medications were scheduled to be administered at 10:00 PM: [MEDICATION NAME] P drops 0.1%, one (1) drop each eye; and [MEDICATION NAME] HCL drops 2%, one (1) drop each eye. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for all medications scheduled from 3:00 PM to 10:00 PM. Further review of the the physician's orders [REDACTED]. However, review of the eTAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware. 7. Review of Resident #28's clinical record revealed the facility admitted the resident on 03/27/19, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed the following medications were scheduled 7:00 PM to 10:00 PM: [MEDICATION NAME] Capsule 100 mg and [MEDICATION NAME] tablet 50 mg. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for [MEDICATION NAME] capsule 100 mg; and [MEDICATION NAME] 50 mg tablet scheduled from 7:00 PM to 10:00 PM. 8. Review of Resident #12's clinical record revealed the facility admitted the resident on 05/25/17 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. in patients with heart conditions); [MEDICATION NAME] 50 mg, one (1) tablet at 7:00 PM to 10:00 PM (medication for pain); and, Xarelto 20 mg, one (1) tablet (anticoagulant medication). Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 50 mg was scheduled at 6:00 PM. Further review of the eMAR, revealed the following medications were scheduled 7:00 PM to 10:00 PM: Calcium [MEDICATION NAME] 200 mg tablet, [MEDICATION NAME] Sprinkles 125 mg delayed capsule, [MEDICATION NAME] 30 mg tablet, [MEDICATION NAME] 50 mg tablet, and Xarelto 20 mg tablet. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for [MEDICATION NAME] 50 mg tablet scheduled at 6:00 PM and all medications scheduled 7:00 PM to 10:00 PM. 9. Review of Resident #24's clinical record revealed the facility admitted the resident on 01/13/17, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. mg/hr scheduled to be administered at 8:00 PM (medication used to prevent chest pain). In addition, review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed the [MEDICATION NAME] (1) capsule 400 mg was scheduled to be administered 1:00 PM to 2:00 PM and 4:00 PM to 5:00 PM; [MEDICATION NAME] 6.25 mg, (1) tablet was scheduled to be administered at 8:00 PM, and [MEDICATION NAME] 24 hour, 0.4 mg/hr was scheduled to be administered at 8:00 PM. In addition, [MEDICATION NAME] 20 mg, (1) capsule; Atorvastatin 20 mg, (1) tablet; and, [MEDICATION NAME] 400 mg, (1) capsule was scheduled to be administered 7:00 PM to 10:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for [MEDICATION NAME] capsule 400 mg scheduled to be administered between 1:00 PM and 2:00 PM and between 4:00 PM and 5:00 PM; [MEDICATION NAME] tablet 6.25 mg scheduled to be administered at 8:00 PM; [MEDICATION NAME] 24 hour, 0.4 mg/hr scheduled to be administered 8:00 PM; and, all medications scheduled to be administered 7:00 PM to 10:00 PM. 10. Review of Resident #7's clinical record revealed the facility admitted the resident on 02/02/18 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. In addition, review of the physician's orders [REDACTED]. mEq (medication to increase Vitamin K levels); [MEDICATION NAME] 225 mg, one (1) tablet (medication to prevent irregular heartbeats); Senna Plus 8.6-50 mg, one (1) tablet (medication to prevent constipation); and, [MEDICATION NAME] 100 mg, one (1) tablet (medication to treat depression). Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 10 mg tablet was scheduled 3:00 PM to 7:00 PM; and Atorvastatin 10 mg tablet; [MEDICATION NAME] 10 mg tablet; [MEDICATION NAME] 25 mg; Potassium Chloride 10 mEq; [MEDICATION NAME] 225 mg tablet; Senna Plus 8.6-50 mg tablet; and, [MEDICATION NAME] 100 mg tablet were scheduled 7:00 PM to 10:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for all these medications. 11. Review of Resident #26's clinical record revealed the facility admitted the resident on 04/04/17, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].); [MEDICATION NAME] 30 mg, one (1) tablet (medication used to treat depression); [MEDICATION NAME] tablet 0.5 mg, one (1) tablet (antipsychotic medication used to treat [MEDICAL CONDITION], and [MEDICAL CONDITION] disorder); and, Senna with [MEDICATION NAME] Sodium one (1) tablet 8.6-50 mg (medication used to treat constipation). Review of the eMAR, dated (MONTH) 2019, revealed the following medications were scheduled between 7:00 PM to 10:00 PM: Eliquis tablet 5 mg; [MEDICATION NAME] capsule 100 mg; Potassium Chloride capsule ER 10 mEq; [MEDICATION NAME] tablet 30 mg; [MEDICATION NAME] tablet 0.5 mg; and, Senna with [MEDICATION NAME] Sodium tablet 8.6-50 mg. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for all medications scheduled from 7:00 PM to 10:00 PM. 12. Review of Resident #19's clinical record revealed the facility admitted the resident on 05/09/17, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].); and, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg, oral one (1) tablet scheduled 6:00 PM-10:00 PM (medication used to treat pain). In addition, review of the physician's orders [REDACTED].(medication used to treat depression). Review of the eMAR, dated (MONTH) 7, 2019, revealed [MEDICATION NAME]-[MEDICATION NAME] 25/100 mg was scheduled between 4:00 PM to 5:00 PM and [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg was scheduled 6:00 PM to 10:00 PM. In addition, the following medications were scheduled at 7:00 PM to 10:00 PM: [MEDICATION NAME]-[MEDICATION NAME] tablet 25/100 mg; [MEDICATION NAME] tablet 750 mg; Klonapin tablet 0.5 mg; and, [MEDICATION NAME] tablet 50 mg. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for [MEDICATION NAME]-[MEDICATION NAME] 25/100mg scheduled between 4:00 PM to 5:00 PM; [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg scheduled between 6:00 PM to 10:00 PM; and all medications scheduled 7:00 PM to 10:00 PM. Further review of the physician's orders [REDACTED]. However, review of the eTAR dated 04/07/19 and review of the Administration Compliance Report, dated 04/07/19 for the evening shift (2:00 PM to 10:00 PM), under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware. 13. R

Based on interview, record review, review of facility's Policies, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), it was determined the facility failed to develop and/or implement the Comprehensive Care Plan for twenty-four (24) of thirty-eight (38) sampled residents (Residents #1 #2, #3, #4, #5, #7, #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, and #30). Resident #1's Comprehensive Care Plan, initiated 08/16/17, revealed the resident was receiving [MEDICATION NAME] (anticoagulant therapy) related to a [DIAGNOSES REDACTED]. However, the Care Plan was not developed with an intervention to obtain [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) labs ordered. On 03/11/19, the resident's PT/INR was 2.9, which was in the therapeutic range. The facility notified the Physician of the results and received verbal orders to repeat the PT/INR on 03/14/19; however, there was no documented evidence the PT/INR lab was drawn on 03/14/19. Additionally, review of the medical record revealed physician's orders [REDACTED]. On 03/29/19, the Laboratory Report revealed: PT: > (greater than) 116.1 High and INR: >10.0 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). Resident #1 was transferred to the local Hospital emergency roiagnom on [DATE], and diagnosed with [REDACTED]. (Refer to F-757) Additionally, Resident #2's Comprehensive Care Plan dated 02/06/15, revealed the resident had the potential for bleeding, and abnormal bruising related to use of anticoagulant due to [MEDICAL CONDITION]. However, the Care Plan was not developed with an intervention to ensure [MEDICATION NAME] was administered as prescribed. physician's orders [REDACTED]. Per these orders, Resident #2 was to receive [MEDICATION NAME] 4.5 mg from 04/18/19 through 04/21/19. A new physician's orders [REDACTED]. However, the physician's orders [REDACTED]. On 04/29/19, lab results revealed PT: 75.5 High and INR: 6.5 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1) and on 04/29/19, Resident #2 received treatment of [REDACTED]. (Refer to F-757) Furthermore, Residents #1 #2, #3, #4, #5, #7, #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, and #30's Comprehensive Care Plans were not developed and/or implemented related to administration of medications and/or treatments. Staff interviews, review of the facility's Time Punches, and review of the facility's Staffing Guidelines Policy, revealed the Therapy Lodge Unit did not have the minimum requirement of staff on the evening shift of 04/07/19, as the Unit was short two (2) staff members from 2:00 PM to 4:00 PM and was short one (1) staff member from 4:00 PM to 6:00 PM. Staff interviews further revealed Licensed Practical Nurse (LPN) #1 was the only licensed nurse on the Therapy Lodge Unit for twenty-nine (29) residents to perform treatments as well as provide other care to be performed by a licensed nurse as prescribed, from 6:00 AM until 10:00 PM. In addition, after the Certified Medication Technician (CMT) left at 2:00 PM, LPN #1's duties included administering medications to twenty-nine (29) residents. Interview with LPN #1 revealed he was unable to administer medications and treatments to all twenty-nine (29) residents due to the unit being short staffed on 04/07/19. Twenty-four (24) residents did not receive their medications and/or treatments from 2:00 PM until 10:00 PM. (Refer to F-600, F-725, and F-760) The facility's failure to have an effective system in place to ensure comprehensive person-centered care plans were developed and implemented related to obtaining PT/INR labs as ordered, and administration of medications and treatments as ordered, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate jeopardy (IJ) was identified on 05/23/19 and determined to exist on 04/07/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 alleging removal of the Immediate Jeopardy on 06/06/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/06/19, prior to exit on 06/07/19 with remaining non-compliance at a Scope and Severity of a [NAME] while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Interview with the DON, on 05/23/19 at 3:49 PM, revealed the facility did not have a policy related to Care Plans; however, the facility did utilize the Resident Assessment Instrument (RAI) Manual 3.0. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 07/18/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/04/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of six (6) out of fifteen (15) indicating severe cognitive impairment. Continued review revealed Section N-Medications, revealed Resident #1 received anticoagulant medication five (5) of seven (7) days during the seven (7) day look back period. Review of the Comprehensive Care Plan initiated 08/16/17, revealed Resident #1 had the potential for bleeding/bruising due to receiving [MEDICATION NAME] (anticoagulant therapy) related to a [MEDICAL CONDITION]. The goal with a target date of 08/31/19, stated the resident would have no active bleeding or abnormal bruising without detection through next review. There were several interventions initiated 01/04/19 including: notify MD/NP (Medical Doctor/Nurse Practitioner) of any unusual bleeding and or bruising that resident develops; protect resident from injury/trauma being extra careful during daily care; encourage use of soft toothbrush; and observe for signs of active bleeding (nosebleeds, bleeding gums, petechia, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temperature, pain in joints, abdominal pain, epistaxis). However, the Care Plan was not developed with an intervention to ensure PT/INR levels were obtained as ordered. Review of Resident #1's Laboratory Reports, dated (MONTH) (YEAR) through 03/11/19, revealed laboratory results for PT/INR were obtained at least weekly and sometimes twice a week. After the Physician was notified of the PT/INR results, orders were received for the next PT/INR lab draw. PT/INR labs were obtained on 02/04/19, 02/07/19, 02/15/19, 02/21/19, 02/27/19, 03/04/19, 03/07/19, and 03/11/19. (A PT is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is calculated from a PT result and is used to monitor how well the anticoagulant medication is working to prevent blood clots). (A PT is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is calculated from a PT result and is used to monitor how well the anticoagulant medication is working to prevent blood clots). Review of Resident #1's physician's orders [REDACTED]. Review of the Electronic Medication Administrator Record (eMAR) dated (MONTH) 2019, revealed the Resident #1 received 5.5 mg of [MEDICATION NAME] 03/08/19 through 03/11/19, as ordered. Review of Resident #1's Laboratory Report, dated 03/11/19, reported at 4:18 PM and faxed to the facility on [DATE] at 4:29 PM, revealed PT: 29.3 High and INR: 2.9 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). There was a Notation on the Lab Report written by Licensed Practical Nurse (LPN) #4, which stated, resident currently on [MEDICATION NAME] 5.5 every day; Change [MEDICATION NAME] to 5.5 mg on Mondays, Wednesdays and Fridays, and 5.0 mg on Sundays, Tuesdays, Thursdays and Saturdays; PT/INR on 03/14/19. Review of the Resident #1's Progress Note, dated 03/11/19 at 5:09 PM, revealed the nurse put in a call to the Physician with lab results, and was awaiting return call. Review of the Progress Notes, dated 03/12/19, at 10:39 AM, completed by LPN #4, revealed new orders were received with Advanced Registered Nurse Practitioner (ARNP) visit today concerning PT/INR results from 03/11/19. Further review revealed new orders were received to change [MEDICATION NAME] to 5.5 mg on Mondays, Wednesdays and Fridays, and 5.0 mg on Sundays, Tuesdays, Thursdays and Saturdays; and recheck PT/INR, on 03/14/19. Review of the Physician order [REDACTED]. Continued review revealed orders dated 03/12/19 for [MEDICATION NAME] 5.0 mg tablet orally on Sundays, Tuesdays, Thursdays and Saturdays at 4:00 PM, with a discontinue date of 03/29/19. However, there was no documented evidence of a physician's orders [REDACTED]. Further review of the eMAR dated (MONTH) 2019, revealed Resident # received 5.5 mg of [MEDICATION NAME] on Monday, Wednesday, Friday and 5.0 mg of [MEDICATION NAME] Sunday, Tuesday, Thursday and Saturday from 03/12/19 through 03/28/19, as per orders. Review of Resident #1's physician's orders [REDACTED]. Additionally, there was no documented evidence the resident's PT/INR was monitored from 03/11/19 until 03/29/19, eighteen (18) days later. Review of Resident #1's Laboratory Report, dated 03/29/19, reported at 8:55 AM and faxed to the facility on [DATE] at 8:55 AM, revealed Resident #1's PT: was > (greater than) 116.1 High and INR: >10.0 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). There was a Notation written on the Laboratory Report, which stated resident sent to emergency room (ER). Review of the Progress Notes, dated 03/29/19 at 9:42 AM, revealed, Resident in bed. Refusing medications this AM. Blood Sugar 222. Did not eat AM meal. Blood Pressure: 110/62, heart rate: 90, Respirations: 18, Oxygen Saturation: 99%. Lungs clear. Lab called with critical INR of 10.0 PT of 116.1. Labs called to ARNP. Order noted to send resident to the hospital. Family notified. Review of the Resident #1's Progress Note, dated 03/29/19 at 9:59 AM, revealed a call was placed to Resident #1's Responsible Party/Daughter, and the Daughter called back. Per the Note, the Daughter was informed of current PT/INR results, and also informed the resident was being sent to the ER. Additional review of the Note, revealed a call was placed for 911, in order for the resident to be transported to the emergency room . Review of Resident #1's Hospital Discharge Summary, dated 04/05/19, revealed the resident was admitted to the hospital on [DATE] with the principle [DIAGNOSES REDACTED]. Upon arrival the resident's Hemoglobin was found to be 5.8 (normal level Hemoglobin for females 12 to 16 and for males 14 to 17.4), with INR greater than eleven (11). Resident #1 received 10 mg of intravenous (IV) Vitamin K in the Emergency Department and received two (2) units of Fresh Frozen Plasma and two (2) units of Packed Red Blood Cells. A Computed [NAME]ography (CT) Scan of Resident #1's abdomen revealed a large left Rectus Hematoma with extension into the pelvis. General Surgery recommended no surgical intervention due to the resident's Supratherapeutic INR. Due to the Hematoma, Resident #1's [MEDICATION NAME] was placed on hold. INR had been reversed to 1.6 and withholding [MEDICATION NAME] because risk of stroke greatly outweighed the risk of bleeding into the very large Rectus Sheath Hematoma. Further review revealed the resident's Rectus Sheath Hematoma stabilized and after receiving two (2) units of packed red blood cells, his/her hemoglobin was 9.0 and stable. Interview with LPN #4, on 05/16/19 at 3:39 PM, revealed when Laboratory Reports were faxed to the facility, she would inform the resident's Advanced Registered Nurse Practitioner (ARNP) of the results, and obtain new orders. Per interview, she would then input the new medication orders related to the lab results into the electronic medical record as a new physician's orders [REDACTED]. [REDACTED]. She further stated she should have filled out a Lab Reconciliation and put it in the lab binder to be drawn on 03/14/19 for Resident #1; however, she stated she was unsure if she had actually filled out the Lab Reconciliation for that date, since the PT/INR was not drawn on 03/14/19. Interview with the ARNP, on 05/23/19 at 2:58 PM, revealed it appeared as though Resident #1's PT/INR lab was missed on 03/14/19 and 03/17/19. Per interview, a nurse informed her on 03/29/19, the lab draws were missed, the resident's PT/INR levels were elevated and the resident was sent to the emergency room . Per interview, Resident #1 had a Rectus Hematoma, and the [MEDICATION NAME] medication could be a factor. She stated it was her expectation laboratory data was obtained as ordered. Interview with the Director of Nursing (DON), on 05/23/19 at 3:49 PM, revealed Resident #1's labs should have been obtained as ordered in order to closely monitor him/her as he/she was receiving [MEDICATION NAME] therapy. Per interview, Resident #1 should not have gone eighteen (18) days without the PT/INR being drawn. Post Survey interview on 06/27/19 at 4:02 PM, with the MDS Coordinator, revealed Resident #1's Care Plan should have been developed and implemented related to ensuring PT/INR levels were obtained as ordered. Per interview, this resident needed constant monitoring of his/her PT/INR levels. Post Survey interview on 06/27/19 at 4:02 PM, with the Administrator, revealed Resident #1's Care Plan should have been developed accurately to include an intervention to ensure labs were obtained as ordered. Per interview, labs should have been drawn as ordered for this resident. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 10/14/18 with the [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan dated 02/06/15, revealed the resident had the potential for bleeding, and abnormal bruising related to use of anticoagulant due to a [MEDICAL CONDITION] with Left [MEDICAL CONDITION] and History of [MEDICAL CONDITION]. The goal with a target date of 08/15/19, stated the resident would be free of any signs or symptoms of excess bleeding or bruising through next review. There were several approaches including: monitor for bleeding from gums during oral care, use a soft toothbrush; monitor stool and emesis for obvious signs of bleeding and report to Physician/Nurse Practitioner; and report signs and symptoms of excess bruising of unknown origin. However, the Care Plan was not developed with an intervention to ensure [MEDICATION NAME] was administered as prescribed. Review of the Quarterly MDS Assessment, dated 04/09/19, revealed the facility assessed the resident as having a BIMS of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Continued review revealed Section N-Medications, revealed Resident #2 received anticoagulant medication six (6) out of seven (7) days during the seven (7) day look back period. Review of Resident #2's physician's orders [REDACTED]. According to these orders, the resident was to receive [MEDICATION NAME] 4.5 mg from 04/18/19 through 04/21/19. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's (MONTH) 2019 eMAR, revealed the resident received 4.5 mg [MEDICATION NAME] from 04/18/19 through 04/21/19 as prescribed. Further review of Resident #2's (MONTH) 2019 eMAR, revealed the resident received 4.5 mg of [MEDICATION NAME] 04/22/19 through 04/28/19, instead of the ordered 2.0 mg of [MEDICATION NAME]. This was due to LPN #9's failure to discontinue orders dated 04/18/19 for 2.5 mg of [MEDICATION NAME], when the new order for [MEDICATION NAME] 2.0 mg was entered on the eMAR on 04/22/19. Review of the Laboratory Report, collected on 04/22/19 at 9:10 AM, reported on 04/22/19 at 1:29 PM, and faxed to the facility on [DATE] at 1:38 PM, revealed PT: 22.9 High and INR 2.1 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). There was a Notation written on the Laboratory Report by LPN #9, stating 2.0 mg now, same dose, next Monday 29th (04/29/19). Review of Resident #2's Laboratory Report collected on 04/29/19 on 8:47 AM, reported on 04/29/19 at 1:12 PM, and faxed to the facility on [DATE] at 1:41 PM revealed resident's PT: 75.5 High and INR: 6.5 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). There was a Notation written on the Laboratory Report by LPN #9, stating the resident was currently on 4.5 mg, Vitamin K 5 mg one (1) time only, discontinue current [MEDICATION NAME] dose, and recheck lab on 04/30/19. Review of the Progress Note, dated 04/29/19 at 7:00 PM, completed by LPN #9, revealed PT/INR results 75.5/6.5, discontinue current dose of 4.5 mg, redraw on 04/30/19. One (1) time order of Vitamin K given due to results per Nurse Practitioner, family notified. Interview with LPN #9, on 05/23/19 at 3:15 PM, after she reviewed Resident #2's Laboratory Report, dated 04/22/19, and the notation written by her on the Report, revealed the resident was supposed to receive a 2.0 mg dose of [MEDICATION NAME] on 04/22/19, and then keep the dose at 2.0 mg and recheck PT/INR on 04/29/19. Per interview, she did fail to discontinue the 04/18/19 orders for 2.5 mg when she took off the order to change [MEDICATION NAME] to 2.0 mg on 04/22/19. She further stated she was unaware Resident #2 did not receive medication as prescribed from 04/22/19 through to 04/28/19. Interview with the ARNP, on 05/23/19 at 2:58 PM, revealed when she wrote the physician's orders [REDACTED].#2, she expected her orders to be followed. She further stated she wanted Resident #2 to receive a 2.0 mg dose of [MEDICATION NAME] on 04/22/19 and then continue 2.0 mg as the PT/INR levels were within therapeutic range on 04/22/19. Per interview, she ordered Vitamin K for Resident #2 when the PT/INR lab results came back on 04/29/19, as the resident was supratherapeutic. Further interview revealed [MEDICATION NAME] dosages needed to be administered as ordered. Interview with the DON, on 05/23/19 at 3:49 PM, revealed Resident #2's physician's orders [REDACTED]. Post Survey interview on 06/27/19 at 4:02 PM, with the MDS Coordinator, revealed Resident #2's Care Plan should have been developed and implemented related to administering the correct [MEDICATION NAME] dosage as ordered, to prevent adverse consequences such as bleeding. Post Survey interview on 06/27/19 at 4:02 PM, with the Administrator, revealed Resident #2's Care Plan should have been developed accurately to include an intervention to administer the correct [MEDICATION NAME] dosage as prescribed. Per interview, it was his expectation medications were administered as ordered. Review of the facility's Staffing Guidelines Policy, dated 01/31/14, revealed the facility must have adequate staffing to ensure appropriate care is provided to the residents in accordance with accepted professional standards and practices. Further review revealed the Therapy Lodge Unit required two (2) Nurses or one (1) Nurse and one (1) CMT 6:00 AM to 6:00 PM, and one (1) Nurse on the 6:00 PM to 6:00 AM Shift. Further review revealed the Unit required two (2) to four (4) State Registered Nurse Assistants (SRNA) on the 6:00 AM to 6:00 PM shift and two (2) SRNAs on the 6:00 PM to 6:00 AM shift. Staff interviews and review of the facility's Time Punches, revealed the Therapy Lodge Unit on 04/09/19, from 6:00 AM to 2:00 PM, had one (1) LPN, one (1) CMT and two (2) SRNAs. However, from 2:00 PM to 4:00 PM, the Unit only had one (1) LPN and one (1) SRNA; from 4:00 PM to 6:00 PM, the Unit only had one (1) LPN, one (1) CMT working as a SRNA, and one (1) SRNA; and, from 6:00 PM to 10:00 PM there was one (1) LPN and two (2) SRNAs. Therefore, the Unit did not have the minimum requirement of staff according to the facility's Policy on 04/07/19, as the Unit was short two (2) staff members from 2:00 PM to 4:00 PM and the Unit was short one (1) staff member from 4:00 PM to 6:00 PM. 3. Review of Resident #15's medical record revealed the facility admitted the resident on 10/13/17, with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS]. Review of the Comprehensive Care Plan, dated 01/16/19, revealed Resident #15 was at risk for breathing difficulties due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The goal stated the resident would not exhibit any signs of respiratory distress as evidenced by: no shortness of air (SOA), fatigue, cyanosis, restlessness, or wheezing. There were several interventions including: assess for change in level of consciousness, coherency, report changes, monitor and report signs of respiratory distress, monitor lung sounds every shift and as needed, administer oxygen as ordered and monitor oxygen saturation via pulse oximetry as ordered. Review of the Comprehensive Care Plan, dated 01/16/19, revealed Resident #15 was at risk for complications related to Diabetes Mellitus. The goal stated the resident would be free from signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. There were several interventions including: provide bedtime snack, monitor and record intake of food, offer substitutes, monitor for signs of [MEDICAL CONDITION] or [DIAGNOSES REDACTED], obtain accuchecks before meals and at bed time per physician's orders [REDACTED].>Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #15 as having a BIMS score of fourteen (14) out of fifteen (15), revealing the resident was cognitively intact. Further review revealed the facility assessed the resident as having active [DIAGNOSES REDACTED]. Further review revealed the facility assessed the resident as receiving Insulin injections for seven (7) of seven (7) days during the seven (7) day look back period. Continued review revealed the facility assessed the resident as receiving oxygen therapy. Review of the Electronic Medication Administration Record [REDACTED]. However, further review of the eMAR, dated 04/07/19, and the Administration Compliance Report dated 04/07/19, revealed under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for medications scheduled at 4:00 PM. The Care Plan was not implemented related to administering Insulin as ordered. In addition, review of the Electronic Treatment Administration Record (eTAR) dated 04/07/19, revealed orders for oxygen saturations every shift; and accuchecks before meals and at bedtime at 7:30 AM, 11:30 AM, 4:30 PM and 9:00 PM. However, further review of the eTAR dated 04/07/19 and review of the Administration Compliance Report, dated 04/07/19 revealed the interventions for oxygen saturation every shift for the evening shift, and accuchecks at 4:30 PM and 9:00 PM were not documented as completed. Under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware. The Care Plan was not implemented related to obtaining accuchecks and oxygen saturation as ordered. 4. Review of Resident #21's clinical record revealed the facility admitted the resident on 03/28/19, with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 04/04/19, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having [DIAGNOSES REDACTED]. Continued review revealed the facility assessed the resident as receiving anticoagulant medication six (6) days out of the seven (7) day look back period. Review of Resident #21's Comprehensive Care Plan, dated 04/15/19, revealed the resident was at risk for bleeding or blood clots related to use of anticoagulant medication for [MEDICAL CONDITION] Fibrillation. The goal stated the resident would take anticoagulant as ordered without serious complications. The interventions included: adjust medication dosage and document on Medication Administration Record [REDACTED]. Review of the eMAR, dated 04/07/19, revealed active orders for [MEDICATION NAME] 2 mg, one (1) tablet oral once a day at 5:00 PM (anti-coagulant medication). Further review of the eMAR, dated 04/07/18, revealed [MEDICATION NAME] 2 mg (anticoagulant medication), one (1) tablet was scheduled at 5:00 PM. Continued review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for the [MEDICATION NAME] 2 mg scheduled at 5:00 PM. This indicated the Care Plan was not implemented related to anticoagulation administration as ordered. 5. Review of Resident #13's medical record revealed the facility admitted the resident on 12/20/18 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 01/09/19, revealed the resident was at risk for breathing difficulties. The goal with a target date of 07/31/19, revealed the resident would not exhibit signs of respiratory distress. There were several interventions including: monitor lung sounds every shift and as needed, administer oxygen at two (2) liters via nasal cannula continuously, and obtain oxygen saturation via pulse oximetry every shift and as needed. Review of the Comprehensive Care Plan, dated 01/09/19, revealed the resident was at risk for complications related to Diabetes Mellitus. The goal with a target date of 07/31/19 revealed the resident would be free of signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] through next review. The approaches included: administer Insulin per physician's orders [REDACTED]. Review of the Comprehensive Care Plan, dated 01/09/19, revealed the resident was at risk for breathing difficulties and was on continuous oxygen related to Obstructive Sleep Apnea, and Pneumonia. The goal with a target date of 07/31/19 revealed the resident would not exhibit shortness of air, wheezing, dizziness, and changes in level of consciousness. There were several interventions including: administer oxygen at two (2) liters via nasal cannula, continuously, assess for changes in level of consciousness, monitor and report signs of respiratory distress, monitor lungs sounds every shift and as needed, and obtain oxygen saturation via pulse oximetry every shift and as needed. Review of the Quarterly MDS Assessment, dated 03/27/19, revealed the facility assessed Resident #5 as having a BIMS score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having an active [DIAGNOSES REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed the following medications were scheduled at 7:00 PM to 10:00 PM: [MEDICATION NAME] Insulin, 100 unit/mL administer 14 units. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for [MEDICATION NAME] 100 unit/mL administer 14 units scheduled 7:00 PM to 10:00 PM. The Care Plan was not implemented related to administration of Insulin as ordered. Review of the eTAR, dated 04/07/19, revealed orders for Accucheck twice a day, and oxygen saturation every shift. However, review of the eTAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware. The Care Plan was not implemented related to monitoring blood glucose and oxygen saturation as ordered. 6. Review of Resident #2's medical record revealed the facility admitted the resident on 10/14/18 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 02/06/15, revealed the resident was at risk for bleeding and abnormal bruising related to use of anticoagulant. The goal with a target date of 08/15/19, revealed the resident would be free of signs and symptoms of excess bleeding or bruising. There were several interventions including: monitor for bleeding from gums during oral care, monitor stool and emesis for obvious signs of bleeding, and report signs and symptoms of excess bruising of unknown origins. However, the Care Plan was not developed with an intervention to administer anticoagulant medication as ordered. Review of the Comprehensive Care Plan, dated 02/19/15, revealed the resident was at risk for adve

Based on interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system in place to ensure sufficient numbers of nursing staff were available to provide nursing care on a twenty-four (24) hour basis for twenty-four (24) of thirty-eight (38) sampled residents (Residents #2, #3, #4, #5, #7, #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30). Staff interviews and review of the facility's Time Punches, revealed the Therapy Lodge Unit on 04/07/19, did not have the minimum requirement of staff according to the facility's Policy on 04/07/19, as the Unit was short two (2) staff members from 2:00 PM to 4:00 PM and was short one (1) staff member from 4:00 PM to 6:00 PM. Interview with Licensed Practical Nurse (LPN #1) revealed he was scheduled to work 6:00 AM to 6:00 PM on 04/07/19, but due to a call in, he was informed he would be working until 10:00 PM. Staff interviews revealed LPN #1 was the only licensed nurse on the Therapy Lodge Unit for twenty-nine (29) residents to perform treatments as well as provide other care to be performed by a licensed nurse as prescribed, from 6:00 AM until 10:00 PM. Also, after the Certified Medication Technician (CMT) left at 2:00 PM, LPN #1's duties included administering medications to twenty-nine (29) residents. Review of the screen shots of LPN #1's phone related to outgoing phone calls and text messages on 04/07/19, revealed LPN #1 reached out to the Director of Nursing (DON), Administrator, and the Staffing Coordinator ten (10) times between 7:45 AM and 5:42 PM and interview with LPN #1 revealed the phone calls were related to the staffing issue. However, the facility failed to take action to assure there was sufficient staffing available between the hours of 2:00 PM and 6:00 PM, when staffing was below the required minimum. As a result, twenty-four (24) residents did not receive their medications and/or treatments and/or other care as scheduled from 2:00 PM until 10:00 PM. This affected Residents #2, #3, #4, #5, #7, #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30. The facility's failure to have an effective system in place to ensure sufficient numbers of nursing staff to provide care on a twenty-four (24) hour basis has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate jeopardy (IJ) was identified on 05/23/19 and determined to exist on 04/07/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 alleging removal of the Immediate Jeopardy on 06/06/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/06/19, prior to exit on 06/07/19 with remaining non-compliance at a Scope and Severity of a [NAME] while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Staffing Guidelines Policy, dated 01/31/14, revealed the facility must have adequate staffing to ensure appropriate care is provided to the residents in accordance with accepted professional standards and practices. Further review revealed the Therapy Lodge Unit required two (2) Nurses or one (1) Nurse and one (1) CMT 6:00 AM to 6:00 PM, and one (1) Nurse on the 6:00 PM to 6:00 AM Shift. Further review revealed the Unit required two (2) to four (4) State Registered Nurse Assistants (SRNA) on the 6:00 AM to 6:00 PM shift and two (2) SRNAs on the 6:00 PM to 6:00 AM shift. Staff interviews and review of the facility's Time Punches, revealed the Therapy Lodge Unit on 04/09/19, from 6:00 AM to 2:00 PM, had one (1) LPN, one (1) CMT and two (2) SRNAs. However, from 2:00 PM to 4:00 PM, the Unit only had one (1) LPN and one (1) SRNA; from 4:00 PM to 6:00 PM, the Unit only had one (1) LPN, one (1) CMT working as a SRNA, and one (1) SRNA; and, from 6:00 PM to 10:00 PM there was one (1) LPN and two (2) SRNAs. Therefore, the Unit did not have the minimum requirement of staff according to the facility's Policy on 04/07/19, as the Unit was short two (2) staff members from 2:00 PM to 4:00 PM and the Unit was short one (1) staff member from 4:00 PM to 6:00 PM. Review of Resident #2, #3, #4, #5, #7, #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30's Electronic Administration Records (eMAR) dated 04/07/19, Treatment Administration Records (eTAR), dated 04/07/19, and the correlating Administration Compliance Report, dated 04/07/19, revealed documentation by LPN #1 stating Not administered: not adequately staffed, management aware for medications, scheduled on 04/07/19, between 2:00 PM and 10:00 PM, on the Therapy Lodge Unit. Review of the screen shots of LPN #1's phone sent to the State Agency Representative, revealed on 04/07/19, LPN #1 phoned the DON at 1:38 PM, 4:10 PM, and 5:42 PM and phoned the Administrator on 04/07/19 at 2:09 PM and 3:58 PM. Continued review revealed LPN #1 also text messaged the Administrator on 04/07/19 at 7:45 AM, stating he did not have relief when the shift ended at 6:00 PM; at 8:55 AM, stating again he did not have relief and was the only nurse for twenty-nine (29) residents and his CMT would be leaving at 2:00 PM; and, at 3:45 PM letting the Administrator know he could not stay past 6:00 PM that night. LPN #1 also text messaged the Staffing Coordinator at 12:23 PM and at 3:38 PM asking her when he would have relief. Interview with LPN #1, on 05/14/19 at 3:30 PM, revealed he was the only nurse on the Therapy Lodge Unit, on 04/07/19 from 6:00 AM until 10:00 PM for a total of twenty-nine (29) residents. Per interview, when the CMT left at 2:00 PM, there was just him and a SRNA to provide care for twenty-nine (29) residents from 2:00 PM until 4:00 PM. He stated, during this time he had to assist the SRNA with toileting, and assisting those residents to bed who needed to lie down before supper. He further stated at 4:00 PM, another CMT was sent to the unit, but she had to work as an aide on the floor and therefore was unable to assist with passing medications. Per interview, on 04/07/19, during the evening shift on the Therapy Lodge Unit, the required minimum staffing was two (2) licensed nurses or one (1) licensed nurse and a CMT and at least two (2) to three (3) SRNAs from 6:00 AM through 6:00 PM. Further interview revealed he did contact the Staffing Coordinator, DON, and Administrator via phone calls or texting related to the staffing situation, and was just told to do the best he could. However, he stated due to insufficient staff the evening of 04/07/19, he was unable to administer medications, perform treatments and deliver other services required of a licensed nurse to all residents. Interview with LPN #2, on 05/15/19 at 4:00 PM, revealed the Staffing Coordinator did call her and ask if she could come to work at 6:00 PM, on 04/07/19; however, she informed the Staffing Coordinator she would not be able to come in early and would be at the facility at 10:00 PM. She stated when she arrived for duty on 04/07/19 at 10:00 PM, LPN #1 informed her he was unable to perform treatments and administer all residents medications due to staffing, and only six (6) residents had received their medications after the CMT left at 2:00 PM. LPN #2 stated LPN #1 told her he had contacted the DON, and the Administrator, to let them know he was left alone to take care of twenty-nine (29) residents and could not provide care for that many residents. Interview with CMT #1, on 05/15/19 at 2:30 PM, revealed she was sent to the Therapy Lodge Unit to work as a SRNA on the floor, on 04/07/19 at 4:00 PM, and she worked until 6:00 PM. She confirmed when she arrived on the unit there was just one (1) SRNA and LPN #1. Further interview revealed she (CMT #1) did not assist LPN #1 with administering medications as she and SRNA #2 had to provide direct care to the residents. Continued interview revealed LPN #1 was noticeable upset and making phone calls while seated at the desk at the nurse's station. Per interview, LPN #1 stated the facility had left him by himself as the only staff to pass medications and perform the treatments and other duties required to be completed by a licensed nurse. Interview with SRNA #2 on 05/16/19 at 8:17 AM revealed she worked with LPN #1 on 04/07/19 from 6:00 AM until 10:00 PM. Per interview, LPN #1 did have to help her with toileting residents and assisting residents to bed for naps between 2:00 PM and 4:00 PM when she and LPN #1 were the only staff on the Unit. Interview with the Staffing Coordinator, on 05/15/19 at 3:12 PM, revealed LPN #1 messaged her on the staffing scheduler's phone to let her know there was nobody to cover for him on 04/07/19 at 6:00 PM. Per interview, he also notified her the CMT would be leaving at 2:00 PM. She stated she informed LPN #1 she was working on finding him coverage due to the person who had been scheduled to relieve him at 6:00 PM, had called in sick. She revealed she did contact LPN #2 who told her she would be unable to come in until 10:00 PM. When asked what the protocol was for finding coverage when a staff member called in, and what actions she took in trying to find coverage for LPN #1 besides calling LPN #2, she stated she was unable to answer those questions. When questioned about her system for ensuring the Units had at least the minimum staffing requirements, as per the facility's Policy each shift, she stated she was unable to answer any further questions. Interview with the DON, on 05/23/19 at 3:49 PM, revealed LPN #1 called her on 04/07/19 to inform her the unit was short staffed and she remembered telling him the Staffing Coordinator was attempting to find coverage. However, she stated she was not aware LPN #1 did not actually administer the medications and treatments to the residents on the Therapy Lodge Unit on the evening of 04/07/19, until she was notified on 04/08/19. Further interview revealed she did acknowledge the Therapy Lodge Unit was below the required staffing numbers on the evening of 04/07/19. She stated the facility used a master grid for scheduling staff and the Staffing Coordinator was to find coverage when there was a call in. Per interview, she monitored for the deployment of sufficient and competent staff by observing on the units to make sure staff was delivering care as necessary. She stated she expected the Staffing Coordinator to follow the staffing guidelines to ensure the facility was appropriately staffed. Interview with the Administrator on 05/23/19 at 3:11 PM, revealed LPN #1 had contacted him related to the staffing situation on 04/07/19 and he was aware of how stressed LPN #1 was related to staffing that evening. However, the Administrator stated he was unaware LPN #1 did not administer the residents medications and treatments on the evening of 04/07/19, until he was informed on 04/08/19. Per interview, there should have been action taken to ensure sufficient staff was available after LPN #1 notified the Staffing Coordinator, the DON and himself of the staffing problem on the Therapy Lodge Unit. He stated it was his expectation there was sufficient staff to resident ratios on the Units at all times as per Policy. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 that alleged removal of the Immediate Jeopardy (IJ) on 06/06/19. Review of the AoC revealed the facility implemented the following. 1. The Administrator was provided counseling and assistance on 05/29/19 by the President and Chief Executive Officer (CEO) of the facility's minimum staffing standards and the steps to take when the daily schedule did not meet the standards. On 06/05/19, the CEO and Administrator met again and the CEO re-emphasized with the Administrator that it was the Administrator's responsibility to ensure care and services were provided for the residents, twenty-four (24) hours a day. 2. On 05/30/19, the Administrator educated/reviewed with the Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UM) the actions to take if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to the residents. 3. On 6/05/19, the Administrator and the Social Services Director visited all interviewable residents and asked if they have been receiving medications, treatments and services to their satisfaction. They were also asked if they knew who to report to if they had issues. The Administrator and Social Services Director will continue to interview the residents two (2) times a week for one (1) month. The Quality Assurance (QA) team will determine ongoing frequency based on findings after the first month. 4. On 04/09/19, the Director of Nursing (DON) notified the Physician/Advanced Registered Nurse Practitioner (ARNP) of the missed medications on 04/07/19 with follow-up orders implemented as indicated for Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30. Additionally the DON assessed the residents to determine if there was any adverse effects to the residents that missed their medications with no adverse effects noted. 5. The Resident Representatives were notified of the missed medications on 04/11/19 and 04/12/19 by the DON and Registered Nurse (RN) #2 for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30. 6. Licensed Practical Nurse (LPN) #2, who did not report the previous nurse's missed medication administration, was provided education related to the facility's policies related to notification on 04/14/19 and again on 05/31/19 by the Staff Development Director (SDD). 7. Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25, and #28 and all other current in-house residents, will be administered their medications and treatments in accordance with the Medical Doctor's (MD)/ARNP's orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) will be checked, by the Administrator and/or DON for late and due medication administrations. The MARS and TARS will be checked twice daily for two (2) weeks, then once daily for one (1) month and will then be re-evaluated by the Quality Assurance Performance Improvement (QAPI) committee to determine ongoing frequency. 8. The facility had employed twenty-eight (28) new staff, ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN) and twelve (12) State Registered Nurses Aides (SRNA), since 04/01/19. This was done to fill positions on the nursing schedule to provide staffing and to provide nursing and related services. This will assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house resident. 9. To assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house residents, care observations of six (6) residents will be completed, two (2) residents will be observed per wing. These observations will be performed by the Administrative Nursing Staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors weekly for two (2) months and will then be re-evaluated by the QAPI committee to determine ongoing frequency using the Care Observation tool. The first observation occurred on 06/03/19. 10. The CEO, Administrator and DON developed facility Minimum staffing standards, and procedures to take when the daily schedule did not meet the established facility staffing standards. The procedures included: a) when there was a call in at the last minute, the designated staffing person will try to find a replacement. If a replacement could not be found, the designated staffing person will look at moving staff around if there is extra staff available on another unit; b) There may be times when the staff member was a no-call, no-show. In this case, a nurse at the facility must call the designated staffing person to inform them of the no-show. c) If the staffing person could not be reached, the nurse will call the DON. If the DON could not be reached, the nurse will call the Administrator. If the staffing level on any day falls below the minimum staff level, one (1) of the administrative staff will be asked to come in to support the staff currently working. d) Due to weekends being more difficult to staff, the Unit Managers and other Nursing Directors agreed to a weekend on call schedule and will be available to come in on the weekends if staff drops below the minimum staffing level. 11. Resident #1 is no longer on [MEDICATION NAME]. The facility currently had three (3) Residents including Resident #2, which were required to have [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) labs, and have their PT/INR labs obtained/followed-up in accordance with their Physician/ARNP orders and their care plan as determined by PT/INR monitoring. The DON will track [MEDICATION NAME] labs and follow-up orders. Three (3) times a week on weekdays, a binder that contains a lab log page for each resident will be brought to the morning meeting. The DON will initial she reviewed the labs, including the PT/INR, to check that labs were collected and reported timely to the Physicians/ARNPs. The DON or Unit Managers (UM) will also check with the lab to ensure the lab is in a Pending status, which indicates the lab work is in process. Lab tracking sheets are now being used and will be brought to the morning meeting. [MEDICATION NAME] tracking sheets were implemented for each resident on [MEDICATION NAME]. The DON will initial that she has reviewed labs and the [MEDICATION NAME] tracking sheets to verify that they have been obtained and reported to the attending Physician/APRN in a timely manner. 12. Facility licensed nursing staff were provided in-service education on 05/30/29; 05/31/19; 06/01/19; 06/02/19; 06/03/19; and, 06/04/19 by the DON and SDC on the following: the requirement to administer resident medications in accordance with the Medical Doctor (MD)/ARNP orders and the resident care plan; the need to notify a fell ow charge nurse, their Unit Manager, the QA Nurse, the SDC, or the DON if they were unable to complete medication administration for their assigned residents in accordance with the /ARNP orders and the resident care plan so that assistance would be provided; the requirement to perform PT/INR labs in accordance with MD/APRN orders and the resident care plan; the requirement to notify the MD/APRN and the Resident Representative if medications were not administered to the resident in accordance with their orders, care plan and facility policy; and, the components of the facility's Abuse/Neglect Policy, including what constitutes abuse/neglect and the reporting aspects if a staff has neglected to provide medications or treatments to residents, and the disciplinary action that will be implemented for failure to follow the requirements, which is disciplinary action up to termination, was addressed in this training. 13. A review of the facility's staffing, as compared to the established staffing standards, will be provided to the Board of Directors at their monthly meeting. This will include, but not be limited to, the protocol steps taken by the facility when the daily schedule did not meet the established staffing standards. 14. The DON and Administrator have and will continue to monitor staffing levels based on census and acuity levels. The facility developed a Minimum Staffing Target worksheet that established a minimum staffing level for all three units for all three shifts. The instructions on the sheet indicated what the Managers were to do in the case of a call-in or shortage and what to do if a replacement could not be found. It listed the DON's and Administrator's phone number for assistance. The State Survey Agency validated the implementation of the facility's A[NAME] as follows: 1. Record Review confirmed the President and CEO of the facility provided counseling and assistance to the Administrator, on 05/29/19, related to the minimum staffing standards and the steps to take when the daily schedule did not meet the established standards. Record Review of the document titled, Minimum Staffing Targets, 2019, dated 05/29/19, confirmed the Administrator was educated by the President and CEO of the facility on minimum staffing standards and steps to take when the daily schedule did not meet the established standards. Further review confirmed the Administrator reviewed Scoring Rules for staffing and ratings with the President and CEO. Continued review confirmed, the President and CEO again met with the Administrator to ensure care and services were provided for the residents, twenty-four (24) hours a day. Interview with the Administrator on 06/07/19 at 1:10 PM revealed he received counseling related to ensure minimum staffing standards and the steps to take when the daily schedule did not meet the standard. Continued interview revealed he was also educated that it was the Administrator's responsibility Interview with the President and CEO of the facility, on 06/07/19 at 2:01 PM, confirmed he met with the Administrator several times about staffing concerns and the need for the facility to make the resident's care a priority. Further interview revealed, the administrator was educated on facility staffing standards, and the administrator's responsibility twenty-four (24) hours a day to ensure care and services are provided. 2. Review of the Chain of Command, dated 06/06/19, validated the administrator educated/reviewed with the DON, SDC, and Unit Managers about what they would need to do if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to our residents. Interview with the DON on 06/06/19 at 1:49 PM, confirmed she had received education related to the facility's Chain of Command, staffing standards Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking and Notification of Change. Interview with South Wing Unit Manager, on 06/07/19 at 12:00 PM and the Staff Development Coordinator (SDC), at 1:00 PM, confirmed they were educated on the Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking, Notification of Change, Chain of Command and Staffing Standards. 3. Review of the Midnight Census Worksheet utilized 06/05/19 with resident statements confirmed, revealed the Administrator and the Social Services Director (SSD) visited all interviewable residents and asked if they had been receiving care, medications, treatments and services and if care was to their satisfaction. They were also questioned related to who they should report issues to, regarding care provided. Interview with the Administrator, on 06/07/19, confirmed interviewable residents were asked if they were receiving their medications, treatments, and care to their satisfaction. Per interview, the interviewable residents were also asked if they were aware of how to report problems concerning their care, and who they should notify if there was a concern related to care. Further interview revealed the SSD and Administrator were able to interview fifty (50) residents. Per interview, interviews were scheduled to continue two (2) times weekly for one (1) month and then the Quality Assurance team would determine the ongoing frequency based on the findings. 4. Review of the Medication Error Report Sheets, dated 04/09/19, revealed notification was made by the Director of Nursing (DON) to the Physician/Advanced Practice Registered Nurse (APRN) for each of Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29 and #30 from 04/08/19 to 04/09/19. The Physicians/APRN was notified the residents listed above, on the Therapy Unit, did not received their medications on 04/07/19 from the time of 3:00 PM to 10:00 PM. Interview with the DON, on 06/06/19 at 3:39 PM, confirmed she had informed the Physician/APRN and the Resident Representative of medications not being administered to Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30 on 04/07/19. Continued interview revealed she assessed all of the residents by observation, clinical review, such as monitoring blood pressure and blood sugars, and record review for any adverse effects of missing their medications and there were no adverse effects on any of the residents. Interview with Physician #1, on 05/22/19 at 9:30 AM, confirmed he was notified the residents on the Therapy Unit had not received their evening medications on 04/07/19. He reported he had been informed of this immediately after the facility became aware of the situation on 04/08/19 but could not recall the time. Further interview revealed, there were plans for ongoing monitoring of vital signs, pain or any changes related to medications missed to assure there are no adverse effects. Interview with Physician #2, on 05/22/19 at 8:30 PM, confirmed he was informed on 04/08/19 the residents on the Therapy Unit did not receive their medications the night of 04/07/19. Physician #2 also confirmed during the interview, the DON and his Nurse Practitioner discussed the incident prior to him having knowledge. Further interview confirmed he was uncertain of when he was informed. Physician #2 requested the Residents effected have their vital signs monitored and the nursing staff alert the Physician of any adverse changes. 5. Review of the Medication Error Report Sheets, dated 04/09/19, revealed notification was made by the DON and RN # 2 to the Resident Representatives between 04/11/19 and 04/12/19 informing them medications had not been administered for Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29 and #30. The Resident Representatives were also informed the Resident's Physician/APRN had been informed of the missed medications. Interview with RN #2, on 06/06/19, confirmed he did notified six (6) to seven (7) of the Resident Representative to inform them the residents did not receive their medications the evening of 04/07/19 on the Therapy Unit. Interview with the DON, on 06/06/19, confirmed she and RN #2 did notify the Resident Representatives of the residents not receiving medications on the evening of 04/07/19.3 6. Review of the Education Sign-In Roster, dated 04/14/19 and 05/31/19, revealed Licensed Practical Nurse (LPN) #2, who did not report the previous nurses' missed medication administration, was provided education by the Staff Development Director (SDD). Continued review revealed education included the Scope of Practice, High Risk Medication, Medication Administration, Abuse and Change in Condition Process, Interview with LPN #2, on 06/06/19 at 7:35 PM, confirmed education was received over the last few weeks. LPN #2 stated the physician should have been notified at the time she received the information. The previous nurse, LPN #1, had not informed the physician the medications had not been given the evening of 04/07/19, but informed LPN #2 when giving report. 7. Review of the Medication Administration Checks, initiated on 06/01/19, validated Resident #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25 and #28, and all other current in-house residents, were administered their medications and treatments in accordance with the Medical Doctor's (MD)/APRN orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) were checked twice daily by the Administrator of DON. The MARS and TARS checks were initiated twice daily beginning 06/01/19 to present. Interview with the DON, on 06/07/19 at 1:49 PM, confirmed the MAR and TAR have been monitored twice daily by herself or the Administrator. Interview with the Administrator, on 06/07/19 at 1:08 PM, confirmed the MARs and TARS are monitored and reviewed for any missed or past due medications. The Administrator confirmed the MARS and TARS are check twice daily and will continue to be check twice each day for two (2) weeks, then once daily for one (1) month and then will be evaluated by QAPI committee to determine ongoing frequency. Per interview, if any issues are found, the DON will be contacted to follow-up with the floor nurse during the week and on the weekends. 8. Review of the facility's Human Resources records, New Hire list, dated 04/01/19 to present, validated the facility had employed twenty-eight (28) new staff. Continued review revealed ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN), and twelve (12) State Registered Nurses Aides (SRNA) were hired by the facility since 04/01/19. Interview with the DON, on 06/06/19 at 1:49 PM, confirmed the facility has hired many new nurses and aides and had increased the staffing level. This facility has joined with a corporation that will assist with staffing. Further interview confirmed the facility is following the Minimum Staffing Target, 2019. Continued interview revealed if they did not meet the minimum level of staffing, Managers had been educated to call the Unit Managers and they can work the carts and they are able to contact an agency nursing staff. Interview with the Administrator, on 06/07/19 at 1:08 PM, confirmed if the facility's minimum staffing level was not achieved, the DON and or Administrator was notified. Continued interview revealed staff may be moved around to provide coverage to each unit. Further interview revealed on the weekends, administrative staff will come in to support staff working if staffing levels fall below the minimum staffing level. 9. Review of the Resident Observation Tool validated care observations of six (6) residents weekly was initiated as of 06/03/19. Continued review revealed the Resident Observation Tool confirmed two residents were observed per wing. Further review revealed the observations were performed by the administrative nursing staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors. Interview with the North Hall Unit Manager, on 06/07/19 at 11:15 AM, confirmed the administrative staff was responsible to complete resident observations for six (6) residents, two (2) from each unit using the Resident Observation Tool. Interview with the Quality Nurse (QA) nurse, on 06/07/19 at 2:07 PM, revealed the DON, Administrator or herself would utilize the Resident Observation Tool for six (6) Residents. Continued interview revealed two (2) residents on each unit would be observed using the tool for two (2) months, then it would be re-evaluated to make a decision if they were going to do it once a week. Interview with the DON, on 06/06/19 at 1:49 PM, revealed she and the Quality Assurance (QA) Nurse use the Resident Observation Tool. Per interview, two (2) residents are selected from every unit to observe the care. Further interview revealed this tool is utilized weekly for a total of two (2) months. Per int

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system to ensure residents were free from significant medication errors for eleven (11) of thirty-eight (38) sampled residents (Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, and #28). Resident #2's physician's orders [REDACTED]. Per these orders, Resident #2 was to receive [MEDICATION NAME] 4.5 mg from 04/18/19 through 04/21/19. A new physician's orders [REDACTED]. However, the physician's orders [REDACTED]. On 04/29/19, lab results revealed PT: 75.5 High and INR: 6.5 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1) and Resident #2 received Vitamin K 5 mg on 04/29/19. (Refer to F-757) Additionally, review of Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, and #28's Electronic Medication Administration Records (eMAR) and the correlating Administration Compliance Report, dated 04/07/19, revealed documentation by Licensed Practical Nurse (LPN) #1, stating Not administered: not adequately staffed, management aware for significant medications scheduled between 4:00 PM and 10:00 PM on the Therapy Lodge Unit. The significant medications that were not administered included: Insulin; Anti-Hypertensive Medications; Anticoagulant Medications; Antibiotics; Anti-[MEDICAL CONDITION] Medications; [MEDICATION NAME]; and Anti-arrhythmic Medications. Interview with Licensed Practical Nurse (LPN) #1, who was the only nurse on the Therapy Unit Lodge from 6:00 AM to 10:00 PM, for twenty-nine (29) residents, revealed after the Certified Medication Technician (CMT) left at 2:00 PM, there was not adequate staffing and he was unable to perform medication administration pass to all residents on the unit. (Refer to F-600 and F-725) The facility's failure to have an effective system in place to ensure residents were free from significant medication errors has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 05/23/19 and determined to exist on 04/07/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 alleging removal of the Immediate Jeopardy on 06/06/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/06/19, prior to exit on 06/07/19 with remaining non-compliance at a Scope and Severity of a [NAME] while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Policy, titled Home-Like Medication Administration, dated 10/18/11, revealed the policy objective was to provide quality nursing care and medication administration while also honoring the resident's right to set their own daily schedule. Continued review of the Policy, revealed [MEDICATION NAME] (anticoagulant medication) will be administered in the afternoon. Further review of the Policy, revealed all administration times may be adjusted to best suit a resident's needs if Physician approval is obtained. 1. Review of Resident #2's clinical record revealed the facility admitted the resident on 10/14/18 with [DIAGNOSES REDACTED]. Further review of Resident #2's clinical record revealed physician's orders [REDACTED]. According to these orders, Resident #2 was to receive [MEDICATION NAME] 4.5 mg from 04/18/19 through 04/21/19. Review of physician's orders [REDACTED]. Review of the (MONTH) 2019 Electronic Medication Administration Record [REDACTED]. However, further review of the (MONTH) 2019 eMAR, revealed the resident received 4.5 mg of [MEDICATION NAME] 04/22/19 through 04/28/19, instead of the ordered 2.0 mg of [MEDICATION NAME]. This was due to the new physician's orders [REDACTED]. LPN #9 failed to discontinue the order dated 04/18/19 for [MEDICATION NAME] 2.5 mg when she took off the order to change [MEDICATION NAME] to 2.0 mg on 04/22/19. Review of Resident #2's Laboratory Report, collected on 04/22/19 at 9:10 AM, reported on 04/22/19 at 1:29 PM, and faxed to the facility on [DATE] at 1:38 PM, revealed results of PT: 22.9 High and INR 2.1 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). The Notation written on the Laboratory Report by Licensed Practical Nurse (LPN) #9, revealed 2.0 mg now, same dose, next Monday 29th (04/29/19). Review of the Laboratory Report collected on 04/29/19 on 8:47 AM, reported on 04/29/19 at 1:12 PM, and faxed to the facility on [DATE] at 1:41 PM revealed results of PT: 75.5 High and INR: 6.5 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). The Notation written on the Laboratory Report by LPN #9, revealed the resident was currently on 4.5 mg, Vitamin K 5 mg one (1) time only, discontinue current [MEDICATION NAME] dose, and recheck lab on 04/30/19. Review of Resident #2's Progress Note, dated 04/29/19 at 7:00 PM, written by LPN #9, revealed PT/INR results 75.5/6.5, discontinue current dose of 4.5 mg, redraw on 04/30/19. One (1) time order of Vitamin K given due to results per Nurse Practitioner, family notified. Interview with LPN #9, on 05/23/19 at 3:15 PM, after she reviewed Resident #2's Laboratory Report, dated 04/22/19, and looked at the notation written by her on the Report, revealed the resident was to receive a 2.0 mg dose of [MEDICATION NAME] on 04/22/19, and then keep the dose at 2.0 mg and recheck PT/INR levels on 04/29/19. She stated she inadvertently failed to discontinue the 04/18/19 orders for [MEDICATION NAME] 2.5 mg when she took off the order to change [MEDICATION NAME] to 2.0 mg on 04/22/19. Per interview, she was also unaware the resident did not receive medication as prescribed from 04/22/19 through to 04/28/19. Interview with the Advanced Registered Nurse Practitioner (ARNP), on 05/23/19 at 2:58 PM, revealed when she wrote physician's orders [REDACTED]. She further stated she wanted Resident #2 to receive a 2.0 mg dose of [MEDICATION NAME] on 04/22/19 and then continue [MEDICATION NAME] 2.0 mg as the PT/INR levels were within therapeutic range on 04/22/19. Per interview, she ordered Vitamin K for Resident #2 when the PT/INR lab results came back on 04/29/19, as the resident was supratherapeutic. Interview with the Director of Nursing (DON), on 05/23/19 at 3:49 PM, revealed it was important to ensure residents received [MEDICATION NAME] dosages as prescribed to prevent adverse consequences. Per interview, Resident #2's [MEDICATION NAME] orders should have been inputted accurately into the eMAR by the nurse on 04/22/19. Further interview revealed as a result of the resident not receiving [MEDICATION NAME] as prescribed, the resident received Vitamin K on 04/29/19. Interview with the Administrator, on 05/23/19 at 3:11 PM, revealed it was his expectation the nurses accurately input physician's orders [REDACTED]. Further interview revealed it was his expectation Resident #2 receive medications as prescribed. The following are examples from record review of significant medication errors related to medications not being administered as prescribed on 04/07/19 between 4:00 PM and 10:00 PM on the Therapy Lodge Unit, by LPN #1. 2. Review of Resident #15's clinical record revealed the facility admitted the resident on 10/13/17, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 4:00 PM. In addition, review of Resident #15's physician's orders [REDACTED]. Review of Resident 15's eMAR, dated (MONTH) 7, 2019, revealed the following medications were scheduled at 4:00 PM: [MEDICATION NAME] Insulin 100 units/milliliter (ml), 10 units SQ and [MEDICATION NAME] 25 mg tablet. In addition, the following medications were scheduled 7:00 PM to 10:00 PM: [MEDICATION NAME] tablet 5 mg; [MEDICATION NAME] HCL tablet 0.1 mg; and [MEDICATION NAME] 100 mg tablet. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for all medications scheduled for all medications scheduled at 4:00 PM and for all medications scheduled 7:00 PM to 10:00 PM. Review of Resident #15's Nurse's Notes, for the month of (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's Insulin and blood pressure medications in order to seek guidance related to the missed medications. 3. Review of Resident #13's clinical record revealed the facility admitted the resident on 12/20/18 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated 04/07/19, revealed the [MEDICATION NAME] 100 unit/mL, administer 14 units was scheduled at 7:00 PM to 10:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for the [MEDICATION NAME] Insulin scheduled 7:00 PM to 10:00 PM. Review of Resident #13's Nurse's Notes, for the month of (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's Insulin on 04/07/19 in order to seek guidance related to the missed medications. 4. Review of Resident #2's clinical record revealed the facility admitted the resident on 10/14/18 with [DIAGNOSES REDACTED]. Review of Resident #2's clinical record revealed the facility admitted the resident on 10/14/18 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. revealed Losartan 50 mg tablet orally was scheduled 7:00 PM to 10:00 PM (anti-hypertensive medication), and [MEDICATION NAME] 25 mg tablet ½ tablet to equal 12.5 mg orally was scheduled 7:00 PM to 10:00 PM (antihypertensive medication). Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 5.5 mg tablet was scheduled to be administered at 5:00 PM; and Losartan 50 mg tablet and [MEDICATION NAME] 25 mg tablet ½ tablet to equal 12.5 mg were scheduled to be administered 7:00 PM to 10:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, revealed under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for [MEDICATION NAME] 5.5 mg scheduled at 5:00 PM; and the Losartan 50 mg tablet; [MEDICATION NAME] 25 mg tablet ½ tablet to equal 12.5 mg scheduled 7:00 PM to 10:00 PM. Review of Resident #2's Nurse's Notes, for the month of (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's anticoagulant and antihypertensive medication on 04/07/19 in order to seek guidance related to the missed medications. 5. Review of Resident #21's clinical record revealed the facility admitted the resident on 03/28/19, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 2.0 mg was scheduled at 5:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for [MEDICATION NAME] 2.0 mg scheduled at 5:00 PM. Review of Resident #21's Nurse's Notes, for the month of (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's anticoagulant medication on 04/07/19 in order to seek guidance related to the missed medications. 6. Review of Resident #14's clinical record revealed the facility admitted the resident on 04/24/17, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. In addition, review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 4.0 mg was scheduled at 5:00 PM and Losartan 50 mg, one (1) tablet was scheduled 7:00 PM to 10:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for the [MEDICATION NAME] 4.0 mg scheduled at 5:00 PM and the Losartan 50 mg scheduled for 7:00 PM to 10:00 PM. Review of Resident #14's Nurse's Notes, dated (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's anticoagulant medication or anti-hypertensive medication on 04/07/19 in order to seek guidance related to the missed medications. 7. Review of Resident #23's clinical record revealed the facility admitted the resident on 05/03/17, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] tablet 25 mg was scheduled to be administered 7:00 PM-10:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for all medications scheduled 7:00 PM to 10:00 PM. Review of Resident #23's Nurse's Notes, dated (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's blood pressure medication on 04/07/19 in order to seek guidance related to the missed medications. 8. Review of Resident #28's clinical record revealed the facility admitted the resident on 03/27/19, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed the following medications were scheduled at 7:00 PM to 10:00 PM: [MEDICATION NAME] tablet 50 mg, and [MEDICATION NAME] Capsule 100 mg. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for the [MEDICATION NAME] capsule 100 mg and the [MEDICATION NAME] 50 mg tablet scheduled 7:00 PM to 10:00 PM. Review of Resident #28's Nurse's notes, dated (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's anticoagulant medication on 04/07/19 in order to seek guidance related to the missed medications. 9. Review of Resident #12's clinical record revealed the facility admitted the resident on 05/25/17 with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed [MEDICATION NAME] 30 mg tablet was scheduled to be administered 7:00 PM-10:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for the [MEDICATION NAME] 30 mg tablet scheduled 7:00 PM to 10:00 PM. Review of Resident #12's Nurse's Notes, dated (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's anti-[MEDICAL CONDITION] medication on 04/07/19 in order to seek guidance related to the missed medications. 10. Review of Resident #24's clinical record revealed the facility admitted the resident on 01/13/17, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed the following medications were scheduled at 8:00 PM: [MEDICATION NAME] tablet 6.25 mg and [MEDICATION NAME] 24 hour, 0.4 mg/hr. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for [MEDICATION NAME] tablet 6.25 mg scheduled to be administered at 8:00 PM, and the [MEDICATION NAME] 24 hour, 0.4 mg/hr scheduled to be administered 8:00 PM. Review of Resident #24's Nurse's Notes, dated (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's [MEDICATION NAME] and [MEDICATION NAME] medication on 04/07/19 in order to seek guidance related to the missed medications. 11. Review of Resident #7's clinical record revealed the facility admitted the resident on 02/02/18 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 2019, revealed the following medications were scheduled at 7:00 PM to 10:00 PM: [MEDICATION NAME] 25 mg, and [MEDICATION NAME] 225 mg tablet. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, dated 04/07/19, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for all medications scheduled for 7:00 PM to 10:00 PM. Review of Resident #7's Nurse's Notes dated (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the resident's medication on 04/07/19 in order to seek guidance related to the missed medications. 12. Review of Resident #16's clinical record revealed the facility admitted the resident on 04/18/17 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the eMAR, dated (MONTH) 7, 2019, revealed the [MEDICATION NAME] 12.5 mg tablet was scheduled 7:00 PM to 10:00 PM. Further review of the eMAR, dated 04/07/19, and the Administration Compliance Report, under the section titled, Administration Information, revealed Not administered: other comment: not adequately staffed, management aware, for the [MEDICATION NAME] tablet scheduled for 7:00 PM to 10:00 PM. Review of Resident #16's Nurse's Notes, dated (MONTH) 2019, revealed there was no documented evidence the resident's Physician was notified of the failure to administer the Resident's anti-hypertensive medication on 04/07/19 in order to seek guidance related to the missed medications. Interview with LPN #1 on 05/14/19 at 3:30 PM, revealed he was the only nurse on the Therapy Lodge Unit, on 04/07/19 from 6:00 AM until 10:00 PM. Per interview, after the Certified Medication Technician (CMT) left at 2:00 PM, he and a State Registered Nursing Assistant (SRNA) were the only staff on the unit for twenty-nine (29) residents from 2:00 PM until 4:00 PM, and during this time he had to assist the SRNA with providing care to the residents including toileting, and assisting those residents to bed who wanted a nap before supper. At 4:00 PM, another CMT was sent to the unit, but she had to work as an aide on the floor and was unable to assist with passing medications. He further stated there was supposed to be two (2) licensed nurses or one (1) licensed nurse and a CMT and at least two (2) to three (3) SRNAs from 6:00 AM through 6:00 PM on the Therapy Lodge Unit. Further interview revealed he was unable to administer medications to all twenty-nine (29) residents on the unit and only six (6) residents received medications that were due from 3:00 PM through 10:00 PM. Per interview, some residents did not receive significant medications including Insulin, [MEDICATION NAME], anti-hypertensive medications and other cardiac medications, as well as antibiotics. He stated the failure to administer significant medications resulted in significant medication errors as there was the potential for adverse consequences when these significant medications were not administered as prescribed. However, he stated he did not notify the Physician the medication was not administered in order to seek guidance related to missed dosages. Interview with LPN #2, on 05/16/19 at 3:45 PM, revealed she arrived at the Therapy Lodge Unit at 10:00 PM, on 04/07/19, to relieve LPN #1. Per interview, he informed her he was unable to pass all the medications due to lack of staff. She stated he told her everyone in management including the DON and the Administrator were aware of the situation. Continued interview revealed she did not notify the Physician of the missed medications, but did check the residents and obtain their vital signs. Per interview, it could be a significant medication error to miss medications such as insulin, blood pressure medications, cardiac medications, [MEDICATION NAME] or antibiotics. Interview with Physician #1, on 05/22/19 at 4:30 PM, revealed it was his expectation medications be administered as prescribed. Further interview revealed it was a significant medication error to miss giving medications such as [MEDICATION NAME], Insulin, and blood pressure medications. Per interview, there was the potential for serious consequences when the residents did not receive significant medications as ordered. Interview with Physician #2 on 05/22/19 at 9:30 AM revealed he expected medications to be administered as per his physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 05/23/19 at 3:49 PM revealed it was her expectation staff administer medications as ordered. Per interview, if a resident did not receive his/her medications including [MEDICATION NAME], Insulin, cardiac or or blood pressure medications or antibiotics, this would be a significant medication error. Further interview revealed there was the potential for adverse consequences for the residents who did not receive significant medications on 04/07/19. Further interview revealed she admitted the Therapy Lodge Unit was short staffed for part of the day on 04/07/19; however, she further stated the unit was fully staffed by 6:00 PM and LPN #1 should have ensured the residents received their medications. Interview with the Administrator, on 05/23/19 at 3:11 PM, revealed it was his expectation medications administered as per the physician's orders [REDACTED].#1's failure to administer blood pressure medications, Insulin, antibiotics and [MEDICATION NAME] on 04/07/19 for numerous residents resulted in significant medication errors. He stated he knew the facility was short staffed on the Therapy Lodge Unit on 04/07/19 and he should have ensured there was sufficient staffing in order for the care to be delivered as ordered, including medications. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 that alleged removal of the Immediate Jeopardy (IJ) on 06/06/19. Review of the AoC revealed the facility implemented the following. 1. The Administrator was provided counseling and assistance on 05/29/19 by the President and Chief Executive Officer (CEO) of the facility's minimum staffing standards and the steps to take when the daily schedule did not meet the standards. On 06/05/19, the CEO and Administrator met again and the CEO re-emphasized with the Administrator that it was the Administrator's responsibility to ensure care and services were provided for the residents, twenty-four (24) hours a day. 2. On 05/30/19, the Administrator educated/reviewed with the Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UM) the actions to take if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to the residents. 3. On 6/05/19, the Administrator and the Social Services Director visited all interviewable residents and asked if they have been receiving medications, treatments and services to their satisfaction. They were also asked if they knew who to report to if they had issues. The Administrator and Social Services Director will continue to interview the residents two (2) times a week for one (1) month. The Quality Assurance (QA) team will determine ongoing frequency based on findings after the first month. 4. On 04/09/19, the Director of Nursing (DON) notified the Physician/Advanced Registered Nurse Practitioner (ARNP) of the missed medications on 04/07/19 with follow-up orders implemented as indicated for Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30. Additionally the DON assessed the residents to determine if there was any adverse effects to the residents that missed their medications with no adverse effects noted. 5. The Resident Representatives were notified of the missed medications on 04/11/19 and 04/12/19 by the DON and Registered Nurse (RN) #2 for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30. 6. Licensed Practical Nurse (LPN) #2, who did not report the previous nurse's missed medication administration, was provided education related to the facility's policies related to notification on 04/14/19 and again on 05/31/19 by the Staff Development Director (SDD). 7. Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25, and #28 and all other current in-house residents, will be administered their medications and treatments in accordance with the Medical Doctor's (MD)/ARNP's orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) will be checked, by the Administrator and/or DON for late and due medication administrations. The MARS and TARS will be checked twice daily for two (2) weeks, then once daily for one (1) month and will then be re-evaluated by the Quality Assurance Performance Improvement (QAPI) committee to determine ongoing frequency. 8. The facility had employed twenty-eight (28) new staff, ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN) and twelve (12) State Registered Nurses Aides (SRNA), since 04/01/19. This was done to fill positions on the nursing schedule to provide staffing and to provide nursing and related services. This will assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house resident. 9. To assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house residents, care observations of six (6) residents will be completed, two (2) residents will be observed per wing. These observations will be performed by the Administrative Nursing Staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors weekly for two (2) months and will then be re-evaluated by the QAPI committee to determine ongoing frequency using the Care Observation tool. The first observation occurred on 06/03/1

Based on interview, record review, review of the Director of Nursing and Administrator's Job Descriptions, and review of the facility's Policies and Procedures, it was determined the facility failed to have an effective system to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to ensuring residents were free from neglect and free from significant medication errors. Staff interviews and review of the facility's Time Punches, revealed on 04/07/19, the Therapy Lodge Unit did not have the minimum requirement of staff according to the facility's Policy on 04/07/19, from 2:00 PM to 6:00 PM. Review of the screen shots of Licensed Practical Nurse (LPN) #1's phone related to outgoing phone calls and text messages on 04/07/19, revealed LPN #1 reached out to the Director of Nursing (DON), Administrator, and the Staffing Coordinator ten (10) times between 7:45 AM and 5:42 PM and interview with LPN #1 revealed these phone calls were related to the staffing issue. However, the facility failed to act, to ensure there was sufficient staffing available between the hours of 2:00 PM and 6:00 PM on this Unit, when staffing was below the required minimum. As a result, twenty-four (24) residents did not receive their medications and/or treatments and/or other care to be delivered by a licensed nurse as scheduled from 2:00 PM until 10:00 PM. This affected Residents #2, #3, #4, #5, #7, #8 #10, #11, #12, #13, #14, #15 #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30. (Refer to F-600, F-725, and F-760) The facility's failure to have an effective system in place to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 05/23/19, and determined to exist on 04/07/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19, with the facility alleging removal of Immediate Jeopardy 06/07/19. The State Survey Agency validated the Immediate Jeopardy was removed 06/06/19, prior to exit on 06/07/19, with remaining non-compliance at a Scope and Severity of an [NAME] while the facility develops and implements a Plan of Correction. The findings include: Review of the Job Description for Administrator, dated (MONTH) 2009, revealed the Administrator was responsible for the overall operation of the facility, directing and coordinating all activities of Springhurst Health and Rehabilitation to ensure the best possible care for each resident. The Administrator ensures compliance with regulations governing nursing homes by continually monitoring the facility's service delivery and initiating changes as required. Per the Job Description, the Administrator fosters a smooth functioning, efficient organization through timely and effective resolution of disruptions. The Administrator facilitates the encouragement and development of new policies and procedures designed to use organizational resources to maximize quality care and cost effective operations. Review of the Job Description for Director of Nursing (DON), undated, revealed the DON works under the direction of the Administrator to organize and direct Springhurst Health and Rehabilitation to ensure nursing personnel are properly trained and capable, and to ensure good patient care based on physical needs of the residents. The DON, under the direction of the Administrative, is the Leader in Nursing Services in assuming responsibility for the Standards of Nursing Services. Per the Job Description, the DON plans and implements a system for the evaluation of individual resident care; and provides leadership and promotes and participates in the formulation or revision of Nursing Department policies and procedures as necessary for obtaining the highest level of resident care. The DON's duties include: ensuring the facility operates within the facility staffing pattern which is designed to fulfill Nursing Department objectives which promote maximum utilization of all Nursing Department personnel; and organizing, directing and supervising the Nursing Department around the clock, in order to ensure sufficient and competent nursing care for residents. Further review of the Job Description, revealed the DON ensures the Nursing Department is following State and Federal standards. Review of the Job Description for the Staffing Coordinator, dated 01/07/15, revealed the Staffing Coordinator has the primary responsibility of staffing the units with sufficient Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs), and Certified Nursing Assistants (CNAs) {or State Registered Nurse Aides (SRNAs)} to adequately provide resident care. Continued review revealed the general responsibilities for the Staffing Coordinator is to schedule nursing staff to ensure sufficient numbers to provide adequate resident care, to be available by phone to respond to emergency staffing problems, to adjust staffing during the shift as needed related to resident census, and to take call-ins and replace staff as needed. Review of the facility's Staffing Guidelines Policy, dated 01/31/14, revealed the facility must have adequate staffing to ensure appropriate care is provided to the residents in accordance with accepted professional standards and practices. Further review revealed the Therapy Lodge Unit required two (2) Licensed Nurses or one (1) Nurse and one (1) Certified Medication Technician (CMT) 6:00 AM to 6:00 PM, and one (1) Licensed Nurse on the 6:00 PM to 6:00 AM Shift. Additional review revealed the Unit required two (2) to four (4) State Registered Nurse Assistants (SRNA) on the 6:00 AM to 6:00 PM shift and two (2) SRNAs on the 6:00 PM to 6:00 AM shift. Staff interviews and review of the Time Punches, revealed the Therapy Lodge Unit on 04/09/19, from 6:00 AM to 2:00 PM, had one (1) LPN, one (1) CMT and two (2) SRNAs. However, from 2:00 PM to 4:00 PM, the Unit only had one (1) LPN and one (1) SRNA; from 4:00 PM to 6:00 PM, the Unit only had one (1) LPN, one (1) CMT working as a SRNA, and one (1) SRNA; and, from 6:00 PM to 10:00 PM there was one (1) LPN and two (2) SRNAs. Thus, the Unit did not have the minimum requirement of staff according to the facility's Policy on 04/07/19, as the Unit was short two (2) staff members from 2:00 PM to 4:00 PM and the Unit was short one (1) staff member from 4:00 PM to 6:00 PM. Interview with LPN #1, on 05/14/19 at 3:30 PM, revealed he was scheduled to work 6:00 AM to 6:00 PM on 04/07/19; however, due to a nurse calling in sick, he had to work until 10:00 PM. He further stated there was just him and a SRNA to provide care for twenty-nine (29) residents from 2:00 PM until 4:00 PM on the Therapy Unit, after the CMT and a SRNA left at 2:00 PM at the end of their shift. Per interview, during this time he had to assist the SRNA with toileting, and assisting those residents to bed who needed to lie down before supper. He further stated at 4:00 PM, another CMT arrived to work on the unit, but she had to work as an aide on the floor and therefore was unable to assist with passing medications. LPN #4 stated, on 04/07/19, during the evening shift on the Therapy Lodge Unit, the required minimum staffing was two (2) licensed nurses or one (1) licensed nurse and a CMT and at least two (2) to three (3) SRNAs from 6:00 AM through 6:00 PM. Further interview revealed the unit was short two (2) staff members from 2:00 PM to 4:00 PM, and was short one (1) staff member from 4:00 PM to 6:00 PM. Although he stated he contacted the Staffing Coordinator, DON, and Administrator via phone calls or texting related to the staffing situation, he was just told to do the best he could. Continued interview revealed due to insufficient staff the evening of 04/07/19, he was unable to administer medications, perform treatments and deliver other services required of a licensed nurse to all residents. He stated he only administered medication to six (6) out of twenty-nine (29) residents from 2:00 PM to 10:00 PM, and some residents did not receive significant medications including [MEDICATION NAME], Insulin, and cardiac or anti-hypertensive medications. Interview with the Staffing Coordinator, on 05/15/19 at 3:12 PM, revealed LPN #1 did message her on the staffing scheduler's phone to let her know there was no nurse to cover for him on 04/07/19 at 6:00 PM at the end of his shift, and he also notified her the CMT would be leaving at 2:00 PM. She stated she informed LPN #1 she was working on finding him coverage due to the person, who had been scheduled to relieve him at 6:00 PM, called in sick. Per interview, she did contact LPN #2 who told her she would be unable to come in until 10:00 PM. When questioned related to the protocol for finding coverage when a staff member called in, and questioned about her system for ensuring the Units had at least the minimum staffing requirements, as per the facility's Policy each shift, she stated she was unable to answer any further questions. Interview with the DON on 05/23/19 at 3:49 PM, revealed she did recall LPN #1 calling her on 04/07/19 to inform her the unit was short staffed and she remembered telling him the Staffing Coordinator was attempting to find coverage. However, she stated she was not aware LPN #1 did not actually administer the medications and treatments to the residents on the Therapy Lodge Unit on the evening of 04/07/19, until she was informed the morning of 04/08/19. Per interview, the failure of the residents to receive their prescribed medications on 04/07/19, would be considered neglect. She stated the residents did not receive medications such as Insulin, [MEDICATION NAME] and anti-hypertensives, which were significant medication errors. Additional interview revealed the Therapy Lodge Unit was below the required staffing numbers on the evening of 04/07/19. The DON acknowledged her Job Description included ensuring the facility operated within the facility's staffing pattern and she further acknowledged she was to direct and supervise the Nursing Department around the clock. She stated she should have ensured the Staffing Coordinator was following the facility guidelines related to having sufficient staff on the units. Interview with the Administrator, on 05/23/19 at 3:11 PM, revealed he was responsible for the overall management and operation of the building. He further stated he was responsible to ensure compliance with regulations governing nursing homes by continually monitoring the facility's service delivery and initiating changes as required. He revealed LPN #1 did contact him related to the staffing situation on 04/07/19 and he was aware of how stressed LPN #1 was related to staffing that evening. However, the Administrator stated he was unaware LPN #1 did not administer the residents medications and treatments on the evening of 04/07/19, until he was notified of this on 04/08/19. Per interview, he did feel like it was neglect related to the residents not receiving their medications as ordered 04/07/19. He revealed he did consider there to be significant medication errors on 04/07/19 when residents did not receive their Insulin, [MEDICATION NAME] and other medications as ordered. Additional interview revealed there should have been action taken to ensure sufficient staff was available after LPN #1 notified the Staffing Coordinator, the DON and himself of the staffing problem on the Therapy Lodge Unit. He further stated it was his expectation there was sufficient staff to resident ratios on the Units at all times per the facility's Policy. Per interview, he was ultimately responsible for what occurred in his building. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 that alleged removal of the Immediate Jeopardy (IJ) on 06/06/19. Review of the AoC revealed the facility implemented the following. 1. The Administrator was provided counseling and assistance on 05/29/19 by the President and Chief Executive Officer (CEO) of the facility's minimum staffing standards and the steps to take when the daily schedule did not meet the standards. On 06/05/19, the CEO and Administrator met again and the CEO re-emphasized with the Administrator that it was the Administrator's responsibility to ensure care and services were provided for the residents, twenty-four (24) hours a day. 2. On 05/30/19, the Administrator educated/reviewed with the Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UM) the actions to take if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to the residents. 3. On 6/05/19, the Administrator and the Social Services Director visited all interviewable residents and asked if they have been receiving medications, treatments and services to their satisfaction. They were also asked if they knew who to report to if they had issues. The Administrator and Social Services Director will continue to interview the residents two (2) times a week for one (1) month. The Quality Assurance (QA) team will determine ongoing frequency based on findings after the first month. 4. On 04/09/19, the Director of Nursing (DON) notified the Physician/Advanced Registered Nurse Practitioner (ARNP) of the missed medications on 04/07/19 with follow-up orders implemented as indicated for Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30. Additionally the DON assessed the residents to determine if there was any adverse effects to the residents that missed their medications with no adverse effects noted. 5. The Resident Representatives were notified of the missed medications on 04/11/19 and 04/12/19 by the DON and Registered Nurse (RN) #2 for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30. 6. Licensed Practical Nurse (LPN) #2, who did not report the previous nurse's missed medication administration, was provided education related to the facility's policies related to notification on 04/14/19 and again on 05/31/19 by the Staff Development Director (SDD). 7. Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25, and #28 and all other current in-house residents, will be administered their medications and treatments in accordance with the Medical Doctor's (MD)/ARNP's orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) will be checked, by the Administrator and/or DON for late and due medication administrations. The MARS and TARS will be checked twice daily for two (2) weeks, then once daily for one (1) month and will then be re-evaluated by the Quality Assurance Performance Improvement (QAPI) committee to determine ongoing frequency. 8. The facility had employed twenty-eight (28) new staff, ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN) and twelve (12) State Registered Nurses Aides (SRNA), since 04/01/19. This was done to fill positions on the nursing schedule to provide staffing and to provide nursing and related services. This will assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house resident. 9. To assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house residents, care observations of six (6) residents will be completed, two (2) residents will be observed per wing. These observations will be performed by the Administrative Nursing Staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors weekly for two (2) months and will then be re-evaluated by the QAPI committee to determine ongoing frequency using the Care Observation tool. The first observation occurred on 06/03/19. 10. The CEO, Administrator and DON developed facility Minimum staffing standards, and procedures to take when the daily schedule did not meet the established facility staffing standards. The procedures included: a) when there was a call in at the last minute, the designated staffing person will try to find a replacement. If a replacement could not be found, the designated staffing person will look at moving staff around if there is extra staff available on another unit; b) There may be times when the staff member was a no-call, no-show. In this case, a nurse at the facility must call the designated staffing person to inform them of the no-show. c) If the staffing person could not be reached, the nurse will call the DON. If the DON could not be reached, the nurse will call the Administrator. If the staffing level on any day falls below the minimum staff level, one (1) of the administrative staff will be asked to come in to support the staff currently working. d) Due to weekends being more difficult to staff, the Unit Managers and other Nursing Directors agreed to a weekend on call schedule and will be available to come in on the weekends if staff drops below the minimum staffing level. 11. Resident #1 is no longer on [MEDICATION NAME]. The facility currently had three (3) Residents including Resident #2, which were required to have [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) labs, and have their PT/INR labs obtained/followed-up in accordance with their Physician/ARNP orders and their care plan as determined by PT/INR monitoring. The DON will track [MEDICATION NAME] labs and follow-up orders. Three (3) times a week on weekdays, a binder that contains a lab log page for each resident will be brought to the morning meeting. The DON will initial she reviewed the labs, including the PT/INR, to check that labs were collected and reported timely to the Physicians/ARNPs. The DON or Unit Managers (UM) will also check with the lab to ensure the lab is in a Pending status, which indicates the lab work is in process. Lab tracking sheets are now being used and will be brought to the morning meeting. [MEDICATION NAME] tracking sheets were implemented for each resident on [MEDICATION NAME]. The DON will initial that she has reviewed labs and the [MEDICATION NAME] tracking sheets to verify that they have been obtained and reported to the attending Physician/APRN in a timely manner. 12. Facility licensed nursing staff were provided in-service education on 05/30/29; 05/31/19; 06/01/19; 06/02/19; 06/03/19; and, 06/04/19 by the DON and SDC on the following: the requirement to administer resident medications in accordance with the Medical Doctor (MD)/ARNP orders and the resident care plan; the need to notify a fell ow charge nurse, their Unit Manager, the QA Nurse, the SDC, or the DON if they were unable to complete medication administration for their assigned residents in accordance with the /ARNP orders and the resident care plan so that assistance would be provided; the requirement to perform PT/INR labs in accordance with MD/APRN orders and the resident care plan; the requirement to notify the MD/APRN and the Resident Representative if medications were not administered to the resident in accordance with their orders, care plan and facility policy; and, the components of the facility's Abuse/Neglect Policy, including what constitutes abuse/neglect and the reporting aspects if a staff has neglected to provide medications or treatments to residents, and the disciplinary action that will be implemented for failure to follow the requirements, which is disciplinary action up to termination, was addressed in this training. 13. A review of the facility's staffing, as compared to the established staffing standards, will be provided to the Board of Directors at their monthly meeting. This will include, but not be limited to, the protocol steps taken by the facility when the daily schedule did not meet the established staffing standards. 14. The DON and Administrator have and will continue to monitor staffing levels based on census and acuity levels. The facility developed a Minimum Staffing Target worksheet that established a minimum staffing level for all three units for all three shifts. The instructions on the sheet indicated what the Managers were to do in the case of a call-in or shortage and what to do if a replacement could not be found. It listed the DON's and Administrator's phone number for assistance. The State Survey Agency validated the implementation of the facility's A[NAME] as follows: 1. Record Review confirmed the President and CEO of the facility provided counseling and assistance to the Administrator, on 05/29/19, related to the minimum staffing standards and the steps to take when the daily schedule did not meet the established standards. Record Review of the document titled, Minimum Staffing Targets, 2019, dated 05/29/19, confirmed the Administrator was educated by the President and CEO of the facility on minimum staffing standards and steps to take when the daily schedule did not meet the established standards. Further review confirmed the Administrator reviewed Scoring Rules for staffing and ratings with the President and CEO. Continued review confirmed, the President and CEO again met with the Administrator to ensure care and services were provided for the residents, twenty-four (24) hours a day. Interview with the Administrator on 06/07/19 at 1:10 PM revealed he received counseling related to ensure minimum staffing standards and the steps to take when the daily schedule did not meet the standard. Continued interview revealed he was also educated that it was the Administrator's responsibility Interview with the President and CEO of the facility, on 06/07/19 at 2:01 PM, confirmed he met with the Administrator several times about staffing concerns and the need for the facility to make the resident's care a priority. Further interview revealed, the administrator was educated on facility staffing standards, and the administrator's responsibility twenty-four (24) hours a day to ensure care and services are provided. 2. Review of the Chain of Command, dated 06/06/19, validated the administrator educated/reviewed with the DON, SDC, and Unit Managers about what they would need to do if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to our residents. Interview with the DON on 06/06/19 at 1:49 PM, confirmed she had received education related to the facility's Chain of Command, staffing standards Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking and Notification of Change. Interview with South Wing Unit Manager, on 06/07/19 at 12:00 PM and the Staff Development Coordinator (SDC), at 1:00 PM, confirmed they were educated on the Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking, Notification of Change, Chain of Command and Staffing Standards. 3. Review of the Midnight Census Worksheet utilized 06/05/19 with resident statements confirmed, revealed the Administrator and the Social Services Director (SSD) visited all interviewable residents and asked if they had been receiving care, medications, treatments and services and if care was to their satisfaction. They were also questioned related to who they should report issues to, regarding care provided. Interview with the Administrator, on 06/07/19, confirmed interviewable residents were asked if they were receiving their medications, treatments, and care to their satisfaction. Per interview, the interviewable residents were also asked if they were aware of how to report problems concerning their care, and who they should notify if there was a concern related to care. Further interview revealed the SSD and Administrator were able to interview fifty (50) residents. Per interview, interviews were scheduled to continue two (2) times weekly for one (1) month and then the Quality Assurance team would determine the ongoing frequency based on the findings. 4. Review of the Medication Error Report Sheets, dated 04/09/19, revealed notification was made by the Director of Nursing (DON) to the Physician/Advanced Practice Registered Nurse (APRN) for each of Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29 and #30 from 04/08/19 to 04/09/19. The Physicians/APRN was notified the residents listed above, on the Therapy Unit, did not received their medications on 04/07/19 from the time of 3:00 PM to 10:00 PM. Interview with the DON, on 06/06/19 at 3:39 PM, confirmed she had informed the Physician/APRN and the Resident Representative of medications not being administered to Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30 on 04/07/19. Continued interview revealed she assessed all of the residents by observation, clinical review, such as monitoring blood pressure and blood sugars, and record review for any adverse effects of missing their medications and there were no adverse effects on any of the residents. Interview with Physician #1, on 05/22/19 at 9:30 AM, confirmed he was notified the residents on the Therapy Unit had not received their evening medications on 04/07/19. He reported he had been informed of this immediately after the facility became aware of the situation on 04/08/19 but could not recall the time. Further interview revealed, there were plans for ongoing monitoring of vital signs, pain or any changes related to medications missed to assure there are no adverse effects. Interview with Physician #2, on 05/22/19 at 8:30 PM, confirmed he was informed on 04/08/19 the residents on the Therapy Unit did not receive their medications the night of 04/07/19. Physician #2 also confirmed during the interview, the DON and his Nurse Practitioner discussed the incident prior to him having knowledge. Further interview confirmed he was uncertain of when he was informed. Physician #2 requested the Residents effected have their vital signs monitored and the nursing staff alert the Physician of any adverse changes. 5. Review of the Medication Error Report Sheets, dated 04/09/19, revealed notification was made by the DON and RN # 2 to the Resident Representatives between 04/11/19 and 04/12/19 informing them medications had not been administered for Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29 and #30. The Resident Representatives were also informed the Resident's Physician/APRN had been informed of the missed medications. Interview with RN #2, on 06/06/19, confirmed he did notified six (6) to seven (7) of the Resident Representative to inform them the residents did not receive their medications the evening of 04/07/19 on the Therapy Unit. Interview with the DON, on 06/06/19, confirmed she and RN #2 did notify the Resident Representatives of the residents not receiving medications on the evening of 04/07/19.3 6. Review of the Education Sign-In Roster, dated 04/14/19 and 05/31/19, revealed Licensed Practical Nurse (LPN) #2, who did not report the previous nurses' missed medication administration, was provided education by the Staff Development Director (SDD). Continued review revealed education included the Scope of Practice, High Risk Medication, Medication Administration, Abuse and Change in Condition Process, Interview with LPN #2, on 06/06/19 at 7:35 PM, confirmed education was received over the last few weeks. LPN #2 stated the physician should have been notified at the time she received the information. The previous nurse, LPN #1, had not informed the physician the medications had not been given the evening of 04/07/19, but informed LPN #2 when giving report. 7. Review of the Medication Administration Checks, initiated on 06/01/19, validated Resident #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25 and #28, and all other current in-house residents, were administered their medications and treatments in accordance with the Medical Doctor's (MD)/APRN orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) were checked twice daily by the Administrator of DON. The MARS and TARS checks were initiated twice daily beginning 06/01/19 to present. Interview with the DON, on 06/07/19 at 1:49 PM, confirmed the MAR and TAR have been monitored twice daily by herself or the Administrator. Interview with the Administrator, on 06/07/19 at 1:08 PM, confirmed the MARs and TARS are monitored and reviewed for any missed or past due medications. The Administrator confirmed the MARS and TARS are check twice daily and will continue to be check twice each day for two (2) weeks, then once daily for one (1) month and then will be evaluated by QAPI committee to determine ongoing frequency. Per interview, if any issues are found, the DON will be contacted to follow-up with the floor nurse during the week and on the weekends. 8. Review of the facility's Human Resources records, New Hire list, dated 04/01/19 to present, validated the facility had employed twenty-eight (28) new staff. Continued review revealed ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN), and twelve (12) State Registered Nurses Aides (SRNA) were hired by the facility since 04/01/19. Interview with the DON, on 06/06/19 at 1:49 PM, confirmed the facility has hired many new nurses and aides and had increased the staffing level. This facility has joined with a corporation that will assist with staffing. Further interview confirmed the facility is following the Minimum Staffing Target, 2019. Continued interview revealed if they did not meet the minimum level of staffing, Managers had been educated to call the Unit Managers and they can work the carts and they are able to contact an agency nursing staff. Interview with the Administrator, on 06/07/19 at 1:08 PM, confirmed if the facility's minimum staffing level was not achieved, the DON and or Administrator was notified. Continued interview revealed staff may be moved around to provide coverage to each unit. Further interview revealed on the weekends, administrative staff will come in to support staff working if staffing levels fall below the minimum staffing level. 9. Review of the Resident Observation Tool validated care observations of six (6) residents weekly was initiated as of 06/03/19. Continued review revealed the Resident Observation Tool confirmed two residents were observed per wing. Further review revealed the observations were performed by the administrative nursing staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors. Interview with the North Hall Unit Manager, on 06/07/19 at 11:15 AM, confirmed the administrative staff was responsible to complete resident observations for six (6) residents, two (2) from each unit using the Resident Observation Tool. Interview with the Quality Nurse (QA) nurse, on 06/07/19 at 2:07 PM, revealed the DON, Administrator or herself would utilize the Resident Observation Tool for six (6) Residents. Continued interview revealed two (2) residents on each unit would be observed using the tool for two (2) mo

Based on interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system to ensure monitoring of anticoagulant medication and [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) levels for residents receiving [MEDICATION NAME] for two (2) of three (3) sampled residents reviewed for medication management related to [MEDICATION NAME] (anticoagulant medication) out of a total of thirty-eight (38) sampled residents (Resident #1 and Resident #2). Interview and record review revealed the facility did not have a system in place to monitor and track laboratory values, in order to ensure laboratory values for [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) were obtained as ordered. Resident #1 received PT/INR levels at least once a week and sometimes twice a week in (MONTH) 2019 related to [MEDICATION NAME] (anticoagulant) Therapy. On 03/11/19, the resident's PT/INR was 2.9, which was in the therapeutic range. Although the facility notified the Physician of the results and received verbal orders to repeat the PT/INR on 03/14/19, there was no documented evidence these orders were entered into the electronic medical record as a physician's orders [REDACTED]. In addition, review of the medical record revealed physician's orders [REDACTED]. Resident #1 went eighteen (18) days without monitoring of PT/INR levels and on 03/29/19, the PT/INR results were PT: > (greater than) 116.1 High and INR: >10.0 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). Resident #1 was transferred to the Hospital emergency roiagnom on [DATE] and diagnosed with [REDACTED]. (Refer to F-656) Additionally, the facility failed to have an effective system to monitor anticoagulant medication to ensure the medication was administered as prescribed. Resident #2's physician's orders [REDACTED]. According to these orders, Resident #2 was to receive [MEDICATION NAME] 4.5 mg from 04/18/19 through 04/21/19. A new order was obtained on 04/22/19 for [MEDICATION NAME] 2.0 mg daily after lab results for PT/INR were received on 04/22/19. However, the physician's orders [REDACTED]. On 04/29/19, lab results revealed PT: 75.5 High and INR: 6.5 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1) and Resident #2 received Vitamin K 5 mg on 04/29/19. (Refer to F-656) The facility's failure to ensure monitoring of anticoagulant medication and PT/INR levels for residents receiving [MEDICATION NAME], has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 05/23/19 and determined to exist on 03/14/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 alleging removal of the Immediate Jeopardy on 06/06/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/06/19, prior to exit on 06/07/19 with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure complianceThe findings include: Review of the facility Diagnostic Services Policy, revised 11/24/14, revealed the facility would provide or obtain laboratory services to meet the needs of its residents and would be responsible for the quality and timeliness of the services. The facility would promptly notify the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with policies and procedures. The Laboratory Company utilized by the facility, revealed the following ranges for Normal PT/INR levels: Normal range for [MEDICATION NAME] Time (PT) 9.5 seconds to 11.8 seconds and Normal range for International Normalized Ratio (INR) 0.9 -1.1. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 07/18/13 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/04/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of six (6) out of fifteen (15) indicating severe cognitive impairment. Further review revealed Section N-Medications, revealed Resident #1 received anticoagulant medication five (5) of seven (7) days during the seven (7) day look back period. Review of Resident #1's Comprehensive Care Plan initiated 08/16/17, revealed the resident had the potential for bleeding/bruising due to receiving [MEDICATION NAME] (anticoagulant therapy) related to a [MEDICAL CONDITION]. The goal with a target date of 08/31/19, revealed the resident would have no active bleeding or abnormal bruising without detection through next review. The interventions initiated 01/04/19 included: notify MD/NP (Medical Doctor/Nurse Practitioner) of any unusual bleeding and or bruising that resident develops; protect resident from injury/trauma being extra careful during daily care; encourage use of soft toothbrush; and observe for signs of active bleeding (nosebleeds, bleeding gums, petechia, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temperature, pain in joints, abdominal pain, epistaxis). Review of the Laboratory Reports, dated (MONTH) (YEAR) through 03/11/19, revealed laboratory results for PT/INR were obtained at least weekly and sometimes twice a week. Once the Physician was notified of the PT/INR results, orders were received for the next PT/INR lab draw. PT/INR labs were obtained on 02/04/19, 02/07/19, 02/15/19, 02/21/19, 02/27/19, 03/04/19, 03/07/19, and 03/11/19. (A PT is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is calculated from a PT result and is used to monitor how well the anticoagulant medication is working to prevent blood clots). Review of Resident #1's physician's orders [REDACTED]. Review of the Electronic Medication Administrator Record (eMAR) dated (MONTH) 2019, revealed the resident received 5.5 mg of [MEDICATION NAME] 03/08/19 through 03/11/19, as ordered. Review of the Laboratory Report, dated 03/11/19, reported at 4:18 PM and faxed to the facility on [DATE] at 4:29 PM, revealed PT: 29.3 High and INR: 2.9 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). A Notation on the Lab Report written by Licensed Practical Nurse (LPN) #4 stated, resident currently on [MEDICATION NAME] 5.5 every day; Change [MEDICATION NAME] to 5.5 mg on Mondays, Wednesdays and Fridays, and 5.0 mg on Sundays, Tuesdays, Thursdays and Saturdays; PT/INR on 03/14/19. Review of the Progress Note dated 03/11/19 at 5:09 PM, revealed the nurse put in a call to the Physician with lab results, and was awaiting return call. Review of Resident #1's Progress Notes, dated 03/12/19, at 10:39 AM, completed by LPN #4, revealed new orders were received with Advanced Registered Nurse Practitioner (ARNP) visit today concerning PT/INR results from 03/11/19. New orders received to change [MEDICATION NAME] to 5.5 mg on Mondays, Wednesdays and Fridays, and 5.0 mg on Sundays, Tuesdays, Thursdays and Saturdays; and recheck PT/INR, on 03/14/19. Review of Resident #1's Physician order [REDACTED]. Continued review revealed orders dated 03/12/19 for [MEDICATION NAME] 5.0 mg tablet orally on Sundays, Tuesdays, Thursdays and Saturdays at 4:00 PM, with a discontinue date of 03/29/19. However, there was no documented evidence of a physician's orders [REDACTED]. Further review of the eMAR dated (MONTH) 2019, revealed the resident received 5.5 mg of [MEDICATION NAME] on Monday, Wednesday, Friday and 5.0 mg of [MEDICATION NAME] Sunday, Tuesday, Thursday and Saturday from 03/12/19 through 03/28/19, as per orders. Review of the physician's orders [REDACTED]. In addition, there was no documented evidence the resident's PT/INR was monitored from 03/11/19 until 03/29/19, eighteen (18) days later. Review of the Laboratory Report, dated 03/29/19, reported at 8:55 AM and faxed to the facility on [DATE] at 8:55 AM, revealed Resident #1's PT: was > (greater than) 116.1 High and INR: >10.0 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). There was a Notation on the Laboratory Report which stated resident sent to emergency room (ER). Review of Resident #1's Progress Notes, dated 03/29/19 at 9:42 AM, revealed, Resident in bed. Refusing medications this AM. Blood Sugar 222. Did not eat AM meal. Blood Pressure: 110/62, heart rate: 90, Respirations: 18, Oxygen Saturation: 99%. Lungs clear. Lab called with critical INR of 10.0 PT of 116.1. Labs called to ARNP. Order noted to send resident to the hospital. Family notified. Review of the subsequent Progress Note, dated 03/29/19 at 9:59 AM, revealed a call was placed to Resident #1's Responsible Party/Daughter, and the Daughter called back. Per the Note, the Daughter was informed regarding current PT/INR results, and informed the resident was being sent to the ER. Further review of the Note, revealed a call was placed for 911, in order for the resident to be transported to the emergency room . Review of the Hospital Discharge Summary, dated 04/05/19, revealed Resident #1 was admitted to the hospital on [DATE] with the principle [DIAGNOSES REDACTED]. Upon arrival his/her Hemoglobin was found to be 5.8 (normal level Hemoglobin for females 12 to 16 and for males 14 to 17.4), with INR greater than eleven (11). Resident #1 was given 10 mg of intravenous (IV) Vitamin K in the Emergency Department and received two (2) units of Fresh Frozen Plasma and two (2) units of Packed Red Blood Cells. A Computed [NAME]ography (CT) Scan of Resident #1's abdomen showed a large left Rectus Hematoma with extension into the pelvis. Consult with General Surgery recommended no surgical intervention due to the resident's Supratherapeutic INR. Due to the Hematoma, the resident's [MEDICATION NAME] was placed on hold. INR had been reversed to 1.6 and withholding [MEDICATION NAME] because risk of stroke greatly outweighed the risk of bleeding into the very large Rectus Sheath Hematoma. Resident's Rectus Sheath Hematoma stabilized and after receiving two (2) units of packed red blood cells, the resident's hemoglobin was 9.0 and stable. Interview with LPN #4, on 05/16/19 at 3:39 PM, revealed when Laboratory Reports were faxed to the facility, she would inform the resident's ARNP of the results, and obtain new orders. Per interview, she would input the new medication orders related to the lab results into the electronic medical record as a new physician's orders [REDACTED]. [REDACTED]. She stated she should have filled out a Lab Reconciliation and put it in the lab binder to be drawn on 03/14/19 for Resident #1; however, she stated she was unsure if she had actually filled out the Lab Reconciliation for that date, since the PT/INR was not drawn on 03/14/19. Interview with the ARNP, on 05/23/19 at 2:58 PM, revealed Resident #1 had always been stable with his/her PT/INR lab results. However, she stated it appeared as though the resident's PT/INR lab was missed on 03/14/19 and 03/17/19. Per interview, a nurse brought it to her attention on 03/29/19, the lab draws were missed, and the resident's PT/INR levels were elevated and the resident was sent to the emergency room . The ARNP further stated Resident #1 had a Rectus Hematoma, and the [MEDICATION NAME] medication could be a factor. Per interview, it was her expectation laboratory data was obtained as ordered. Interview with the Director of Nursing (DON), on 05/23/19 at 3:49 PM, revealed Resident #1's labs should have been obtained as ordered in order to closely monitor this resident who was receiving [MEDICATION NAME] therapy. Per interview, if a nurse obtained a physician's orders [REDACTED]. Per interview, Resident #1 should not have gone eighteen (18) days without the PT/INR being drawn. When questioned if there was a tracking system for monitoring [MEDICATION NAME] dosages and laboratory results related to PT/INR levels, she was unable to submit for review any documented evidence this was being monitored and tracked. The DON stated, my lab system is not perfect and needs improvement. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 10/14/18 with the [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan dated 02/06/15, revealed the resident had the potential for bleeding, and abnormal bruising related to daily use of anticoagulant due to a [MEDICAL CONDITION] with Left [MEDICAL CONDITION] and History of [MEDICAL CONDITION]. The goal with a target date of 08/15/19, stated the resident would be free of signs or symptoms of excess bleeding or bruising through next review. The approaches included: monitor for bleeding from gums during oral care, use a soft toothbrush; monitor stool and emesis for obvious signs of bleeding and report to Physician/Nurse Practitioner; and report signs and symptoms of excess bruising of unknown origin. Review of Resident #2's Quarterly MDS Assessment, dated 04/09/19, revealed the facility assessed the resident as having a BIMS of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Further review revealed Section N-Medications, revealed Resident #2 received anticoagulant medication six (6) out of seven (7) days during the seven (7) day look back period. Review of physician's orders [REDACTED]. According to these orders, Resident #2 was to receive [MEDICATION NAME] 4.5 mg from 04/18/19 through 04/21/19. Review of physician's orders [REDACTED]. Review of the (MONTH) 2019 eMAR, revealed the resident received 4.5 mg [MEDICATION NAME] from 04/18/19 through 04/21/19 as prescribed. Further review of the (MONTH) 2019 eMAR, revealed the resident received 4.5 mg of [MEDICATION NAME] 04/22/19 through 04/28/19, instead of the ordered 2.0 mg of [MEDICATION NAME]. This was due to LPN #9's failure to discontinue the order dated 04/18/19 for 2.5 mg of [MEDICATION NAME], when the new order for [MEDICATION NAME] 2.0 mg was entered on the eMAR on 04/22/19. Review of Resident #2's Laboratory Report, collected on 04/22/19 at 9:10 AM, reported on 04/22/19 at 1:29 PM, and faxed to the facility on [DATE] at 1:38 PM, revealed PT: 22.9 High and INR 2.1 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). The Notation written on the Laboratory Report by LPN #9, revealed 2.0 mg now, same dose, next Monday 29th (04/29/19). Review of the Laboratory Report collected on 04/29/19 on 8:47 AM, reported on 04/29/19 at 1:12 PM, and faxed to the facility on [DATE] at 1:41 PM revealed resident's PT: 75.5 High and INR: 6.5 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). The Notation written on the Laboratory Report by LPN #9, stated the resident was currently on 4.5 mg, Vitamin K 5 mg one (1) time only, discontinue current [MEDICATION NAME] dose, and recheck lab on 04/30/19. Review of Resident #2's Progress Note, dated 04/29/19 at 7:00 PM, completed by LPN #9, revealed PT/INR results 75.5/6.5, discontinue current dose of 4.5 mg, redraw on 04/30/19. One (1) time order of Vitamin K given due to results per Nurse Practitioner, family notified. Interview with LPN #9, on 05/23/19 at 3:15 PM, after she reviewed Resident #2's Laboratory Report, dated 04/22/19, and the notation written by her on the Report, revealed the resident was to receive a 2.0 mg dose of [MEDICATION NAME] on 04/22/19, and then keep the dose at 2.0 mg and recheck PT/INR on 04/29/19. Per interview, she failed to discontinue the 04/18/19 orders for 2.5 mg when she took off the order to change [MEDICATION NAME] to 2.0 mg on 04/22/19. She further stated she was unaware the resident did not receive medication as prescribed from 04/22/19 through to 04/28/19. Interview with the ARNP, on 05/23/19 at 2:58 PM, revealed when she wrote physician's orders [REDACTED]. She stated she wanted Resident #2 to receive a 2.0 mg dose of [MEDICATION NAME] on 04/22/19 and then continue 2.0 mg as the PT/INR levels were within therapeutic range on 04/22/19. She stated she ordered Vitamin K for Resident #2 when the PT/INR lab results came back on 04/29/19, as the resident was supratherapeutic. Interview with the DON, on 05/23/19 at 3:49 PM, revealed it was important to monitor residents who were receiving [MEDICATION NAME] to ensure therapeutic PT/INR levels were maintained and to prevent residents from possible adverse reactions such as bleeding. Per interview, [MEDICATION NAME] orders should be entered accurately into the eMAR, and Resident #2's physician's orders [REDACTED]. Interview with the Administrator, on 05/23/19 at 3:11 PM, revealed it was his expectation laboratory data be obtained as per physician's orders [REDACTED]. Per interview, it was also his expectation the nurses accurately input physician's orders [REDACTED]. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 that alleged removal of the Immediate Jeopardy (IJ) on 06/06/19. Review of the AoC revealed the facility implemented the following. 1. The Administrator was provided counseling and assistance on 05/29/19 by the President and Chief Executive Officer (CEO) of the facility's minimum staffing standards and the steps to take when the daily schedule did not meet the standards. On 06/05/19, the CEO and Administrator met again and the CEO re-emphasized with the Administrator that it was the Administrator's responsibility to ensure care and services were provided for the residents, twenty-four (24) hours a day. 2. On 05/30/19, the Administrator educated/reviewed with the Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UM) the actions to take if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to the residents. 3. On 6/05/19, the Administrator and the Social Services Director visited all interviewable residents and asked if they have been receiving medications, treatments and services to their satisfaction. They were also asked if they knew who to report to if they had issues. The Administrator and Social Services Director will continue to interview the residents two (2) times a week for one (1) month. The Quality Assurance (QA) team will determine ongoing frequency based on findings after the first month. 4. On 04/09/19, the Director of Nursing (DON) notified the Physician/Advanced Registered Nurse Practitioner (ARNP) of the missed medications on 04/07/19 with follow-up orders implemented as indicated for Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30. Additionally the DON assessed the residents to determine if there was any adverse effects to the residents that missed their medications with no adverse effects noted. 5. The Resident Representatives were notified of the missed medications on 04/11/19 and 04/12/19 by the DON and Registered Nurse (RN) #2 for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30. 6. Licensed Practical Nurse (LPN) #2, who did not report the previous nurse's missed medication administration, was provided education related to the facility's policies related to notification on 04/14/19 and again on 05/31/19 by the Staff Development Director (SDD). 7. Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25, and #28 and all other current in-house residents, will be administered their medications and treatments in accordance with the Medical Doctor's (MD)/ARNP's orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) will be checked, by the Administrator and/or DON for late and due medication administrations. The MARS and TARS will be checked twice daily for two (2) weeks, then once daily for one (1) month and will then be re-evaluated by the Quality Assurance Performance Improvement (QAPI) committee to determine ongoing frequency. 8. The facility had employed twenty-eight (28) new staff, ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN) and twelve (12) State Registered Nurses Aides (SRNA), since 04/01/19. This was done to fill positions on the nursing schedule to provide staffing and to provide nursing and related services. This will assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house resident. 9. To assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house residents, care observations of six (6) residents will be completed, two (2) residents will be observed per wing. These observations will be performed by the Administrative Nursing Staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors weekly for two (2) months and will then be re-evaluated by the QAPI committee to determine ongoing frequency using the Care Observation tool. The first observation occurred on 06/03/19. 10. The CEO, Administrator and DON developed facility Minimum staffing standards, and procedures to take when the daily schedule did not meet the established facility staffing standards. The procedures included: a) when there was a call in at the last minute, the designated staffing person will try to find a replacement. If a replacement could not be found, the designated staffing person will look at moving staff around if there is extra staff available on another unit; b) There may be times when the staff member was a no-call, no-show. In this case, a nurse at the facility must call the designated staffing person to inform them of the no-show. c) If the staffing person could not be reached, the nurse will call the DON. If the DON could not be reached, the nurse will call the Administrator. If the staffing level on any day falls below the minimum staff level, one (1) of the administrative staff will be asked to come in to support the staff currently working. d) Due to weekends being more difficult to staff, the Unit Managers and other Nursing Directors agreed to a weekend on call schedule and will be available to come in on the weekends if staff drops below the minimum staffing level. 11. Resident #1 is no longer on [MEDICATION NAME]. The facility currently had three (3) Residents including Resident #2, which were required to have [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) labs, and have their PT/INR labs obtained/followed-up in accordance with their Physician/ARNP orders and their care plan as determined by PT/INR monitoring. The DON will track [MEDICATION NAME] labs and follow-up orders. Three (3) times a week on weekdays, a binder that contains a lab log page for each resident will be brought to the morning meeting. The DON will initial she reviewed the labs, including the PT/INR, to check that labs were collected and reported timely to the Physicians/ARNPs. The DON or Unit Managers (UM) will also check with the lab to ensure the lab is in a Pending status, which indicates the lab work is in process. Lab tracking sheets are now being used and will be brought to the morning meeting. [MEDICATION NAME] tracking sheets were implemented for each resident on [MEDICATION NAME]. The DON will initial that she has reviewed labs and the [MEDICATION NAME] tracking sheets to verify that they have been obtained and reported to the attending Physician/APRN in a timely manner. 12. Facility licensed nursing staff were provided in-service education on 05/30/29; 05/31/19; 06/01/19; 06/02/19; 06/03/19; and, 06/04/19 by the DON and SDC on the following: the requirement to administer resident medications in accordance with the Medical Doctor (MD)/ARNP orders and the resident care plan; the need to notify a fell ow charge nurse, their Unit Manager, the QA Nurse, the SDC, or the DON if they were unable to complete medication administration for their assigned residents in accordance with the /ARNP orders and the resident care plan so that assistance would be provided; the requirement to perform PT/INR labs in accordance with MD/APRN orders and the resident care plan; the requirement to notify the MD/APRN and the Resident Representative if medications were not administered to the resident in accordance with their orders, care plan and facility policy; and, the components of the facility's Abuse/Neglect Policy, including what constitutes abuse/neglect and the reporting aspects if a staff has neglected to provide medications or treatments to residents, and the disciplinary action that will be implemented for failure to follow the requirements, which is disciplinary action up to termination, was addressed in this training. 13. A review of the facility's staffing, as compared to the established staffing standards, will be provided to the Board of Directors at their monthly meeting. This will include, but not be limited to, the protocol steps taken by the facility when the daily schedule did not meet the established staffing standards. 14. The DON and Administrator have and will continue to monitor staffing levels based on census and acuity levels. The facility developed a Minimum Staffing Target worksheet that established a minimum staffing level for all three units for all three shifts. The instructions on the sheet indicated what the Managers were to do in the case of a call-in or shortage and what to do if a replacement could not be found. It listed the DON's and Administrator's phone number for assistance. The State Survey Agency validated the implementation of the facility's A[NAME] as follows: 1. Record Review confirmed the President and CEO of the facility provided counseling and assistance to the Administrator, on 05/29/19, related to the minimum staffing standards and the steps to take when the daily schedule did not meet the established standards. Record Review of the document titled, Minimum Staffing Targets, 2019, dated 05/29/19, confirmed the Administrator was educated by the President and CEO of the facility on minimum staffing standards and steps to take when the daily schedule did not meet the established standards. Further review confirmed the Administrator reviewed Scoring Rules for staffing and ratings with the President and CEO. Continued review confirmed, the President and CEO again met with the Administrator to ensure care and services were provided for the residents, twenty-four (24) hours a day. Interview with the Administrator on 06/07/19 at 1:10 PM revealed he received counseling related to ensure minimum staffing standards and the steps to take when the daily schedule did not meet the standard. Continued interview revealed he was also educated that it was the Administrator's responsibility Interview with the President and CEO of the facility, on 06/07/19 at 2:01 PM, confirmed he met with the Administrator several times about staffing concerns and the need for the facility to make the resident's care a priority. Further interview revealed, the administrator was educated on facility staffing standards, and the administrator's responsibility twenty-four (24) hours a day to ensure care and services are provided. 2. Review of the Chain of Command, dated 06/06/19, validated the administrator educated/reviewed with the DON, SDC, and Unit Managers about what they would need to do if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to our residents. Interview with the DON on 06/06/19 at 1:49 PM, confirmed she had received education related to the facility's Chain of Command, staffing standards Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking and Notification of Change. Interview with South Wing Unit Manager, on 06/07/19 at 12:00 PM and the Staff Development Coordinator (SDC), at 1:00 PM, confirmed they were educated on the Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking, Notification of Change, Chain of Command and Staffing Standards. 3. Review of the Midnight Census Worksheet utilized 06/05/19 with resident statements confirmed, revealed the Administrator and the Social Services Director (SSD) visited all interviewable residents and asked if they had been receiving care, medications, treatments and services and if care was to their satisfaction. They were also questioned related to who they should report issues to, regarding care provided. Interview with the Administrator, on 06/07/19, confirmed interviewable residents were asked if they were receiving their medications, treatments, and care to their satisfaction. Per interview, the interviewable residents were also asked if they were aware of how to report problems concerning their care, and who they should notify if there was a concern related to care. Further interview revealed the SSD and Administrator were able to interview fifty (50) residents. Per interview, interviews were scheduled to con

Based on interview, record review, and review of facility Policy, it was determined the facility failed to have an effective system to provide or obtain laboratory services to meet the needs of its residents for one (1) of three (3) sampled residents reviewed for labs related to [MEDICATION NAME] Time/International Normalized Ration (PT/INR) laboratory data out of a total thirty-eight (38) sampled residents (Resident #1). A PT is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the INR is calculated from a PT result and is used to monitor how well the blood thinning medication (anticoagulant-[MEDICATION NAME]) is working to prevent blood clots. The facility failed to ensure PT/INR levels were drawn as ordered for Resident #1 who was receiving [MEDICATION NAME] (anticoagulant) medication. Although Resident #1 received PT/INR levels at least once a week and sometimes twice a week in (MONTH) 2019 related to [MEDICATION NAME] Therapy, the facility failed to monitor the resident's PT/INR for eighteen (18) days in (MONTH) 2019, from 03/11/19 until 03/29/19. On 03/11/19, the resident's PT/INR was 2.9, and was in the therapeutic range. The facility notified the Physician of the results and received verbal orders to repeat the PT/INR on 03/14/19; however, there was no documented evidence the lab was drawn on 03/14/19. Additionally, review of the medical record revealed physician's orders [REDACTED]. On 03/29/19, the Laboratory Report revealed the resident's PT: > (greater than) 116.1 High and INR: >10.0 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). Resident #1 was transferred to the Hospital emergency roiagnom on [DATE] and diagnosed with [REDACTED]. (Refer to F-757) The facility's failure to ensure laboratory services were obtained to meet the needs of its resident related to PT/INR levels for residents receiving [MEDICATION NAME] medication has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate jeopardy (IJ) was identified on 05/23/19 and determined to exist on 03/14/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 alleging removal of the Immediate Jeopardy on 06/06/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/06/19, prior to exit on 06/07/19 with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility Diagnostic Services Policy, revised 11/24/14, revealed the facility will provide or obtain laboratory services to meet the needs of its residents and will be responsible for the quality and timeliness of the services. The facility will promptly notify the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with policies and procedures. The Laboratory Company utilized by the facility, revealed the following ranges for Normal PT/INR levels: Normal Range for [MEDICATION NAME] Time (PT) 9.5 seconds to 11.8 seconds; and Normal Range for International Normalized Ratio (INR) 0.9 -1.1. Review of Resident #1's medical record revealed the facility admitted the resident on 07/18/13 with [DIAGNOSES REDACTED]. Review of the Laboratory Report, dated 03/07/19, reported on 03/07/19 at 11:59 PM, and faxed to the facility on [DATE] at 12:07 PM, revealed results: PT 30.9 High and INR 2.8 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). A Notation written on the Lab Report revealed recheck on Monday (03/11/19). Review of Resident #1's physician's orders [REDACTED]. Review of the Laboratory Report, dated 03/11/19, reported at 4:18 PM and faxed to the facility on [DATE] at 4:29 PM, revealed results: PT: 29.3 High and INR: 2.9 High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). A Notation written on the Lab Report by Licensed Practical Nurse (LPN) #4 included PT/INR on 03/14/19. Review of Resident #1's Progress Notes, dated 03/12/19, at 10:39 AM, signed by LPN #4, revealed new orders were received with Advanced Registered Nurse Practitioner (ARNP) visit today concerning PT/INR results from 03/11/19. Further review revealed new orders received included recheck PT/INR, on 03/14/19. However, review of Resident #1's Physician order [REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Additionally, there was no documented evidence the resident's PT/INR was monitored from 03/11/19 until 03/29/19, eighteen (18) days. Review of the Laboratory Report, dated 03/29/19, reported at 8:55 AM and faxed to the facility on [DATE] at 8:55 AM, revealed PT: was > (greater than) 116.1 High and INR: >10.0 Critically High (reference range PT: 9.5-11.8 and INR: 0.9-1.1). There was a Notation on the Laboratory Report stating the resident was sent to the emergency room (ER). Review of Resident #1's Hospital Discharge Summary, dated 04/05/19, revealed the resident was admitted to the hospital on [DATE] with the principle [DIAGNOSES REDACTED]. Resident #1 received 10 mg of intravenous (IV) Vitamin K in the Emergency Department and subsequently received two (2) units of Fresh Frozen Plasma and two (2) units of Packed Red Blood Cells. Interview with LPN #4, on 05/16/19 at 3:39 PM, revealed when Laboratory Reports were faxed to the facility, she would inform the resident's ARNP of the results, and receive new orders. She stated she would input the new medication orders related to the lab results into the electronic medical record as a new physician's orders [REDACTED]. [REDACTED]. LPN #4 stated she should have filled out a Lab Reconciliation and put it in the lab binder to be drawn on 03/14/19 for Resident #1; however, she was unsure if she had actually filled out the Lab Reconciliation for that date, since the PT/INR was not drawn on 03/14/19. Interview with the ARNP, on 05/23/19 at 2:58 PM, revealed it appeared as though Resident #1's PT/INR lab was missed on 03/14/19 and 03/17/19. The ARNP stated a nurse brought it to her attention on 03/29/19, the lab draws were missed, the resident's PT/INR levels were elevated and the resident was sent to the emergency room . Per interview, Resident #1 had a Rectus Hematoma, and the [MEDICATION NAME] medication could be a factor. Further interview revealed it was her expectation laboratory data was obtained as ordered. Interview with the Director of Nursing (DON), on 05/23/19 at 3:49 PM, revealed it was important to monitor residents who were receiving [MEDICATION NAME] to ensure therapeutic PT/INR levels were maintained and to prevent residents from possible adverse reactions including bleeding. Further interview revealed Resident #1's labs should have been obtained as ordered in order to closely monitor this resident who was receiving [MEDICATION NAME] therapy. Per interview, when a nurse obtained a physician's orders [REDACTED]. The DON stated, Resident #1 should not have gone eighteen (18) days without the PT/INR being drawn. When questioned if there was a tracking system for monitoring laboratory results related to PT/INR levels, she was unable to submit for review any documented evidence this was being monitored and tracked. The DON further stated, my lab system is not perfect and needs improvement. Interview with the Administrator, on 05/23/19 at 3:11 PM, revealed it was his expectation laboratory data be obtained as per physician's orders [REDACTED]. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/06/19 that alleged removal of the Immediate Jeopardy (IJ) on 06/06/19. Review of the AoC revealed the facility implemented the following. 1. The Administrator was provided counseling and assistance on 05/29/19 by the President and Chief Executive Officer (CEO) of the facility's minimum staffing standards and the steps to take when the daily schedule did not meet the standards. On 06/05/19, the CEO and Administrator met again and the CEO re-emphasized with the Administrator that it was the Administrator's responsibility to ensure care and services were provided for the residents, twenty-four (24) hours a day. 2. On 05/30/19, the Administrator educated/reviewed with the Director of Nursing (DON), Staff Development Coordinator (SDC) and Unit Managers (UM) the actions to take if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to the residents. 3. On 6/05/19, the Administrator and the Social Services Director visited all interviewable residents and asked if they have been receiving medications, treatments and services to their satisfaction. They were also asked if they knew who to report to if they had issues. The Administrator and Social Services Director will continue to interview the residents two (2) times a week for one (1) month. The Quality Assurance (QA) team will determine ongoing frequency based on findings after the first month. 4. On 04/09/19, the Director of Nursing (DON) notified the Physician/Advanced Registered Nurse Practitioner (ARNP) of the missed medications on 04/07/19 with follow-up orders implemented as indicated for Resident #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30. Additionally the DON assessed the residents to determine if there was any adverse effects to the residents that missed their medications with no adverse effects noted. 5. The Resident Representatives were notified of the missed medications on 04/11/19 and 04/12/19 by the DON and Registered Nurse (RN) #2 for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, and #30. 6. Licensed Practical Nurse (LPN) #2, who did not report the previous nurse's missed medication administration, was provided education related to the facility's policies related to notification on 04/14/19 and again on 05/31/19 by the Staff Development Director (SDD). 7. Residents #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25, and #28 and all other current in-house residents, will be administered their medications and treatments in accordance with the Medical Doctor's (MD)/ARNP's orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) will be checked, by the Administrator and/or DON for late and due medication administrations. The MARS and TARS will be checked twice daily for two (2) weeks, then once daily for one (1) month and will then be re-evaluated by the Quality Assurance Performance Improvement (QAPI) committee to determine ongoing frequency. 8. The facility had employed twenty-eight (28) new staff, ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN) and twelve (12) State Registered Nurses Aides (SRNA), since 04/01/19. This was done to fill positions on the nursing schedule to provide staffing and to provide nursing and related services. This will assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house resident. 9. To assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and all other current in-house residents, care observations of six (6) residents will be completed, two (2) residents will be observed per wing. These observations will be performed by the Administrative Nursing Staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors weekly for two (2) months and will then be re-evaluated by the QAPI committee to determine ongoing frequency using the Care Observation tool. The first observation occurred on 06/03/19. 10. The CEO, Administrator and DON developed facility Minimum staffing standards, and procedures to take when the daily schedule did not meet the established facility staffing standards. The procedures included: a) when there was a call in at the last minute, the designated staffing person will try to find a replacement. If a replacement could not be found, the designated staffing person will look at moving staff around if there is extra staff available on another unit; b) There may be times when the staff member was a no-call, no-show. In this case, a nurse at the facility must call the designated staffing person to inform them of the no-show. c) If the staffing person could not be reached, the nurse will call the DON. If the DON could not be reached, the nurse will call the Administrator. If the staffing level on any day falls below the minimum staff level, one (1) of the administrative staff will be asked to come in to support the staff currently working. d) Due to weekends being more difficult to staff, the Unit Managers and other Nursing Directors agreed to a weekend on call schedule and will be available to come in on the weekends if staff drops below the minimum staffing level. 11. Resident #1 is no longer on [MEDICATION NAME]. The facility currently had three (3) Residents including Resident #2, which were required to have [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) labs, and have their PT/INR labs obtained/followed-up in accordance with their Physician/ARNP orders and their care plan as determined by PT/INR monitoring. The DON will track [MEDICATION NAME] labs and follow-up orders. Three (3) times a week on weekdays, a binder that contains a lab log page for each resident will be brought to the morning meeting. The DON will initial she reviewed the labs, including the PT/INR, to check that labs were collected and reported timely to the Physicians/ARNPs. The DON or Unit Managers (UM) will also check with the lab to ensure the lab is in a Pending status, which indicates the lab work is in process. Lab tracking sheets are now being used and will be brought to the morning meeting. [MEDICATION NAME] tracking sheets were implemented for each resident on [MEDICATION NAME]. The DON will initial that she has reviewed labs and the [MEDICATION NAME] tracking sheets to verify that they have been obtained and reported to the attending Physician/APRN in a timely manner. 12. Facility licensed nursing staff were provided in-service education on 05/30/29; 05/31/19; 06/01/19; 06/02/19; 06/03/19; and, 06/04/19 by the DON and SDC on the following: the requirement to administer resident medications in accordance with the Medical Doctor (MD)/ARNP orders and the resident care plan; the need to notify a fell ow charge nurse, their Unit Manager, the QA Nurse, the SDC, or the DON if they were unable to complete medication administration for their assigned residents in accordance with the /ARNP orders and the resident care plan so that assistance would be provided; the requirement to perform PT/INR labs in accordance with MD/APRN orders and the resident care plan; the requirement to notify the MD/APRN and the Resident Representative if medications were not administered to the resident in accordance with their orders, care plan and facility policy; and, the components of the facility's Abuse/Neglect Policy, including what constitutes abuse/neglect and the reporting aspects if a staff has neglected to provide medications or treatments to residents, and the disciplinary action that will be implemented for failure to follow the requirements, which is disciplinary action up to termination, was addressed in this training. 13. A review of the facility's staffing, as compared to the established staffing standards, will be provided to the Board of Directors at their monthly meeting. This will include, but not be limited to, the protocol steps taken by the facility when the daily schedule did not meet the established staffing standards. 14. The DON and Administrator have and will continue to monitor staffing levels based on census and acuity levels. The facility developed a Minimum Staffing Target worksheet that established a minimum staffing level for all three units for all three shifts. The instructions on the sheet indicated what the Managers were to do in the case of a call-in or shortage and what to do if a replacement could not be found. It listed the DON's and Administrator's phone number for assistance. The State Survey Agency validated the implementation of the facility's A[NAME] as follows: 1. Record Review confirmed the President and CEO of the facility provided counseling and assistance to the Administrator, on 05/29/19, related to the minimum staffing standards and the steps to take when the daily schedule did not meet the established standards. Record Review of the document titled, Minimum Staffing Targets, 2019, dated 05/29/19, confirmed the Administrator was educated by the President and CEO of the facility on minimum staffing standards and steps to take when the daily schedule did not meet the established standards. Further review confirmed the Administrator reviewed Scoring Rules for staffing and ratings with the President and CEO. Continued review confirmed, the President and CEO again met with the Administrator to ensure care and services were provided for the residents, twenty-four (24) hours a day. Interview with the Administrator on 06/07/19 at 1:10 PM revealed he received counseling related to ensure minimum staffing standards and the steps to take when the daily schedule did not meet the standard. Continued interview revealed he was also educated that it was the Administrator's responsibility Interview with the President and CEO of the facility, on 06/07/19 at 2:01 PM, confirmed he met with the Administrator several times about staffing concerns and the need for the facility to make the resident's care a priority. Further interview revealed, the administrator was educated on facility staffing standards, and the administrator's responsibility twenty-four (24) hours a day to ensure care and services are provided. 2. Review of the Chain of Command, dated 06/06/19, validated the administrator educated/reviewed with the DON, SDC, and Unit Managers about what they would need to do if they received a call from the facility regarding the inability of current staff to provide medications, treatments, and or basic care to our residents. Interview with the DON on 06/06/19 at 1:49 PM, confirmed she had received education related to the facility's Chain of Command, staffing standards Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking and Notification of Change. Interview with South Wing Unit Manager, on 06/07/19 at 12:00 PM and the Staff Development Coordinator (SDC), at 1:00 PM, confirmed they were educated on the Nursing Scope of Practice, High Risk Medications, Medication Administration, Abuse/Neglect, Lab Tracking, [MEDICATION NAME] Tracking, Notification of Change, Chain of Command and Staffing Standards. 3. Review of the Midnight Census Worksheet utilized 06/05/19 with resident statements confirmed, revealed the Administrator and the Social Services Director (SSD) visited all interviewable residents and asked if they had been receiving care, medications, treatments and services and if care was to their satisfaction. They were also questioned related to who they should report issues to, regarding care provided. Interview with the Administrator, on 06/07/19, confirmed interviewable residents were asked if they were receiving their medications, treatments, and care to their satisfaction. Per interview, the interviewable residents were also asked if they were aware of how to report problems concerning their care, and who they should notify if there was a concern related to care. Further interview revealed the SSD and Administrator were able to interview fifty (50) residents. Per interview, interviews were scheduled to continue two (2) times weekly for one (1) month and then the Quality Assurance team would determine the ongoing frequency based on the findings. 4. Review of the Medication Error Report Sheets, dated 04/09/19, revealed notification was made by the Director of Nursing (DON) to the Physician/Advanced Practice Registered Nurse (APRN) for each of Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29 and #30 from 04/08/19 to 04/09/19. The Physicians/APRN was notified the residents listed above, on the Therapy Unit, did not received their medications on 04/07/19 from the time of 3:00 PM to 10:00 PM. Interview with the DON, on 06/06/19 at 3:39 PM, confirmed she had informed the Physician/APRN and the Resident Representative of medications not being administered to Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29, and #30 on 04/07/19. Continued interview revealed she assessed all of the residents by observation, clinical review, such as monitoring blood pressure and blood sugars, and record review for any adverse effects of missing their medications and there were no adverse effects on any of the residents. Interview with Physician #1, on 05/22/19 at 9:30 AM, confirmed he was notified the residents on the Therapy Unit had not received their evening medications on 04/07/19. He reported he had been informed of this immediately after the facility became aware of the situation on 04/08/19 but could not recall the time. Further interview revealed, there were plans for ongoing monitoring of vital signs, pain or any changes related to medications missed to assure there are no adverse effects. Interview with Physician #2, on 05/22/19 at 8:30 PM, confirmed he was informed on 04/08/19 the residents on the Therapy Unit did not receive their medications the night of 04/07/19. Physician #2 also confirmed during the interview, the DON and his Nurse Practitioner discussed the incident prior to him having knowledge. Further interview confirmed he was uncertain of when he was informed. Physician #2 requested the Residents effected have their vital signs monitored and the nursing staff alert the Physician of any adverse changes. 5. Review of the Medication Error Report Sheets, dated 04/09/19, revealed notification was made by the DON and RN # 2 to the Resident Representatives between 04/11/19 and 04/12/19 informing them medications had not been administered for Resident #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #28, #29 and #30. The Resident Representatives were also informed the Resident's Physician/APRN had been informed of the missed medications. Interview with RN #2, on 06/06/19, confirmed he did notified six (6) to seven (7) of the Resident Representative to inform them the residents did not receive their medications the evening of 04/07/19 on the Therapy Unit. Interview with the DON, on 06/06/19, confirmed she and RN #2 did notify the Resident Representatives of the residents not receiving medications on the evening of 04/07/19.3 6. Review of the Education Sign-In Roster, dated 04/14/19 and 05/31/19, revealed Licensed Practical Nurse (LPN) #2, who did not report the previous nurses' missed medication administration, was provided education by the Staff Development Director (SDD). Continued review revealed education included the Scope of Practice, High Risk Medication, Medication Administration, Abuse and Change in Condition Process, Interview with LPN #2, on 06/06/19 at 7:35 PM, confirmed education was received over the last few weeks. LPN #2 stated the physician should have been notified at the time she received the information. The previous nurse, LPN #1, had not informed the physician the medications had not been given the evening of 04/07/19, but informed LPN #2 when giving report. 7. Review of the Medication Administration Checks, initiated on 06/01/19, validated Resident #2, #7, #12, #13, #14, #15, #16, #21, #23, #24, #25 and #28, and all other current in-house residents, were administered their medications and treatments in accordance with the Medical Doctor's (MD)/APRN orders, their care plan, and facility policy, as determined by the Administrator and/or DON. The Medication Administration Records (MAR) and Treatment Administration Records (TAR) were checked twice daily by the Administrator of DON. The MARS and TARS checks were initiated twice daily beginning 06/01/19 to present. Interview with the DON, on 06/07/19 at 1:49 PM, confirmed the MAR and TAR have been monitored twice daily by herself or the Administrator. Interview with the Administrator, on 06/07/19 at 1:08 PM, confirmed the MARs and TARS are monitored and reviewed for any missed or past due medications. The Administrator confirmed the MARS and TARS are check twice daily and will continue to be check twice each day for two (2) weeks, then once daily for one (1) month and then will be evaluated by QAPI committee to determine ongoing frequency. Per interview, if any issues are found, the DON will be contacted to follow-up with the floor nurse during the week and on the weekends. 8. Review of the facility's Human Resources records, New Hire list, dated 04/01/19 to present, validated the facility had employed twenty-eight (28) new staff. Continued review revealed ten (10) Registered Nurses (RN), six (6) Licensed Practical Nurses (LPN), and twelve (12) State Registered Nurses Aides (SRNA) were hired by the facility since 04/01/19. Interview with the DON, on 06/06/19 at 1:49 PM, confirmed the facility has hired many new nurses and aides and had increased the staffing level. This facility has joined with a corporation that will assist with staffing. Further interview confirmed the facility is following the Minimum Staffing Target, 2019. Continued interview revealed if they did not meet the minimum level of staffing, Managers had been educated to call the Unit Managers and they can work the carts and they are able to contact an agency nursing staff. Interview with the Administrator, on 06/07/19 at 1:08 PM, confirmed if the facility's minimum staffing level was not achieved, the DON and or Administrator was notified. Continued interview revealed staff may be moved around to provide coverage to each unit. Further interview revealed on the weekends, administrative staff will come in to support staff working if staffing levels fall below the minimum staffing level. 9. Review of the Resident Observation Tool validated care observations of six (6) residents weekly was initiated as of 06/03/19. Continued review revealed the Resident Observation Tool confirmed two residents were observed per wing. Further review revealed the observations were performed by the administrative nursing staff including the DON, Quality Assurance (QA) Nurse, Staff Development Coordinator (SDC), Unit Managers or Shift Supervisors. Interview with the North Hall Unit Manager, on 06/07/19 at 11:15 AM, confirmed the administrative staff was responsible to complete resident observations for six (6) residents, two (2) from each unit using the Resident Observation Tool. Interview with the Quality Nurse (QA) nurse, on 06/07/19 at 2:07 PM, revealed the DON, Administrator or herself would utilize the Resident Observation Tool for six (6) Residents. Continued interview revealed two (2) residents on each unit would be observed using the tool for two (2) months, then it would be re-evaluated to make a decision if they were going to do it once a week. Interview with the DON, on 06/06/19 at 1:49 PM, revealed she and the Quality Assurance (QA) Nurse use the Resident Observation Tool. Per interview, two (2) residents are selected from every unit to observe the care. Further interview revealed this tool is utilized weekly for a total of two (2) months. Per interview, the tool will assist the facility to ensure residents are receiving good care and things are going well. She stated they look at shower care, nail care, hair care, and general overall care and have not identified any issues with the observations. Interview with the Administrator, on 06/07/19 at 1:08 PM, revealed the facility was utilizing the Resident Observation Tool. Per interview, the tool looks at how residents are dressed, it covers dignity, privacy, the resident mood/behavior, and any accident or hazards in the room, call lights and functioning for safety. Further interview confirmed the tool also assesses areas to ensure the resident is receiving good care. He stated, the Resident Observation Tool is utilized weekly for two months on six (6) residents, two (2) from each wing. 10. Review of the Minimum Staffing Targets, 2019 validated the Chief Executive Officer (CEO) the Administrator and DON developed facility Minimum Staffing Standards, and steps to take when the daily schedule does not meet the established facility staffing standards. Further review revealed, the minimum staffing was established using the Scoring Rules Table 3: of the National Star Cut Points for Staffing Measures Based on adjusted hours per Resident Day, updated (MONTH) 2019 and Table 4: Staffing and Rating, updated, (MONTH) 2019. This method was used for both RN Staffing and total staffing; a rating of 1 to 5 stars is assigned. Continued review revealed the facility initiated protocols on 05/29/19, for last minute call-in by staff. The designated staffing person works toward to finding a replacement. If a replacement cannot be found, the designated staffing person will look at moving staff around if there is extra staff available on another unit. Interview with the Therapy Unit Manager, on 06/07/19 at 11:35 AM, revealed the policy of the facility when a staff member is a no-show, no-call is to notify the staffing coordinator so they can began to work on staffing. Per interview, the staffing coordinator had previously been responsible for staffing. She stated, the new policy designate this responsibility to all managers. If the staffing coordinator cannot be reached, then

Based on observation, interview, and record review, it was determined the facility failed to have an effective system to implement the plan of care for one (1) of five (5) sampled residents, Residents #6. Record review revealed the resident had a care plan intervention to monitor the resident for coughing or choking when eating and drinking related to a [DIAGNOSES REDACTED]. However, observation of the resident on 10/09/18 revealed the resident alone in his/her room with a tray of food in front of him/her and staff was not present to monitor the resident, as per the care plan. The facility's failure to ensure care plan interventions were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/13/18 and was determined to exist on 10/08/18. The facility was notified of the IJ on 11/13/18. The facility provided an acceptable Allegation of Compliance (AOC) on 11/21/18, which alleged removal of the IJ on 11/09/18. The State Survey Agency (SSA) verified the IJ was removed on 11/09/18, prior to exit on 11/29/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the Clinical Record for Resident #6 revealed the facility admitted the resident on 02/07/17, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set for Resident #6, dated 09/28/18, revealed the facility assessed the resident required supervision for eating. Review of the Care Plan for Resident #6, dated 09/06/18, revealed the resident was at nutritional risk related to Dysphagia with an intervention to monitor for any signs and symptoms of coughing or choking while eating and drinking. However, observation of Resident #6, on 10/09/18 at 8:08 AM, revealed the resident was in bed with the breakfast tray in front of him/her and stated he/she was able to feed himself/herself. There was no staff in the room monitoring the resident for coughing and choking as per the care plan. Interview with Certified Nursing Assistant (CNA) #2, on 10/09/18 at 9:50 AM, revealed Resident #6 could feed himself/herself and she was not aware the resident could not eat alone and was not aware the resident had Dysphagia. She stated she did not see that information on the care plan. Interview with CNA #7, on 10/09/18 at 2:15 PM, revealed they have a care card on the computer but there was nothing about aspiration precautions on any resident that she could remember. Interview with CNA #9, on 10/09/18 at 1:00 PM, revealed she did not see the whole care plan but rather got some information regarding activities of daily living and bathing. Interview with Licensed Practical Nurse #4, on 10/25/18 at 4:27 PM, via telephone, revealed she monitored CNAs to ensure care plan interventions were followed when she completed rounds on the residents. Interview with Registered Nurse #4, on 10/09/18 at 9:20 AM, revealed Resident #6's care plan was not clear on the resident needing to be supervised during meals, especially when the resident told everyone that he/she could eat alone. Interview with the Director of Nursing, on 10/25/18 at 4:25 PM and 11/20/18 at 2:55 PM, revealed she thought the unit managers ensured care plan interventions were implemented. She stated having Resident #6 eat without direct supervision was unsafe and could have resulted in aspiration. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #6 no longer resided at the facility. Resident #10 was included in the observed dining program as of 10/16/18 for meal supervision. The Interdisciplinary Team (IDT) reviewed and revised Resident #10's care plan on 10/30/18 to include aspiration precautions and supervision during meals. 2. The Director of Nursing, Quality Assurance (QA) Nurse, Staff Development Coordinator, or Unit Manager (UM) would conduct observations of the dining rooms weekly for six (6) weeks, then every other week for six (6) weeks by a contracted therapist. 3. The IDT completed a care plan audit on 11/05/18 for all current residents to determine if aspiration precautions were on the plan, if indicated. 4. The Contracted Nurse Consultant educated the Social Services Director, Minimum Data Set (MDS) Coordinator, UM, Activity Director, and DON on 10/22/18 regarding accurate completion of the MDS, care plans with focus on interventions such as aspiration precautions, and review of the RAI (Resident Assessment Instrument) Manual. Newly hired staff that would be members of the MDS/Care Plan team would be provided the education prior to coding MDS assessments or updating care plans. 5. On 10/29/18, the DON and Dietary Manager reviewed and revised the breakfast meal tray delivery schedule to provide time between meal carts to allow time for staff to provide required supervision for residents who eat in their rooms. 6. The Staff Development Coordinator educated nursing staff on 11/08/18 regarding the new observed dining program, the revised meal monitoring assignments, and the need to request a replacement if unable to be present during meal service as assigned. Staff not educated by 11/08/18 would be provided training prior to working. Each nurses' station was provided dining room instructions for reference and for agency staff use. 7. A QAPI (Quality Assurance, Performance Improvement) meeting was held on 11/06/18 with the QAPI team and the Medical Director to review findings of the survey and the Plan of Correction. 8. Audits of five (5) selected residents for MDS and Care Plan documentation would be completed, under the supervision of the DON, using the QAPI tool. The audits would be conducted monthly for two (2) months, quarterly for two (2) quarters, then every six (6) months. Failure to meet 95% accuracy would result in development of a plan of action. 9. Audits of five (5) randomly selected residents for meal observations would be conducted under the direction of the Dietary Manager using the QAPI tool to determined residents were provided supervision during meals in accordance with the care plan. The audits would be conducted weekly for two (2) weeks, then monthly. Meal observations would be conducted for residents eating in their rooms weekly for six (6) weeks then monthly by the DON, QA Nurse, Staff Development Coordinator, UMs, or the Administrator. 10. Results of completed QAPI tools and any action plans would be reviewed in the QAPI meetings. 11. The President and CEO (Chief Executive Officer) of the company would meet with the Administrator two (2) times per week for one (1) month, then weekly for one (1) month, then monthly thereafter to review the Plan of Correction and implementation and assist with QAPI meeting follow-up issues. The SSA validated the facility implemented the following actions: 1. Observation of Resident #10, on 11/29/18 at 11:51 PM, revealed the resident eating lunch in the observed dining room with LPN #9, UM #3, and UM #4 present. Interview with the DON, on 11/29/18 at 9:36 AM, revealed Resident #10 was moved to the observed dining room by 10/16/18 so he/she could be monitored for choking when eating. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT revised Resident #10's care plan to include aspiration precautions and meal monitoring. Review of Resident #10's Care Plan revealed the facility updated the plan on 10/16/18 to include aspiration precautions and monitoring. Review of the facility's census and observation revealed Resident #6 no longer resided at the facility. 2. Observation, on 11/29/18 at 11:51 PM, revealed the UM #3 and #4 were observing the main dining room and UM #2 was observing the dining room on the rehabilitation unit. Interview with the DON, on 11/29/18 at 9:36 AM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed they monitored the dining rooms to ensure staff was present observing the residents. Interview with the Speech Therapist (ST) via telephone, on 11/29/18 at 1:42 PM, revealed she came to the facility every other Sunday and conducted dining room observations to ensure staff was present and if any resident appeared to need referral for swallowing difficulties. Record review revealed the UMs monitored the dining rooms weekly from 10/05/18 to 11/25/18; the ST monitored the dining room on 10/14/18, 10/30/18, 11/12/18, 11/15/18, and 11/25/18. 3. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT reviewed and revised all resident care plans with the focus to ensure aspiration precautions were on the appropriate plans. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the IDT audited all resident care plans and plans were updated as needed. Record review revealed all resident care plans were reviewed and updated by 11/05/18. 4. Interview with the Contracted Nurse Consultant via telephone, on 11/29/18 at 11:01 AM, revealed she educated staff on 10/22/18 regarding MDS assessment completion using the RAI Manual and care plan development. Interview with the DON, on 11/29/18 at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed the Contracted Nurse Consultant educated them on completing MDS assessments and care plans. Record review revealed the Contracted Nurse Consultant education the DON, UMs, MDS Coordinator, and Social Services Director on 10/22/18. Review of the facility's staff roster revealed no staff that would complete MDS assessments or develop and revise care plans was newly hired. 5. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, and the DON at 9:36 AM, revealed they reviewed the breakfast meal tray delivery times and adjusted the times the trays were delivered in order to allow staff time to assist and monitor residents with eating. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9, at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the time breakfast was served was adjusted to ensure residents were observed while eating. 6. Observation of the South Nurses' Station, on 11/29/18 at 7:39 AM, the Rehab's Nurses' Station at 7:43 AM, revealed dining room instructions available. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9 at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the Staff Development Coordinator educated them on the observed dining programs and meal monitoring. Interview revealed the staff was knowledgeable regarding observing residents with swallowing difficulties for choking and ensuring staff was present in the dining rooms during meals. Interview with the Staff Development Coordinator, on 11/29/18 at 10:15 AM, revealed she educated all staff on the dining room program and meal monitoring assignments. She stated she used the employee roster to keep track of who was educated and who was not. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the Staff Development Coordinator kept track of which staff needed to be educated. She stated staff was not allowed to work on the units until education was completed. 7. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, and the Administrator at 2:55 PM, revealed they attended the 11/06/18 QAPI meeting where they discussed the findings of the survey and the action plan. Interview with the Medical Director, on 11/29/18 at 2:45 PM, revealed he attended the 11/06/18 QAPI meeting and the action plan and survey findings were discussed. Review of the sign in sheet for the 11/06/18 QAPI meeting revealed the Administrator, Medical Director, MDS Coordinator, UM #2, the DON, the QA Nurse, the Social Services Director, the Activities Director, and the CEO attended the meeting. 8. Interview with the QA Nurse, on 11/29/18 at 1:47 PM, revealed she conducted the MDS and care plan audit and completed the QAPI tool. Interview with the DON, on 11/29/18 at 9:36 AM, revealed care plans and MDS assessments were audited using the QAPI tool. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed a care plan and MDS audit was conducted using the QAPI tool on 11/05/18 by the QA Nurse. 9. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, revealed she conducted meal observations and completed the QAPI tool. She stated she ensured a nurse monitored the residents and that no meals were served unless a nurse was present. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he conducted audits of residents eating in their rooms to ensure staff was monitoring the residents while they ate. He stated he ensured the dining room audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed meal observation audits were conducted using the QAPI tool by the Dietary Manager. Audits were completed on 09/25/18, 10/05/18, 10/25/18, 11/02/18, 11/07/18, 11/18/18, and 11/20/18. Record review revealed meal observations were conducted by the Administrator for residents who ate in their rooms on 11/03/18, 11/05/18, 11/09/18, 11/12/18, 11/18/18, 11/20/18, 11/23/18, and 11/24/18. 10. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, and the Social Services Director at 2:06 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Medical Director via telephone, on 11/29/18 at 2:45 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. He stated the action plan and audits were reviewed in the QAPI meeting. 11. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he and the CEO met almost daily to discuss any issues, as the CEO was at the facility almost daily. Record review revealed between 10/23/18 to 11/27/18, the Administrator and CEO met more than twice weekly.

Based on observation, interview, and record review, it was determined the facility failed to have an effective system to implement the plan of care for one (1) of five (5) sampled residents, Residents #6. Record review revealed the resident had a care plan intervention to monitor the resident for coughing or choking when eating and drinking related to a [DIAGNOSES REDACTED]. However, observation of the resident on 10/09/18 revealed the resident alone in his/her room with a tray of food in front of him/her and staff was not present to monitor the resident, as per the care plan. The facility's failure to ensure care plan interventions were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/13/18 and was determined to exist on 10/08/18. The facility was notified of the IJ on 11/13/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 11/21/18, which alleged removal of the IJ on 11/09/18. The State Survey Agency (SSA) verified the IJ was removed on 11/09/18, prior to exit on 11/29/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the Clinical Record for Resident #6 revealed the facility admitted the resident on 02/07/17, with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set for Resident #6, dated 09/28/18, revealed the facility assessed the resident required supervision for eating. Review of the Care Plan for Resident #6, dated 09/06/18, revealed the resident was at nutritional risk related to Dysphagia with an intervention to monitor for any signs and symptoms of coughing or choking while eating and drinking. However, observation of Resident #6, on 10/09/18 at 8:08 AM, revealed the resident was in bed with the breakfast tray in front of him/her and stated he/she was able to feed himself/herself. There was no staff in the room monitoring the resident for coughing and choking as per the care plan. Interview with Certified Nursing Assistant (CNA) #2, on 10/09/18 at 9:50 AM, revealed Resident #6 could feed himself/herself and she was not aware the resident could not eat alone and was not aware the resident had Dysphagia. She stated she did not see that information on the care plan. Interview with CNA #7, on 10/09/18 at 2:15 PM, revealed they have a care card on the computer but there was nothing about aspiration precautions on any resident that she could remember. Interview with CNA #9, on 10/09/18 at 1:00 PM, revealed she did not see the whole care plan but rather got some information regarding activities of daily living and bathing. Interview with Licensed Practical Nurse #4, on 10/25/18 at 4:27 PM, via telephone, revealed she monitored CNAs to ensure care plan interventions were followed when she completed rounds on the residents. Interview with Registered Nurse #4, on 10/09/18 at 9:20 AM, revealed Resident #6's care plan was not clear on the resident needing to be supervised during meals, especially when the resident told everyone that he/she could eat alone. Interview with the Director of Nursing, on 10/25/18 at 4:25 PM and 11/20/18 at 2:55 PM, revealed she thought the unit managers ensured care plan interventions were implemented. She stated having Resident #6 eat without direct supervision was unsafe and could have resulted in aspiration. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #6 no longer resided at the facility. Resident #10 was included in the observed dining program as of 10/16/18 for meal supervision. The Interdisciplinary Team (IDT) reviewed and revised Resident #10's care plan on 10/30/18 to include aspiration precautions and supervision during meals. 2. The Director of Nursing, Quality Assurance (QA) Nurse, Staff Development Coordinator, or Unit Manager (UM) would conduct observations of the dining rooms weekly for six (6) weeks, then every other week for six (6) weeks by a contracted therapist. 3. The IDT completed a care plan audit on 11/05/18 for all current residents to determine if aspiration precautions were on the plan, if indicated. 4. The Contracted Nurse Consultant educated the Social Services Director, Minimum Data Set (MDS) Coordinator, UM, Activity Director, and DON on 10/22/18 regarding accurate completion of the MDS, care plans with focus on interventions such as aspiration precautions, and review of the RAI (Resident Assessment Instrument) Manual. Newly hired staff that would be members of the MDS/Care Plan team would be provided the education prior to coding MDS assessments or updating care plans. 5. On 10/29/18, the DON and Dietary Manager reviewed and revised the breakfast meal tray delivery schedule to provide time between meal carts to allow time for staff to provide required supervision for residents who eat in their rooms. 6. The Staff Development Coordinator educated nursing staff on 11/08/18 regarding the new observed dining program, the revised meal monitoring assignments, and the need to request a replacement if unable to be present during meal service as assigned. Staff not educated by 11/08/18 would be provided training prior to working. Each nurses' station was provided dining room instructions for reference and for agency staff use. 7. A QAPI (Quality Assurance, Performance Improvement) meeting was held on 11/06/18 with the QAPI team and the Medical Director to review findings of the survey and the Plan of Correction. 8. Audits of five (5) selected residents for MDS and Care Plan documentation would be completed, under the supervision of the DON, using the QAPI tool. The audits would be conducted monthly for two (2) months, quarterly for two (2) quarters, then every six (6) months. Failure to meet 95% accuracy would result in development of a plan of action. 9. Audits of five (5) randomly selected residents for meal observations would be conducted under the direction of the Dietary Manager using the QAPI tool to determined residents were provided supervision during meals in accordance with the care plan. The audits would be conducted weekly for two (2) weeks, then monthly. Meal observations would be conducted for residents eating in their rooms weekly for six (6) weeks then monthly by the DON, QA Nurse, Staff Development Coordinator, UMs, or the Administrator. 10. Results of completed QAPI tools and any action plans would be reviewed in the QAPI meetings. 11. The President and CEO (Chief Executive Officer) of the company would meet with the Administrator two (2) times per week for one (1) month, then weekly for one (1) month, then monthly thereafter to review the Plan of Correction and implementation and assist with QAPI meeting follow-up issues. The SSA validated the facility implemented the following actions: 1. Observation of Resident #10, on 11/29/18 at 11:51 PM, revealed the resident eating lunch in the observed dining room with LPN #9, UM #3, and UM #4 present. Interview with the DON, on 11/29/18 at 9:36 AM, revealed Resident #10 was moved to the observed dining room by 10/16/18 so he/she could be monitored for choking when eating. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT revised Resident #10's care plan to include aspiration precautions and meal monitoring. Review of Resident #10's Care Plan revealed the facility updated the plan on 10/16/18 to include aspiration precautions and monitoring. Review of the facility's census and observation revealed Resident #6 no longer resided at the facility. 2. Observation, on 11/29/18 at 11:51 PM, revealed the UM #3 and #4 were observing the main dining room and UM #2 was observing the dining room on the rehabilitation unit. Interview with the DON, on 11/29/18 at 9:36 AM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed they monitored the dining rooms to ensure staff was present observing the residents. Interview with the Speech Therapist (ST) via telephone, on 11/29/18 at 1:42 PM, revealed she came to the facility every other Sunday and conducted dining room observations to ensure staff was present and if any resident appeared to need referral for swallowing difficulties. Record review revealed the UMs monitored the dining rooms weekly from 10/05/18 to 11/25/18; the ST monitored the dining room on 10/14/18, 10/30/18, 11/12/18, 11/15/18, and 11/25/18. 3. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT reviewed and revised all resident care plans with the focus to ensure aspiration precautions were on the appropriate plans. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the IDT audited all resident care plans and plans were updated as needed. Record review revealed all resident care plans were reviewed and updated by 11/05/18. 4. Interview with the Contracted Nurse Consultant via telephone, on 11/29/18 at 11:01 AM, revealed she educated staff on 10/22/18 regarding MDS assessment completion using the RAI Manual and care plan development. Interview with the DON, on 11/29/18 at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed the Contracted Nurse Consultant educated them on completing MDS assessments and care plans. Record review revealed the Contracted Nurse Consultant education the DON, UMs, MDS Coordinator, and Social Services Director on 10/22/18. Review of the facility's staff roster revealed no staff that would complete MDS assessments or develop and revise care plans was newly hired. 5. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, and the DON at 9:36 AM, revealed they reviewed the breakfast meal tray delivery times and adjusted the times the trays were delivered in order to allow staff time to assist and monitor residents with eating. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9, at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the time breakfast was served was adjusted to ensure residents were observed while eating. 6. Observation of the South Nurses' Station, on 11/29/18 at 7:39 AM, the Rehab's Nurses' Station at 7:43 AM, revealed dining room instructions available. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9 at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the Staff Development Coordinator educated them on the observed dining programs and meal monitoring. Interview revealed the staff was knowledgeable regarding observing residents with swallowing difficulties for choking and ensuring staff was present in the dining rooms during meals. Interview with the Staff Development Coordinator, on 11/29/18 at 10:15 AM, revealed she educated all staff on the dining room program and meal monitoring assignments. She stated she used the employee roster to keep track of who was educated and who was not. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the Staff Development Coordinator kept track of which staff needed to be educated. She stated staff was not allowed to work on the units until education was completed. 7. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, and the Administrator at 2:55 PM, revealed they attended the 11/06/18 QAPI meeting where they discussed the findings of the survey and the action plan. Interview with the Medical Director, on 11/29/18 at 2:45 PM, revealed he attended the 11/06/18 QAPI meeting and the action plan and survey findings were discussed. Review of the sign in sheet for the 11/06/18 QAPI meeting revealed the Administrator, Medical Director, MDS Coordinator, UM #2, the DON, the QA Nurse, the Social Services Director, the Activities Director, and the CEO attended the meeting. 8. Interview with the QA Nurse, on 11/29/18 at 1:47 PM, revealed she conducted the MDS and care plan audit and completed the QAPI tool. Interview with the DON, on 11/29/18 at 9:36 AM, revealed care plans and MDS assessments were audited using the QAPI tool. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed a care plan and MDS audit was conducted using the QAPI tool on 11/05/18 by the QA Nurse. 9. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, revealed she conducted meal observations and completed the QAPI tool. She stated she ensured a nurse monitored the residents and that no meals were served unless a nurse was present. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he conducted audits of residents eating in their rooms to ensure staff was monitoring the residents while they ate. He stated he ensured the dining room audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed meal observation audits were conducted using the QAPI tool by the Dietary Manager. Audits were completed on 09/25/18, 10/05/18, 10/25/18, 11/02/18, 11/07/18, 11/18/18, and 11/20/18. Record review revealed meal observations were conducted by the Administrator for residents who ate in their rooms on 11/03/18, 11/05/18, 11/09/18, 11/12/18, 11/18/18, 11/20/18, 11/23/18, and 11/24/18. 10. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, and the Social Services Director at 2:06 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Medical Director via telephone, on 11/29/18 at 2:45 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. He stated the action plan and audits were reviewed in the QAPI meeting. 11. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he and the CEO met almost daily to discuss any issues, as the CEO was at the facility almost daily. Record review revealed between 10/23/18 to 11/27/18, the Administrator and CEO met more than twice weekly.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to revise the care plan after each assessment and when residents had a risk affecting their care for one (1) of five (5) sampled residents, Resident #10. Record review revealed the resident had a [DIAGNOSES REDACTED]. However, observation revealed the resident eating a meal in the dining room without staff supervision. The resident ate rapidly and made gurgling noises as he/she swallowed. Review of the care plan revealed the facility did not revise the resident's care plan with interventions to monitor the resident during meals to keep the resident from choking on food while eating. The facility's failure to revise resident care plans has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/13/18 and was determined to exist on 10/08/18. The facility was notified of the IJ on 11/13/18. The facility provided an acceptable Allegation of Compliance (AOC) on 11/21/18, which alleged removal of the IJ on 11/09/18. The State Survey Agency (SSA) verified the IJ was removed on 11/09/18, prior to exit on 11/29/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Care Plan policy, undated, revealed the facility was to review and revise care plans as per the RAI Manual with significant changes and changes in physician orders. Record review revealed the facility readmitted Resident #10 on 08/25/18, with [DIAGNOSES REDACTED]. The resident had a gastric tube in place and received bolus feedings with a supplement. The resident signed a waiver to be able to eat regular pureed food and received mashed potatoes with gravy and chocolate pudding at meals. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 required extensive assistance of one (1) person to eat. However, review of the Care Plan for Resident #10, dated 09/11/18, revealed the resident received pureed food/pudding thick liquids for meals and snacks and assistance to set up the meal. There was no intervention that the resident required the presence of a staff member while eating. Observation of Resident #10, on 10/08/18 at 12:00 PM, revealed the resident in the dining room sitting at a table eating very rapidly and swallowing large spoonful's of food. The resident tilted his/her head back to drink a thickened glass of liquid in several large swallows. The resident made a gurgling noise when swallowing. No staff was present in the dining room during the observation to monitor for swallowing difficulty related to his/her Dysphagia. Interview with Certified Nursing Assistant (CNA) #7, on 10/09/18 at 2:15 PM, revealed Resident #10's care plan did not mention the resident required special feeding or aspiration precautions to eat safely. She stated the resident was in the independent dining room so staff thought he/she was all right to be there. She stated the resident ate fast and made a gurgling sound after swallowing and fed himself/herself independently. Interview with the MDS Nurse, on 10/09/18 at 3:20 PM, revealed Resident #10 required monitoring during meals related to his/her decision to eat textured food. She stated the care plan was not revised to include instructions on how to assist the resident in eating safely to prevent aspiration. Interview with the Restorative Nurse, on 10/10/18 at 10:30 AM, revealed Resident #10 required one to one supervision for meals to prevent aspiration related to his/her rapid eating and overloading of the spoon. She stated that type of eating was hazardous to someone with Dysphagia. The nurse stated she was aware the care plan should have been revised to prevent harm to the resident. Interview with the Director of Nursing (DON), on 11/20/18 at 2:55 PM, revealed having Resident #10 eat without direct supervision was unsafe and could have resulted in aspiration. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #6 no longer resided at the facility. Resident #10 was included in the observed dining program as of 10/16/18 for meal supervision. The Interdisciplinary Team (IDT) reviewed and revised Resident #10's care plan on 10/30/18 to include aspiration precautions and supervision during meals. 2. The Director of Nursing, Quality Assurance (QA) Nurse, Staff Development Coordinator, or Unit Manager (UM) would conduct observations of the dining rooms weekly for six (6) weeks, then every other week for six (6) weeks by a contracted therapist. 3. The IDT completed a care plan audit on 11/05/18 for all current residents to determine if aspiration precautions were on the plan, if indicated. 4. The Contracted Nurse Consultant educated the Social Services Director, Minimum Data Set (MDS) Coordinator, UM, Activity Director, and DON on 10/22/18 regarding accurate completion of the MDS, care plans with focus on interventions such as aspiration precautions, and review of the RAI (Resident Assessment Instrument) Manual. Newly hired staff that would be members of the MDS/Care Plan team would be provided the education prior to coding MDS assessments or updating care plans. 5. On 10/29/18, the DON and Dietary Manager reviewed and revised the breakfast meal tray delivery schedule to provide time between meal carts to allow time for staff to provide required supervision for residents who eat in their rooms. 6. The Staff Development Coordinator educated nursing staff on 11/08/18 regarding the new observed dining program, the revised meal monitoring assignments, and the need to request a replacement if unable to be present during meal service as assigned. Staff not educated by 11/08/18 would be provided training prior to working. Each nurses' station was provided dining room instructions for reference and for agency staff use. 7. A QAPI (Quality Assurance, Performance Improvement) meeting was held on 11/06/18 with the QAPI team and the Medical Director to review findings of the survey and the Plan of Correction. 8. Audits of five (5) selected residents for MDS and Care Plan documentation would be completed, under the supervision of the DON, using the QAPI tool. The audits would be conducted monthly for two (2) months, quarterly for two (2) quarters, then every six (6) months. Failure to meet 95% accuracy would result in development of a plan of action. 9. Audits of five (5) randomly selected residents for meal observations would be conducted under the direction of the Dietary Manager using the QAPI tool to determined residents were provided supervision during meals in accordance with the care plan. The audits would be conducted weekly for two (2) weeks, then monthly. Meal observations would be conducted for residents eating in their rooms weekly for six (6) weeks then monthly by the DON, QA Nurse, Staff Development Coordinator, UMs, or the Administrator. 10. Results of completed QAPI tools and any action plans would be reviewed in the QAPI meetings. 11. The President and CEO (Chief Executive Officer) of the company would meet with the Administrator two (2) times per week for one (1) month, then weekly for one (1) month, then monthly thereafter to review the Plan of Correction and implementation and assist with QAPI meeting follow-up issues. The SSA validated the facility implemented the following actions: 1. Observation of Resident #10, on 11/29/18 at 11:51 PM, revealed the resident eating lunch in the observed dining room with LPN #9, UM #3, and UM #4 present. Interview with the DON, on 11/29/18 at 9:36 AM, revealed Resident #10 was moved to the observed dining room by 10/16/18 so he/she could be monitored for choking when eating. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT revised Resident #10's care plan to include aspiration precautions and meal monitoring. Review of Resident #10's Care Plan revealed the facility updated the plan on 10/16/18 to include aspiration precautions and monitoring. Review of the facility's census and observation revealed Resident #6 no longer resided at the facility. 2. Observation, on 11/29/18 at 11:51 PM, revealed the UM #3 and #4 were observing the main dining room and UM #2 was observing the dining room on the rehabilitation unit. Interview with the DON, on 11/29/18 at 9:36 AM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed they monitored the dining rooms to ensure staff was present observing the residents. Interview with the Speech Therapist (ST) via telephone, on 11/29/18 at 1:42 PM, revealed she came to the facility every other Sunday and conducted dining room observations to ensure staff was present and if any resident appeared to need referral for swallowing difficulties. Record review revealed the UMs monitored the dining rooms weekly from 10/05/18 to 11/25/18; the ST monitored the dining room on 10/14/18, 10/30/18, 11/12/18, 11/15/18, and 11/25/18. 3. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT reviewed and revised all resident care plans with the focus to ensure aspiration precautions were on the appropriate plans. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the IDT audited all resident care plans and plans were updated as needed. Record review revealed all resident care plans were reviewed and updated by 11/05/18. 4. Interview with the Contracted Nurse Consultant via telephone, on 11/29/18 at 11:01 AM, revealed she educated staff on 10/22/18 regarding MDS assessment completion using the RAI Manual and care plan development. Interview with the DON, on 11/29/18 at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed the Contracted Nurse Consultant educated them on completing MDS assessments and care plans. Record review revealed the Contracted Nurse Consultant education the DON, UMs, MDS Coordinator, and Social Services Director on 10/22/18. Review of the facility's staff roster revealed no staff that would complete MDS assessments or develop and revise care plans was newly hired. 5. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, and the DON at 9:36 AM, revealed they reviewed the breakfast meal tray delivery times and adjusted the times the trays were delivered in order to allow staff time to assist and monitor residents with eating. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9, at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the time breakfast was served was adjusted to ensure residents were observed while eating. 6. Observation of the South Nurses' Station, on 11/29/18 at 7:39 AM, the Rehab's Nurses' Station at 7:43 AM, revealed dining room instructions available. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9 at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the Staff Development Coordinator educated them on the observed dining programs and meal monitoring. Interview revealed the staff was knowledgeable regarding observing residents with swallowing difficulties for choking and ensuring staff was present in the dining rooms during meals. Interview with the Staff Development Coordinator, on 11/29/18 at 10:15 AM, revealed she educated all staff on the dining room program and meal monitoring assignments. She stated she used the employee roster to keep track of who was educated and who was not. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the Staff Development Coordinator kept track of which staff needed to be educated. She stated staff was not allowed to work on the units until education was completed. 7. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, and the Administrator at 2:55 PM, revealed they attended the 11/06/18 QAPI meeting where they discussed the findings of the survey and the action plan. Interview with the Medical Director, on 11/29/18 at 2:45 PM, revealed he attended the 11/06/18 QAPI meeting and the action plan and survey findings were discussed. Review of the sign in sheet for the 11/06/18 QAPI meeting revealed the Administrator, Medical Director, MDS Coordinator, UM #2, the DON, the QA Nurse, the Social Services Director, the Activities Director, and the CEO attended the meeting. 8. Interview with the QA Nurse, on 11/29/18 at 1:47 PM, revealed she conducted the MDS and care plan audit and completed the QAPI tool. Interview with the DON, on 11/29/18 at 9:36 AM, revealed care plans and MDS assessments were audited using the QAPI tool. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed a care plan and MDS audit was conducted using the QAPI tool on 11/05/18 by the QA Nurse. 9. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, revealed she conducted meal observations and completed the QAPI tool. She stated she ensured a nurse monitored the residents and that no meals were served unless a nurse was present. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he conducted audits of residents eating in their rooms to ensure staff was monitoring the residents while they ate. He stated he ensured the dining room audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed meal observation audits were conducted using the QAPI tool by the Dietary Manager. Audits were completed on 09/25/18, 10/05/18, 10/25/18, 11/02/18, 11/07/18, 11/18/18, and 11/20/18. Record review revealed meal observations were conducted by the Administrator for residents who ate in their rooms on 11/03/18, 11/05/18, 11/09/18, 11/12/18, 11/18/18, 11/20/18, 11/23/18, and 11/24/18. 10. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, and the Social Services Director at 2:06 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Medical Director via telephone, on 11/29/18 at 2:45 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. He stated the action plan and audits were reviewed in the QAPI meeting. 11. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he and the CEO met almost daily to discuss any issues, as the CEO was at the facility almost daily. Record review revealed between 10/23/18 to 11/27/18, the Administrator and CEO met more than twice weekly.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to revise the care plan after each assessment and when residents had a risk affecting their care for one (1) of five (5) sampled residents, Resident #10. Record review revealed the resident had a [DIAGNOSES REDACTED]. However, observation revealed the resident eating a meal in the dining room without staff supervision. The resident ate rapidly and made gurgling noises as he/she swallowed. Review of the care plan revealed the facility did not revise the resident's care plan with interventions to monitor the resident during meals to keep the resident from choking on food while eating. The facility's failure to revise resident care plans has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/13/18 and was determined to exist on 10/08/18. The facility was notified of the IJ on 11/13/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 11/21/18, which alleged removal of the IJ on 11/09/18. The State Survey Agency (SSA) verified the IJ was removed on 11/09/18, prior to exit on 11/29/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Care Plan policy, undated, revealed the facility was to review and revise care plans as per the RAI Manual with significant changes and changes in physician orders. Record review revealed the facility readmitted Resident #10 on 08/25/18, with [DIAGNOSES REDACTED]. The resident had a gastric tube in place and received bolus feedings with a supplement. The resident signed a waiver to be able to eat regular pureed food and received mashed potatoes with gravy and chocolate pudding at meals. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 required extensive assistance of one (1) person to eat. However, review of the Care Plan for Resident #10, dated 09/11/18, revealed the resident received pureed food/pudding thick liquids for meals and snacks and assistance to set up the meal. There was no intervention that the resident required the presence of a staff member while eating. Observation of Resident #10, on 10/08/18 at 12:00 PM, revealed the resident in the dining room sitting at a table eating very rapidly and swallowing large spoonful's of food. The resident tilted his/her head back to drink a thickened glass of liquid in several large swallows. The resident made a gurgling noise when swallowing. No staff was present in the dining room during the observation to monitor for swallowing difficulty related to his/her Dysphagia. Interview with Certified Nursing Assistant (CNA) #7, on 10/09/18 at 2:15 PM, revealed Resident #10's care plan did not mention the resident required special feeding or aspiration precautions to eat safely. She stated the resident was in the independent dining room so staff thought he/she was all right to be there. She stated the resident ate fast and made a gurgling sound after swallowing and fed himself/herself independently. Interview with the MDS Nurse, on 10/09/18 at 3:20 PM, revealed Resident #10 required monitoring during meals related to his/her decision to eat textured food. She stated the care plan was not revised to include instructions on how to assist the resident in eating safely to prevent aspiration. Interview with the Restorative Nurse, on 10/10/18 at 10:30 AM, revealed Resident #10 required one to one supervision for meals to prevent aspiration related to his/her rapid eating and overloading of the spoon. She stated that type of eating was hazardous to someone with Dysphagia. The nurse stated she was aware the care plan should have been revised to prevent harm to the resident. Interview with the Director of Nursing (DON), on 11/20/18 at 2:55 PM, revealed having Resident #10 eat without direct supervision was unsafe and could have resulted in aspiration. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #6 no longer resided at the facility. Resident #10 was included in the observed dining program as of 10/16/18 for meal supervision. The Interdisciplinary Team (IDT) reviewed and revised Resident #10's care plan on 10/30/18 to include aspiration precautions and supervision during meals. 2. The Director of Nursing, Quality Assurance (QA) Nurse, Staff Development Coordinator, or Unit Manager (UM) would conduct observations of the dining rooms weekly for six (6) weeks, then every other week for six (6) weeks by a contracted therapist. 3. The IDT completed a care plan audit on 11/05/18 for all current residents to determine if aspiration precautions were on the plan, if indicated. 4. The Contracted Nurse Consultant educated the Social Services Director, Minimum Data Set (MDS) Coordinator, UM, Activity Director, and DON on 10/22/18 regarding accurate completion of the MDS, care plans with focus on interventions such as aspiration precautions, and review of the RAI (Resident Assessment Instrument) Manual. Newly hired staff that would be members of the MDS/Care Plan team would be provided the education prior to coding MDS assessments or updating care plans. 5. On 10/29/18, the DON and Dietary Manager reviewed and revised the breakfast meal tray delivery schedule to provide time between meal carts to allow time for staff to provide required supervision for residents who eat in their rooms. 6. The Staff Development Coordinator educated nursing staff on 11/08/18 regarding the new observed dining program, the revised meal monitoring assignments, and the need to request a replacement if unable to be present during meal service as assigned. Staff not educated by 11/08/18 would be provided training prior to working. Each nurses' station was provided dining room instructions for reference and for agency staff use. 7. A QAPI (Quality Assurance, Performance Improvement) meeting was held on 11/06/18 with the QAPI team and the Medical Director to review findings of the survey and the Plan of Correction. 8. Audits of five (5) selected residents for MDS and Care Plan documentation would be completed, under the supervision of the DON, using the QAPI tool. The audits would be conducted monthly for two (2) months, quarterly for two (2) quarters, then every six (6) months. Failure to meet 95% accuracy would result in development of a plan of action. 9. Audits of five (5) randomly selected residents for meal observations would be conducted under the direction of the Dietary Manager using the QAPI tool to determined residents were provided supervision during meals in accordance with the care plan. The audits would be conducted weekly for two (2) weeks, then monthly. Meal observations would be conducted for residents eating in their rooms weekly for six (6) weeks then monthly by the DON, QA Nurse, Staff Development Coordinator, UMs, or the Administrator. 10. Results of completed QAPI tools and any action plans would be reviewed in the QAPI meetings. 11. The President and CEO (Chief Executive Officer) of the company would meet with the Administrator two (2) times per week for one (1) month, then weekly for one (1) month, then monthly thereafter to review the Plan of Correction and implementation and assist with QAPI meeting follow-up issues. The SSA validated the facility implemented the following actions: 1. Observation of Resident #10, on 11/29/18 at 11:51 PM, revealed the resident eating lunch in the observed dining room with LPN #9, UM #3, and UM #4 present. Interview with the DON, on 11/29/18 at 9:36 AM, revealed Resident #10 was moved to the observed dining room by 10/16/18 so he/she could be monitored for choking when eating. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT revised Resident #10's care plan to include aspiration precautions and meal monitoring. Review of Resident #10's Care Plan revealed the facility updated the plan on 10/16/18 to include aspiration precautions and monitoring. Review of the facility's census and observation revealed Resident #6 no longer resided at the facility. 2. Observation, on 11/29/18 at 11:51 PM, revealed the UM #3 and #4 were observing the main dining room and UM #2 was observing the dining room on the rehabilitation unit. Interview with the DON, on 11/29/18 at 9:36 AM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed they monitored the dining rooms to ensure staff was present observing the residents. Interview with the Speech Therapist (ST) via telephone, on 11/29/18 at 1:42 PM, revealed she came to the facility every other Sunday and conducted dining room observations to ensure staff was present and if any resident appeared to need referral for swallowing difficulties. Record review revealed the UMs monitored the dining rooms weekly from 10/05/18 to 11/25/18; the ST monitored the dining room on 10/14/18, 10/30/18, 11/12/18, 11/15/18, and 11/25/18. 3. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT reviewed and revised all resident care plans with the focus to ensure aspiration precautions were on the appropriate plans. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the IDT audited all resident care plans and plans were updated as needed. Record review revealed all resident care plans were reviewed and updated by 11/05/18. 4. Interview with the Contracted Nurse Consultant via telephone, on 11/29/18 at 11:01 AM, revealed she educated staff on 10/22/18 regarding MDS assessment completion using the RAI Manual and care plan development. Interview with the DON, on 11/29/18 at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed the Contracted Nurse Consultant educated them on completing MDS assessments and care plans. Record review revealed the Contracted Nurse Consultant education the DON, UMs, MDS Coordinator, and Social Services Director on 10/22/18. Review of the facility's staff roster revealed no staff that would complete MDS assessments or develop and revise care plans was newly hired. 5. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, and the DON at 9:36 AM, revealed they reviewed the breakfast meal tray delivery times and adjusted the times the trays were delivered in order to allow staff time to assist and monitor residents with eating. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9, at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the time breakfast was served was adjusted to ensure residents were observed while eating. 6. Observation of the South Nurses' Station, on 11/29/18 at 7:39 AM, the Rehab's Nurses' Station at 7:43 AM, revealed dining room instructions available. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9 at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the Staff Development Coordinator educated them on the observed dining programs and meal monitoring. Interview revealed the staff was knowledgeable regarding observing residents with swallowing difficulties for choking and ensuring staff was present in the dining rooms during meals. Interview with the Staff Development Coordinator, on 11/29/18 at 10:15 AM, revealed she educated all staff on the dining room program and meal monitoring assignments. She stated she used the employee roster to keep track of who was educated and who was not. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the Staff Development Coordinator kept track of which staff needed to be educated. She stated staff was not allowed to work on the units until education was completed. 7. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, and the Administrator at 2:55 PM, revealed they attended the 11/06/18 QAPI meeting where they discussed the findings of the survey and the action plan. Interview with the Medical Director, on 11/29/18 at 2:45 PM, revealed he attended the 11/06/18 QAPI meeting and the action plan and survey findings were discussed. Review of the sign in sheet for the 11/06/18 QAPI meeting revealed the Administrator, Medical Director, MDS Coordinator, UM #2, the DON, the QA Nurse, the Social Services Director, the Activities Director, and the CEO attended the meeting. 8. Interview with the QA Nurse, on 11/29/18 at 1:47 PM, revealed she conducted the MDS and care plan audit and completed the QAPI tool. Interview with the DON, on 11/29/18 at 9:36 AM, revealed care plans and MDS assessments were audited using the QAPI tool. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed a care plan and MDS audit was conducted using the QAPI tool on 11/05/18 by the QA Nurse. 9. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, revealed she conducted meal observations and completed the QAPI tool. She stated she ensured a nurse monitored the residents and that no meals were served unless a nurse was present. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he conducted audits of residents eating in their rooms to ensure staff was monitoring the residents while they ate. He stated he ensured the dining room audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed meal observation audits were conducted using the QAPI tool by the Dietary Manager. Audits were completed on 09/25/18, 10/05/18, 10/25/18, 11/02/18, 11/07/18, 11/18/18, and 11/20/18. Record review revealed meal observations were conducted by the Administrator for residents who ate in their rooms on 11/03/18, 11/05/18, 11/09/18, 11/12/18, 11/18/18, 11/20/18, 11/23/18, and 11/24/18. 10. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, and the Social Services Director at 2:06 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Medical Director via telephone, on 11/29/18 at 2:45 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. He stated the action plan and audits were reviewed in the QAPI meeting. 11. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he and the CEO met almost daily to discuss any issues, as the CEO was at the facility almost daily. Record review revealed between 10/23/18 to 11/27/18, the Administrator and CEO met more than twice weekly.

Based on observation, interview, and record review, it was determined the facility failed to supervise two (2) of five (5) sampled residents, Resident #4 and #5 during meals. The facility assessed Resident #4 and #5 required staff supervision during meals to monitor for difficulties in swallowing food and prevent choking. However, observation revealed the residents ate lunch in a dining area with no staff supervision. The findings include: Observation, on 08/29/18 at 12:45 PM until 1:05 PM, of the dining area on the Rehabilitation Hallway revealed Resident #4 and #5 were eating their meal. There was no staff present in the dining area, at the nurses' station, or in the hallway. Continued observation of Resident #5, on 08/29/18 at 12:45 PM, revealed Family Member #6 assisted the resident with the meal. Interview with Family Member #6, on 08/29/18 at 12:45 PM, revealed she visited Resident #5 daily and often there were no staff present, or within eyesight, when residents were eating meals. She stated she was concerned a resident could choke. She revealed the facility should not rely upon family members to supervise the residents, and she dreaded the weekends because the facility tended to use many agency staff not always familiar with the residents' needs. Record review revealed the facility admitted Resident #5 on 12/01/17, with multiple diagnoses, which included [MEDICAL CONDITION] and [MEDICAL CONDITION] affecting left non-dominant side, Anorexia, Abnormal Weight loss, and Dysphagia (difficulty swallowing). Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE] revealed the facility determined the resident required supervision when eating. Review of Resident #5's Care Plan, dated 03/16/18, revealed the resident was at nutritional risk and required a mechanically altered diet due to chewing/swallowing difficulty. Interventions included monitoring the resident for coughing or choking with oral intake and report to nursing. Continued observation of Resident #4, on 08/29/18 at 12:15 PM, revealed a plate of mechanically altered food in front of the resident and the resident slowly took bites of food without staff assistance. Interview with Resident #4, on 08/29/18 at 12:15 PM, revealed staff helped set-up his/her meal. She stated she had recently developed coughing and choking episodes and had been in the hospital. She stated staff was sometimes available and within eyesight during mealtimes, and sometimes were not. Record review revealed the facility admitted Resident #4 on 08/28/17, with multiple diagnoses, which included Unspecified Dementia, [DIAGNOSES REDACTED], Dehydration, and Dysphagia. Review of Resident #4's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a Brief Interview Mental Status (BIMS) score of nine (9) out of fifteen (15) and determined the resident interviewable. The facility determined the resident required supervision when eating. Review of Resident #4's Care Plan, dated 09/12/17, revealed the resident was at nutritional risk and required assistance and supervision with eating and drinking. Interventions included monitoring for chewing, swallowing, and choking difficulties and report to the nurse. Observation of the dining area, on 08/29/18 at 1:06 PM, with the Unit Manager revealed staff was not present in the dining area, nor the nursing station, or in the hallways. Interview with the Unit Manager, on 08/29/18 at 1:10 PM, revealed he had recently been out on the unit and staff was present. He stated the Certified Nursing Assistants (CNA) or the nurse should always be available to monitor and supervise residents when they were in the dining area eating meals to assist residents who were a choking or aspiration risk. Interview with CNA #2, on 08/31/18 at 2:05 PM, revealed staff had been educated to supervise residents while they ate and to monitor for choking. She stated staff supervision could also prevent a resident fall. Interview with CNA #3, on 08/31/18 at 2:20 PM, revealed the nurse had to supervise residents while the residents ate their meals; however, the CNAs could help too, to ensure residents had the right diet and to make sure no one choked. He stated staff monitored the residents for falls as well. Interview with CNA #4, on 08/31/18 at 2:25 PM, revealed her job during resident mealtime was to pass the fluids, pass the trays, and assist the residents in the dining room. She stated a nurse should be present too, as some residents were a choking risk or a fall risk. Interview with Licensed Practical Nurse (LPN) #5, on 08/31/18 at 1:10 PM, revealed the facility trained staff to be present in the dining area when residents ate meals. She stated some residents needed extra assistance and some residents had to be monitored for complications such as choking. Interview with LPN #4, on 08/31/18 at 1:30 PM, revealed when residents ate in the dining area, staff should be constantly monitoring for signs or symptoms of choking or swallowing issues. The nurse should always monitor residents in the dining area because anything could happen, like a blocked airway or a fall. Supervision during dining was important as it could prevent a resident death. Interview with the Director of Nursing, on 08/31/18 at 1:30 PM, revealed a nurse should always be present at the nurses' station to observe residents while they ate so they could help intervene if a resident choked or fell .

Based on observation, interview, record review, facility policy review, facility job description review, and review of the Plan of Correction (POC) for the 08/31/18 Abbreviated Survey, it was determined the facility's Administration failed to have an effective system to ensure the facility maintained substantial compliance related to residents receiving adequate supervision during meals for two (2) of five (5) sampled residents, Resident #6 and #10. Resident #10 was assessed to require assistance of one (1) staff for eating. Observation on 10/08/18 revealed the resident eating in the dining room with no staff present. Each time the resident swallowed, he/she made a gurgling, choking sound. Interview with staff revealed they were not aware the resident needed supervision while eating. Resident #6 was assessed and care planned to be assisted at meals and monitored for any signs and symptoms of coughing or choking while eating or drinking. Observation on 10/09/18 revealed Resident #6 in bed with the breakfast tray in front of him/her. There was no staff in the room monitoring to prevent coughing and choking. The facility's failure to ensure substantial compliance was maintained related to residents receiving adequate supervision during meals has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/13/18 and was determined to exist on 10/08/18. The facility was notified of the IJ on 11/13/18. The facility provided an acceptable Allegation of Compliance (AOC) on 11/21/18, which alleged removal of the IJ on 11/09/18. The State Survey Agency (SSA) verified the IJ was removed on 11/09/18, prior to exit on 11/29/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Job Description for Administrator, dated November 2009, revealed general responsibilities included overall management and operation of the facility. Directing and coordinating all activities was part of carrying out the objectives of providing the best care for each resident and assuring sound fiscal operation of the facility. The Administrator ensured compliance with regulations governing the facility by continuously monitoring the facility's service delivery, and fostering a smooth functioning organization through timely and effective resolutions of disruptions. Review of the facility's Job Description for the Director of Nursing (DON), not dated, revealed the DON administered the policies and procedures of the facility and the nursing department, kept the Administrator informed of the activities in the nursing department and any problems in relation to the care of the residents, and planned and directed the corrective actions necessary in the event of deficiencies in nursing. Review of the facility's Dining Room Policy revealed nurses and Certified Nursing Assistants (CNA) were to be in the dining room. An Abbreviated Survey was conducted on 08/31/18 and determined deficient practice existed related to staff not supervising residents eating meals in the dining area. Review of the POC submitted by the facility on 09/24/18, for the Abbreviated Survey conducted 08/31/18, revealed the facility would post daily assignments of nursing staff to monitor residents during meals. The Director of Nursing (DON), Staff Development Coordinator, and or the QA (Quality Assurance) Nurse educated all unit managers and floor nurses on the meal monitoring assignments and the need to request a replacement if they were unable to be present during the meal service as assigned. Review of the facility's assignment sheet for 10/08/18, revealed the North Hall Nurse was assigned to monitor the dining room. However, observation of the dining room, on 10/08/18 at 12:30 PM, revealed Resident #10 eating lunch with no staff in the dining room providing supervision. The resident used a spoon to scoop up large amounts of food in a rapid manner and when drinking, the resident tilted back his/her head and drank most of the liquid in consecutive swallows. Each time the resident swallowed, he/she made a gurgling, choking sound. In addition, Resident #6 was assessed by the facility to require supervision for eating related to Dysphagia and observation on 10/09/18 at 8:08 AM, revealed the resident in bed with the breakfast tray in front of him/her and no staff present to monitor per the plan of care. Interview with Unit Manager #2, on 10/10/18 at 10:00 AM, revealed a nurse should have been in the dining room on 10/08/18, but there was not one present to provide supervision, per the facility's POC. Post survey interview with Licensed Practical Nurse (LPN) #4, on 10/25/18 at 4:27 PM, via telephone, revealed she worked the North Hall and remembered she was in the dining room and left the independent side of the dining room (where Resident #10 was eating) and went to the other side of the dining room to get something and then went back to the independent side. Post survey interview with the DON, on 10/25/18 at 3:44 PM and 4:25 PM, via telephone, revealed she or the Nurse Educator made rounds of the dining rooms to ensure nursing staff was monitoring residents during meals and did not know how it was missed that a nurse was not in the dining room on 10/08/18. She stated LPN #4 was the North Hall nurse on 10/08/18. Interview with the Administrator, on 10/10/18 at 10:30 AM, revealed he did not go to the dining room regularly. He stated he attended the Quality Assurance Committee meetings and had just completed two (2) meetings. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #6 no longer resided at the facility. Resident #10 was included in the observed dining program as of 10/16/18 for meal supervision. The Interdisciplinary Team (IDT) reviewed and revised Resident #10's care plan on 10/30/18 to include aspiration precautions and supervision during meals. 2. The Director of Nursing, Quality Assurance (QA) Nurse, Staff Development Coordinator, or Unit Manager (UM) would conduct observations of the dining rooms weekly for six (6) weeks, then every other week for six (6) weeks by a contracted therapist. 3. The IDT completed a care plan audit on 11/05/18 for all current residents to determine if aspiration precautions were on the plan, if indicated. 4. The Contracted Nurse Consultant educated the Social Services Director, Minimum Data Set (MDS) Coordinator, UM, Activity Director, and DON on 10/22/18 regarding accurate completion of the MDS, care plans with focus on interventions such as aspiration precautions, and review of the RAI (Resident Assessment Instrument) Manual. Newly hired staff that would be members of the MDS/Care Plan team would be provided the education prior to coding MDS assessments or updating care plans. 5. On 10/29/18, the DON and Dietary Manager reviewed and revised the breakfast meal tray delivery schedule to provide time between meal carts to allow time for staff to provide required supervision for residents who eat in their rooms. 6. The Staff Development Coordinator educated nursing staff on 11/08/18 regarding the new observed dining program, the revised meal monitoring assignments, and the need to request a replacement if unable to be present during meal service as assigned. Staff not educated by 11/08/18 would be provided training prior to working. Each nurses' station was provided dining room instructions for reference and for agency staff use. 7. A QAPI (Quality Assurance, Performance Improvement) meeting was held on 11/06/18 with the QAPI team and the Medical Director to review findings of the survey and the Plan of Correction. 8. Audits of five (5) selected residents for MDS and Care Plan documentation would be completed, under the supervision of the DON, using the QAPI tool. The audits would be conducted monthly for two (2) months, quarterly for two (2) quarters, then every six (6) months. Failure to meet 95% accuracy would result in development of a plan of action. 9. Audits of five (5) randomly selected residents for meal observations would be conducted under the direction of the Dietary Manager using the QAPI tool to determined residents were provided supervision during meals in accordance with the care plan. The audits would be conducted weekly for two (2) weeks, then monthly. Meal observations would be conducted for residents eating in their rooms weekly for six (6) weeks then monthly by the DON, QA Nurse, Staff Development Coordinator, UMs, or the Administrator. 10. Results of completed QAPI tools and any action plans would be reviewed in the QAPI meetings. 11. The President and CEO (Chief Executive Officer) of the company would meet with the Administrator two (2) times per week for one (1) month, then weekly for one (1) month, then monthly thereafter to review the Plan of Correction and implementation and assist with QAPI meeting follow-up issues. The SSA validated the facility implemented the following actions: 1. Observation of Resident #10, on 11/29/18 at 11:51 PM, revealed the resident eating lunch in the observed dining room with LPN #9, UM #3, and UM #4 present. Interview with the DON, on 11/29/18 at 9:36 AM, revealed Resident #10 was moved to the observed dining room by 10/16/18 so he/she could be monitored for choking when eating. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT revised Resident #10's care plan to include aspiration precautions and meal monitoring. Review of Resident #10's Care Plan revealed the facility updated the plan on 10/16/18 to include aspiration precautions and monitoring. Review of the facility's census and observation revealed Resident #6 no longer resided at the facility. 2. Observation, on 11/29/18 at 11:51 PM, revealed the UM #3 and #4 were observing the main dining room and UM #2 was observing the dining room on the rehabilitation unit. Interview with the DON, on 11/29/18 at 9:36 AM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed they monitored the dining rooms to ensure staff was present observing the residents. Interview with the Speech Therapist (ST) via telephone, on 11/29/18 at 1:42 PM, revealed she came to the facility every other Sunday and conducted dining room observations to ensure staff was present and if any resident appeared to need referral for swallowing difficulties. Record review revealed the UMs monitored the dining rooms weekly from 10/05/18 to 11/25/18; the ST monitored the dining room on 10/14/18, 10/30/18, 11/12/18, 11/15/18, and 11/25/18. 3. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT reviewed and revised all resident care plans with the focus to ensure aspiration precautions were on the appropriate plans. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the IDT audited all resident care plans and plans were updated as needed. Record review revealed all resident care plans were reviewed and updated by 11/05/18. 4. Interview with the Contracted Nurse Consultant via telephone, on 11/29/18 at 11:01 AM, revealed she educated staff on 10/22/18 regarding MDS assessment completion using the RAI Manual and care plan development. Interview with the DON, on 11/29/18 at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed the Contracted Nurse Consultant educated them on completing MDS assessments and care plans. Record review revealed the Contracted Nurse Consultant education the DON, UMs, MDS Coordinator, and Social Services Director on 10/22/18. Review of the facility's staff roster revealed no staff that would complete MDS assessments or develop and revise care plans was newly hired. 5. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, and the DON at 9:36 AM, revealed they reviewed the breakfast meal tray delivery times and adjusted the times the trays were delivered in order to allow staff time to assist and monitor residents with eating. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9, at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the time breakfast was served was adjusted to ensure residents were observed while eating. 6. Observation of the South Nurses' Station, on 11/29/18 at 7:39 AM, the Rehab's Nurses' Station at 7:43 AM, revealed dining room instructions available. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9 at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the Staff Development Coordinator educated them on the observed dining programs and meal monitoring. Interview revealed the staff was knowledgeable regarding observing residents with swallowing difficulties for choking and ensuring staff was present in the dining rooms during meals. Interview with the Staff Development Coordinator, on 11/29/18 at 10:15 AM, revealed she educated all staff on the dining room program and meal monitoring assignments. She stated she used the employee roster to keep track of who was educated and who was not. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the Staff Development Coordinator kept track of which staff needed to be educated. She stated staff was not allowed to work on the units until education was completed. 7. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, and the Administrator at 2:55 PM, revealed they attended the 11/06/18 QAPI meeting where they discussed the findings of the survey and the action plan. Interview with the Medical Director, on 11/29/18 at 2:45 PM, revealed he attended the 11/06/18 QAPI meeting and the action plan and survey findings were discussed. Review of the sign in sheet for the 11/06/18 QAPI meeting revealed the Administrator, Medical Director, MDS Coordinator, UM #2, the DON, the QA Nurse, the Social Services Director, the Activities Director, and the CEO attended the meeting. 8. Interview with the QA Nurse, on 11/29/18 at 1:47 PM, revealed she conducted the MDS and care plan audit and completed the QAPI tool. Interview with the DON, on 11/29/18 at 9:36 AM, revealed care plans and MDS assessments were audited using the QAPI tool. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed a care plan and MDS audit was conducted using the QAPI tool on 11/05/18 by the QA Nurse. 9. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, revealed she conducted meal observations and completed the QAPI tool. She stated she ensured a nurse monitored the residents and that no meals were served unless a nurse was present. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he conducted audits of residents eating in their rooms to ensure staff was monitoring the residents while they ate. He stated he ensured the dining room audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed meal observation audits were conducted using the QAPI tool by the Dietary Manager. Audits were completed on 09/25/18, 10/05/18, 10/25/18, 11/02/18, 11/07/18, 11/18/18, and 11/20/18. Record review revealed meal observations were conducted by the Administrator for residents who ate in their rooms on 11/03/18, 11/05/18, 11/09/18, 11/12/18, 11/18/18, 11/20/18, 11/23/18, and 11/24/18. 10. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, and the Social Services Director at 2:06 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Medical Director via telephone, on 11/29/18 at 2:45 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. He stated the action plan and audits were reviewed in the QAPI meeting. 11. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he and the CEO met almost daily to discuss any issues, as the CEO was at the facility almost daily. Record review revealed between 10/23/18 to 11/27/18, the Administrator and CEO met more than twice weekly.

Based on observation, interview, record review, facility policy review, facility job description review, and review of the Plan of Correction (P[NAME]) for the 08/31/18 Abbreviated Survey, it was determined the facility's Administration failed to have an effective system to ensure the facility maintained substantial compliance related to residents receiving adequate supervision during meals for two (2) of five (5) sampled residents, Resident #6 and #10. Resident #10 was assessed to require assistance of one (1) staff for eating. Observation on 10/08/18 revealed the resident eating in the dining room with no staff present. Each time the resident swallowed, he/she made a gurgling, choking sound. Interview with staff revealed they were not aware the resident needed supervision while eating. Resident #6 was assessed and care planned to be assisted at meals and monitored for any signs and symptoms of coughing or choking while eating or drinking. Observation on 10/09/18 revealed Resident #6 in bed with the breakfast tray in front of him/her. There was no staff in the room monitoring to prevent coughing and choking. The facility's failure to ensure substantial compliance was maintained related to residents receiving adequate supervision during meals has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/13/18 and was determined to exist on 10/08/18. The facility was notified of the IJ on 11/13/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 11/21/18, which alleged removal of the IJ on 11/09/18. The State Survey Agency (SSA) verified the IJ was removed on 11/09/18, prior to exit on 11/29/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Job Description for Administrator, dated (MONTH) 2009, revealed general responsibilities included overall management and operation of the facility. Directing and coordinating all activities was part of carrying out the objectives of providing the best care for each resident and assuring sound fiscal operation of the facility. The Administrator ensured compliance with regulations governing the facility by continuously monitoring the facility's service delivery, and fostering a smooth functioning organization through timely and effective resolutions of disruptions. Review of the facility's Job Description for the Director of Nursing (DON), not dated, revealed the DON administered the policies and procedures of the facility and the nursing department, kept the Administrator informed of the activities in the nursing department and any problems in relation to the care of the residents, and planned and directed the corrective actions necessary in the event of deficiencies in nursing. Review of the facility's Dining Room Policy revealed nurses and Certified Nursing Assistants (CNA) were to be in the dining room. An Abbreviated Survey was conducted on 08/31/18 and determined deficient practice existed related to staff not supervising residents eating meals in the dining area. Review of the P[NAME] submitted by the facility on 09/24/18, for the Abbreviated Survey conducted 08/31/18, revealed the facility would post daily assignments of nursing staff to monitor residents during meals. The Director of Nursing (DON), Staff Development Coordinator, and or the QA (Quality Assurance) Nurse educated all unit managers and floor nurses on the meal monitoring assignments and the need to request a replacement if they were unable to be present during the meal service as assigned. Review of the facility's assignment sheet for 10/08/18, revealed the North Hall Nurse was assigned to monitor the dining room. However, observation of the dining room, on 10/08/18 at 12:30 PM, revealed Resident #10 eating lunch with no staff in the dining room providing supervision. The resident used a spoon to scoop up large amounts of food in a rapid manner and when drinking, the resident tilted back his/her head and drank most of the liquid in consecutive swallows. Each time the resident swallowed, he/she made a gurgling, choking sound. In addition, Resident #6 was assessed by the facility to require supervision for eating related to Dysphagia and observation on 10/09/18 at 8:08 AM, revealed the resident in bed with the breakfast tray in front of him/her and no staff present to monitor per the plan of care. Interview with Unit Manager #2, on 10/10/18 at 10:00 AM, revealed a nurse should have been in the dining room on 10/08/18, but there was not one present to provide supervision, per the facility's P[NAME]. Post survey interview with Licensed Practical Nurse (LPN) #4, on 10/25/18 at 4:27 PM, via telephone, revealed she worked the North Hall and remembered she was in the dining room and left the independent side of the dining room (where Resident #10 was eating) and went to the other side of the dining room to get something and then went back to the independent side. Post survey interview with the DON, on 10/25/18 at 3:44 PM and 4:25 PM, via telephone, revealed she or the Nurse Educator made rounds of the dining rooms to ensure nursing staff was monitoring residents during meals and did not know how it was missed that a nurse was not in the dining room on 10/08/18. She stated LPN #4 was the North Hall nurse on 10/08/18. Interview with the Administrator, on 10/10/18 at 10:30 AM, revealed he did not go to the dining room regularly. He stated he attended the Quality Assurance Committee meetings and had just completed two (2) meetings. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #6 no longer resided at the facility. Resident #10 was included in the observed dining program as of 10/16/18 for meal supervision. The Interdisciplinary Team (IDT) reviewed and revised Resident #10's care plan on 10/30/18 to include aspiration precautions and supervision during meals. 2. The Director of Nursing, Quality Assurance (QA) Nurse, Staff Development Coordinator, or Unit Manager (UM) would conduct observations of the dining rooms weekly for six (6) weeks, then every other week for six (6) weeks by a contracted therapist. 3. The IDT completed a care plan audit on 11/05/18 for all current residents to determine if aspiration precautions were on the plan, if indicated. 4. The Contracted Nurse Consultant educated the Social Services Director, Minimum Data Set (MDS) Coordinator, UM, Activity Director, and DON on 10/22/18 regarding accurate completion of the MDS, care plans with focus on interventions such as aspiration precautions, and review of the RAI (Resident Assessment Instrument) Manual. Newly hired staff that would be members of the MDS/Care Plan team would be provided the education prior to coding MDS assessments or updating care plans. 5. On 10/29/18, the DON and Dietary Manager reviewed and revised the breakfast meal tray delivery schedule to provide time between meal carts to allow time for staff to provide required supervision for residents who eat in their rooms. 6. The Staff Development Coordinator educated nursing staff on 11/08/18 regarding the new observed dining program, the revised meal monitoring assignments, and the need to request a replacement if unable to be present during meal service as assigned. Staff not educated by 11/08/18 would be provided training prior to working. Each nurses' station was provided dining room instructions for reference and for agency staff use. 7. A QAPI (Quality Assurance, Performance Improvement) meeting was held on 11/06/18 with the QAPI team and the Medical Director to review findings of the survey and the Plan of Correction. 8. Audits of five (5) selected residents for MDS and Care Plan documentation would be completed, under the supervision of the DON, using the QAPI tool. The audits would be conducted monthly for two (2) months, quarterly for two (2) quarters, then every six (6) months. Failure to meet 95% accuracy would result in development of a plan of action. 9. Audits of five (5) randomly selected residents for meal observations would be conducted under the direction of the Dietary Manager using the QAPI tool to determined residents were provided supervision during meals in accordance with the care plan. The audits would be conducted weekly for two (2) weeks, then monthly. Meal observations would be conducted for residents eating in their rooms weekly for six (6) weeks then monthly by the DON, QA Nurse, Staff Development Coordinator, UMs, or the Administrator. 10. Results of completed QAPI tools and any action plans would be reviewed in the QAPI meetings. 11. The President and CEO (Chief Executive Officer) of the company would meet with the Administrator two (2) times per week for one (1) month, then weekly for one (1) month, then monthly thereafter to review the Plan of Correction and implementation and assist with QAPI meeting follow-up issues. The SSA validated the facility implemented the following actions: 1. Observation of Resident #10, on 11/29/18 at 11:51 PM, revealed the resident eating lunch in the observed dining room with LPN #9, UM #3, and UM #4 present. Interview with the DON, on 11/29/18 at 9:36 AM, revealed Resident #10 was moved to the observed dining room by 10/16/18 so he/she could be monitored for choking when eating. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT revised Resident #10's care plan to include aspiration precautions and meal monitoring. Review of Resident #10's Care Plan revealed the facility updated the plan on 10/16/18 to include aspiration precautions and monitoring. Review of the facility's census and observation revealed Resident #6 no longer resided at the facility. 2. Observation, on 11/29/18 at 11:51 PM, revealed the UM #3 and #4 were observing the main dining room and UM #2 was observing the dining room on the rehabilitation unit. Interview with the DON, on 11/29/18 at 9:36 AM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed they monitored the dining rooms to ensure staff was present observing the residents. Interview with the Speech Therapist (ST) via telephone, on 11/29/18 at 1:42 PM, revealed she came to the facility every other Sunday and conducted dining room observations to ensure staff was present and if any resident appeared to need referral for swallowing difficulties. Record review revealed the UMs monitored the dining rooms weekly from 10/05/18 to 11/25/18; the ST monitored the dining room on 10/14/18, 10/30/18, 11/12/18, 11/15/18, and 11/25/18. 3. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT reviewed and revised all resident care plans with the focus to ensure aspiration precautions were on the appropriate plans. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the IDT audited all resident care plans and plans were updated as needed. Record review revealed all resident care plans were reviewed and updated by 11/05/18. 4. Interview with the Contracted Nurse Consultant via telephone, on 11/29/18 at 11:01 AM, revealed she educated staff on 10/22/18 regarding MDS assessment completion using the RAI Manual and care plan development. Interview with the DON, on 11/29/18 at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed the Contracted Nurse Consultant educated them on completing MDS assessments and care plans. Record review revealed the Contracted Nurse Consultant education the DON, UMs, MDS Coordinator, and Social Services Director on 10/22/18. Review of the facility's staff roster revealed no staff that would complete MDS assessments or develop and revise care plans was newly hired. 5. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, and the DON at 9:36 AM, revealed they reviewed the breakfast meal tray delivery times and adjusted the times the trays were delivered in order to allow staff time to assist and monitor residents with eating. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9, at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the time breakfast was served was adjusted to ensure residents were observed while eating. 6. Observation of the South Nurses' Station, on 11/29/18 at 7:39 AM, the Rehab's Nurses' Station at 7:43 AM, revealed dining room instructions available. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9 at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the Staff Development Coordinator educated them on the observed dining programs and meal monitoring. Interview revealed the staff was knowledgeable regarding observing residents with swallowing difficulties for choking and ensuring staff was present in the dining rooms during meals. Interview with the Staff Development Coordinator, on 11/29/18 at 10:15 AM, revealed she educated all staff on the dining room program and meal monitoring assignments. She stated she used the employee roster to keep track of who was educated and who was not. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the Staff Development Coordinator kept track of which staff needed to be educated. She stated staff was not allowed to work on the units until education was completed. 7. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, and the Administrator at 2:55 PM, revealed they attended the 11/06/18 QAPI meeting where they discussed the findings of the survey and the action plan. Interview with the Medical Director, on 11/29/18 at 2:45 PM, revealed he attended the 11/06/18 QAPI meeting and the action plan and survey findings were discussed. Review of the sign in sheet for the 11/06/18 QAPI meeting revealed the Administrator, Medical Director, MDS Coordinator, UM #2, the DON, the QA Nurse, the Social Services Director, the Activities Director, and the CEO attended the meeting. 8. Interview with the QA Nurse, on 11/29/18 at 1:47 PM, revealed she conducted the MDS and care plan audit and completed the QAPI tool. Interview with the DON, on 11/29/18 at 9:36 AM, revealed care plans and MDS assessments were audited using the QAPI tool. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed a care plan and MDS audit was conducted using the QAPI tool on 11/05/18 by the QA Nurse. 9. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, revealed she conducted meal observations and completed the QAPI tool. She stated she ensured a nurse monitored the residents and that no meals were served unless a nurse was present. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he conducted audits of residents eating in their rooms to ensure staff was monitoring the residents while they ate. He stated he ensured the dining room audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed meal observation audits were conducted using the QAPI tool by the Dietary Manager. Audits were completed on 09/25/18, 10/05/18, 10/25/18, 11/02/18, 11/07/18, 11/18/18, and 11/20/18. Record review revealed meal observations were conducted by the Administrator for residents who ate in their rooms on 11/03/18, 11/05/18, 11/09/18, 11/12/18, 11/18/18, 11/20/18, 11/23/18, and 11/24/18. 10. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, and the Social Services Director at 2:06 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Medical Director via telephone, on 11/29/18 at 2:45 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. He stated the action plan and audits were reviewed in the QAPI meeting. 11. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he and the CEO met almost daily to discuss any issues, as the CEO was at the facility almost daily. Record review revealed between 10/23/18 to 11/27/18, the Administrator and CEO met more than twice weekly.

Based on observation, interview, record review, review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan, and review of the Plan of Correction (POC) for the 08/31/18 Abbreviated Survey, it was determined the facility's Quality Assessment and Assurance (QAA) Committee failed to have an effective system to ensure the facility maintained compliance regarding staff supervision of residents during meals for two (2) of five (5) sampled residents, Resident #6 and #10. Resident #10 was assessed to require assistance of one (1) staff for eating. Observation on 10/08/18 revealed the resident eating in the dining room with no staff present. Each time the resident swallowed, he/she made a gurgling, choking sound. Interview with staff revealed they were not aware the resident needed supervision while eating. Resident #6 was assessed and care planned to be assisted at meals and monitored for any signs and symptoms of coughing or choking while eating or drinking. Observation on 10/09/18 revealed Resident #6 in bed with the breakfast tray in front of him/her. There was no staff in the room monitoring to prevent coughing and choking. The facility's failure to ensure quality assurance was implemented to maintain substantial compliance related to resident supervision in the dining room has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/13/18 and was determined to exist on 10/08/18. The facility was notified of the IJ on 11/13/18. The facility provided an acceptable Allegation of Compliance (AOC) on 11/21/18, which alleged removal of the IJ on 11/09/18. The State Survey Agency (SSA) verified the IJ was removed on 11/09/18, prior to exit on 11/29/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's QAPI Plan revealed the facility would put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems included using performance indicators to monitor a wide range of care processes and outcomes; tracking, investigating, and monitoring adverse events every time they occurred; and action plans implemented through the QAPI plan to prevent recurrences. Review of the facility's Job Description for the Quality Assurance (QA) Nurse, not dated, revealed the QA Nurse collected and analyzed data for QA and suggested changes, as needed, to the QA committee. He/she performed compliance rounds and audited facility programs for corrective action implementation. On 08/31/18, an Abbreviated Survey was conducted at the facility and deficient practice was determined to exist related to no staff supervision of residents eating meals in the dining area. Review of the POC submitted by the facility on 09/24/18, for the 08/31/18 survey, revealed the facility would post daily assignments of nursing staff to monitor residents during meals. The Director of Nursing, Staff Development Coordinator, and or the QA Nurse educated all unit managers and floor nurses on the meal monitoring assignments and the need to request a replacement if they were unable to be present during the meal service as assigned. However, observation of the dining room, on 10/08/18 at 12:30 PM, revealed Resident #10 eating lunch with no staff in the dining room providing supervision. Per record review, the resident had a [DIAGNOSES REDACTED]. (Refer to F689) Interview with Licensed Practical Nurse (LPN) #7, on 10/25/18 at 4:27 PM, revealed she was assigned to the independent dining room on 10/08/18. She stated she left the independent dining room and went to the other dining room and was only gone for a minute. Interview with the Director of Nursing (DON), on 10/08/18 at 3:00 PM, revealed she rounded at mealtime to ensure supervision was managed in the dining room by the assigned nursing staff. She stated she had no answer for why the staff was not in the dining room on 10/08/18. In addition, observation of Resident #6, on 10/09/18 at 8:08 AM, revealed the resident was in bed with the breakfast tray in front of him/her and stated he/she was able to feed himself/herself. There was no staff in the room. Per record review, the resident had a [DIAGNOSES REDACTED]. (Refer to F689) Interview with the QA Nurse, on 10/09/18 at 10:40 AM, revealed she completed the audits for the POC and stated the facility was not meeting the threshold set after the survey. She stated she reviewed compliance with dining room requirements, MDS completion, and care plans by using audits to ensure the POC was followed. The dining audit included observations made by the QA Nurse during the meals, such as the meals were served with assistive devices as per the care plan; staff members were following specific swallowing precautions per the care plan; residents were assisted with tray set-up; and, residents were assisted with eating per the care plan. The audit did not identify Resident #6 as requiring supervision during the meal related to the [DIAGNOSES REDACTED]. She also stated the resident needed to eat in the dining room so one to one supervision could be done. She stated most QA activity regarded falls, incidents, infection, and that sort of thing. Interview with the Administrator, on 10/10/18 at 10:30 AM, revealed the facility had just completed QAPI work on the Abbreviated Survey. He stated he did not go to the dining room regularly and he just found out about issues that day. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #6 no longer resided at the facility. Resident #10 was included in the observed dining program as of 10/16/18 for meal supervision. The Interdisciplinary Team (IDT) reviewed and revised Resident #10's care plan on 10/30/18 to include aspiration precautions and supervision during meals. 2. The Director of Nursing, Quality Assurance (QA) Nurse, Staff Development Coordinator, or Unit Manager (UM) would conduct observations of the dining rooms weekly for six (6) weeks, then every other week for six (6) weeks by a contracted therapist. 3. The IDT completed a care plan audit on 11/05/18 for all current residents to determine if aspiration precautions were on the plan, if indicated. 4. The Contracted Nurse Consultant educated the Social Services Director, Minimum Data Set (MDS) Coordinator, UM, Activity Director, and DON on 10/22/18 regarding accurate completion of the MDS, care plans with focus on interventions such as aspiration precautions, and review of the RAI (Resident Assessment Instrument) Manual. Newly hired staff that would be members of the MDS/Care Plan team would be provided the education prior to coding MDS assessments or updating care plans. 5. On 10/29/18, the DON and Dietary Manager reviewed and revised the breakfast meal tray delivery schedule to provide time between meal carts to allow time for staff to provide required supervision for residents who eat in their rooms. 6. The Staff Development Coordinator educated nursing staff on 11/08/18 regarding the new observed dining program, the revised meal monitoring assignments, and the need to request a replacement if unable to be present during meal service as assigned. Staff not educated by 11/08/18 would be provided training prior to working. Each nurses' station was provided dining room instructions for reference and for agency staff use. 7. A QAPI (Quality Assurance, Performance Improvement) meeting was held on 11/06/18 with the QAPI team and the Medical Director to review findings of the survey and the Plan of Correction. 8. Audits of five (5) selected residents for MDS and Care Plan documentation would be completed, under the supervision of the DON, using the QAPI tool. The audits would be conducted monthly for two (2) months, quarterly for two (2) quarters, then every six (6) months. Failure to meet 95% accuracy would result in development of a plan of action. 9. Audits of five (5) randomly selected residents for meal observations would be conducted under the direction of the Dietary Manager using the QAPI tool to determined residents were provided supervision during meals in accordance with the care plan. The audits would be conducted weekly for two (2) weeks, then monthly. Meal observations would be conducted for residents eating in their rooms weekly for six (6) weeks then monthly by the DON, QA Nurse, Staff Development Coordinator, UMs, or the Administrator. 10. Results of completed QAPI tools and any action plans would be reviewed in the QAPI meetings. 11. The President and CEO (Chief Executive Officer) of the company would meet with the Administrator two (2) times per week for one (1) month, then weekly for one (1) month, then monthly thereafter to review the Plan of Correction and implementation and assist with QAPI meeting follow-up issues. The SSA validated the facility implemented the following actions: 1. Observation of Resident #10, on 11/29/18 at 11:51 PM, revealed the resident eating lunch in the observed dining room with LPN #9, UM #3, and UM #4 present. Interview with the DON, on 11/29/18 at 9:36 AM, revealed Resident #10 was moved to the observed dining room by 10/16/18 so he/she could be monitored for choking when eating. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT revised Resident #10's care plan to include aspiration precautions and meal monitoring. Review of Resident #10's Care Plan revealed the facility updated the plan on 10/16/18 to include aspiration precautions and monitoring. Review of the facility's census and observation revealed Resident #6 no longer resided at the facility. 2. Observation, on 11/29/18 at 11:51 PM, revealed the UM #3 and #4 were observing the main dining room and UM #2 was observing the dining room on the rehabilitation unit. Interview with the DON, on 11/29/18 at 9:36 AM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed they monitored the dining rooms to ensure staff was present observing the residents. Interview with the Speech Therapist (ST) via telephone, on 11/29/18 at 1:42 PM, revealed she came to the facility every other Sunday and conducted dining room observations to ensure staff was present and if any resident appeared to need referral for swallowing difficulties. Record review revealed the UMs monitored the dining rooms weekly from 10/05/18 to 11/25/18; the ST monitored the dining room on 10/14/18, 10/30/18, 11/12/18, 11/15/18, and 11/25/18. 3. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT reviewed and revised all resident care plans with the focus to ensure aspiration precautions were on the appropriate plans. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the IDT audited all resident care plans and plans were updated as needed. Record review revealed all resident care plans were reviewed and updated by 11/05/18. 4. Interview with the Contracted Nurse Consultant via telephone, on 11/29/18 at 11:01 AM, revealed she educated staff on 10/22/18 regarding MDS assessment completion using the RAI Manual and care plan development. Interview with the DON, on 11/29/18 at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed the Contracted Nurse Consultant educated them on completing MDS assessments and care plans. Record review revealed the Contracted Nurse Consultant education the DON, UMs, MDS Coordinator, and Social Services Director on 10/22/18. Review of the facility's staff roster revealed no staff that would complete MDS assessments or develop and revise care plans was newly hired. 5. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, and the DON at 9:36 AM, revealed they reviewed the breakfast meal tray delivery times and adjusted the times the trays were delivered in order to allow staff time to assist and monitor residents with eating. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9, at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the time breakfast was served was adjusted to ensure residents were observed while eating. 6. Observation of the South Nurses' Station, on 11/29/18 at 7:39 AM, the Rehab's Nurses' Station at 7:43 AM, revealed dining room instructions available. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9 at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the Staff Development Coordinator educated them on the observed dining programs and meal monitoring. Interview revealed the staff was knowledgeable regarding observing residents with swallowing difficulties for choking and ensuring staff was present in the dining rooms during meals. Interview with the Staff Development Coordinator, on 11/29/18 at 10:15 AM, revealed she educated all staff on the dining room program and meal monitoring assignments. She stated she used the employee roster to keep track of who was educated and who was not. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the Staff Development Coordinator kept track of which staff needed to be educated. She stated staff was not allowed to work on the units until education was completed. 7. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, and the Administrator at 2:55 PM, revealed they attended the 11/06/18 QAPI meeting where they discussed the findings of the survey and the action plan. Interview with the Medical Director, on 11/29/18 at 2:45 PM, revealed he attended the 11/06/18 QAPI meeting and the action plan and survey findings were discussed. Review of the sign in sheet for the 11/06/18 QAPI meeting revealed the Administrator, Medical Director, MDS Coordinator, UM #2, the DON, the QA Nurse, the Social Services Director, the Activities Director, and the CEO attended the meeting. 8. Interview with the QA Nurse, on 11/29/18 at 1:47 PM, revealed she conducted the MDS and care plan audit and completed the QAPI tool. Interview with the DON, on 11/29/18 at 9:36 AM, revealed care plans and MDS assessments were audited using the QAPI tool. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed a care plan and MDS audit was conducted using the QAPI tool on 11/05/18 by the QA Nurse. 9. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, revealed she conducted meal observations and completed the QAPI tool. She stated she ensured a nurse monitored the residents and that no meals were served unless a nurse was present. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he conducted audits of residents eating in their rooms to ensure staff was monitoring the residents while they ate. He stated he ensured the dining room audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed meal observation audits were conducted using the QAPI tool by the Dietary Manager. Audits were completed on 09/25/18, 10/05/18, 10/25/18, 11/02/18, 11/07/18, 11/18/18, and 11/20/18. Record review revealed meal observations were conducted by the Administrator for residents who ate in their rooms on 11/03/18, 11/05/18, 11/09/18, 11/12/18, 11/18/18, 11/20/18, 11/23/18, and 11/24/18. 10. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, and the Social Services Director at 2:06 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Medical Director via telephone, on 11/29/18 at 2:45 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. He stated the action plan and audits were reviewed in the QAPI meeting. 11. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he and the CEO met almost daily to discuss any issues, as the CEO was at the facility almost daily. Record review revealed between 10/23/18 to 11/27/18, the Administrator and CEO met more than twice weekly.

Based on observation, interview, record review, review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan, and review of the Plan of Correction (P[NAME]) for the 08/31/18 Abbreviated Survey, it was determined the facility's Quality Assessment and Assurance (QAA) Committee failed to have an effective system to ensure the facility maintained compliance regarding staff supervision of residents during meals for two (2) of five (5) sampled residents, Resident #6 and #10. Resident #10 was assessed to require assistance of one (1) staff for eating. Observation on 10/08/18 revealed the resident eating in the dining room with no staff present. Each time the resident swallowed, he/she made a gurgling, choking sound. Interview with staff revealed they were not aware the resident needed supervision while eating. Resident #6 was assessed and care planned to be assisted at meals and monitored for any signs and symptoms of coughing or choking while eating or drinking. Observation on 10/09/18 revealed Resident #6 in bed with the breakfast tray in front of him/her. There was no staff in the room monitoring to prevent coughing and choking. The facility's failure to ensure quality assurance was implemented to maintain substantial compliance related to resident supervision in the dining room has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/13/18 and was determined to exist on 10/08/18. The facility was notified of the IJ on 11/13/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 11/21/18, which alleged removal of the IJ on 11/09/18. The State Survey Agency (SSA) verified the IJ was removed on 11/09/18, prior to exit on 11/29/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's QAPI Plan revealed the facility would put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems included using performance indicators to monitor a wide range of care processes and outcomes; tracking, investigating, and monitoring adverse events every time they occurred; and action plans implemented through the QAPI plan to prevent recurrences. Review of the facility's Job Description for the Quality Assurance (QA) Nurse, not dated, revealed the QA Nurse collected and analyzed data for QA and suggested changes, as needed, to the QA committee. He/she performed compliance rounds and audited facility programs for corrective action implementation. On 08/31/18, an Abbreviated Survey was conducted at the facility and deficient practice was determined to exist related to no staff supervision of residents eating meals in the dining area. Review of the P[NAME] submitted by the facility on 09/24/18, for the 08/31/18 survey, revealed the facility would post daily assignments of nursing staff to monitor residents during meals. The Director of Nursing, Staff Development Coordinator, and or the QA Nurse educated all unit managers and floor nurses on the meal monitoring assignments and the need to request a replacement if they were unable to be present during the meal service as assigned. However, observation of the dining room, on 10/08/18 at 12:30 PM, revealed Resident #10 eating lunch with no staff in the dining room providing supervision. Per record review, the resident had a [DIAGNOSES REDACTED]. (Refer to F689) Interview with Licensed Practical Nurse (LPN) #7, on 10/25/18 at 4:27 PM, revealed she was assigned to the independent dining room on 10/08/18. She stated she left the independent dining room and went to the other dining room and was only gone for a minute. Interview with the Director of Nursing (DON), on 10/08/18 at 3:00 PM, revealed she rounded at mealtime to ensure supervision was managed in the dining room by the assigned nursing staff. She stated she had no answer for why the staff was not in the dining room on 10/08/18. In addition, observation of Resident #6, on 10/09/18 at 8:08 AM, revealed the resident was in bed with the breakfast tray in front of him/her and stated he/she was able to feed himself/herself. There was no staff in the room. Per record review, the resident had a [DIAGNOSES REDACTED]. (Refer to F689) Interview with the QA Nurse, on 10/09/18 at 10:40 AM, revealed she completed the audits for the P[NAME] and stated the facility was not meeting the threshold set after the survey. She stated she reviewed compliance with dining room requirements, MDS completion, and care plans by using audits to ensure the P[NAME] was followed. The dining audit included observations made by the QA Nurse during the meals, such as the meals were served with assistive devices as per the care plan; staff members were following specific swallowing precautions per the care plan; residents were assisted with tray set-up; and, residents were assisted with eating per the care plan. The audit did not identify Resident #6 as requiring supervision during the meal related to the [DIAGNOSES REDACTED]. She also stated the resident needed to eat in the dining room so one to one supervision could be done. She stated most QA activity regarded falls, incidents, infection, and that sort of thing. Interview with the Administrator, on 10/10/18 at 10:30 AM, revealed the facility had just completed QAPI work on the Abbreviated Survey. He stated he did not go to the dining room regularly and he just found out about issues that day. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #6 no longer resided at the facility. Resident #10 was included in the observed dining program as of 10/16/18 for meal supervision. The Interdisciplinary Team (IDT) reviewed and revised Resident #10's care plan on 10/30/18 to include aspiration precautions and supervision during meals. 2. The Director of Nursing, Quality Assurance (QA) Nurse, Staff Development Coordinator, or Unit Manager (UM) would conduct observations of the dining rooms weekly for six (6) weeks, then every other week for six (6) weeks by a contracted therapist. 3. The IDT completed a care plan audit on 11/05/18 for all current residents to determine if aspiration precautions were on the plan, if indicated. 4. The Contracted Nurse Consultant educated the Social Services Director, Minimum Data Set (MDS) Coordinator, UM, Activity Director, and DON on 10/22/18 regarding accurate completion of the MDS, care plans with focus on interventions such as aspiration precautions, and review of the RAI (Resident Assessment Instrument) Manual. Newly hired staff that would be members of the MDS/Care Plan team would be provided the education prior to coding MDS assessments or updating care plans. 5. On 10/29/18, the DON and Dietary Manager reviewed and revised the breakfast meal tray delivery schedule to provide time between meal carts to allow time for staff to provide required supervision for residents who eat in their rooms. 6. The Staff Development Coordinator educated nursing staff on 11/08/18 regarding the new observed dining program, the revised meal monitoring assignments, and the need to request a replacement if unable to be present during meal service as assigned. Staff not educated by 11/08/18 would be provided training prior to working. Each nurses' station was provided dining room instructions for reference and for agency staff use. 7. A QAPI (Quality Assurance, Performance Improvement) meeting was held on 11/06/18 with the QAPI team and the Medical Director to review findings of the survey and the Plan of Correction. 8. Audits of five (5) selected residents for MDS and Care Plan documentation would be completed, under the supervision of the DON, using the QAPI tool. The audits would be conducted monthly for two (2) months, quarterly for two (2) quarters, then every six (6) months. Failure to meet 95% accuracy would result in development of a plan of action. 9. Audits of five (5) randomly selected residents for meal observations would be conducted under the direction of the Dietary Manager using the QAPI tool to determined residents were provided supervision during meals in accordance with the care plan. The audits would be conducted weekly for two (2) weeks, then monthly. Meal observations would be conducted for residents eating in their rooms weekly for six (6) weeks then monthly by the DON, QA Nurse, Staff Development Coordinator, UMs, or the Administrator. 10. Results of completed QAPI tools and any action plans would be reviewed in the QAPI meetings. 11. The President and CEO (Chief Executive Officer) of the company would meet with the Administrator two (2) times per week for one (1) month, then weekly for one (1) month, then monthly thereafter to review the Plan of Correction and implementation and assist with QAPI meeting follow-up issues. The SSA validated the facility implemented the following actions: 1. Observation of Resident #10, on 11/29/18 at 11:51 PM, revealed the resident eating lunch in the observed dining room with LPN #9, UM #3, and UM #4 present. Interview with the DON, on 11/29/18 at 9:36 AM, revealed Resident #10 was moved to the observed dining room by 10/16/18 so he/she could be monitored for choking when eating. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT revised Resident #10's care plan to include aspiration precautions and meal monitoring. Review of Resident #10's Care Plan revealed the facility updated the plan on 10/16/18 to include aspiration precautions and monitoring. Review of the facility's census and observation revealed Resident #6 no longer resided at the facility. 2. Observation, on 11/29/18 at 11:51 PM, revealed the UM #3 and #4 were observing the main dining room and UM #2 was observing the dining room on the rehabilitation unit. Interview with the DON, on 11/29/18 at 9:36 AM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed they monitored the dining rooms to ensure staff was present observing the residents. Interview with the Speech Therapist (ST) via telephone, on 11/29/18 at 1:42 PM, revealed she came to the facility every other Sunday and conducted dining room observations to ensure staff was present and if any resident appeared to need referral for swallowing difficulties. Record review revealed the UMs monitored the dining rooms weekly from 10/05/18 to 11/25/18; the ST monitored the dining room on 10/14/18, 10/30/18, 11/12/18, 11/15/18, and 11/25/18. 3. Interview with the MDS Coordinator, on 11/29/18 at 1:30 PM, revealed the IDT reviewed and revised all resident care plans with the focus to ensure aspiration precautions were on the appropriate plans. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the IDT audited all resident care plans and plans were updated as needed. Record review revealed all resident care plans were reviewed and updated by 11/05/18. 4. Interview with the Contracted Nurse Consultant via telephone, on 11/29/18 at 11:01 AM, revealed she educated staff on 10/22/18 regarding MDS assessment completion using the RAI Manual and care plan development. Interview with the DON, on 11/29/18 at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, UM #3 at 2:25 PM, and UM #4 at 2:35 PM, revealed the Contracted Nurse Consultant educated them on completing MDS assessments and care plans. Record review revealed the Contracted Nurse Consultant education the DON, UMs, MDS Coordinator, and Social Services Director on 10/22/18. Review of the facility's staff roster revealed no staff that would complete MDS assessments or develop and revise care plans was newly hired. 5. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, and the DON at 9:36 AM, revealed they reviewed the breakfast meal tray delivery times and adjusted the times the trays were delivered in order to allow staff time to assist and monitor residents with eating. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9, at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the time breakfast was served was adjusted to ensure residents were observed while eating. 6. Observation of the South Nurses' Station, on 11/29/18 at 7:39 AM, the Rehab's Nurses' Station at 7:43 AM, revealed dining room instructions available. Interview with LPN #5, on 11/29/18 at 7:40 AM, CNA #10 at 8:30 AM, CNA #1 at 9:04 AM, LPN #9 at 10:17 AM, CNA #5 at 10:31 AM, and Registered Nurse (RN) #3 at 10:30 AM, revealed the Staff Development Coordinator educated them on the observed dining programs and meal monitoring. Interview revealed the staff was knowledgeable regarding observing residents with swallowing difficulties for choking and ensuring staff was present in the dining rooms during meals. Interview with the Staff Development Coordinator, on 11/29/18 at 10:15 AM, revealed she educated all staff on the dining room program and meal monitoring assignments. She stated she used the employee roster to keep track of who was educated and who was not. Interview with the DON, on 11/29/18 at 9:36 AM, revealed the Staff Development Coordinator kept track of which staff needed to be educated. She stated staff was not allowed to work on the units until education was completed. 7. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, the Social Services Director at 2:06 PM, and the Administrator at 2:55 PM, revealed they attended the 11/06/18 QAPI meeting where they discussed the findings of the survey and the action plan. Interview with the Medical Director, on 11/29/18 at 2:45 PM, revealed he attended the 11/06/18 QAPI meeting and the action plan and survey findings were discussed. Review of the sign in sheet for the 11/06/18 QAPI meeting revealed the Administrator, Medical Director, MDS Coordinator, UM #2, the DON, the QA Nurse, the Social Services Director, the Activities Director, and the CEO attended the meeting. 8. Interview with the QA Nurse, on 11/29/18 at 1:47 PM, revealed she conducted the MDS and care plan audit and completed the QAPI tool. Interview with the DON, on 11/29/18 at 9:36 AM, revealed care plans and MDS assessments were audited using the QAPI tool. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed a care plan and MDS audit was conducted using the QAPI tool on 11/05/18 by the QA Nurse. 9. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, revealed she conducted meal observations and completed the QAPI tool. She stated she ensured a nurse monitored the residents and that no meals were served unless a nurse was present. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he conducted audits of residents eating in their rooms to ensure staff was monitoring the residents while they ate. He stated he ensured the dining room audits were conducted by having staff give him copies of the audits after they were conducted. Record review revealed meal observation audits were conducted using the QAPI tool by the Dietary Manager. Audits were completed on 09/25/18, 10/05/18, 10/25/18, 11/02/18, 11/07/18, 11/18/18, and 11/20/18. Record review revealed meal observations were conducted by the Administrator for residents who ate in their rooms on 11/03/18, 11/05/18, 11/09/18, 11/12/18, 11/18/18, 11/20/18, 11/23/18, and 11/24/18. 10. Interview with the Dietary Manager, on 11/29/18 at 7:50 AM, the DON at 9:36 AM, UM #2 at 11:17 AM, the MDS Coordinator at 1:30 PM, and the Social Services Director at 2:06 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Medical Director via telephone, on 11/29/18 at 2:45 PM, revealed the action plan and audits were discussed in the QAPI meeting. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he ensured audits were conducted by having staff give him copies of the audits after they were conducted. He stated the action plan and audits were reviewed in the QAPI meeting. 11. Interview with the Administrator, on 11/29/18 at 2:55 PM, revealed he and the CEO met almost daily to discuss any issues, as the CEO was at the facility almost daily. Record review revealed between 10/23/18 to 11/27/18, the Administrator and CEO met more than twice weekly.

Based on observation, interview, record review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to provide care and services in accordance with accepted standards of practice for two (2) of five (5) sampled residents, Resident #1 and #2. Resident #1 presented with signs and symptoms of a change in condition; however, the nurse failed to respond in a timely manner. The resident was transferred to the hospital and admitted to the Intensive Care Unit. The facility admitted Resident #2 from the hospital after the resident had surgery and complained of pain; however, the facility failed to administer prescribed pain medication in a timely manner. The findings include: Review of the KBN, AOS #14, Roles of Nurses in the implementation of Patient Care Orders, revised (MONTH) (YEAR), revealed a Registered Nurse was an independent professional licensed to exercise independent judgment regarding the well-being of patients. The duty to exercise critical thinking skills and sound nursing judgment, based upon an individual's educational preparation and experience, was personal to each licensee and may not be relinquished to others. This duty took precedence over qualified provider instructions or facility policies where following such instructions or policies would risk harm to a patient. The facility did not provide a policy related to change in a resident condition. Review of the facility's Registered Nurse (RN) job description revealed a RN had the primary responsibility to provide necessary medical services, supervision, and care plan implementation to residents. The RN was to provide physical, mental, and psychological well-being of each resident, work as a team member, communicate effectively with residents and family members, assist with or institute emergency measures, monitor for changes in a resident's condition and report appropriately to the doctor or the nurse practitioner, and document care and condition of the resident in the electronic medical record. Review of the facility's Licensed Practical Nurse (LPN) job description revealed the LPN had the primary responsibility to provide the necessary medical services, supervision, and care plan implementation to residents. The LPN was responsible to promote the physical, mental, and psychosocial well-being of the resident, and work as a team member. 1. Review of the closed clinical record revealed the facility admitted Resident #1 on 08/11/18, from an acute care hospital post surgical procedure to repair a [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. The facility discharged the resident back to the hospital on [DATE], per family request. Telephone interview with Family Member #1, on 08/30/18 at 4:00 PM, revealed she was at the facility on the evening of 08/11/18 to visit Resident #1 and the resident was alert and talkative. However, she stated when she visited the resident on 08/12/18 at 1:30 PM, she had to shake the resident very aggressively to wake up. She stated it seemed like the resident tried to speak with her but the resident's eyes kept rolling back in his/her head. She immediately talked to RN #1 and asked the nurse what dosage pain medication Resident #1 had received and stated the RN was also concerned about the dosage of pain medication the resident received. The family member stated RN #1 assured her Resident #1 could not die from high dosages of pain medication and seemed to brush it off. The family member stated she immediately called another family member and told her to come to the facility because she was very concerned about Resident #1. She went on to state the family called 911 because the facility had insisted the resident was fine but he/she was sweating heavily in the afternoon hours. She stated one of the nurses mocked her family and said to another nurse they had better call 911 or the family would. Review of Resident #1's Progress Notes, dated 08/11/18 10:45 AM, revealed RN #1 documented the resident arrived to the facility from the hospital via ambulance. Admission vital signs were blood pressure 110/60, pulse 74, respirations were even and unlabored at 18, temperature 96.9 degrees Fahrenheit, and oxygen saturation was 91% on room air. The resident had no complaints of shortness of breath. The Unit Manager completed the admission assessment of the resident. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Medication Administration History, dated 08/11/12 to 08/12/18, revealed staff administered [MEDICATION NAME] 10 mg on 08/11/18 at 1:21 PM, and [MEDICATION NAME] 30 mg on 08/11/18 at 4:00 PM. Continued review of the Progress Notes, dated 08/11/18 at 5:51 PM, revealed Resident #1 complained of difficulty breathing. The resident's oxygen saturation was 83% on room air, respirations were 24. LPN #2 notified the Advanced Practice Registered Nurse (ARNP) and obtained an order for [REDACTED]. Review of Resident #1's Vitals Report, dated 08/11/18 at 10:27 PM, revealed the resident's blood pressure was 98/58, four (4) hours and twenty-three (23) minutes after the resident complained of shortness of breath. Further review of Progress Notes, dated 08/12/18 at 5:38 AM revealed no signs or symptoms of distress or discomfort. Routine pain medication was given as ordered, blood pressure 106/52 and oxygen saturation of 92% on 2L of O2. Review of the Observation Detail List Report, dated 08/12/18 at 1:31 AM, by LPN #3 revealed Resident #1 had no dyspnea, was always continent, skin was warm and dry, was alert and oriented to person, place, and time, and fed self independently. Continued review of Resident #1's Medication Administration History, dated 08/11/12 to 08/12/18, revealed staff administered [MEDICATION NAME] 30 mg on 08/12/18 at 12:00 AM and 8:00 AM. In addition, staff administered [MEDICATION NAME] 70/30 insulin, 55 units, on 08/12/18 at 7:30 AM. Telephone interview with Family Member #4, on 08/31/18 at 8:30 AM, revealed Resident #1 looked good on admission from the hospital, but seemed confused. She stated when she walked into Resident #1's room on 08/12/18 at 8:00 AM, the resident was much worse. The resident had a breakfast tray set up in front of him/her and the resident attempted to scoop up oatmeal with a spoon and pushed the spoon right into his/her chest. She stated the resident was also wringing wet with sweat that poured down the resident's face and the resident's gown was soaking wet as well. She stated Resident #1 laid in the bed and never spoke a word. She stated the resident's eyes were open, but just stared at the ceiling. Family Member #4 asked RN #1 what was wrong with Resident #1 and the nurse stated she intended to notify the physician first thing in the morning, 08/13/18, to inform him Resident #1 might be getting too much pain medication. Family members queried RN #1 in regards to medications the resident received; however, the nurse was not forthright about the [MEDICATION NAME] the family specifically asked her how much the resident received. The Family Member stated she overheard RN #1 and LPN #2 speaking and one of the nurses stated to the other they had better call 911 or the family was going to. The family member went on to state the resident was transferred to the emergency department and admitted to the Intensive Care Unit. Interview with RN #1, on 08/30/18 at 11:52 AM, revealed when she gave Resident #1's morning medications on 08/12/18, the resident informed her he/she usually ate breakfast around 10:00 AM and wanted to go back to sleep. She stated the next time she saw the resident was around 10:00 AM when she went into the resident's room with a concerned family member regarding the resident's cognition. She stated the family was also concerned the resident was not able to feed himself/herself and had dropped some oatmeal on his/her shirt. The RN stated she and Certified Nursing Assistant (CNA) #1 went back into the resident's room to check the resident for incontinence and to turn the resident and felt the resident was more lethargic at that time. The nurse stated a family member informed her the resident had previously been on [MEDICATION NAME] mg at home, not [MEDICATION NAME] mg, which the resident had been prescribed and received in the facility. She stated she tried to call the APRN and left messages on her phone; however, the APRN never called her back. She stated she went ahead and called 911 because she did not want to wait any longer to transfer the resident. She stated the resident's level of consciousness had changed but the resident was arousable and she had frequently monitored the resident's vital signs and hoped she did not forget to chart them. The nurse stated she administered the resident's prescribed morning medications to include [MEDICATION NAME] MG and 55 units of [MEDICATION NAME] 70/30 insulin because in her assessment, other than the resident complained of tiredness, she did not feel there was anything wrong. She stated she already gave the resident his/her morning insulin before the resident informed her he/she did not want to eat breakfast until around 10:00 AM. She stated she did not notice any signs or symptoms of a possible drug overdose during the morning hours on 08/12/18. She also stated she felt the resident took enough nourishment at breakfast and lunch on 08/12/18 to cover the morning insulin administration and did not notice any signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar). She stated she followed the physician's orders [REDACTED]. Continued review of the clinical record revealed no documentation RN #1 frequently monitored Resident #1's vital signs or completed a comprehensive assessment on Resident #1. Further review of the Vitals Report, dated 08/12/18, revealed Resident #1 consumed 1-25% of dinner on 08/11/18 and 1-25% of breakfast on 08/12/18. The resident refused the lunch meal on 08/12/18. Review of RN #1's written statement to the facility, dated 08/12/18, revealed she administered Resident #1's prescribed pain medication and morning medications at 8:00 AM. At 9:30 AM, the resident was sleeping but would open his/her eyes and ate breakfast. A family member queried her if the resident would be all right and the RN told the family the resident was very sleepy and she would contact the Nurse Practitioner in regards to the pain medication because she thought the pain medication made the resident sleep more. Another family member approached her and stated the resident would not stay awake. The nurse asked the family if it was okay she transfer the resident back to the hospital. She then called 911 and the resident was alert and oriented when he/she left the facility. Review of another written statement from RN #1, dated 08/13/18, revealed the RN did not see any changes in the resident between his/her admission on 08/11/18 and his/her transfer out of the facility on 08/12/18. Continued review of Progress Notes, dated 08/12/18 at 3:45 PM, revealed LPN #2 called the APRN and obtained an order to send Resident #1 to the hospital per family request. The resident's blood pressure was 122/60, pulse 88, respirations 18, temperature 97.4, oxygen saturation 91% on 2L of oxygen, and blood sugar was 110. Review of LPN #2's written statement to the facility, dated 08/13/18, revealed the LPN was at the nurses' station at 2:00 PM on 08/12/18, and the family of Resident #1 wanted the resident sent back to the hospital. The LPN told the RN, unlike her, she was going to call and get the resident sent out. When the APRN responded to her call, she went into the room to inform the family and stated the family informed her they had already called 911. Interview with CNA #1, on 08/29/18 at 12:30 PM, revealed on 08/11/18, Resident #1 was alert and laughing. She stated on 08/12/18, during her early morning rounds, Resident #1 was in a deep sleep, but was arousable. She stated the resident said he/she was tired so she just let the resident sleep. Shortly after that, the resident's breakfast was delivered and she helped set up the breakfast tray for the resident. After twenty (20) minutes or so, she went back into the resident's room to check on him/her, there was no one else in the resident's room at that time, and she tried to assist the resident to eat some oatmeal, but the resident held the oatmeal in his/her mouth and did not chew. At that point, she alerted RN #1 the resident had changed, which she stated was around 8:00 AM. She stated she went back into the resident's room shortly after 8:00 AM and some of the resident's family had arrived and the resident seemed confused as to who his/her family members were. She stated she did not remember entering the room with the nurse at any time on 08/12/18. Telephone interview with LPN #2, on 08/31/18 at 7:00 AM, revealed she worked second shift on 08/12/18, and when she arrived to the unit RN #1 informed her Resident #1's family had asked the RN all day long to transfer the resident to the hospital. She recalled the family informed her and the RN of their concerns related to the resident being diaphoretic and concerned the resident's blood sugar was too low. The LPN stated she went and assessed the resident, the resident was sweating, and she took the resident's blood sugar, which was normal, and informed the family of the result. She stated the family informed her the resident's normal blood sugar was close to 200 and anything under 150 was too low for the resident to tolerate. She stated she agreed with the family about transferring the resident to the hospital. The LPN stated she believed the family should get what they want, and the resident did not look well, appeared less alert, and was sweating. Interview with the Risk Manager/Quality Assurance, on 8/30/18 at 2:50 PM, revealed the facility investigated and reprimanded RN #1 for poor quality of care related to Resident #1. She stated the facility investigation revealed the resident was heavily sedated and not eating and the facility questioned the RN on why she gave the resident insulin and more pain medication. The Risk Manager stated the nurse should have held the medications until she spoke with the APRN or the physician on the phone. She also revealed RN #1's assessment and documentation had not been up to facility expectations in accordance with a resident who was rapidly declining, and RN #1 had used very poor nursing judgement and delivered poor nursing care. Interview with the Physician, on 08/30/18 at 4:30 PM, revealed the facility did not make him aware of the events that led to Resident #1's transfer to the hospital. He stated the resident was a high risk for decline due to his/her recent hospitalization and any licensed nurse should have the skills to identify, assess, and intervene when a resident developed a decrease in their L[NAME] and should not delay transferring the resident to the hospital. He went on to state the nurses were aware when a resident had a change in mental assessment or physical assessment; they should notify the physician right away. However, in an event where a resident had a rapid decline, the nurse should immediately call 911 and not delay treatment until the physician or the APRN returned their call. He stated family members knew their loved ones better than the facility and a nurse should listen closely to what the family said. The Physician continued to state anytime a resident had not eaten well, the nurse should have enough common sense and nursing judgement to hold the insulin and speak with the physician. Review of the Hospital Records revealed Resident #1 arrived to the emergency department on 08/12/18 at 3:55 PM. At 4:13 PM, the resident's blood sugar reading via glucose glucometer was 73 with a reference range 74 to 99. The resident's vital signs at 4:19 PM revealed the blood pressure was 75/46, pulse 86, respirations 12, and oxygen saturation at 91%. The resident was treated with intravenous fluids to replace fluid loss, which included [MEDICATION NAME] (to treat low blood sugar). The resident was also administered [MEDICATION NAME] (to treat pain medication overdose) and [MEDICATION NAME] (used to treat low blood pressure). The resident was treated in the emergency department and subsequently transferred to the Intensive Care Unit on 08/12/18 at 9:12 PM. Review of the hospital physician progress notes [REDACTED].#1 was lethargic, hypoxic (oxygen deficiency), and hypoglycemic at 73. The resident was given [MEDICATION NAME] and became slightly more alert afterwards. The Physician Assistant's (PA) Progress Note, dated 08/12/18 at 4:33 PM, revealed Resident #1 appeared gray, was diaphoretic, was moaning and non-communicative. Review of the hospital History and Physical, dated 08/12/18 at 8:59 PM, revealed Resident #1 presented to the emergency department from the facility for altered mental status and [MEDICAL CONDITION]. Resident #1 had reportedly received too much pain medication at the facility and received [MEDICATION NAME] several times upon arrival to the emergency department. The resident was assessed in the Intensive Care Unit and still lethargic. The resident was on a high concentration of oxygen. Review of the hospital Discharge Summary, dated 08/18/18, revealed Resident #1's discharge [DIAGNOSES REDACTED]. The resident's [MEDICAL CONDITION] was due to unintentional overdose related to a miscommunication between the family and the RN during transfer from the last hospitalization . The resident was hypotensive (low blood pressure), likely due to opiates (pain medication) and dehydration. Review of [MEDICATION NAME] Guide, dated (MONTH) 2014 and approved by the U.S. Food and Drug Administration, revealed [MEDICATION NAME] a long-acting (extended-release) pain medicine that could put an individual at risk for overdose and death. Get emergency help right away if too much of medication was taken. The medication should not be taken if the individual had severe asthma, trouble breathing, or other lung problems. Telephone interview with Resident #1, on 08/30/18 at 3:45 PM, revealed he/she did not remember anything about being at the facility. Interview with LPN #4, on 08/31/18 at 1:30 PM, revealed a change in a resident's condition could be identified through an assessment of their level of consciousness (L[NAME]), such as lethargy. She stated other signs and symptoms included clammy skin, loss of appetite, low or high blood sugar readings, abnormal behaviors, and abnormal vital signs. She stated all changes in conditions should be documented, timed, and dated in the progress notes. She revealed some people adjusted to abnormally high blood sugars, so a normal blood sugar reading might be abnormal for them. She stated signs of someone who experienced [DIAGNOSES REDACTED] would be moist, clammy skin, a decrease in L[NAME], and they could become unresponsive if not treated. The LPN stated the physician should always be notified anytime a resident displayed signs or symptoms of an adverse reaction to narcotics or [DIAGNOSES REDACTED]. She stated when a resident had not eaten well, or developed lethargy, she would hold the resident's insulin and call the physician. The nurse stated she thought the facility had reference manuals for the nurses, but was unsure. Interview with LPN #5, on 08/31/18 at 1:10 PM, revealed a change in a resident's condition could indicate a resident was getting sick. She stated signs and symptoms included sleeping too much, sleeping too little, hard to arouse, or unusual behaviors. The LPN stated it was very important to ask the resident and/or the family what blood sugar level was normal for them, and how they knew if their blood sugar was getting low. She stated the nurse should always question insulin administration and dosage when a resident had not eaten well, or was confused. She revealed some of the commons signs of [DIAGNOSES REDACTED] were pale skin color and clammy skin and if not treated quickly, could lead to death. She stated she found the APRN to be very responsive to her calls in response to a resident concern. Continued interview with the Risk Manager/Quality Assurance, on 08/31/18 at 2:45 PM, revealed the facility did not have a policy on change of condition for the staff to refer too. She stated nurses should perform, at minimal, a full body assessment to include vital signs and record the findings in the clinical record. She stated the nurses were trained to use good nursing judgement whenever a resident's health declined, and to call 911 as needed without hesitation. She also stated pain medications should not be administered to obtunded (having diminished arousal and awareness) residents, and the nurses had been trained on narcotic administration and insulin administration and were educated enough not to give insulin or pain medication to a resident who was not responsive. In addition, the Risk Manager revealed Quality Assurance meeting were held once a month, which all department heads attended, and next month's meeting would address these issues. However, record review revealed a Quality Assurance meeting was held on 08/14/18, two (2) days after Resident #1 declined and was transferred back to the hospital, and the issue regarding the care the resident received was not addressed. Interview with the Director of Nursing (DON), on 08/31/18 at 1:30 PM, revealed staff should call 911 and then the physician if/when a resident was deteriorating. She stated nurses had to use practical and sound nursing judgement and should always listen to what families told them, as well as the residents. The DON revealed RN #1 had not used sound nursing judgment when she administered Resident #1's insulin and pain medication. 2. Record review revealed the facility admitted Resident #2, on 08/26/18 at 3:00 PM, from an acute care hospital after a Right Total Knee Arthroplasty (surgery). Review of the physician progress notes [REDACTED].#2 complained of right knee pain which was sharp, intermittent, moderate to severe, non-radiating, aggravated with movements, and relieved with pain medication. Observation and interview of Resident #2, on 08/29/18 at 12:10 PM and 08/31/18 at 10:45 AM, revealed the resident sitting in a chair in his/her room, alert and oriented to person, place, and time. The resident stated he/she was transferred to the facility on Sunday, 08/26/18, from the hospital after knee surgery. The resident stated on the day he/she arrived at the facility, she felt like the facility had no real plan in place. She stated LPN #1 met him/her in the room, handed him/her a bunch of admission papers, and told the resident he/she needed to sign them. The resident informed LPN #1 shortly after admission he/she was in pain and needed pain medication. He/she asked the LPN and a CNA for pain medication at different times that day and both staff stated they were not authorized to give pain medication. The resident stated later in the evening, he/she had asked staff again for pain medication and told them he/she could not stand the pain, but staff did not administer pain medication so he/she just stopped asking for it. The resident revealed he/she did not get pain medication until the next day and he/she spoke with the Unit Manager and he told the resident he/she should not have had to wait for pain medication. The resident stated he/she informed the facility of his/her dissatisfaction during the Care Plan Meeting. Telephone interview with Family Member #5, on 08/31/18 at 12:00 PM, revealed she took Resident #2 to the facility from the hospital on [DATE]. She stated she gave LPN #1 the discharge orders from the hospital and the LPN told her he would look into getting the resident some pain medication. She stated the resident was in a lot of pain due to the recent knee surgery and transferring in and out of the car. The next morning Resident #2 told her he/she did not receive any pain medication throughout the night and his/her leg hurt. Review of the hospital Discharge Summary, dated 08/26/18, revealed Resident #2 was prescribed [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 7.5-325 milligrams (mg), one (1) to two (2) tablets every four (4) to six (6) hours for pain control. The pain medication needed to be taken consistently for the first week post-operatively to decrease pain, and promote adequate pain relief and participation in Physical Therapy, and should be taken for up to six (6) or eight (8) weeks. The Medication Administration Report revealed the hospital last administered [MEDICATION NAME] to the resident at 1:42 PM on 08/26/18. Review of Resident #2's Admission Pain Management Assessment, dated 08/26/18, revealed the resident had pain in the right knee over the last five (5) days that he/she described as severe with [MEDICATION NAME] listed as an intervention. Review of Resident #2's Physician order [REDACTED]. Review of the Medication Administration History, dated 08/26/18 to 08/30/18, revealed Resident #2 received [MEDICATION NAME] 7.5-325 mg on 08/27/18 at 1:55 PM, twenty-two (22) hours and fifty-five (55) minutes after his/her admission to the facility. Telephone interview with CNA #1, on 08/31/18 at 1:00 PM, revealed she answered Resident #2's call light sometime after 2:00 PM on 08/26/18, and the resident told her he/she had pain in his/her leg. She stated she told the resident she was not able to give him/her medication but would tell the nurse. The CNA stated she informed the nurse of the resident's request for pain medication. Telephone interview, on 08/31/18 at 9:15 AM, with LPN #1 revealed he could not recall Resident #2 asking for any pain medicine, but he anticipated the resident might need some throughout the night and called the pharmacy, but the pain medication never arrived during his shift. He stated [MEDICATION NAME] 7.5-325 mg was not in the facility's emergency drug kit (EDK). He stated he did not call the physician for another order because he thought the medication would eventually come, but when the next shift came on, he told the nurse she might have to call for the medication again. He stated he followed the proper procedures. Review of the facility's pharmacy Packing Slip revealed six (6) [MEDICATION NAME] 7.5-325 mg tablets were delivered to the facility on [DATE]. There was no time documented on the Packing Slip. Interview with the Social Worker, on 08/31/18 at 9:40 AM, revealed the resident stated during the care plan meeting, he/she was upset the pain medication was not administered the first day of admission. Review of the Care Plan Conference, dated 08/29/18, revealed Resident #2 did not have a great admission experience. The resident stated there was no one to help and the nurse could not give any pain medication to him/her. The resident stated he/she had discussed the matter with the Unit Manager. Interview with the Unit Manager, on 08/29/18 at 2:20 PM, revealed he did not like Sunday admissions because of possible issues related to resident medications. He stated the nurses had access to an emergency supply of medications and could sign out medications not stocked or available in the facility. He stated Resident #2 should not have had to wait on pain medications, if the medication was not available in the emergency supply, the physician or APRN should have be notified. He stated the facility provided the means for staff to do their jobs. Interview with LPN #4, on 08/31/18 at 1:30 PM, revealed anytime a resident was in pain, the resident should be relieved of the pain and it was not ethical for a nurse to let a resident lay in pain. She stated if a pain medication or any medication was not available, and not in the emergency supply, the nurse should call the physician and possibly obtain another order. Interview with LPN #5, on 08/31/18 at 1:10 PM, revealed whenever an ordered medication was not available, the nurse should always refer to the emergency supply. If the medication was not available in the emergency supply, the nurse should call the physician and request a different medication. She stated pain was what a resident said it was and should be treated. Review of the facility's Control Emergency Drug Check Schedule revealed [MEDICATION NAME] 5-325 mg and 10-325 mg tablets were available in the facility's emergency supply. Interview with the DON, on 08/31/18 at 1:30 PM, revealed the nurse should have used better nursing judgement and Resident #2's pain medication should have been administered in a timely manner. She stated the LPN should have called the physician and requested another order for an available medication for pain, even if it was a one-time dose. The DON stated she and the Risk Manager were both unaware of this issue with Resident #2. She stated the Unit Manager and the Social Worker should have informed both the DON and the Risk Manager immediately in regards to Resident #2's complaint.

Based on observation, interview, and record review, it was determined the facility failed to provide effective pain management for one (1) of five (5) sampled residents, Resident #2. The facility admitted Resident #2 after knee surgery and the resident complained of pain in his/her knee; however, the facility did not provided pain medication as prescribed by the physician. The findings include: Review of the facility's policy, MD Order, revised 05/15/18, revealed all MD/APRN (Medical Doctor/Advanced Practice Registered Nurse) orders were expected to be followed. Review of the facility's job description, Licensed Practical Nurse, revealed the Licensed Practical Nurse (LPN) had the primary responsibility to provide the necessary medical services, supervision, and care plan implementation to residents. The LPN was responsible to promote the physical, mental, and psychosocial well-being of the resident. Observation of Resident #2, on 08/29/18 at 12:10 PM, revealed the resident in a chair, awake and alert. Interview with Resident #2, on 08/29/18 at 12:10 PM, during the observation, revealed the resident arrived at the facility on Sunday, 08/26/18, for rehab after having knee surgery. The resident stated he/she informed LPN #1 shortly after admission; he/she was in pain and needed pain medication. Resident #2 stated the LPN replied he was not authorized to give the pain medication. The resident stated the evening went on and on and he/she asked staff again for pain medication and told them he/she could not stand the pain. The resident stated staff did not administer pain medication, so he/she just stopped asking for it and he/she did not get medication for pain until the next day. She went on to state she spoke with the Unit Manager who told the resident he/she should never have to wait for pain medication. She stated she also informed the facility of his/her dissatisfaction during the Care Plan Meeting. Record review revealed the facility admitted Resident #2 on 08/26/18 at 3:00 PM, from an acute care hospital for rehabilitation after a Right Total Knee Arthroplasty (surgery). Interview with Family Member #5 via telephone, on 08/31/18 at 12:00 PM, revealed she took Resident #2 to the facility on [DATE], and the resident was in a lot of pain due to the recent surgery and getting in and out of the car. She stated she gave LPN #1 paperwork from the hospital that contained discharge orders and the LPN told her he would look into getting the resident pain medication. The next morning, Resident #2 told her he/she did not receive any pain medication throughout the night and his/her leg hurt. Review of the hospital Discharge Summary, dated 08/26/18, revealed [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 7.5-325 milligrams (mg), one (1) to two (2) tablets every four (4) to six (6) hours for pain control was prescribed for the resident. The pain medication needed to be taken consistently for the first week post-operatively to decrease pain, and promote adequate pain relief and participation in Physical Therapy. The medication should be taken for up to six (6) or eight (8) weeks. The hospital last administered [MEDICATION NAME] to the resident at 1:42 PM on 08/26/18. Review of Resident #2's Admission Pain Management Assessment, dated 08/26/18, revealed the resident had pain in the right knee over the last five (5) days that he/she described as severe with [MEDICATION NAME] listed as an intervention. Review of the facility's Physician order [REDACTED].#2, dated 08/26/18, revealed an order for [REDACTED]. Review of the Medication Administration History, dated 08/26/18, revealed Resident #2 received his/her first dose of [MEDICATION NAME] 7.5-325 mg for pain on 08/27/18 at 1:55 PM, twenty-two (22) hours and fifty-five (55) minutes after his/her admission to the facility. Review of Resident #2's physician progress notes [REDACTED]. The resident had a past medical history of [REDACTED]. Interview with Certified Nursing Assistant (CNA) #1, on 08/31/18 at 1:00 PM, via telephone revealed she answered Resident #2's call light sometime after 2:00 PM on 08/26/18, and the resident told her he/she had pain in his/her leg. The CNA stated she told the resident she was not able to give him/her medication but would tell the nurse, which the CNA stated she did. Interview with LPN #1, on 08/31/18 at 9:15 AM, via telephone revealed he could not recall Resident #2 asking for pain medicine on 08/26/18, but he anticipated the resident might need some throughout the night and called the pharmacy, but the medicine never arrived during his shift. He stated [MEDICATION NAME] 7.5-325 mg was not in the facility's emergency drug kit (EDK). The LPN stated he did not call the physician for another order because he thought the medication would eventually come, and when the next shift came on, he told the nurse she might have to call for the medication again. He stated he followed proper procedures. However, review of the facility's Control Emergency Drug Check Schedule revealed [MEDICATION NAME] 5-325 mg and 10-325 mg tablets were available in the EDK. Review of the Packing Slip from the pharmacy revealed six (6) [MEDICATION NAME] 7.5-325 mg tablets were delivered to the facility on [DATE]. There was no time documented on the Packing Slip. Interview with the Social Worker, on 08/31/18 at 9:40 AM, revealed during Resident #2's care plan meeting, the resident stated he/she was upset pain medication was not given to him/her on the day of admission. Review of the Care Plan Conference, dated 08/29/18, revealed Resident #2 did not have a great admission experience. The resident stated there was no one to help and the nurse could not give any pain medication to him/her. Interview with the Unit Manager, on 08/29/18 at 2:20 PM, revealed nurses had access to the EDK and could sign out medications not available. He stated staff should not have made Resident #2 wait to get pain medication, if a medication was not available in the EDK, staff should contact the physician or APRN. He stated the facility provided the means for staff to give residents' pain medication. Interview with LPN #4, on 08/31/18 at 1:30 PM, revealed anytime a resident was in pain, the resident should be relieved of the pain and it was not ethical for a nurse to let a resident lay in pain. She stated if a pain medication was not available, and not in the EDK, the nurse should call the physician to obtain another pain medication order. Interview with LPN #5, on 08/31/18 at 1:10 PM, revealed whenever an ordered medication was not available, the nurse could always refer to the EDK. If the medication was not available in the EDK, the nurse should call the physician and request a one-time dose of different medication. She stated pain was whatever a resident said it was and should be treated as ordered by the physician. Interview with the Director of Nursing (DON), on 08/31/18 at 1:30 PM, revealed the nurse should have administered Resident #2 pain medication in a timely manner. She stated the LPN should have called the physician and requested an order for [REDACTED].#2 and stated the Unit Manager and Social Worker should have informed both the DON and the Risk Manager immediately in regards to Resident #2's complaint. The DON was unsure why the Social Worker had not informed her of the resident's concern.

Based on interview, record review, facility policy review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to have an effective system in place to ensure services provided met the standards of practice for medication administration for three (3) of eight (8) sampled residents, Resident #1, #6, and #7. On 04/10/18, Resident #1 returned to the facility from an acute hospital stay with medication orders that were verified with the provider; however, review of records revealed staff transcribed the orders incorrectly, which were not verified by a second staff member per policy, and the resident received incorrect doses of medications. In addition, staff did not verify the correct dose of pain medication prior to administration resulting in the resident receiving a higher dose than ordered, as per interview was a standard practice. The facility transferred the resident back to the hospital for evaluation with admission [DIAGNOSES REDACTED]. Staff discovered Resident #7 had been receiving the wrong medication for seven (7) days due to staff not verifying the medication against what was ordered, as was standard practice. The resident was sent to the hospital for evaluation and treatment for [REDACTED]. In addition, Resident #6 returned to the facility from an acute hospital stay with medication orders verified but transcribed incorrectly resulting in the resident receiving a lower dose than ordered for his/her treatment of [REDACTED]. The facility's failure to have a system in place to ensure services were provided per professional standards, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/11/18 and was determined to exist on 04/10/18. The facility was notified of the Immediate Jeopardy on 05/11/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 05/25/18, which alleged removal of the IJ on 05/24/18. The State Survey Agency (SSA) verified the IJ was removed on 05/24/18, prior to exit on 05/25/18. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, MD (Physician) Order, dated 04/17/18, revealed when a nurse received a verbal, telephone, or written order from the Physician, Physician's Assistant, or Nurse Practitioner, the nurse transcribed the order according to accepted, standard nursing practice. The policy further stated all orders would be reviewed for accuracy by a second nurse and the Unit Manager. All physician orders [REDACTED]. Review of the facility's policy, Home-Like Medication Administration, dated 10/18/11, revealed all medications would be administered at times consistent with medical standards and medication times could be adjusted with approval from the physician. The policy stated all twice daily (BID) medications would be given upon rising and at bedtime. Review of the KBN, AOS #14, Roles of Nurses in the implementation of Patient Care Orders, revised (MONTH) (YEAR), revealed licensed nurses should administer medication and treatment as prescribed by the Physician, Physician Assistant, Dentist, or Advanced Practice Registered Nurse (APRN). This included preparing and administering medications in the prescribed dosage, route, and frequency. A nurse is obligated to not change an order of a qualified provider without the qualified provider's order to do so. 1. Review of the closed medical record for Resident #1 revealed the facility readmitted the resident from the hospital on [DATE] at 10:00 PM. The hospital discharge paperwork, dated 04/10/18, revealed Resident #1 had the following medications ordered: Aspirin 81 milligram (mg) taken one (1) time daily to begin after one (1) week, [MEDICATION NAME] 0.5 mg taken every six (6) hours as needed (PRN), [MEDICATION NAME] 300 mg taken twice daily, [MEDICATION NAME] 50 mg taken at bedtime, and [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg every six (6) hours PRN. However, review of Resident #1's Physician order [REDACTED]. Aspirin 81 mg one (1) time daily was entered with a start date of 04/10/18 instead of in one (1) week, per the order from the hospital. [MEDICATION NAME] 300 mg was listed four (4) times daily instead of twice daily per the hospital order. [MEDICATION NAME] 150 mg at bedtime; however, the dose from the hospital was for 50 mg. In addition, [MEDICATION NAME] 1 mg every six (6) hours routine; however, per the hospital orders, the dose was 0.5 mg and was to be given PRN. Interview with Unit Manger (UM) #1, on 05/08/18 at 2:23 PM, revealed she entered the medication orders into the EMAR for Resident #1 on 04/10/18, after she verified with the provider to continue the medications per the hospital discharge paperwork. She stated she did not realize she had entered the medications incorrectly until 04/11/18. She further stated she did not review the orders after entering them into the EMAR system and she did not have another nurse review them for accuracy per the facility's policy. Interview with Licensed Practical Nurse (LPN) #2, on 05/09/18 at 2:49 PM, via telephone revealed the discharge summary for Resident #1 was sent to the facility around 4:00 PM - 5:00 PM and UM #1 entered the orders after verifying them with the provider. LPN #2 stated the resident arrived at the facility around 10:00 PM that evening and she was the nurse assigned to care for the resident. She stated she assumed UM #1 entered the medication orders correctly and did not review what was entered. She stated orders should always be checked for accuracy after entering them into the EMAR. Review of Resident #1's EMAR, dated 04/11/18, revealed Certified Medication Technician (CMT) #1 administered Aspirin 81 mg between 7:00 - 11:00 AM, [MEDICATION NAME] 300 mg administered between 7:00 - 11:00 AM and between 11:00 AM - 2:00 PM with two (2) more doses scheduled to be given 3:00 PM - 7:00 PM and 7:00 PM - 10:00 PM, [MEDICATION NAME] 1 mg at 12:00 AM, 6:00 AM, and 12:00 PM. In addition, the resident received all scheduled blood pressure medications as well as [MEDICATION NAME] 50 mg between 7:00 - 11:00 AM and 11:00 AM - 2:00 PM. In addition, review of the Narcotic Log for Resident #1 revealed one (1) dose of [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was signed out on 04/11/18 by CMT #1 and per review of a Medication Error Report, dated 04/11/18 at 2:09 PM, revealed CMT #1 administered [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg to Resident #1 and he/she was ordered to receive 5-325 mg. Adverse drug reactions checked were Cardiovascular/Respiratory and CNS (Central Nervous System). Per the report, the facility sent the resident to the emergency room for evaluation and treatment of [REDACTED]. Interview with CMT #1, on 05/08/18 at 2:47 PM, revealed he did not compare the package to the EMAR before administering the narcotic pain medication, and as a result, administered [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg instead of 5-325 mg to Resident #1 on 04/11/18. He stated medication packaging should be compared to the EMAR orders before administering to prevent errors. Further interview with UM #1, on 05/16/18 at 4:17 PM, revealed it was standard practice to check the medication package against the EMAR prior to administering medications. She stated medication should be administered as ordered by the Physician to prevent errors. The UM further stated Resident #1 had an order for [REDACTED]. Interview with LPN #1, on 05/09/18 at 3:54 PM, revealed all hospital discharge orders should be verified with the Physician or Nurse Practitioner prior to entering them into the EMAR and the verification documented in the nursing note. In addition, the facility's policy stated after orders were entered into the EMAR, a second nurse was required to review the orders and sign that they were correct. LPN #1 further stated when a resident was admitted to the hospital, all medications for that resident should be pulled from the cart. Per interview, when a narcotic medication was discontinued, if it could not be removed from the cart, the nurse should note on the narcotic sign out sheet that the medication was discontinued so it was not signed out and given accidentally. Interview with LPN #5, on 05/15/18 at 11:13 AM, revealed prior to giving a medication, the package should always be checked against the EMAR system to ensure the accurate dose and medication was given. In addition, he stated all medication orders should be verified with the Physician when a resident returned from the hospital. He also stated facility policy stated a second nurse would review the orders once they were entered to ensure they were transcribed correctly. Interview with the Quality Assurance (QA) Nurse, on 05/08/18 at 10:58 AM, revealed the orders entered into the EMAR system for Resident #1 did not match the orders on the hospital discharge summary. She stated orders should always be verified by the Physician and entered into the EMAR system per the direction of the physician. She also stated staff should always check medication packaging with the orders on the EMAR prior to administering the medication. 2. Review of the clinical record for Resident #7 revealed a medication order for [MEDICATION NAME] 1.5 mg one (1) time daily at bedtime. Review of the EMAR for Resident #7, for (MONTH) (YEAR), revealed [MEDICATION NAME] 1.5 mg was administered nightly from 05/03/18 through 05/11/18. However, interview with LPN #7, on 05/16/18 at 2:08 PM via telephone, revealed while he was preparing medications for Resident #7 on 05/12/18, he realized the box labeled [MEDICATION NAME] 1.5 mg, with Resident #7's name on it, contained packages of [MEDICATION NAME] 1.5 mg instead. He stated it was very important for staff to always check the medication packages prior to administering the medication to prevent a possible medication error. Review of a Medication Error Report, dated 05/12/18, revealed a box labeled [MEDICATION NAME] 1.5 mg, with Resident #7's name, was found to contain packets of [MEDICATION NAME] 1.5 mg. The report stated the resident received seven (7) doses of [MEDICATION NAME] 1.5 mg over the course of seven (7) days. The on-call Nurse Practitioner was notified and ordered to send the resident to the hospital for evaluation. Review of the Hospital Discharge Summary, dated 05/12/18, revealed Resident #7 was seen in the emergency room for [MEDICATION NAME] ([MEDICATION NAME]) toxicity. Interview with RN #2, on 05/16/18 at 2:39 PM, via telephone revealed she gave Resident #7 medication on 05/08/18, and was aware there was a medication error involving the resident. She stated she did not believe she had made a medication error because she usually checked the medication packages before administering medications. She further stated it was very important to check the package against the EMAR every time a medication was administered to prevent medication errors. Interview with CMT #2, on 05/16/18 at 3:16 PM, revealed she administered what she thought was [MEDICATION NAME] 1.5 mg on 05/05/18, 05/06/18, 05/09/18, 05/10/18, and 05/11/18. She stated she did not remember if the medication package said [MEDICATION NAME] or [MEDICATION NAME] when she administered the medication. CMT #2 revealed it was important to check both the box and the packaging prior to administering medication to ensure it matched the EMAR. Interview with LPN #8, on 05/17/18 at 9:04 AM, via telephone revealed she worked on 05/07/18 on second shift. She stated she could not recall if she gave Resident #7 his/her medication that evening, but stated it was possible she gave the wrong medication if she did. She stated it was important to check, every time, the package of the medication with the EMAR. Continued interview with the Weekend Shift Supervisor, on 05/17/18 at 11:12 AM, revealed it was very important to check the medication packages against the EMAR prior to administering medications to ensure the correct medication was administered. She further stated she expected all nurses and CMTs to check the packages of the medications they administered. Interview with the Staff Development Nurse, on 05/17/18 at 10:43 AM, revealed nurses and CMTs should check the medication packages with the orders in the EMAR before administering the medication to ensure they were giving the correct medication and dosage. Interview with the Pharmacist Consultant, on 05/24/18 at 2:11 PM, via telephone revealed he was very concerned staff did not use standard nursing practices in regards to medication administration. He stated medications should always be checked against the orders prior to administration. He further stated medications were packaged in separate labeled packages so staff could check to ensure the correct medication and dosage was administered. He stated it was packaged in that way to make it easier to check against the EMAR and reduce the likelihood of a medication error occurring. 3. Review of the clinical record for Resident #6 revealed the facility readmitted the resident from the hospital on [DATE]. Review of the hospital discharge paperwork, dated 04/21/18, revealed a Physician order [REDACTED]. However, review of the medication orders entered in the EMAR for Resident #6 revealed, on 04/21/18, the Weekend Shift Supervisor entered an order for [REDACTED]. Review of the EMAR for 04/22/18, revealed [MEDICATION NAME] 0.25 mg was administered to the resident at 11:11 AM and 7:10 PM for Anxiety. Further review of the EMAR revealed Resident #6 received [MEDICATION NAME] 0.25 mg on 04/23/18 at 6:09 PM for Anxiety. Review of an e-mail from the QA Nurse to the Director of Nursing (DON), Administrator, and UM #1, dated 04/24/18, revealed the [MEDICATION NAME] order entered into the EMAR did not match the discharge order for [MEDICATION NAME] from the hospital. The e-mail further revealed there was not a nursing note in the medical record for Resident #6 related to verification of his/her medication orders. Review of a Nursing Note for Resident #6, dated 04/21/18 and entered as a 'Late Entry' on 04/26/18, revealed the Weekend Shift Supervisor verified and entered the medication orders for Resident #6 upon his/her return to the facility. There was no documentation of a change in dose for the [MEDICATION NAME] order. Interview with the Weekend Shift Supervisor, on 05/17/18 at 11:12 AM, revealed all hospital discharge orders should be verified with a Physician prior to entering them into the computer system. She also stated she recalled Resident #6 returning from the hospital and entering the medications into the computer. She stated she did not recall a change in the [MEDICATION NAME] order. She also stated if there were a change in the order, she would have documented it in a nursing note during the order verification. Interview with the DON, on 05/11/18 at 12:07 PM, per telephone revealed she did not recall the medication error for Resident #6. Post survey interview with the Interim Director of Nursing, on 05/29/18 at 3:09 PM via telephone, revealed she believed the facility referenced Lippincott's Nursing Manual, in regards to nursing standards of practice; however, the manual was not available in the facility. She further stated checking medications for the Five Rights, which included ensuring right medication and right dose, was a standard nursing practice and she expected all the nurses to perform that prior to administration of medications. She also stated verifying medications and ensuring they were transcribed correctly was also standard nursing practice. She stated it was important to ensure residents received the correct medications, because if they did not, the resident could experience psychological or physical harm. Interview with the Administrator, on 05/17/18 at 12:01 PM, revealed he expected the DON and other management staff to oversee all aspects of resident care, and staff education and training related to resident care. The SSA validated the facility implemented the following actions: 1. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed Resident #1 was back from the hospital about twelve (12) hours when she discovered the transcription errors. Record review revealed three (3) medication error reports involving Resident #1 were completed by the QA Nurse for 04/11/18 with MD notification. No new orders were received as the resident had been transferred to the hospital. 2. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM, revealed she received verbal counseling, related to transcription errors, by the DON initially; however, received an in-service later by the SDC regarding the new medication error protocol, verification of all admission/re-admission orders [REDACTED]. 3. Interview with the SDC, on 05/25/18 at 2:00 PM, revealed she completed medication pass observation on all medication administration staff and pharmacy would do random audits on their monthly visits. Record review revealed medication pass observations completed, no concern noted. 4. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she initially reviewed the thirty (30) day look-back period for transcription errors; however, was later directed to review MD orders from 05/01/18 through 05/22/18 for accurate medication transcriptions. Record review revealed on 04/26/18, the QA Nurse reviewed all newly admitted /readmitted residents from 03/11/18 through 04/11/18 MD orders. One (1) additional error was identified and addressed appropriately. Record review revealed MD orders were reviewed for admissions/re-admissions during 05/01/18 through 05/22/18. Four (4) errors were identified and addressed appropriately. 5. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON, on 05/25/18 at 2:40 PM, and a phone interview with the Contracted Nurse Consultant, on 05/25/18 at 12:55 PM, revealed they were responsible for the 3rd check of all new admission/re-admission orders [REDACTED]. They stated after the 2nd licensed nurse check, one of them would be notified to ensure accuracy (discharge summary orders compared to what was put in the computer). If there were discrepancies, the floor nurse and the MD would be notified for clarification. Record review revealed new admissions/re-admissions from 05/20/18 through 05/22/18 had the 3rd check for medication transcription accuracy. 6. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM and Unit Manager #2, on 05/25/18 at 12:08 PM, revealed they were both aware of the new process of removing medication immediately from the cart when a resident was admitted to the hospital. Additionally, all orders were removed from the computer so the orders could not be re-activated upon re-admission. Interview with the Interim DON, on 05/25/18 at 2:40 PM, revealed the Weekend Supervisor was no longer employed at the facility. She revealed an appointed person (DON, SDC, or QA Nurse) would be responsible for the removal of medication and orders when a resident was hospitalized over the weekend. 7. Interview with Licensed Practical Nurse (LPN) #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, Registered Nurse (RN) #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they had been trained on the new medication error process. They revealed the new form was filled out by a licensed nurse and put in a binder for the Unit Manager to review. Interview with Unit Manager #2, on 05/25/18 at 12:08 PM, and Unit Manager #1 at 2:17 PM, revealed they reviewed medication error reports and turned them in to the QA Nurse. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she reviewed all the medication error reports and used the information for tracking and trending purposes. Review of four (4) medication error reports revealed they were complete and reviewed by the QA Nurse. 8. Interview with the Administrator, on 05/25/18 at 1:45 PM, revealed education was completed for licensed nurses. Two (2) as needed nurses had yet to receive the education but neither employee would work until the education was completed. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated the nurses on accurate medication order transcription, reading back the orders to the MD/APRN, having two (2) nurses check new admission/re-admission orders [REDACTED]. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Record review revealed all licensed nurses were educated on accurate transcription of MD orders, the requirement for two (2) licensed nurse checks of new admission/readmission orders [REDACTED]. There was (1) LPN and (1) RN who had not received education as they were both as needed (PRN) employees. 9. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated nurses and CMTs about medication administration, which included the five (5) rights, verifying medication in the correct boxes, comparing the medication to the MAR, notifying the charge nurse about discrepancies, missing medications, and about medications errors. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Interview with CMT #3, on 05/25/18 at 12:15 PM, and CMT #1 at 1:03 PM, revealed they were knowledgeable of the education information. Record review revealed medication administration staff was educated on medication administration, charge nurse notification of discrepancies, and the new medication error protocol. One (1) CMT had not been in-serviced; however, interview with the Administrator, on 05/25/18 at 1:45 PM, revealed the employee would not work until education was completed. 10. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON at 2:40 PM, and the Administrator at 2:30 PM, revealed they were present for both QAPI meetings and knowledgeable of the content of the meetings. Record review revealed QAPI meetings were held on 05/15/18 and 05/22/18 to include Medical Directors. 11. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she would continue tracking and trending the medication error data monthly to review in the QAPI meetings; however, if there were an increase in errors they would meet more often. She stated the data was stored on spreadsheets to identify reason, time of day, day of week, etc. She would complete the QAPI tool monthly for two (2) months at least, then quarterly (but would do more often, if needed). Interview with the Administrator, on 05/25/18 at 2:30 PM, revealed pharmacy staff attend the monthly QAPI meeting and they would have all the tracking and trending data as well. Record review revealed the QAPI tool was completed on 05/22/18.

Based on interview, record review, review of facility Job Descriptions, and review of the facility's policy, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident to ensure medications were transcribed and administered as ordered by the Physician for three (3) of eight (8) sampled residents, Resident #1, #6, and #7. The facility readmitted Resident #1 and #6 after acute hospital stays with medication orders in which staff failed to transcribe correctly resulting in the residents receiving the wrong doses of medications. In addition, staff failed to verify medication packages with the Physician ordered medication resulting in Resident #1 receiving a higher dose of medication than ordered and Resident #7 receiving the wrong medication, which occurred on seven (7) days. As a result of the errors, Resident #1 and #7 were sent to the hospital for evaluation and treatment. (Refer to F658, and F760) The facility failed to have an ineffective system in place to ensure the facility administered care and services effectively to residents, which has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/11/18 and was determined to exist on 04/10/18. The facility was notified of the Immediate Jeopardy on 05/11/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 05/25/18, which alleged removal of the IJ on 05/24/18. The State Survey Agency (SSA) verified the IJ was removed on 05/24/18, prior to exit on 05/25/18. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Job Description for the Administrator, dated (MONTH) 2009, revealed the Administrator was responsible for overall management and operation of the facility. Specifically, the policy stated the Administrator was responsible for directing and coordinating all activities of the facility as part of carrying out the objectives of providing the best possible care for each resident; ensuring compliance with regulations governing nursing homes by continually monitoring the facility's service delivery and initiating changes as required; fostering a smooth functioning, efficient, organization through timely and effective resolution of disruptions; facilitating the encouragement and development of new policies and procedures designed to use organizational resources to maximize quality care and cost effective operations; and finally, reporting to the CEO (Chief Executive Officer) on the operation of the facility, the financial condition, and emerging trends that might encourage development of new policies or procedures in both medical care and fiscal management. Review of the facility's Job Description for the Director of Nursing, undated, revealed the general purpose of the Director of Nursing (DON) was to organize and direct the Nursing Services department, under the direction of the Administrator, to ensure properly trained and capable nursing personnel to ensure maintenance of good patient care based on the physical needs of the residents. It further stated as the Administrative Leader in Nursing Services, the DON assumed responsibility for the standard of the nursing services. In addition, the DON would administer the policies and procedures of the facility and the Nursing Department; plan and implement a system for the evaluation of individual resident care; promote and participate in the formulation or revision of Nursing Department policies and procedures when necessary for obtaining the highest level of resident care; provide and maintain records of minutes of Nursing Department activities; develop and maintain records and reports to provide information for present and future planning as deemed essential for the Nursing Department; attend professional meetings, workshops, and institutes to maintain a knowledge of current and future trends in the Nursing Department; ensure the Nursing Department followed state and federal standards, and performed other duties as delegated and assigned by the Administrator. Review of the facility's policy, MD (Physician) Order, dated 04/17/18, revealed the facility would maintain accurate clinical records on each resident in accordance with accepted professional standards. All orders received would be transcribed according to accepted, standard nursing practice. The policy further stated orders entered into the Electronic Medication Administration (EMAR) System would be verified by a second nurse for accuracy. The policy further stated the facility expected all Physician orders [REDACTED]. Review of copies of emails sent by the QA Nurse to the DON, Administrator, and Unit Manager revealed five (5) emails were sent on 04/11/18, regarding medication orders for Resident #1 in the EMAR system that did not match the Hospital Discharge Paperwork. An email was sent on 04/24/18 related to an incorrect dosage of [MEDICATION NAME] transcribed for Resident #6. The order was entered into the EMAR system on 04/21/18 and did not match the Hospital Discharge Paperwork. In addition there was not a nursing note entered regarding whether verification of medications had been performed. Interview with the QA Nurse, on 05/08/18 at 10:58 AM, revealed she discovered medications for Resident #1 had been transcribed incorrectly when he/she returned from the hospital on [DATE]. She stated the errors were discovered on 04/11/18, at which time the resident had already received several incorrect doses of medications (see F760). She stated she initially sent emails regarding the discrepancies to the DON, Administrator, and Unit Manager; however, after discovering multiple errors she went to the unit to speak with the Unit Manager about the errors and discovered the medications had been verified with APRN #1 to remain the same. She stated Resident #1 was unresponsive and after speaking with APRN #1, was instructed to send the resident to the hospital. Per interview, a Medication Error Report was completed for Resident #1 for one (1) incorrect dose of [MEDICATION NAME]-[MEDICATION NAME]; however, no additional action was taken regarding the incorrectly transcribed medications into the EMAR and administered to the resident. Additional interview with the QA Nurse, on 05/17/18 at 9:43 AM, revealed following the discovery of the medication errors on 04/11/18, she reviewed additional orders for residents who had returned in the past thirty (30) days; however, she did not document her review and was not instructed to do so by the DON. She stated she emailed any errors found to the DON, Unit Managers, and the Administrator. She stated she was unaware of any documentation the DON might have in reference to the identified issues. Per interview, she often reviewed residents newly admitted or readmitted from the hospital and had discovered an additional error involving Resident #6 on 04/24/18. She stated she discovered an order for [REDACTED]. She stated she informed the DON, Administrator, and Unit Manager, and the DON did not provide any additional direction related to the medication error. The QA Nurse stated a medication error report was not completed for the resident. In addition, she stated the DON and Administrator did not instruct her to track and trend any issues related to medication administration or transcription errors. She further stated she was not involved in medication pass audits or education of staff. Interview with the DON, on 05/10/18 at 2:25 PM, revealed she had not made, or suggested, any changes related to medication administration or transcription. She stated she did however review the policy titled MD Order. Continued Interview at 4:56 PM, revealed she had not identified the cause of the medication transcription errors, and instead believed the Provider had approved changing the orders originally, despite knowing UM #1 had made an error in transcription. Interview with the Administrator, on 05/17/18 at 12:01 PM, revealed he expected the DON to monitor nursing related issues. He stated he did not keep track of medication errors as he assumed the DON or QA Nurse would track and trend the errors. He further stated he was not aware of any changes made to policy and procedures related to medications. He stated it was his responsibility to ensure the DON was collecting useful data and using it to identify areas for improvement. He also stated he had received several issues from the QA Nurse related to issues with resident charts, but was not aware how many of the emails were related to medication errors. He stated he monitored to ensure the DON or Unit Managers responded to the emails; however, he did not keep track of the types of errors reported. The SSA validated the facility implemented the following actions: 1. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed Resident #1 was back from the hospital about twelve (12) hours when she discovered the transcription errors. Record review revealed three (3) medication error reports involving Resident #1 were completed by the QA Nurse for 04/11/18 with MD notification. No new orders were received as the resident had been transferred to the hospital. 2. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM, revealed she received verbal counseling, related to transcription errors, by the DON initially; however, received an in-service later by the SDC regarding the new medication error protocol, verification of all admission/re-admission orders [REDACTED]. 3. Interview with the SDC, on 05/25/18 at 2:00 PM, revealed she completed medication pass observation on all medication administration staff and pharmacy would do random audits on their monthly visits. Record review revealed medication pass observations completed, no concern noted. 4. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she initially reviewed the thirty (30) day look-back period for transcription errors; however, was later directed to review MD orders from 05/01/18 through 05/22/18 for accurate medication transcriptions. Record review revealed on 04/26/18, the QA Nurse reviewed all newly admitted /readmitted residents from 03/11/18 through 04/11/18 MD orders. One (1) additional error was identified and addressed appropriately. Record review revealed MD orders were reviewed for admissions/re-admissions during 05/01/18 through 05/22/18. Four (4) errors were identified and addressed appropriately. 5. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON, on 05/25/18 at 2:40 PM, and a phone interview with the Contracted Nurse Consultant, on 05/25/18 at 12:55 PM, revealed they were responsible for the 3rd check of all new admission/re-admission orders [REDACTED]. They stated after the 2nd licensed nurse check, one of them would be notified to ensure accuracy (discharge summary orders compared to what was put in the computer). If there were discrepancies, the floor nurse and the MD would be notified for clarification. Record review revealed new admissions/re-admissions from 05/20/18 through 05/22/18 had the 3rd check for medication transcription accuracy. 6. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM and Unit Manager #2, on 05/25/18 at 12:08 PM, revealed they were both aware of the new process of removing medication immediately from the cart when a resident was admitted to the hospital. Additionally, all orders were removed from the computer so the orders could not be re-activated upon re-admission. Interview with the Interim DON, on 05/25/18 at 2:40 PM, revealed the Weekend Supervisor was no longer employed at the facility. She revealed an appointed person (DON, SDC, or QA Nurse) would be responsible for the removal of medication and orders when a resident was hospitalized over the weekend. 7. Interview with Licensed Practical Nurse (LPN) #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, Registered Nurse (RN) #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they had been trained on the new medication error process. They revealed the new form was filled out by a licensed nurse and put in a binder for the Unit Manager to review. Interview with Unit Manager #2, on 05/25/18 at 12:08 PM, and Unit Manager #1 at 2:17 PM, revealed they reviewed medication error reports and turned them in to the QA Nurse. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she reviewed all the medication error reports and used the information for tracking and trending purposes. Review of four (4) medication error reports revealed they were complete and reviewed by the QA Nurse. 8. Interview with the Administrator, on 05/25/18 at 1:45 PM, revealed education was completed for licensed nurses. Two (2) as needed nurses had yet to receive the education but neither employee would work until the education was completed. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated the nurses on accurate medication order transcription, reading back the orders to the MD/APRN, having two (2) nurses check new admission/re-admission orders [REDACTED]. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Record review revealed all licensed nurses were educated on accurate transcription of MD orders, the requirement for two (2) licensed nurse checks of new admission/readmission orders [REDACTED]. There was (1) LPN and (1) RN who had not received education as they were both as needed (PRN) employees. 9. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated nurses and CMTs about medication administration, which included the five (5) rights, verifying medication in the correct boxes, comparing the medication to the MAR, notifying the charge nurse about discrepancies, missing medications, and about medications errors. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Interview with CMT #3, on 05/25/18 at 12:15 PM, and CMT #1 at 1:03 PM, revealed they were knowledgeable of the education information. Record review revealed medication administration staff was educated on medication administration, charge nurse notification of discrepancies, and the new medication error protocol. One (1) CMT had not been in-serviced; however, interview with the Administrator, on 05/25/18 at 1:45 PM, revealed the employee would not work until education was completed. 10. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON at 2:40 PM, and the Administrator at 2:30 PM, revealed they were present for both QAPI meetings and knowledgeable of the content of the meetings. Record review revealed QAPI meetings were held on 05/15/18 and 05/22/18 to include Medical Directors. 11. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she would continue tracking and trending the medication error data monthly to review in the QAPI meetings; however, if there were an increase in errors they would meet more often. She stated the data was stored on spreadsheets to identify reason, time of day, day of week, etc. She would complete the QAPI tool monthly for two (2) months at least, then quarterly (but would do more often, if needed). Interview with the Administrator, on 05/25/18 at 2:30 PM, revealed pharmacy staff attend the monthly QAPI meeting and they would have all the tracking and trending data as well. Record review revealed the QAPI tool was completed on 05/22/18.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to identify quality issues and/or develop and implement an effective plan to correct identified quality deficiencies in a timely manner related to medication errors. This failure affected three (3) of eight (8) sampled residents, Resident #1, #6, and #7. The facility readmitted Resident #1 after an acute hospital stay with medication orders in which staff failed to transcribe correctly resulting in the resident receiving the wrong doses of medications. In addition, staff failed to verify medication packages with the Physician ordered medication resulting in Resident #1 receiving a higher dose of medication than ordered. On 04/11/18, the Quality Assurance (QA) Nurse identified issues with medication transcription and administration related to Resident #1, and notified the Administrator and Director of Nursing (DON). However, no plan was put in place to address the issues. Ten (10) days later, Resident #6 was readmitted to the facility on [DATE] with new medication orders. However, the medication orders were transcribed incorrectly resulting in the resident receiving the wrong dose of medication on three (3) occasions. Interview revealed a QA meeting was held on 05/07/18; however, the medication errors were not discussed and therefore no plan was put in place to address the issues. On 05/12/18, staff discovered Resident #7 had been receiving the wrong medication for seven (7) days due to staff not verifying the name of the medication on the package with the Physician order. As a result of medication errors, Resident #1 and #7 were sent to the hospital for evaluation and treatment. (Refer to F658, and F760) The facility's failure to develop and implement appropriate plans of action to correct identified quality deficiencies has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/11/18 and was determined to exist on 04/10/18. The facility was notified of the Immediate Jeopardy on 05/11/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 05/25/18, which alleged removal of the IJ on 05/24/18. The State Survey Agency (SSA) verified the IJ was removed on 05/24/18, prior to exit on 05/25/18. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan, dated (YEAR), revealed the purpose of QAPI was to take a proactive approach to continually improve the care provided and to provide the best environment and care available. According to the plan, the facility used QAPI to make decisions to guide day-to-day operations. In addition, QAPI would focus on systems and processes with an emphasis on identifying system gaps. Review of the facility's Job Description for the Quality Assurance Nurse, undated, revealed the Quality Assurance (QA) Nurse would collect data for QA as directed by the Director of Nursing (DON) and analyze the data, report results, and suggest changes as needed to the QA Committee. In addition, the QA Nurse would conduct chart audits; review supplementary assessments; perform compliance rounds; review implementation of corporate policies; medication pass review; assist with corporate DON meetings and trainings; attend all QA Committee Meetings; and perform other duties as directed by the Administrator or DON. Interview with the QA Nurse, on 05/10/18 at 4:22 PM, revealed she was part of the QA Committee and attended the monthly QA meetings. She stated she discovered Resident #1's medication errors when reviewing the hospital discharge orders with the EMAR. She stated she reported the issues to the DON, Administrator, and Unit Manager right away and completed chart reviews for residents admitted or readmitted in the past thirty (30) days. She stated she did not document the findings of the reviews; however, she did send emails related to errors she found in the resident charts. She revealed she was not instructed to do anything further by the DON or the Administrator. The QA Nurse stated a QA meeting had not been held to discuss the medication error identified on 04/11/18 involving Resident #1, or any of the other errors or issues identified during her chart audits. Per interview, she was not aware of any tracking or trending that occurred following the discovery of the medication error identified on 04/11/18, and she stated failure to track and trend meant the reason for the errors could not be determined and they would continue to occur. Interview with Unit Manager (UM) #1, on 05/08/18 at 11:28 AM, revealed she verified and transcribed orders for Resident #1 prior to his/her return from the hospital on [DATE]. She stated she did not know why the orders did not match the orders on the discharge summary from the hospital and she had likely made a mistake when entering the orders and possibly reactivated old orders unintentionally. She further stated she did not review the orders after entering them into the EMAR system and she did not have another nurse review the orders for accuracy. The UM revealed the QA Nurse made her aware of the error on 04/11/18. She stated she had not reviewed or been instructed by the DON to review any additional resident orders for accuracy. She further stated one of her job duties was to review all new orders for accuracy and document on a QAPI form, which she turned in to the DON or QA Nurse. However, she had not had any follow-up regarding the forms and she did not know what was done with them after she turned them in. Interview with the DON, on 05/11/18 at 12:07 PM via telephone, revealed there had not been a QA meeting to discuss medication administration and transcription errors. She revealed she received emails from the QA Nurse related to errors identified in resident charts, including medication transcription errors. However, she did not document the errors, or track them in an attempt to determine a trend. She stated she did not give direction to the QA Nurse to track and trend the medication errors identified, as she assumed the QA Nurse did that. She further stated the Unit Managers reviewed new transcribed orders and documented them on the QAPI tool, which was reviewed by herself or the QA Nurse; however, she did not document the findings of those reviews. She also stated did not instruct the QA Nurse to document the findings. Post survey interview with the Interim Director of Nursing via telephone, on 05/29/18 at 3:09 PM, revealed failure to address issues related to medication errors would result in a failure to identify the cause of these errors, which would result in failure to prevent future medication errors. She stated medication errors could result in physical or psychological harm for all residents in the facility. Interview with Medical Director #2 via telephone, on 05/11/18 at 11:23 AM, revealed he was not aware of the medication error involving Resident #1. He stated he was at the facility on 05/07/18 for a QAPI meeting; however, medication errors were not discussed. Interview with the Administrator, on 05/11/18 at 11:38 AM, revealed a QAPI meeting had not occurred related to medication errors identified for Resident #1 on 04/11/18. Continued interview on 05/23/18 at 4:44 PM, revealed the Quality Assurance (QA) Committee included all department heads, the Director of Nursing (DON), Unit Managers, Medical Director, Quality Assurance Nurse, Therapy, and Staff Development. He stated he believed there were QA documents used to monitor medication administration and transcription errors; however, he was unsure who was completing them. He further stated he was not tracking the medication errors reported to him through emails from the QA Nurse; he expected the DON or one of the Unit Managers to respond to the issues. Per interview, there had not been a QA Committee meeting about the medication issues until 05/15/18; over one (1) month after the medication error was identified and after the facility was notified of the Immediate Jeopardy. He stated there was a QA Committee meeting on 05/07/18, but medication errors were not discussed. The SSA validated the facility implemented the following actions: 1. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed Resident #1 was back from the hospital about twelve (12) hours when she discovered the transcription errors. Record review revealed three (3) medication error reports involving Resident #1 were completed by the QA Nurse for 04/11/18 with MD notification. No new orders were received as the resident had been transferred to the hospital. 2. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM, revealed she received verbal counseling, related to transcription errors, by the DON initially; however, received an in-service later by the SDC regarding the new medication error protocol, verification of all admission/re-admission orders [REDACTED]. 3. Interview with the SDC, on 05/25/18 at 2:00 PM, revealed she completed medication pass observation on all medication administration staff and pharmacy would do random audits on their monthly visits. Record review revealed medication pass observations completed, no concern noted. 4. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she initially reviewed the thirty (30) day look-back period for transcription errors; however, was later directed to review MD orders from 05/01/18 through 05/22/18 for accurate medication transcriptions. Record review revealed on 04/26/18, the QA Nurse reviewed all newly admitted /readmitted residents from 03/11/18 through 04/11/18 MD orders. One (1) additional error was identified and addressed appropriately. Record review revealed MD orders were reviewed for admissions/re-admissions during 05/01/18 through 05/22/18. Four (4) errors were identified and addressed appropriately. 5. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON, on 05/25/18 at 2:40 PM, and a phone interview with the Contracted Nurse Consultant, on 05/25/18 at 12:55 PM, revealed they were responsible for the 3rd check of all new admission/re-admission orders [REDACTED]. They stated after the 2nd licensed nurse check, one of them would be notified to ensure accuracy (discharge summary orders compared to what was put in the computer). If there were discrepancies, the floor nurse and the MD would be notified for clarification. Record review revealed new admissions/re-admissions from 05/20/18 through 05/22/18 had the 3rd check for medication transcription accuracy. 6. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM and Unit Manager #2, on 05/25/18 at 12:08 PM, revealed they were both aware of the new process of removing medication immediately from the cart when a resident was admitted to the hospital. Additionally, all orders were removed from the computer so the orders could not be re-activated upon re-admission. Interview with the Interim DON, on 05/25/18 at 2:40 PM, revealed the Weekend Supervisor was no longer employed at the facility. She revealed an appointed person (DON, SDC, or QA Nurse) would be responsible for the removal of medication and orders when a resident was hospitalized over the weekend. 7. Interview with Licensed Practical Nurse (LPN) #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, Registered Nurse (RN) #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they had been trained on the new medication error process. They revealed the new form was filled out by a licensed nurse and put in a binder for the Unit Manager to review. Interview with Unit Manager #2, on 05/25/18 at 12:08 PM, and Unit Manager #1 at 2:17 PM, revealed they reviewed medication error reports and turned them in to the QA Nurse. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she reviewed all the medication error reports and used the information for tracking and trending purposes. Review of four (4) medication error reports revealed they were complete and reviewed by the QA Nurse. 8. Interview with the Administrator, on 05/25/18 at 1:45 PM, revealed education was completed for licensed nurses. Two (2) as needed nurses had yet to receive the education but neither employee would work until the education was completed. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated the nurses on accurate medication order transcription, reading back the orders to the MD/APRN, having two (2) nurses check new admission/re-admission orders [REDACTED]. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Record review revealed all licensed nurses were educated on accurate transcription of MD orders, the requirement for two (2) licensed nurse checks of new admission/readmission orders [REDACTED]. There was (1) LPN and (1) RN who had not received education as they were both as needed (PRN) employees. 9. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated nurses and CMTs about medication administration, which included the five (5) rights, verifying medication in the correct boxes, comparing the medication to the MAR, notifying the charge nurse about discrepancies, missing medications, and about medications errors. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Interview with CMT #3, on 05/25/18 at 12:15 PM, and CMT #1 at 1:03 PM, revealed they were knowledgeable of the education information. Record review revealed medication administration staff was educated on medication administration, charge nurse notification of discrepancies, and the new medication error protocol. One (1) CMT had not been in-serviced; however, interview with the Administrator, on 05/25/18 at 1:45 PM, revealed the employee would not work until education was completed. 10. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON at 2:40 PM, and the Administrator at 2:30 PM, revealed they were present for both QAPI meetings and knowledgeable of the content of the meetings. Record review revealed QAPI meetings were held on 05/15/18 and 05/22/18 to include Medical Directors. 11. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she would continue tracking and trending the medication error data monthly to review in the QAPI meetings; however, if there were an increase in errors they would meet more often. She stated the data was stored on spreadsheets to identify reason, time of day, day of week, etc. She would complete the QAPI tool monthly for two (2) months at least, then quarterly (but would do more often, if needed). Interview with the Administrator, on 05/25/18 at 2:30 PM, revealed pharmacy staff attend the monthly QAPI meeting and they would have all the tracking and trending data as well. Record review revealed the QAPI tool was completed on 05/22/18.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure staff implemented care plans related to following physician orders [REDACTED].#1. Per record review and staff interview, Resident #1 was readmitted to the facility after an acute hospital stay on 04/10/18, with care plan interventions for staff to administer medications per Physician order. However, staff did not transcribe the medication orders correctly resulting in the resident receiving incorrect doses of medications. In addition, staff did not verify the resident's dose of pain medication prior to administration and the resident did not receive the dose as ordered. The resident was sent back to the hospital and admitted with [DIAGNOSES REDACTED]. On 04/25/18, Resident #1 was transferred to a long term care facility that provided ventilator care due to the inability of the resident to be removed from the ventilator. The facility's failure to have a system in place to ensure care plan interventions were implemented, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/11/18 and was determined to exist on 04/10/18. The facility was notified of the Immediate Jeopardy on 05/11/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 05/25/18, which alleged removal of the IJ on 05/24/18. The State Survey Agency (SSA) verified the IJ was removed on 05/24/18, prior to exit on 05/25/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Care Plan Guidelines, dated 09/07/17, revealed each care plan was specific to each individual resident. The policy further stated accepted standards of care might not be included on the resident care plan, but would be expected to be followed. In addition, the standards might be added to the care plan in the event it was considered appropriate for the individual resident. Review of the closed medical record for Resident #1 revealed the facility admitted the resident on 04/11/14, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) for Resident #1, dated 03/16/18, revealed the resident received antipsychotic, antianxiety, and antidepressant medications during the seven (7) days prior to the assessment and he/she received opioids for six (6) days prior to the assessment. Review of the Care Plan, dated 03/15/18, revealed medications would be administered per Physician orders [REDACTED]. Further review of the medical record revealed the resident had an acute hospital stay from 04/08/18 to 04/10/18. Review of the hospital discharge paperwork, dated 04/10/18, revealed Resident #1 had the following medications ordered: Aspirin 81 milligrams (mg) one (1) time daily to begin after one (1) week, [MEDICATION NAME] 0.5 mg every six (6) hours as needed (PRN), [MEDICATION NAME] 300 mg twice daily, [MEDICATION NAME] 50 mg at bedtime, and [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg every six (6) hours PRN. However, review of the Physician order [REDACTED]. [MEDICATION NAME] 300 mg was entered four (4) times daily instead of twice daily. [MEDICATION NAME] 150 mg was entered instead of 50 mg, and [MEDICATION NAME] 1 mg every six (6) hours routine was entered instead of 0.5 mg PRN. Review of Resident #1's EMAR, dated 04/11/18, revealed Resident #1 was administered Aspirin 81 mg between 7:00 AM - 11:00 AM, [MEDICATION NAME] 300 mg between 7:00 AM - 11:00 AM and between 11:00 AM - 2:00 PM, with two (2) more doses scheduled to be given 3:00 PM - 7:00 PM and 7:00 PM - 10:00 PM, and [MEDICATION NAME] 1 mg was administered at 12:00 AM, 6:00 AM, and 12:00 PM. In addition, review of the Narcotic Log for Resident #1 revealed one (1) dose of [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was signed out on 04/11/18; however, the resident was ordered to receive 5-325 mg. Review of a Medication Error Report, dated 04/11/18, revealed the resident was administered 10-325 mg on 04/11/18. The Report further revealed the resident was sent to the emergency room for evaluation and treatment. Review of the emergency room Report, dated 04/11/18, revealed Resident #1 experienced respiratory distress and was intubated upon arrival to the hospital. The resident required endotracheal intubation, ventilator support, and experienced [MEDICAL CONDITION] (low blood pressure) after arrival and was admitted to the Intensive Care Unit (ICU). The [DIAGNOSES REDACTED]. Interview with Certified Medication Technician, (CMT) #2, on 05/16/18 at 3:16 PM, revealed the care plan was specific to each resident and it was important for staff to follow the care plan interventions to ensure the resident received necessary care. If medications were not given as ordered, then the care plan was not followed, which could cause harm to a resident. Interview with Licensed Practical Nurse (LPN) #4, on 05/15/18 at 10:32 AM, revealed if medications were not given as ordered, which was an intervention listed on the care plan, then the care plan was not followed. Interview with LPN #8, on 05/17/18 at 9:04 AM, via telephone revealed a resident care plan gave staff information about the resident and failure to administer medications as ordered meant the physician orders [REDACTED]. Interview with Registered Nurse (RN) #2, on 05/16/18 at 2:39 PM, via telephone revealed the care plan gave staff information about the resident and changed as the resident care needs changed. If staff did not administer medications as ordered, then the care plan was not followed appropriately and the resident could be harmed. Interview with Unit Manager (UM) #1, on 05/16/18 at 4:17 PM, revealed the care plan was a learning tool for staff to learn about the residents' needs. If the care plan interventions stated staff should follow physician orders, and physician orders [REDACTED]. She further stated failure to follow the care plan could result in harm for the resident. Interview with the Quality Assurance (QA) Nurse, on 05/17/18 at 9:43 AM, revealed it was important for staff to follow physician orders [REDACTED]. She stated most care plans had interventions that spoke to following physician orders [REDACTED]. Interview with the Staff Development Nurse, on 05/17/18 at 10:43 AM, revealed if physician orders [REDACTED]. She stated it was important to follow the resident care plan as it was resident specific and if not followed, the resident would not get the care needed. She also stated failure to provide residents with the care needed could result in serious injury or death. Post survey interview with the Interim Director of Nursing (DON), on 05/29/18 at 3:09 PM via telephone, revealed she expected staff to follow resident care plans. She stated failure to administer medications as ordered by the Physician for Resident #1 meant staff had not followed the care plan and failure to do so could result in psychological or physical harm for the resident. Interview with the Administrator, on 05/17/18 at 12:01 PM, revealed he expected staff to follow care plans as written. He further stated he expected the DON to oversee all aspects of the medical care provided by staff. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 04/11/18, the Quality Assurance (QA) Nurse reviewed Resident #1's Physician orders [REDACTED]. 2. On 04/13/18, the Director of Nursing (DON) provided verbal counseling to the nurse responsible for the transcription errors, to include accurate transcription of MD orders, and repeating back verbal orders to the MD/APRN (Advanced Practiced Registered Nurse). The nurse was later in-serviced on 05/18/18 by the Staff Development Coordinator (SDC) on obtaining clarification of any orders that did not include necessary information, the facility protocol that required two (2) licensed nurses check all new admission/readmission orders [REDACTED]. 3. On 04/19/18, the SDC performed medication pass observations for all medication administration staff. On-going, random audits would be performed during the monthly Pharmacy Consultant visits on randomly selected staff. 4. On 04/26/18, the QA Nurse reviewed all orders for all newly admitted /readmitted residents from 03/11/18 to 04/11/18 to ensure accurate transcription. Any errors were addressed per the facility policy, with MD notification and follow-up. MD orders from 05/01/18 through 05/22/18 were also reviewed by the QA Nurse to determine accurate medication transcription. 5. In addition to two (2) licensed nurses checking all new admission/re-admission orders [REDACTED]. 6. A new protocol was put in place to ensure medications were removed from the cart and MD orders were removed from the computer after a resident was admitted to an acute-care setting. The Unit Manger would be responsible for this task during the week, and the Weekend Supervisor on the weekend. 7. A new medication error report was implemented to include more documentation for tracking and trending errors. The form would be completed by licensed nurses, then put in a binder for the Unit Manager to review. After review, it would be turned in to the QA Nurse for tracking and trending. 8. From 05/15/18 through 05/23/18, the SDC educated all licensed nurses on accurate transcription of MD orders, repeating back to the MD/APRN of all verbal orders, obtaining clarification for any orders with discrepancies, the requirement of two (2) licensed nurse checks for all new admission/re-admission orders [REDACTED]. 9. On 05/17/17, the SDC educated all medication administration staff on accurate medication administration including the five (5) rights of medication administration (right resident, right medication, right dose, right time, and right route), immediate notification of the charge nurse if any discrepancies, and the new medication error protocol. 10. A Quality Assurance Performance Improvement (QAPI) meeting was held on 05/15/18 to review the events involving Resident #1, the action plan developed, and the interventions being implemented. Another meeting was held on 05/23/18 to review tracking and trending, the new medication error report, and education provided to staff. 11. The QA Nurse would present the medication error report tracking and trending information at the monthly QAPI meeting, along with action plans developed/implemented to address the identified trends. Information would be reviewed with the Pharmacy Consultant monthly. QAPI tool for monitoring compliance with transcription of medication orders would be utilized monthly for two (2) months and then quarterly. Five (5) records for recently admitted /readmitted residents would be reviewed using the tool. The SSA validated the facility implemented the following actions: 1. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed Resident #1 was back from the hospital about twelve (12) hours when she discovered the transcription errors. Record review revealed three (3) medication error reports involving Resident #1 were completed by the QA Nurse for 04/11/18 with MD notification. No new orders were received as the resident had been transferred to the hospital. 2. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM, revealed she received verbal counseling, related to transcription errors, by the DON initially; however, received an in-service later by the SDC regarding the new medication error protocol, verification of all admission/re-admission orders [REDACTED]. 3. Interview with the SDC, on 05/25/18 at 2:00 PM, revealed she completed medication pass observation on all medication administration staff and pharmacy would do random audits on their monthly visits. Record review revealed medication pass observations completed, no concern noted. 4. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she initially reviewed the thirty (30) day look-back period for transcription errors; however, was later directed to review MD orders from 05/01/18 through 05/22/18 for accurate medication transcriptions. Record review revealed on 04/26/18, the QA Nurse reviewed all newly admitted /readmitted residents from 03/11/18 through 04/11/18 MD orders. One (1) additional error was identified and addressed appropriately. Record review revealed MD orders were reviewed for admissions/re-admissions during 05/01/18 through 05/22/18. Four (4) errors were identified and addressed appropriately. 5. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON, on 05/25/18 at 2:40 PM, and a phone interview with the Contracted Nurse Consultant, on 05/25/18 at 12:55 PM, revealed they were responsible for the 3rd check of all new admission/re-admission orders [REDACTED]. They stated after the 2nd licensed nurse check, one of them would be notified to ensure accuracy (discharge summary orders compared to what was put in the computer). If there were discrepancies, the floor nurse and the MD would be notified for clarification. Record review revealed new admissions/re-admissions from 05/20/18 through 05/22/18 had the 3rd check for medication transcription accuracy. 6. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM and Unit Manager #2, on 05/25/18 at 12:08 PM, revealed they were both aware of the new process of removing medication immediately from the cart when a resident was admitted to the hospital. Additionally, all orders were removed from the computer so the orders could not be re-activated upon re-admission. Interview with the Interim DON, on 05/25/18 at 2:40 PM, revealed the Weekend Supervisor was no longer employed at the facility. She revealed an appointed person (DON, SDC, or QA Nurse) would be responsible for the removal of medication and orders when a resident was hospitalized over the weekend. 7. Interview with Licensed Practical Nurse (LPN) #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, Registered Nurse (RN) #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they had been trained on the new medication error process. They revealed the new form was filled out by a licensed nurse and put in a binder for the Unit Manager to review. Interview with Unit Manager #2, on 05/25/18 at 12:08 PM, and Unit Manager #1 at 2:17 PM, revealed they reviewed medication error reports and turned them in to the QA Nurse. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she reviewed all the medication error reports and used the information for tracking and trending purposes. Review of four (4) medication error reports revealed they were complete and reviewed by the QA Nurse. 8. Interview with the Administrator, on 05/25/18 at 1:45 PM, revealed education was completed for licensed nurses. Two (2) as needed nurses had yet to receive the education but neither employee would work until the education was completed. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated the nurses on accurate medication order transcription, reading back the orders to the MD/APRN, having two (2) nurses check new admission/re-admission orders [REDACTED]. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Record review revealed all licensed nurses were educated on accurate transcription of MD orders, the requirement for two (2) licensed nurse checks of new admission/readmission orders [REDACTED]. There was (1) LPN and (1) RN who had not received education as they were both as needed (PRN) employees. 9. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated nurses and CMTs about medication administration, which included the five (5) rights, verifying medication in the correct boxes, comparing the medication to the MAR, notifying the charge nurse about discrepancies, missing medications, and about medications errors. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Interview with CMT #3, on 05/25/18 at 12:15 PM, and CMT #1 at 1:03 PM, revealed they were knowledgeable of the education information. Record review revealed medication administration staff was educated on medication administration, charge nurse notification of discrepancies, and the new medication error protocol. One (1) CMT had not been in-serviced; however, interview with the Administrator, on 05/25/18 at 1:45 PM, revealed the employee would not work until education was completed. 10. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON at 2:40 PM, and the Administrator at 2:30 PM, revealed they were present for both QAPI meetings and knowledgeable of the content of the meetings. Record review revealed QAPI meetings were held on 05/15/18 and 05/22/18 to include Medical Directors. 11. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she would continue tracking and trending the medication error data monthly to review in the QAPI meetings; however, if there were an increase in errors they would meet more often. She stated the data was stored on spreadsheets to identify reason, time of day, day of week, etc. She would complete the QAPI tool monthly for two (2) months at least, then quarterly (but would do more often, if needed). Interview with the Administrator, on 05/25/18 at 2:30 PM, revealed pharmacy staff attend the monthly QAPI meeting and they would have all the tracking and trending data as well. Record review revealed the QAPI tool was completed on 05/22/18.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure residents were free from significant medication errors for two (2) of eight (8) sampled residents, Resident #1 and #7. Record review and interview revealed, on 04/08/18, Resident #1 was transferred to the hospital after a change in status and was readmitted to the facility on [DATE] with new medication orders. Unit Manager #1 transcribed the medication orders incorrectly, and a second nurse did not verify the orders for accuracy per the facility's policy, resulting in the resident receiving the wrong doses of several medications. In addition, staff did not verify the dose of pain medication on the package against the order on the Electronic Medication Administration Record (EMAR) resulting in Resident #1 receiving a higher dose of pain medication than ordered. On 04/11/18, facility staff found Resident #1 unresponsive with low blood pressure and low heart rate. The resident required EMS transport to the hospital, where he/she experienced respiratory distress requiring ventilator support. On 04/25/18, Resident #1 was transferred to a long term care facility that provided ventilator care due to the inability of the resident to be removed from the ventilator. In addition, staff failed to verify the medication in the package against the medication ordered on the EMAR for Resident #7. The resident had an order for [REDACTED]. Resident #7 received seven (7) doses of [MEDICATION NAME] 1.5 mg over the course of seven (7) days, between 05/03/18 through 05/11/18. When the error was identified, the resident was administered Vitamin K at the facility and transferred to the hospital for evaluation for [MEDICATION NAME] ([MEDICATION NAME]) toxicity. The facility's failure to ensure residents were free of significant medication errors, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/11/18 and was determined to exist on 04/10/18. The facility was notified of the Immediate Jeopardy on 05/11/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 05/25/18, which alleged removal of the IJ on 05/24/18. The State Survey Agency (SSA) verified the IJ was removed on 05/24/18, prior to exit on 05/25/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of facility's policy, MD (Physician) Order, dated 04/17/18, revealed all orders entered into the Electronic Medication Administration (EMAR) System would be verified by a second nurse for accuracy. The policy further stated the facility expected all Physician orders [REDACTED]. Review of the facility's policy, Home-Like Medication Administration, dated 10/18/11, revealed all medications ordered twice daily (BID) would be given once upon rising and once at bedtime. 1. Review of the closed medical record for Resident #1, revealed the facility admitted the resident on 04/11/14, with [DIAGNOSES REDACTED]. The resident had an acute hospital stay from 04/08/18 to 04/10/18, and returned to the facility on [DATE] at 10:00 PM with an additional [DIAGNOSES REDACTED]. A nursing note dated 04/11/18 at 2:23 AM, revealed Resident #1 returned from the hospital alert and oriented. Review of the Hospital Discharge Paperwork, dated 04/10/18, revealed multiple medications ordered for Resident #1, which included Aspirin 81 milligrams (mg) one (1) time daily to begin after one (1) week, [MEDICATION NAME] 0.5 mg every six (6) hours as needed (PRN), [MEDICATION NAME] 300 mg twice daily, [MEDICATION NAME] 50 mg at bedtime, and [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg every six (6) hours PRN. Review of a Nursing Note, dated 04/10/18 at 6:30 PM, revealed Unit Manager (UM) #1 verified orders with Advanced Practice Registered Nurse (APRN) #1. The note did not mention any changes in medication orders. However, review of the medication orders entered into the EMAR on 04/10/18, revealed staff transcribed the medication orders incorrectly. Aspirin 81 mg one time daily was entered with a start date of 04/10/18 instead of a start date in one (1) week. [MEDICATION NAME] 300 mg was entered four (4) times daily instead of twice daily. [MEDICATION NAME] 150 mg was entered instead of 50 mg, and [MEDICATION NAME] 1 mg every six (6) hours routine was entered instead of 0.5 mg PRN. Review of the EMAR, dated 04/11/18, revealed Resident #1 was administered Aspirin 81 mg between 7:00 AM - 11:00 AM; [MEDICATION NAME] 300 mg between 7:00 AM - 11:00 AM and between 11:00 AM - 2:00 PM, with two (2) more doses scheduled to be given 3:00 PM - 7:00 PM and 7:00 PM - 10:00 PM; and, [MEDICATION NAME] 1 mg was administered at 12:00 AM, 6:00 AM, and 12:00 PM. In addition, the resident received all scheduled blood pressure medications, as well as [MEDICATION NAME] 50 mg between 7:00 AM - 11:00 AM and 11:00 AM - 2:00 PM. Interview with UM #1, on 05/08/18 at 2:23 PM, revealed she entered Resident #1's medication orders into the EMAR on 04/10/18. She stated she did not review the orders after entering them into the EMAR and she did not have another nurse review them. She stated she was updating the resident's prior medication orders and could have accidentally reactivated those orders. Interview with the Staff Development Nurse, on 05/17/18 at 10:43 AM, revealed staff should always call the Physician with the most recent hospital orders to verify medications when a resident returned from the hospital. She stated staff should never assume orders would be resumed as they were before the hospital stay. In addition to the transcription error, causing Resident #1 to receive incorrect doses of medication, review of a Medication Error Report, dated 04/11/18, revealed Certified Medication Technician (CMT) #1 administered [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg to Resident #1 on 04/11/18; however, the resident was ordered [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. Review of the Narcotic Log for Resident #1, revealed one (1) dose of [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg was signed out on 04/11/18. Interview with CMT #1, on 05/08/18 at 2:47 PM, revealed he administered [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg to Resident #1 on 04/11/18. He stated he did not compare the medication package to the EMAR before administering the medication. Continued interview with UM #1, on 05/08/18 at 2:23 PM, revealed Resident #1 received [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg prior to hospitalization and she should have removed the medication from the medication cart since the new order was for 5-325 mg. She also stated it was important to ensure medications were administered correctly, as failure to do so could result in serious harm or death of a resident. Review of a Nursing Note, dated 04/11/18, revealed Resident #1 became very lethargic, with low blood pressure and low heart rate. The resident would only respond to sternal rubs and was sent back to the hospital. Interview with Licensed Practical Nurse (LPN) #2, on 05/09/18 at 2:49 PM, via telephone revealed Resident #1 returned to the facility on [DATE] at approximately 10:00 PM. She further stated the resident was alert and communicating upon his/her return and continued to be alert the next morning when she left the facility. Interview with LPN #3, on 05/09/18 at 12:55 PM, revealed she arrived to work on 04/11/18 at approximately 6:00 AM. She stated Resident #1 was alert and oriented upon her arrival, talking with staff and in his/her wheelchair. She stated around lunchtime, the resident was lethargic and unresponsive and was minimally responsive to a sternal rub. She further stated she obtained vital signs for the resident and recalled Resident #1 had low blood pressure and a low heart rate. Per interview, Emergency Medical Services were contacted at that time and the resident was sent to the hospital. LPN #3 also stated per facility policy, all medications on the hospital discharge summary were to be verified with the Physician or Nurse Practitioner and then entered into the computer system as verified. Interview with APRN #1, on 05/09/18 at 9:23 AM, via telephone revealed on 04/10/18, she verified Resident #1 orders for Aspirin, [MEDICATION NAME], and [MEDICATION NAME]-[MEDICATION NAME] as ordered on the hospital discharge paperwork. She stated she received a call from the facility the next morning, on 04/11/18, related to the resident receiving multiple medications at the incorrect dose. She stated she told the facility to send him/her to the hospital, as she was concerned the resident would experience respiratory arrest. Review of the emergency room Report, dated 04/11/18, revealed Resident #1 was seen at 2:47 PM, experiencing respiratory distress and was intubated upon arrival to the hospital. The report further stated the resident required endotracheal intubation, ventilator support, and experienced [MEDICAL CONDITION] after arrival and admitted to the Intensive Care Unit (ICU). The [DIAGNOSES REDACTED]. Review of the Hospital Discharge Paperwork, dated 04/25/18, revealed Resident #1 was discharged to a Long Term Care Facility that could provide care for residents on ventilator support due to the inability to discontinue ventilator support for Resident #1. Interview with LPN #1, on 05/09/18 at 3:54 PM, revealed all hospital discharge orders should be verified with the Physician or Nurse Practitioner prior to entering them into the EMAR. She also stated after the orders were entered, a second nurse was required to review the orders and sign that they were correct. The nurse should document in the nursing note when he/she verified and entered new orders into the EMAR. LPN #1 further stated when a resident was admitted to the hospital, all medications for that resident should be pulled from the cart. She stated when a narcotic medication was discontinued, if it could not be removed from the cart, the nurse should write 'discontinued' on the narcotic sign out sheet so it was not signed out and given accidentally. Interview with Registered Nurse (RN) #1, on 05/09/18 at 4:15 PM, revealed all medication orders should be verified with the Physician or Nurse Practitioner prior to entering the orders into the EMAR. She stated all orders should be entered as new orders and old orders should not be reactivated when a resident returned from the hospital. Interview with LPN #4, on 05/15/18 at 10:32 AM, revealed medication packages should always be checked prior to administering medication to a resident. She also stated when a resident returned from the hospital, all new medication orders should be verified with the Physician or Nurse Practitioner and then entered into the EMAR. Interview with LPN #5, on 05/15/18 at 11:13 AM, revealed medication packages should always be checked against the EMAR prior to administering the medication to the resident. He stated medication orders should be verified with the Physician prior to entering the orders into the EMAR. LPN #5 revealed when a resident was admitted to the hospital, all medications should be removed from the medication cart to prevent a medication error, as an error could result in death. Interview with LPN #6, on 05/15/18 at 11:31 AM, revealed staff administering medications should always double check the medication package prior to giving a medication. She further stated when entering orders into the EMAR, staff must first verify the orders with the Physician and then after entering the orders into the EMAR, the orders must be verified with another nurse to ensure proper transcription. According to LPN #6, when a resident was admitted to the hospital, all medications for that resident should be removed from the medication cart and returned to pharmacy to prevent medication errors. She stated if a medication error occurred, the resident could experience a number of adverse effects, including death. Interview with RN #2, on 05/16/18 at 2:39 PM, via telephone revealed medication orders must be verified with a Physician before entering them in the EMAR, and they must be checked by a second nurse for accuracy. She stated if medication orders were not entered into the computer system correctly, the resident could experience serious consequences, including physical harm and death. Interview with the Quality Assurance (QA) Nurse, on 05/08/18 at 10:58 AM, revealed the orders entered into the EMAR system for Resident #1 did not match the orders on the hospital discharge paperwork. She stated the resident received incorrect doses of several medications that morning (04/11/18) and she observed Resident #1 to appear lethargic and non-responsive. In a later interview on 05/17/18 at 9:43 AM, the QA Nurse stated a medication error could kill a resident. Interview with the Director of Nursing (DON), on 05/10/18 at 4:56 PM, revealed medication errors had occurred with Resident #1. She stated the orders were not entered correctly and she felt it was due to APRN #1 verifying the orders then changing her mind. However, she could not provide proof that APRN #1 had verified changes in the medication orders. Interview with Medical Director #2, on 05/11/18 at 11:23 AM, via telephone revealed the medications administered to Resident #1 could have caused his/her sudden deterioration in condition. Interview with the Pharmacist Consultant, on 05/10/18 at 3:29 PM, via telephone revealed the medications administered to Resident #1 could cause severe sedation and [MEDICATION NAME]-[MEDICATION NAME] was a medication that could cause respiratory suppression. Interview with the Administrator, on 05/11/18 at 11:38 AM, revealed he was made aware of the medication error involving Resident #1; however, he could not say if the medications administered caused the resident to become sedated and go into respiratory arrest. Interview with the hospital's Internal Medicine Specialist via telephone, on 05/10/18 at 10:28 AM, revealed he cared for Resident #1 from 04/08/18 - 04/10/18. He stated the resident was alert, oriented, and stable upon discharge from the hospital on [DATE]; however, he stated the resident returned to the hospital less than twenty-four (24) hours later. He stated upon return, he/she required ventilator support and his/her condition was consistent with a drug overdose and there were no other conditions identified that would lead to the resident's sudden decline. 2. Review of the clinical record for Resident #7 revealed the facility admitted the resident on 07/23/12, with [DIAGNOSES REDACTED]. Review of Medication Orders for Resident #7 revealed [MEDICATION NAME] 1.5 mg to be administered every night at bedtime. Review of the EMAR for Resident #7, for (MONTH) (YEAR), revealed [MEDICATION NAME] 1.5 mg was administered nightly from 05/03/18 through 05/11/18. Review of a Medication Error Report, dated 05/12/18, revealed a box labeled [MEDICATION NAME] 1.5 mg, with Resident #7's name, contained packets of [MEDICATION NAME] 1.5 mg. The resident received seven (7) doses of [MEDICATION NAME] 1.5 mg over the course of seven (7) days. In addition, the document revealed a PT/INR (to see how long it takes blood to clot) was obtained on the resident and resulted greater than 8. The on-call Nurse Practitioner was contacted and she gave orders to administer 5 mg of Vitamin K and to send the resident to the hospital for evaluation. Review of the Hospital Discharge Summary, dated 05/12/18, revealed Resident #7 was seen in the emergency room for [MEDICATION NAME] ([MEDICATION NAME]) toxicity. According to lab results included in the summary, Resident #7 had a [MEDICATION NAME] Time (PT) of 110.0 with a reference range of 9.9 - 12.7. The INR was listed as greater than eleven (11), with no reference range indicated; however, the result was listed as 'high'. Interview with LPN #7, on 05/16/18 at 2:08 PM via telephone, revealed while preparing medications for Resident #7 on 05/12/18, he realized the medication package, in a box labeled [MEDICATION NAME] 1.5 mg, was labeled [MEDICATION NAME] 1.5 mg and he notified his supervisor right away. He further stated it was very important for staff to check the medication packages prior to administering medication to prevent a possible medication error because an error could cause serious physical harm to a resident. Interview with the Weekend Shift Supervisor, on 05/17/18 at 11:12 AM, revealed she was notified [MEDICATION NAME] 1.5 mg was inside a box labeled [MEDICATION NAME] 1.5 mg for Resident #7. She stated she immediately took the resident to his/her room for an assessment and checked his/her PT/INR and obtained a reading greater than 8, because the equipment used in the facility did not read higher than that. She stated she immediately notified the on call Nurse Practitioner and received orders to administer 5 mg Vitamin K via injection and to send the resident to the hospital for further evaluation. She stated she received report from the hospital that Resident #7 had a PT/INR of 11 upon arrival and additional clotting medications were administered. She further stated she knew seven (7) pills had been administered because there were only seven (7) packages in the box and there should have been fourteen (14) packages. She stated pharmacy sent the box of fourteen (14) packages of medication on 05/03/18, but she was unsure what date the box was opened. She stated medication errors could result in serious injury or death of a resident. Interview with APRN #2 via telephone, on 05/24/18 at 12:58 PM, revealed she received a phone call regarding Resident #7 and staff explained to her the resident experienced a medication error and received [MEDICATION NAME] 1.5 mg instead of [MEDICATION NAME] 1.5 mg. She stated staff reported Resident #7 had a PT/INR reading greater than 8 and she told them to administer Vitamin K right away and send the resident to the hospital. She stated she was concerned the resident might have had bleeding that was undetected, as the medication was given so many times without staff aware of it. Interview with RN #2, on 05/16/18 at 2:39 PM via telephone, revealed she administered medications to Resident #7 on 05/08/18, but did not believe she had made a medication error because she usually checked the medication packages before administering medications. She further stated it was very important to check the package against the EMAR every time a medication was administered. RN #2 stated a patient could have serious adverse reactions if they received the incorrect medication. Interview with CMT #2, on 05/16/18 at 3:16 PM, revealed she administered what she thought was [MEDICATION NAME] 1.5 mg to Resident #7 on 05/05/18, 05/06/18, 05/09/18, 05/10/18, and 05/11/18. She stated she did not know if the medication package said [MEDICATION NAME] or [MEDICATION NAME] when she administered the medication. She stated it was important to check both the box and the packaged prior to administering medication to ensure they matched the order in the EMAR. She stated a medication error could cause serious harm to a resident. Interview with LPN #8, on 05/17/18 at 9:04 AM, revealed she worked second shift on 05/07/18, but could not recall if she had given Resident #7 his/her medication that evening; however, stated it was possible she had given the wrong medication if she had administered medications that evening. She stated it was important to always check the package of the medication with the EMAR. She further stated if a resident received the wrong medication, they could experience physical harm or death. Interview with the Staff Development Nurse, on 05/17/18 at 10:43 AM, revealed staff administering medications should always check the packages against the EMAR prior to administering medications to prevent a medication error that could result in serious injury or death. Interview with Medical Director #2 via telephone, on 05/24/18 at 11:53 AM, revealed he was made aware of the medication error involving Resident #7 and was concerned with the potential serious implications for the resident. He stated a PT/INR result of greater than 8 was very dangerous. Interview with the Pharmacist Consultant, on 05/24/18 at 2:11 PM, via telephone revealed he was concerned to learn staff was not checking the medication packages prior to medication administration. He stated the pills were packaged in separate packets in order to make medication administration safer. He stated he was concerned staff was not following standard medication administration procedures. Further interview with the Administrator, 05/17/18 at 12:01 PM, revealed he expected his DON to monitor the care provided to residents and to also monitor the nursing staff providing care. Post survey interview with the Interim Director of Nursing, on 05/29/18 at 3:09 PM via telephone, revealed staff should transcribe medications correctly and have the medications orders verified by a second nurse to ensure accuracy. She stated failure to ensure medications were transcribed and administered correctly could lead to psychological or physical harm of a resident. The SSA validated the facility implemented the following actions: 1. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed Resident #1 was back from the hospital about twelve (12) hours when she discovered the transcription errors. Record review revealed three (3) medication error reports involving Resident #1 were completed by the QA Nurse for 04/11/18 with MD notification. No new orders were received as the resident had been transferred to the hospital. 2. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM, revealed she received verbal counseling, related to transcription errors, by the DON initially; however, received an in-service later by the SDC regarding the new medication error protocol, verification of all admission/re-admission orders [REDACTED]. 3. Interview with the SDC, on 05/25/18 at 2:00 PM, revealed she completed medication pass observation on all medication administration staff and pharmacy would do random audits on their monthly visits. Record review revealed medication pass observations completed, no concern noted. 4. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she initially reviewed the thirty (30) day look-back period for transcription errors; however, was later directed to review MD orders from 05/01/18 through 05/22/18 for accurate medication transcriptions. Record review revealed on 04/26/18, the QA Nurse reviewed all newly admitted /readmitted residents from 03/11/18 through 04/11/18 MD orders. One (1) additional error was identified and addressed appropriately. Record review revealed MD orders were reviewed for admissions/re-admissions during 05/01/18 through 05/22/18. Four (4) errors were identified and addressed appropriately. 5. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON, on 05/25/18 at 2:40 PM, and a phone interview with the Contracted Nurse Consultant, on 05/25/18 at 12:55 PM, revealed they were responsible for the 3rd check of all new admission/re-admission orders [REDACTED]. They stated after the 2nd licensed nurse check, one of them would be notified to ensure accuracy (discharge summary orders compared to what was put in the computer). If there were discrepancies, the floor nurse and the MD would be notified for clarification. Record review revealed new admissions/re-admissions from 05/20/18 through 05/22/18 had the 3rd check for medication transcription accuracy. 6. Interview with Unit Manager #1, on 05/25/18 at 2:17 PM and Unit Manager #2, on 05/25/18 at 12:08 PM, revealed they were both aware of the new process of removing medication immediately from the cart when a resident was admitted to the hospital. Additionally, all orders were removed from the computer so the orders could not be re-activated upon re-admission. Interview with the Interim DON, on 05/25/18 at 2:40 PM, revealed the Weekend Supervisor was no longer employed at the facility. She revealed an appointed person (DON, SDC, or QA Nurse) would be responsible for the removal of medication and orders when a resident was hospitalized over the weekend. 7. Interview with Licensed Practical Nurse (LPN) #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, Registered Nurse (RN) #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they had been trained on the new medication error process. They revealed the new form was filled out by a licensed nurse and put in a binder for the Unit Manager to review. Interview with Unit Manager #2, on 05/25/18 at 12:08 PM, and Unit Manager #1 at 2:17 PM, revealed they reviewed medication error reports and turned them in to the QA Nurse. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she reviewed all the medication error reports and used the information for tracking and trending purposes. Review of four (4) medication error reports revealed they were complete and reviewed by the QA Nurse. 8. Interview with the Administrator, on 05/25/18 at 1:45 PM, revealed education was completed for licensed nurses. Two (2) as needed nurses had yet to receive the education but neither employee would work until the education was completed. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated the nurses on accurate medication order transcription, reading back the orders to the MD/APRN, having two (2) nurses check new admission/re-admission orders [REDACTED]. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Record review revealed all licensed nurses were educated on accurate transcription of MD orders, the requirement for two (2) licensed nurse checks of new admission/readmission orders [REDACTED]. There was (1) LPN and (1) RN who had not received education as they were both as needed (PRN) employees. 9. Interview with the SDC, on 05/25/8 at 2:00 PM, revealed she educated nurses and CMTs about medication administration, which included the five (5) rights, verifying medication in the correct boxes, comparing the medication to the MAR, notifying the charge nurse about discrepancies, missing medications, and about medications errors. Interview with LPN #4, on 05/25/18 at 11:50 AM, LPN #5 at 12:00 PM, LPN #6 at 12:20 PM, LPN #9 at 12:27 PM, RN #3 at 1:10 PM, LPN #10 at 1:15 PM, and RN #4 at 1:33 PM, revealed they were knowledgeable of the education information. Interview with CMT #3, on 05/25/18 at 12:15 PM, and CMT #1 at 1:03 PM, revealed they were knowledgeable of the education information. Record review revealed medication administration staff was educated on medication administration, charge nurse notification of discrepancies, and the new medication error protocol. One (1) CMT had not been in-serviced; however, interview with the Administrator, on 05/25/18 at 1:45 PM, revealed the employee would not work until education was completed. 10. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, the Interim DON at 2:40 PM, and the Administrator at 2:30 PM, revealed they were present for both QAPI meetings and knowledgeable of the content of the meetings. Record review revealed QAPI meetings were held on 05/15/18 and 05/22/18 to include Medical Directors. 11. Interview with the QA Nurse, on 05/25/18 at 12:30 PM, revealed she would continue tracking and trending the medication error data monthly to review in the QAPI meetings; however, if there were an increase in errors they would meet more often. She stated the data was stored on spreadsheets to identify reason, time of day, day of week, etc. She would complete the QAPI tool monthly for two (2) months at least, then quarterly (but would do more often, if needed). Interview with the Administrator, on 05/25/18 at 2:30 PM, revealed pharmacy staff attend the monthly QAPI meeting and they would have all the tracking and trending data as well. Record review revealed the QAPI tool was completed on 05/22/18.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to revise the Care Plans for three (3) of six (6) sampled residents, Resident #1, #4, and #6, relating to prevention of falls. Resident #1 and Resident #6 sustained falls with injury. The findings include: Review of the facility policy, Completion of the Resident Assessment Instrument (RAI) process, dated 10/01/10, revealed the Interdisciplinary Team (IDT) completed the Care Plan as part of the RAI process by day twenty-one (21) after admitting a resident to the facility. The facility updated the Care Plans either on paper, or electronically. The facility reviewed the Care Plan for accuracy at least quarterly and as needed prior to the Annual Review Date (ARD) and updated the Care Plan as needed. An admitting nurse initiated the initial care plan upon admission to the facility. The facility did not provide a Care Plan policy. 1. Review of the facility's clinical record for Resident #6 revealed the facility admitted the resident on 01/20/17, with [DIAGNOSES REDACTED]. Review of Resident #6's Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) and determined the resident was not interviewable. Review of Resident #6's Comprehensive Care Plan for falls, initiated 02/08/17, revealed the resident had a history of [REDACTED]. Care Plan interventions included staff analyzation of the resident's falls to determine a pattern or trend, give the resident verbal reminder not to ambulate or transfer without assistance, keep personal items and frequently used items within reach, keep the resident's walker in easy reach, observe frequently and place in supervised area when out of bed, offer toileting before bed and last round of third shift, staff were to increase observation when in bed, and the facility placed the resident in a fall management program. Additionally, the Care Plan pertaining to Activities of Daily Living (ADL) function and rehabilitation potential revealed the resident had a history of [REDACTED]. The ADL Care Plan interventions included the facility placed the resident in a fall management program with a start date of 02/02/17. The Care Plan was not updated with new interventions for the resident's falls on 02/12/17, 02/23/17, 03/28/17, 04/21/17, 05/22/17, and 05/23/17. Review of the Observation Report for Resident #6, dated 01/20/17, revealed the facility hand wrote interventions on this form. The form stated facility interventions put in place after each fall. The facility documented an intervention of encouraging the resident to ask for assistance and wait for assistance after a fall on 02/12/17, however review of the care plan revealed the intervention was not added. Review of the nursing progress note for Resident #6, dated 02/23/17, revealed staff found the resident on the floor at 2:18 PM. The progress note stated the resident reported trying to get out of bed and had complaints of pain to the right side. The nursing note further stated the facility notified the Advanced Registered Nurse Practitioner (ARNP) who ordered a pelvic, right hip, and femur x-ray. Review of Resident #6 Radiology Reports, dated 02/23/17, revealed the resident sustained [REDACTED]. Review of the facility care plan for Resident #6 revealed no new interventions were added after the fall on 02/23/17. Review of the Advanced Registered Nurse Practitioner (ARNP) progress note, dated 02/28/17, revealed the x-ray showed Resident #6 sustained a fall on 02/23/17 with a pelvic fracture. The care included control of pain and continuance of palliative management. Review of the Event Report for Resident #6, with a recorded date of 03/28/17, revealed the resident sustained [REDACTED]. In the section titled New intervention added to prevent future falls, the facility documented the resident remains non-compliant. However, review of the care plan revealed no new intervention was added. Review of the Event Report for Resident #6, with a recorded date of 04/21/17, revealed the resident sustained [REDACTED]. The section titled New intervention added to prevent future falls, the facility documented use of call light. Review of the care plan revealed the intervention was not added. Review of the Event Report for Resident #6, with a recorded date of 05/22/17, revealed the resident sustained [REDACTED]. The resident sustained [REDACTED]. The section titled New intervention added to prevent future falls, the facility documented staff were to continue to encourage resident to allow the door to remain open for closer observation; however the care plan was not revised with the intervention. Review of the Event Report for Resident #6, with a recorded date of 05/23/17, revealed the resident sustained [REDACTED]. The section titled New intervention added to prevent future falls, the facility documented staff were to offer night time toileting; however the care plan was not updated with the intervention. Review of the Fall Circumstance Form, undated, revealed the Director of Nursing invalidated a fall on 02/23/17 due to incorrect data. Interview with LPN #3, on 05/21/17 at 2:30 PM, revealed staff found Resident #6 on the floor in his/her bathroom. The resident had been attempting to toilet him/herself and fallen. The resident was yelling out for help. The LPN stated the resident complained of hip pain, so she contacted the ARNP and received an order for [REDACTED].#3 stated she usually discussed care plan interventions with her supervisor. LPN #3 stated she did not know who monitored the resident fall investigations or if anyone ensured the facility added new interventions to the Care Plan after a resident fell . Interview with RN #3, on 05/23/17 at 8:24 AM, revealed she wrote fall interventions on the care plan as needed. However, she stated writing a new intervention after a fall was difficult and usually did not write new interventions. Additionally, RN #3 stated the Unit Manager was responsible for maintaining and updating the Care Plan. Interview with Unit Manager #2, on 05/23/17 at 9:56 AM, revealed she was responsible for ensuring the Annex Unit resident care plans were revised and current. Unit Manager #2 stated nurses were to write new interventions in the Care Plan books on the unit. She stated if the nurse did not add the interventions, then she would enter the needed interventions. She stated she then reevaluated fall interventions every three (3) or four (4) falls, depending upon the frequency and pattern. The Unit Manager stated the facility could not come up with a different approach every time. Interview with the MDS Specialist, on 05/22/17 at 11:55 AM, revealed she was responsible for transcribing the handwritten Care Plan interventions to the electronic version at quarterly IDT reviews and with a resident's significant change. She stated staff then placed the revised Care Plans in the Care Plan books on each unit. The MDS Specialist stated staff would not know a resident's care needs if all interventions were not updated on the care plan. 2. Review of Resident #1's clinical record revealed the facility admitted the resident on 05/07/2013, with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, completed 03/21/17, revealed the facility assessed the resident as totally dependent on two (2) staff for transferring between surfaces including to or from the bed, chair, wheelchair or standing position. The facility conducted a Brief Interview for Mental Status (BIMS) score and assessed the resident with a BIMS of fourteen (14) out of fifteen (15) and determined the resident was interviewable. Review of the Physician Order Report, dated 04/01/17, revealed a physician's order for transfer assistance per Hoyer lift and staff times two (2) with a start date of 12/28/17 and an end date listed as open ended. Review of the Comprehensive Care Plan for Resident #1 revealed a problem area of risk for falls, dated 05/22/14, with an intervention of Hoyer lift and two (2) staff for all surface transfers, dated 12/28/16. The Care Plan addressed the resident's ADL functional and rehabilitation potential due to the resident having a history of falls. The facility added interventions to this care plan on 04/26/17, five (5) days after Resident #1 sustained a fall with a fracture. Interventions added on 04/26/17 included staff ensuring the brakes were locked on the resident's wheelchair prior to transferring the resident, reminding the resident not to ambulate or transfer without assistance, keep the resident's bed in the lowest position, and keep the resident's personal items within reach. Review of the facility's investigation, performed by the Social Worker on 04/23/17, for an allegation for an injury of an unknown source revealed, on 04/22/17, Resident #1 complained of pain to his/her left arm. Resident #1 stated he/she fell to the floor on Friday 04/21/27 during a transfer from the bed to the wheelchair because the wheelchair was not locked. Statement by CNA #5 to the facility, on 04/25/17, revealed when he placed Resident #1 in the wheelchair, on Friday 04/21/17, the resident was sliding and he pulled him/her up, but Resident #1 never fell . CNA #5 stated Resident #1 did not want to be transferred with a lift and he knew Resident #1 could transfer without it. He stated he did not report the incident to the nurse because Resident #1 never fell . Review of the Radiology Interpretation for Resident #1, dated 04/22/17, revealed Resident #1 obtained a mildly displaced [MEDICAL CONDITION] left humerus consistent with a relatively acute injury. Review of the Emergency Department Report, dated 04/22/17, revealed Resident #1's [DIAGNOSES REDACTED]. Interview with Resident #1, on 05/22/17 at 8:54 AM, revealed Resident #1 slipped out of the wheelchair while CNA #5 was assisting him/her from the bed to the wheelchair and his/her bottom hit the floor. Resident #1 stated that staff sometimes used a lift to transfer him/her but that he/she usually stood up and sat down in the wheelchair. Resident #1 stated that CNA #5 helped him/her up after the fall but was unable to say how. Resident #1 revealed that the wheelchair moved because it was not locked. Interview with Licensed Practical Nurse (LPN) #6, on 05/18/17 at 10:15 AM, revealed nurses revised and added Care Plan interventions in the computer. LPN #6 stated RN #2 and the Interdisciplinary Team (IDT) monitored resident falls and revised the fall interventions on the Care Plan as well. Interview with LPN #5, on 5/18/17 at 3:47 PM, revealed nurses were responsible for revising Care Plans. The LPN further stated when staff entered certain orders into the electronic medical system, the computer prompted them to update the Care Plan. She stated she was trained on how to update Care Plans, however, she did not do it often and did not remember how to update a care plan in the computer. LPN #5 stated when a resident had a fall, she called her supervisor and reported the fall. LPN #5 stated on 04/21/17, Resident #1 complained of arm pain on second shift. However, the resident did not say he/she had sustained a fall, and therefore, the LPN did not document the fall or update the Care Plan. LPN #5 stated the purpose of the Care Plan was to ensure everyone knew what each resident needed and provided continuity of care. Interview with LPN #4, on 05/19/17 at 10:00 AM, revealed nurses had previously been responsible for hand writing new interventions on the resident care plans located on each unit. However, she stated the facility changed to a [MEDICATION NAME] system whereby the Unit Managers were responsible for revising the care plans. LPN #4 stated staff used resident Care Plans to determine resident care needs. The LPN stated residents could receive improper care if the Care Plans were not current and if staff did not follow the Care Plans. LPN #4 discussed Resident #1. The LPN stated that on 04/22/17 a CNA reported Resident #1 was complaining of left arm pain. The CNA stated the resident reported he/she had fallen the previous day. Interview with Unit Manager #1, on 05/22/17 at 2:12 PM, with Unit Manager #1 revealed she was responsible for revising fall care plans for the North and South nursing units. The Unit Manager stated she revised the North and South unit care plans electronically. The Unit Manager stated the North and South units' nurses referred to the electronic care plans for resident care. Additionally, she stated she was unsure who, if anybody, followed up to ensure the care plans were updated and correct. 3. Review of Resident #4's clinical record revealed the facility admitted the resident on 01/05/17, with [DIAGNOSES REDACTED]. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment, completed 04/18/17, revealed the facility assessed the resident as totally dependent on two (2) staff for transferring between surfaces including to or from the bed, chair, wheelchair or standing position. The facility assessed the resident using the BIMS assessment and assessed the resident with a score of six (6) out of fifteen (15) and determined the resident was not interviewable. Review of the Comprehensive Care Plan for Resident #4, dated 01/05/17, revealed Resident #4 sustained a fall on 01/06/17 and the facility put a Falls Care Plan in place on 01/06/17. The facility put an intervention in place to keep the resident's call light within reach and to educate the resident on the use and placement of the call light. The Care Plan did not reflect new interventions, per the Fall Event Reports, after Resident #4 fell on [DATE], 01/25/17, 01/28/17, 01/29/17, 02/01/17, and 02/16/17. Review of the facility's Fall Event Report for Resident #4, dated 01/23/17, revealed the resident sustained [REDACTED]. The facility documented a new intervention of having the resident up during the day and engaged in activities, however the care plan was not updated with the intervention. Review of the facility's Fall Event Report for Resident #4, dated 01/26/17, revealed the resident sustained [REDACTED]. The facility documented a new intervention of increasing observation of the resident while in bed. Review of the care plan revealed the intervention was not added. Review of the facility's Fall Event Report for Resident #4, dated 01/28/17, revealed the resident sustained [REDACTED]. The facility documented a new intervention of keeping the resident in the common areas of the facility; however the intervention was not added to the care plan. Review of the facility's Fall Event Report for Resident #4, dated 01/29/17, revealed the resident sustained [REDACTED]. The facility documented a new intervention of reminding the resident to ring the call light and wait for assistance prior to getting out of bed. However, review of the care plan revealed the intervention was not added. Review of the facility's Fall Event Report for Resident #4, dated 02/01/17, revealed the resident sustained [REDACTED]. The facility documented a new intervention of having the resident sit in common areas of the facility, however the intervention was not added to the care plan. Review of the facility's Fall Event Report for Resident #4, dated 02/16/17, revealed the resident sustained [REDACTED]. The facility documented a new intervention of asking the family to provide cotton pants instead of the silk material to reduce sliding. However, review of the care plan revealed the care plan was not revised to include the intervention. Interview with RN #3, on 05/23/17 at 8:24 AM, revealed she would hand write fall interventions on the care plan as needed. The RN revealed she did not include a goal target date to re-evaluate the intervention. Interview with Unit Manager #2, on 05/23/17 at 9:56 AM, revealed all nurses were responsible for revising care plans for fall interventions. Unit Manager #2 stated she was ultimately responsible for ensuring the Annex Unit resident care plans were revised and current. If nursing staff did not update a care plan after a fall, she would have updated it. Additionally, the Unit Manager stated she re-evaluated Care Plans after a resident sustained [REDACTED]. She stated that sometimes a resident would have kept falling and that she could not come up with a new intervention every time. Additionally, she stated that a resident who slipped from his/her wheelchair and was caught prior to hitting the floor was still considered a fall. The Unit Manager stated the facility placed repeat interventions on Resident #4's Care Plan after each fall, but that those interventions were not successful. She stated increased monitoring was the only solution. Interview with the MDS Specialist, on 05/22/17 at 11:55 AM, revealed she was responsible for transcribing the handwritten care plan interventions to the electronic version with a resident's significant change and quarterly IDT review. She stated staff then placed the revised Care Plans in the care plan book on each respective unit. The MDS Specialist revealed staff would not know a resident's care needs if the facility did not update Care Plans with all interventions. Interview with the DON, on 05/23/17 at 11:43 AM, revealed she did not participate in the quarterly IDT care plan review. The DON stated she trusted that the Unit Managers revised resident Care Plans after each fall event and maintained revised and up to date Care Plans. After reviewing the Care Plan for Resident #6, the DON stated staff had not revised the resident's Care Plan with new interventions after each fall. Interview with the Administrator, on 05/23/17 at 1:38 PM, revealed he was aware fall events were trending up and he attended the monthly Standard of Care meeting. He stated he was aware of the interventions that were being implemented by the Interdisciplinary Team (IDT). Additionally, the Administrator revealed he could get a sense of what was going on in the facility during the daily morning meetings with the IDT.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for two (2) of six (6) sampled residents, Resident #1 and Resident #4. The facility assisted Resident #1 to stand and pivot into his/her wheelchair, when the resident was care planned for a Hoyer lift, and the resident sustained [REDACTED]. Resident #4 had a history of [REDACTED]. The findings include: Review of the facility policy, Completion of the Resident Assessment Instrument (RAI) process, dated 10/01/10, revealed the Interdisciplinary Team (IDT) completed the Care Plan as part of the RAI process by day twenty-one (21) after admitting a resident to the facility. The facility updated the Care Plans either on paper, or electronically. The facility reviewed the Care Plan for accuracy at least quarterly and as needed prior to the Annual Review Date (ARD) and updated the Care Plan as needed. An admitting nurse initiated the initial care plan upon admission to the facility. The facility did not provide a Care Plan policy. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 05/07/2013, with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, completed 03/21/17, revealed the facility assessed the resident as totally dependent on two (2) staff for transferring between surfaces including to or from the bed, chair, wheelchair or standing position. A Brief Interview for Mental Status (BIMS) was completed and the facility assessed the resident with a BIMS score of fourteen (14) and the resident was interviewable. Review of the Physician Order Report, dated 04/01/17, revealed a physician's order for transfer assistance per Hoyer lift and two (2) staff, with a start date of 12/28/16 and an end date listed as open ended. Review of the Comprehensive Care Plan for Resident #1, revealed a problem area of risk for falls, dated 05/22/14, had a facility intervention of Hoyer lift and two (2) staff for all surface transfers, dated 12/28/16. Review of the facility's investigation, dated 04/23/17, revealed the Social Worker investigated an allegation of an injury of unknown source. The investigation revealed on 04/22/17 Resident #1 complained of pain to his/her left arm. Resident #1 stated he/she fell to the floor on Friday, 04/21/27 during a transfer from the bed to the wheelchair due to the wheelchair not being locked. CNA #5 said in his statement that he transferred Resident #1 without the use of a lift because the resident did not want to be transferred with a lift and because the CNA knew Resident #1 was able to transfer without it. Review of the Radiology Interpretation for Resident #1, dated 04/22/17, revealed Resident #1 obtained a mildly displaced [MEDICAL CONDITION] left humerus consistent with a relatively acute injury. Review of the Emergency Department Report, dated 04/22/17, revealed the hospital diagnosed Resident #1 with a closed non-displaced [MEDICAL CONDITION] end of the left humerus. Review of the facility's Point of Care History for Resident #1, dated 04/21/17, the day of Resident #1's fall, staff documented having transferred Resident #1 without a lift. Interview with Resident #1, on 05/22/17 at 8:54 AM, revealed that Resident #1 slipped out of his/her wheelchair while CNA #5 was assisting him/her from the bed to the wheelchair and that his/her bottom hit the floor. Resident #1 stated that staff sometimes used a lift to transfer him/her but that he/she usually stood up and sat down in the wheelchair. Interview with CNA #5, 5/18/17 at 2:51 PM, revealed he transferred Resident #1 using stand and pivot technique and he did not use a gait belt. The CNA stated he was aware the facility had care planed the use of a Hoyer lift for transferring Resident #1. However, he stated he thought the resident was strong enough to stand and pivot. He stated CNAs can see progress on residents and know what residents can do. CNA #5 stated the resident was able to transfer using the stand and pivot technique. The CNA said when the resident slipped, he placed his arms under the resident's arms and lifted him/her into the wheelchair. CNA #5 further stated that when staff did not follow care plans, residents could get hurt, fall, break their arm, or you could make the resident uncomfortable. Interview with CNA #7, on 05/18/17 at 11:24 AM, revealed CNAs regularly transferred Resident #1 by picking him/her up with a gait belt and turning him/her and assisting into the wheelchair or bed. He stated all of the CNAs transferred Resident #1 that way. He stated when residents were strong enough, they did not have to use the lift even if the care plan stated a lift was required. He stated Resident #1 was strong enough and he/she did not need to use a lift. Interview with Licensed Practical Nurse (LPN) #4, on 05/19/17 at 9:55 AM, revealed he was approached by CNA #8 on 04/22/17 during Resident #1's lunchtime and she informed him that Resident #1 said his/her left arm was hurting. He asked Resident #1 what was wrong with his/her arm and Resident #1 stated that he/she fell on [DATE] while transferring with CNA #5. The nurse stated that he asked CNA #5 what happened on 04/21/17 and CNA #5 stated that Resident #1 slipped from wheelchair and he grabbed her under her arms. LPN #4 stated he had witnessed CNAs and LPNs transferring Resident #1 as a stand and pivot for a while but he had not been Resident #1's nurse and therefore had not reviewed the resident's Care Plan. Interview with LPN #6, on 05/18/17 at 10:31 AM, revealed if a resident had been care planned for a Hoyer lift, and they had been transferred by standing and pivoting from the bed to the wheelchair, then the care plan was not followed. He stated when care plans are not followed, patients could sustain injuries. Interview with the Therapy Director, on 05/17/17 at 9:34 AM, revealed the Physical Therapy department would have been involved in reassessing a resident prior to discontinuing the use of a Hoyer lift. She stated that CNAs and LPNs could not make that determination on their own. She stated that the facility reassessed Resident #1 after the fall and it was determined that a Hoyer lift was appropriate. Interview with Unit Manager #1, on 05/22/17 at 2:11 PM, revealed the facility care planned Resident #1 as requiring a Hoyer lift for transfers. She stated the facility did not follow the care plan when they transferred the resident without the use of the lift. 2. Review of Resident #4's clinical record revealed the facility admitted the resident on 01/05/17, with [DIAGNOSES REDACTED]. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment, completed 04/18/17, revealed the facility assessed the resident as totally dependent on two (2) staff for transferring between surfaces including to or from the bed, chair, wheelchair or standing position. The facility assessed the resident using the Brief Interview for Mental Status (BIMS) examination and assessed the resident with a score of six (6) out of fifteen (15) and determined the resident was not interviewable. Review of the Comprehensive Care Plan for Resident #4, dated 01/05/17, revealed Resident #4 sustained a fall on 01/06/17 and the facility put a Falls Care Plan in place on 01/06/17. The facility put an intervention in place to keep the resident's call light within reach and to educate the resident on the use and placement of the call light. Review of the CNA Care Plan, dated 05/22/17, revealed the facility put fall interventions in place on 01/10/17 that included keep personal items within reach. The facility put fall interventions in place on 01/12/17 instructing staff to give the resident frequent verbal reminders not to ambulate or transfer without assistance. The facility also placed the resident on a Fall Management Program and instructed staff to keep the resident in common areas. Review of the facility's Fall Event Report for Resident #4, dated 01/23/17, revealed the resident sustained [REDACTED]. The facility documented a new intervention of having the resident up during the day and engaged in activities. Review of the facility's Fall Event Report for Resident #4, dated 01/26/17, revealed the resident sustained [REDACTED]. The facility documented a new intervention of increasing observation of the resident while in bed. Review of the facility's Fall Event Report for Resident #4, dated 01/28/17, revealed the resident sustained [REDACTED]. The facility documented a new intervention of keeping the resident in the common areas of the facility. Observation of Resident #4, on 05/19/17 at 3:07 PM, revealed Resident #4 was seated in the common area at a table with two (2) other residents. Resident #4 was seated in a wheelchair with shoes on. Observation of Resident #4, on 05/22/17 at 9:05 AM, revealed Resident #4 was awake lying in bed with his bedside tray table out of reach, horizontally against the wall. Interview with Minimum Data Set (MDS) Specialist, on 05/22/17 at 12:17 PM, revealed that care plan books were located on each unit and every quarter she would take the hand-written interventions in the care plan book and put them into the computer electronic care plan. She stated that the care plan book was the most up to date version of the care plan. She stated that if the care plan was not followed then there was a possibility that a resident would fall. Interview with the Director of Nursing (DON), on 05/23/17 at 11:36 AM, revealed nursing staff were to contact the nurse if they thought a care plan intervention was not appropriate. She stated nurses could then make the determination to change a residents transfer status. The DON stated staff did not follow the care plan for Resident #1 to transfer using a Hoyer lift and two (2) person staff assistance. Interview with the Administrator, on 05/23/17 at 1:38 PM, revealed he was responsible for the facility overall and that he was concerned about the resident falls. He stated falls were trending up and that he needed to evaluate the need for additional resources.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to prevent accidents related to falls for two (2) of six (6) sampled residents, Resident #1 and Resident #6. Resident #1 sustained a fracture when facility staff transferred the resident using a stand and pivot method instead of using the physician ordered Hoyer lift. Resident #6 sustained multiple falls and a fracture after the facility failed to implement fall prevention interventions. The findings include: Review of the facility policy, Falls Prevention Program, dated 08/20/15, revealed the facility completed a Fall Risk Assessment when admitting a resident, at least once per quarter, or when a fall occurred. If the facility assessed a resident with a score of fifteen (15) or higher, the facility initiated a Falls Prevention Program. The Falls Prevention program included, but was not limited to, the use of yellow gripper socks when resident shoes were off. The facility used the information from the Falls Risk assessment to initiate a Care Plan that addressed risk factors and interventions to prevent a fall. Review of the facility's education to Certified Nursing Assistants (CNA) Education on Pre and Post Falls, dated 10/08/15, revealed the facility assessed residents upon admission and re-admission for risk of falls. The nurse initiated the falls kit for residents at high risk of falls. The falls kit included yellow gripper socks, a yellow wrist band, a yellow magnet for resident's door, and a yellow bracelet to go on the resident's walker if applicable. The facility placed a yellow gait belt behind the resident's wheelchair if the resident used a wheelchair. The falls kit signified and alerted staff that the resident was a high risk of falls and to pay extra attention and closely supervise the resident to prevent the resident from falling. Further review revealed that after a fall, the Nurse Managers updated the CNA care plan with any new fall interventions. Staff were to read and follow updated care plans daily to prevent falls. Review of the facility policy, Post Fall Documentation, revised 06/22/11, revealed the facility nurse initiated a Fall Circumstance, Assessment and Intervention event whenever a resident sustained [REDACTED]. Unit Managers reviewed follow up charting for accurateness, completion and appropriateness of new interventions. The facility maintained the Fall Circumstance, Assessment and Intervention form as part of the electronic chart under the Event category. Any resident that sustained two (2) or more falls or that sustained a major injury as a result of a fall was reviewed during the Standards of Care meeting. 1. Observation of Resident #1, on 05/17/17 at 2:03 PM, revealed the resident used a Broda chair in his/her room. The resident was able to use his/her call light to gain assistance and observation revealed two (2) CNAs entered the room and used the Hoyer lift to transfer the resident from the Broda chair to the bed. During the observation, a CNA assisted the resident to remove his/her shirt. The resident called out for staff to be careful while disrobing stating, ow, this arm is broken. The CNA asked the resident if he/she was okay and the resident stated he/she was. Review of Resident #1's clinical record revealed the facility admitted the resident on 05/07/13 with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, completed 03/21/17, revealed the facility assessed the resident as totally dependent on two (2) staff for transferring between surfaces including to or from the bed, chair, wheelchair or standing position. The facility assessed the resident using a Brief Interview for Mental Status (BIMS) exam with a score of fourteen (14) out of fifteen (15) and determined the resident was interviewable. Review of the Physician Order Report, dated 04/01/17, revealed the Physician ordered the facility to provide transfer assistance to Resident #1 using a Hoyer lift and two (2) staff at all times beginning 12/28/16. Review of the Comprehensive Care Plan for Resident #1, dated 05/07/13, revealed the facility identified a problem area of Risk for Falls and placed the problem area on the Care Plan on 5/22/14. The facility placed interventions on the care plan on 12/28/16 stating staff were to use the Hoyer lift and two (2) staff for all surface transfers. Review of the Certified Nursing Assistant (CNA) Care Plan, dated 05/17/17, revealed the facility placed an intervention on the CNA Care Plan stating CNA's were to use a Hoyer lift and two (2) staff members for all transfers for Resident #1 with a start date of 12/28/16. Review of the facility's investigation, dated 04/23/17, revealed Social Worker investigated an allegation of an injury of unknown source. The investigation revealed on 04/22/17 Resident #1 complained of pain to his/her left arm. Resident #1 stated he/she fell to the floor on Friday, 04/21/27 during a transfer from the bed to the wheelchair due to the wheelchair not being locked. The resident stated in the investigation that CNA #5 assisted with the transfer. CNA #5 provided a statement included in the investigation whereby he stated he placed Resident #1 in the wheelchair on Friday 04/21/17. He documented the resident was sliding and he pulled the resident up in the wheelchair, but Resident #1 never fell . CNA #5 said in his statement that he did transfer Resident #1 without the use of a lift because the resident did not want to be transferred with a lift and because the CNA knew Resident #1 was able to transfer without it. CNA #5 stated he did not report the incident to the nurse because Resident #1 did not sustain a fall. Review of the Radiology Interpretation for Resident #1, dated 04/22/17, revealed Resident #1 obtained a mildly displaced fracture of the proximal left humerus consistent with a relatively acute injury. Review of the Emergency Department Report, dated 04/22/17, revealed the hospital diagnosed Resident #1 with a closed non-displaced fracture of the proximal end of the left humerus. Review of the facility's Point of Care History for Resident #1 revealed on 04/21/17, the day of Resident #1's fall, staff documented having transferred Resident #1 without a lift. Interview with Resident #1, on 05/22/17 at 8:54 AM, revealed the resident slipped out of his/her wheelchair while CNA #5 was assisting him/her from the bed to the wheelchair and that his/her bottom hit the floor. Resident #1 stated that staff sometimes used a lift to transfer him/her but that he/she usually stood up and sat down in the wheelchair. Resident #1 stated that CNA #5 helped him/her up after the fall but was unable to say how. Resident #1 revealed that the wheelchair moved because it was not locked. Interview with CNA #5, 5/18/17 at 2:51 PM, revealed he transferred Resident #1 using stand and pivot technique. The CNA stated he was aware the facility had care planned the use of a Hoyer lift for transferring Resident #1. However, he stated the resident had shown improvement and the care plan intervention was old. CNA #5 stated the resident was able to transfer using the stand and pivot technique. CNA #5 stated on the date of the incident, the resident had slipped on his/her blanket in the wheelchair. The CNA said he placed his arms under the resident's arms and lifted him/her into the wheelchair. The CNA stated he did not report the incident because the resident's bottom did not hit the floor and because he believed nothing was wrong at the time. Interview with CNA #7, on 05/18/17 at 11:24 AM, revealed Resident #1 complained of pain in his/her arm during second shift on 04/21/17. CNA #7 stated he reported the resident's pain to the LPN #5. At the time, the resident reported he/she couldn't remember what had happened to cause the arm pain. CNA #7 stated the following morning the resident stated he/she continued to have the arm pain. The resident then reported he/she had fallen the previous day, 04/21/17. The CNA stated he then reported the resident's complaint of pain and fall to LPN #4. CNA #7 also stated he doubted the resident fell as the resident would have required assistance to get up. CNA #7 stated he was aware the resident was care planned to transfer with a Hoyer lift. He stated the resident completed therapy and was stronger now. He stated when residents became stronger, CNAs no longer had to use the lift to transfer that resident. He stated CNA's now transfer the resident by using a gait belt and picking the resident up to transfer him/her. CNA #7 stated CNAs were never to transfer a resident under the arms because it was too easy to bruise the resident that way. Interview with LPN #5, on 5/18/17 at 3:52 PM revealed Resident #1 complained of arm pain on second shift on 4/21/17. She stated the resident reported his/her arm hurt during medication pass. She stated the resident did not state why his/her arm was hurting. LPN #5 stated she assessed the resident's arm and did not see any discoloration but did pass the information along in report at the end of her shift. LPN #5 stated she was pretty sure the CNAs working with her that night used the Hoyer lift with the resident. However, she stated she did not closely supervise the CNAs to ensure they used the lift. Instead, she stated they all work together and she ensured resident care was completed by monitoring during medication pass. Interview with LPN #4, on 05/19/17 at 9:55 AM, revealed that on 04/22/17 a CNA reported Resident #1 was complaining of left arm pain. The CNA stated the resident reported he/she had fallen the previous day. LPN #4 spoke with the CNA who worked with the resident on 04/21/17 and the CNA reported the resident did not fall but had slipped and the CNA caught the resident under the arms. The LPN reported this to the Nurse Manager who instructed the LPN to treat the incident as a fall because the resident should have been transferred using a Hoyer lift. LPN #4 stated he had previously observed CNAs transferring the resident using the stand and pivot technique, but did not know the resident was care planned to use a Hoyer lift and so did not realize it was wrong. Interview with the Physical Therapy Assistant, on 5/18/17 at 4:28 PM, revealed the facility care planned for the use of a lift with Resident #1 because it was not safe for the resident to stand for transferring. She stated the facility needed to complete a therapy evaluation prior to determining if the resident was able to safely transfer without a Hoyer prior to transferring the resident without the Hoyer lift. Interview with the Physical Therapist, on 5/19/17 at 8:47 AM, revealed the therapy department recommended the use of the Hoyer lift to transfer the resident safely. She stated the therapy department continued to recommend the use of the Hoyer lift to transfer the resident safely after 04/21/17. The Physical Therapist stated if nursing staff believed the resident no longer needed to use the Hoyer lift, they were to complete a therapy form for a change in function and then therapy would have assessed the resident for safety. Staff should not have changed the function status without the therapy assessment. 2. Observation of Resident #6's room, on 05/19/17 at 3:12 PM, revealed the resident had a yellow sticker on his/her door signifying to staff that the resident was on the Fall Management Program. The resident was out of the room at the time. Observation of Resident #6, on 05/19/17 at 3:40 PM, revealed the resident sitting in a wheelchair in the common area. The resident was not wearing a yellow fall risk bracelet per the Fall Management Program. Further observation revealed the resident leaving the common area, self-propelling in the wheelchair to the bathroom and shutting the door. Further observation of Resident #6, on 05/22/17 at 1:12 PM, revealed the resident sitting in a wheelchair in front of the entrance door to his/her room. The resident was wearing regular socks with no shoes. The resident was not wearing the yellow gripper socks indicated for residents in the Fall Management Program. Review of the facility's clinical record for Resident #6 revealed the facility admitted the resident on 01/20/17, with [DIAGNOSES REDACTED]. Review of Resident #6's Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) and determined the resident was not interviewable. Review of Resident #6 Admission Interim Care Plan, dated 01/20/17, revealed the resident was at risk for falls related to multiple falls and had impaired mobility related to a wrist fracture. Interventions included call light in place, encourage resident to use, assist with mobility and Activities of Daily Living (ADL), non-slip footwear, place personal items within reach, and assist with transfers as needed. Review of Resident #6 Fall Risk Assessment, dated 01/20/17, revealed a fall risk score of seventeen (17) which indicated the resident was at high risk for falls. Further review of the fall risk assessment revealed the resident was referred for the Falls Prevention Program and to continue the current plan of care. Review of Resident #6's Comprehensive Care Plan, revised date 05/15/17, revealed the facility created a care plan for falls, dated 02/08/17, due to a history of fall with injury. The care plan goal stated the resident would remain free from injury from falls. Care Plan interventions included staff analyzation of the resident's falls to determine a pattern or trend, give the resident verbal reminders to not ambulate or transfer without assistance, keep personal items and frequently used items in reach, keep the resident's walker in easy reach, observe frequently and place in a supervised area when out of bed, offer toileting before bed and last round of third shift, increase observation when in bed, and the facility placed the resident in a fall management program. In addition, the Care Plan for Activities of Daily Living (ADL) Functional/Rehabilitation Potential, dated 02/02/17, revealed the resident had a history of [REDACTED]. The document revealed the resident did not remember to ask for help. The ADL Care Plan interventions included the facility placed the resident in a fall management program. Review of the CNA Care Plan, undated, revealed staff were to provide Resident #6 with an assist of one (1) staff for transfers. Additionally, the resident used a walker, was continent with incontinent episodes, and was at a high risk for falls. Review of the Fall Circumstance Form, undated, revealed the Director of Nursing invalidated a fall on 02/23/17 due to incorrect data. Interview with the DON, on 05/24/17 at 4:15 PM, revealed the facility invalidated the Fall Event Report for Resident #6, dated 02/23/17, because the note was blank. As an invalidated Fall Event Report, the event was not included in the tracking of resident falls. Review of the invalidated Fall Circumstance Form for Resident #6, dated 02/23/17, revealed LPN #3 documented the resident fell in his/her room. The form stated the facility notified the Physician on 02/23/17. The facility did not revise the care plan after the fall on 02/23/17. Review of the nursing progress note for Resident #6, dated 02/23/17, revealed staff found the resident on the floor at 2:18 PM. The progress note stated the resident reported trying to get out of bed and had complaints of pain to the right side. The nursing note further stated the facility notified the Advanced Registered Nurse Practitioner (ARNP) who ordered a pelvic, right hip, and femur x-ray. The note stated the x-ray results came back positive for right hip, femur, and pelvis fracture. Review of Resident #6 Radiology Reports, dated 02/23/17, revealed the resident sustained [REDACTED]. Review of the Advanced Registered Nurse Practitioner (ARNP) progress note, dated 02/28/17, revealed the x-ray showed Resident #6 sustained a fall on 02/23/17 with pelvic fracture. The care included control of pain and continuance of palliative management. Family interview for Resident #6, on 05/22/17 at 4:00 PM, revealed the resident had a fall earlier in the morning on 05/22/17. The family stated the resident was having problems with falls lately. Resident #6 was sitting in a wheelchair next to the family during the interview wearing regular socks with no shoes. Interview with Certified Nursing Assistant (CNA) #1, on 05/22/17 at 9:20 AM, revealed Resident #6 was unsteady during transfers and lost his/her balance a lot. The CNA further revealed the facility instructed staff to monitor Resident #6 due to forgetfulness and self-transfer attempts. CNA #1 revealed she did not know if the facility placed the resident on fall precautions. Interview with CNA #2, on 05/19/17 at 3:55 PM, revealed she used the computer kiosk and the paper CNA Care Plan to determine resident needs. The CNA revealed residents who were a high fall risk usually wore a yellow bracelet and had a yellow sticker at the entrance to his/her room. Interview with CNA #9, on 05/23/17 at 8:10 AM, revealed Resident #6 was at risk of falls. The CNA revealed the facility placed yellow tabs on the doors of residents who were at high risk of falling. CNA #9 stated staff were not to leave Resident #6 unattended and she therefore monitored the resident by seating him/her in the common area and toileted Resident #6 every two (2) hours and as needed. CNA #9 stated she was also responsible for the care of nine (9) other residents in addition to Resident #6. Interview with LPN #3, on 05/21/17 at 2:30 PM, revealed staff found Resident #6 on the floor in his/her bathroom. The resident had been attempting to toilet him/herself and fallen. The resident was yelling out, help, help. The LPN stated the resident complained of hip pain, so she contacted the ARNP and received an order for [REDACTED].#3 stated she completed an event report, per the falls protocol, along with an event packet. She stated she believed she may have completed the event incorrectly, as the event was invalidated. However, LPN #3 stated she was unaware the event was invalidated. LPN #3 stated she did not remember having a conversation with the DON or the Unit Manager about the event after it happened. Interview with Unit Manager #2, on 05/23/17 at 9:56 AM, revealed she was the Unit Manager for the unit where Resident #6 resided. Unit Manager #2 revealed she re-evaluated fall interventions every three (3) or four (4) falls, depending upon the frequency and pattern. The Unit Manager revealed she did not audit resident charts or fall risk assessments. Unit Manager #2 further revealed she had not conducted any staff falls prevention training. Interview with the Director of Nursing (DON) on 05/17/17 at 3:28 PM, revealed she tracked resident falls from admission to determine if there was a pattern for those with two (2) or more falls. Further interview with the DON, on 05/23/17 at 11:43 AM, revealed she conducted monthly, random chart audits when she thought there was a problem or for specific concerns, such as infections. However, the DON also stated she did not participate in the quarterly IDT care plan review. The DON stated she trusted that the Unit Managers were revising Care Plans after each fall event and were maintaining revised and up to date Care Plans. After reviewing the Care Plan for Resident #6, the DON stated staff had not revised the resident's Care Plan with new interventions after each fall. She further stated that staff reminding Resident #6 to use the call light was not an appropriate intervention because of the resident's impaired cognition. The DON discussed staff training on falls prevention and stated the facility had no attendance sign-in sheets to show which staff had been educated. Additionally, the DON stated the facility's annual computer based training for safe transfers was probably not adequate training for falls prevention. Interview with the Administrator, on 05/23/17 at 1:38 PM, revealed he was aware fall events were trending up at the facility. As a result, he stated he sat in on the monthly Standard of Care meeting and was aware of the interventions that were being implemented by the Interdisciplinary Team (IDT). Additionally, the Administrator revealed he could get a sense of what was going on in the facility during the daily morning meetings with the IDT. The Administrator stated he was unaware of any new training for staff on falls prevention. He stated he was unaware of any additional resources needed to address falls and education in the facility.

Based on observation, interview, record review, and review of the facility's video surveillance, and facility policies, Elopement Prevention and Intervention and Accidents, and review of the facility's Health and Rehab Admission Packet, it was determined the facility failed to have an effective system in place to ensure adequate supervision to prevent elopement for one (1) of eight (8) sampled residents (Resident #2). On 07/04/14 at 1:54 PM, Resident #2 was discovered by staff outside the facility approximately one hundred forty (140) feet. Resident #2 exited the facility by way of a set of propped open exit doors leading from the rehabilitation gym to a patio, enclosed with an iron fence and two gates, of which one was open. The gates led to a paved area off of the parking lot. Resident #2 exited the facility without staff knowledge. Resident #2 was found by a housekeeper seated in his/her wheelchair in an offset of a parking lot adjacent to the facility between the dumpsters and a cooling unit. A Housekeeper assisted the resident back to the facility and a unit nurse assessed the resident as having no injury. The facility's failure to have an effective system in place to ensure adequate supervision of residents; and its failure to ensure exit doors in the rehabilitation gym remained closed and locked, and the gates to the parking lot were closed and locked, placed residents of the facility in a situation that caused or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/09/14 and was determined to exist on 07/04/14. The facility was notified of the Immediate Jeopardy on 07/09/14. An acceptable Allegation of Compliance (AOC) was received on 07/15/14, alleging the Immediate Jeopardy was removed on 07/12/14. The State Survey Agency (SSA) determined the Immediate Jeopardy was on 07/15/14 versus 07/12/14 as alleged, prior to exit on 07/17/14. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance Committee monitors the effectiveness of the systemic changes to achieve and maintain substantial compliance. The findings include: Review of the facility's policy regarding Elopement Prevention and Intervention, dated 12/08/11, revealed all exit doors in the resident halls and main entrance would remain alarmed twenty-four (24) hours a day and those residents who were assessed as cognitively or physically impaired must be accompanied when leaving the facility and must be signed in and out. Review of the facility's policy regarding Accidents, undated, revealed the facility would provide an environment that was free of accidents and/or hazards over which the facility had control and all staff would be involved in observing and identifying potential hazards in the environment. Review of the facility's "Health and Rehab Admission Packet" revealed the facility must protect and promote the rights of each resident to include a safe environment. Review of Resident #2's clinical record revealed the facility admitted the resident on 06/15/11, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 06/12/13, revealed no elopement risk as a concern with interventions. Further record review revealed the facility assessed Resident #2, on 06/09/14, with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident had a severe cognitive loss. Review of the Minimum Data Set, dated dated [DATE], revealed the ambulation assessment stated Resident #2 was wheelchair bound, but was capable of self-propelling the wheelchair with his/her feet independently. Review of an Elopement Risk Assessment, dated 06/09/14, revealed Resident #2 was not an elopement risk. Observation of Resident #2, on 07/08/14 at 11:30 AM, revealed the resident self-propelled his/her wheelchair down the South Hall from the resident's room to the dining room and entered the dining room for lunch. Observations of Resident #2, on 07/09/14 at 3:00 PM; on 07/15/14 at 10:00 AM; and on 07/16/14 at 4:00 PM, revealed the resident self-propelled his/her wheelchair up and down the South Hall. Review of the facility's investigation, dated 07/05/14, revealed a housekeeper saw Resident #2 outside the facility seated in his/her wheelchair at approximately 1:54 PM on 07/04/14. The housekeeper immediately brought the resident into the facility. Resident #2 was assessed by the unit nurse as being unharmed and an investigation was initiated. Review of the facility's investigation revealed on 07/04/14, the exit doors from the rehabilitation gym onto the patio were unlocked and propped open from 10:00 AM until 2:00 PM. At 2:00 PM, the doors were closed and locked upon staff's knowledge of Resident #2's elopement. In addition, all other facility locked exit doors were checked for proper working order on 07/04/14 after Resident #2's elopement from the facility. The facility determined the causal factor for Resident #2's elopement was determined to be the propped open exit doors from the rehab gym onto the patio and an open gate in the wrought iron fence at the perimeter of the patio. The facility notified the appropriate State agencies and Resident #2's family and physician. Review, of the 07/04/14 video surveillance tape, on 07/10/14 at 2:40 PM, revealed Resident #2 self-propelled his/her wheelchair onto the patio directly in front of the rehab gym exit doors at 1:37 PM. The rehab gym exit doors were in deep shadow on the video surveillance at 1:37 PM and Resident #2 could not be observed going over the threshold and through the exit doors of the rehab gym. Continued review of the video surveillance revealed Resident #2 turned left and self-propelled his/her wheelchair to a closed gate in a wrought iron fence at the perimeter of the patio. The resident then turned right and self-propelled along two (2) gardening boxes to a second open gate in the fence at the perimeter of the patio. Resident #2 proceeded to self-propel through the open gate at 1:40 PM onto a sidewalk ending at a facility parking lot. Video surveillance ended at 1:42 PM at the end of the sidewalk and patio. Interview, on 07/09/14 at 11:30 AM, with the Housekeeper revealed she discovered Resident #2 self-propelling his/her wheelchair toward the facility dumpsters which were located on a parking lot inset between two (2) buildings at the facility, on 07/04/14 at 1:54 PM. The Housekeeper indicated she immediately called for help and took the resident into the facility and to the nurse on the resident's living unit, the South Hall. She stated the resident was dressed in street clothing appropriate to the dry, warm weather with tennis shoes on and was smiling when she spoke to him/her. Observation of the rehab gym, on 07/08/14 at 11:00 AM, revealed a room measured by the Maintenance Director to be thirty-six (36) feet North to South and thirty-two (32) feet East to West. The rehab gym was one room with an offset approximately ten (10) by ten (10) feet with computers and chairs for the staff's use. The open room held multiple forms of therapy equipment, with open spaces allowing wheelchairs to be maneuvered throughout the room. The door to the rehab gym was located on the West side of the room at the end of the North Hall and the exit doors onto the patio were located on the South side of the room. The rehab gym exit doors onto the patio were closed and locked with signs on the doors to keep them locked, alarmed and never propped open. Interview with the Administrator, on 07/08/14 at 9:45 AM, revealed he was unaware the Therapy Staff was in the habit of unlocking and propping the exit doors from the therapy gym onto the patio, but he should have known. He stated the exit doors were closed and locked immediately by the Therapy Staff when they were informed of Resident #2's elopement from the facility and all of the therapy staff had been inserviced on 07/04/14 and 07/05/14 regarding keeping the rehab gym exit doors closed and locked and never propping them open. Interview, on 07/08/14 at 11:31 AM, with Physical Therapist (PT) #1 revealed she had worked on 07/04/14 and she had unlocked and propped open the double exit doors from the therapy gym to the patio around 10:00 AM for the residents to enjoy the weather. She stated Resident #2 had visited in the therapy gym on 07/04/14 in the morning and she had assisted the resident over the threshold of the double exit doors to go onto the patio. She revealed she told the resident to stay on the patio and after the resident had self-propelled around the patio, PT #1 assisted him/her back into the therapy gym. PT #1 indicated Resident #2 returned to the therapy gym on 07/04/14 in the afternoon around 1:30 PM. She stated she and another Physical Therapist were in the gym the entire afternoon. However, she did not see Resident #2 exit the double doors onto the patio in the afternoon and she did not know how the resident maneuvered the wheelchair over the exit doors' threshold unassisted. Interview, on 07/09/14 at 2:35 PM, with PT #2 revealed she worked on 07/04/14 until about 3:00 PM and she was in the Therapy Gym the entire afternoon. However, she revealed she did not see Resident #2 exit the propped open exit doors onto the patio in the afternoon. She was busy at the fax machine with her back turned away from the doors. PT #2 indicated PT #1 was also in the Therapy Gym in the afternoon, but she was working with another resident who was seated in front of her and PT #1's view of the exit double doors was possibly obstructed by the other resident. She further indicated she did not think Resident #2 could self-propel over the double exit door threshold independently and did not know how the resident exited the therapy gym. Interview with the Rehabilitation Director, on 07/08/14 at 1:47 PM, revealed she was aware the exit double doors from the Therapy Gym onto the patio were sometimes unlocked and propped open when residents were receiving occupational therapy on the patio. She stated the staff knew to close and lock the doors if they were not in the Therapy Gym. She further stated she had never recognized the doors being unlocked and propped open was a concern to be reported to the Administrator. Interview, on 07/08/14 at 1:35 PM, with Certified Nursing Assistant (CNA) #6, who was assigned to Resident #2 on day shift, on 07/04/14, revealed she had taken Resident #2 into the sun room for a music program around 1:00 PM on 07/04/14. CNA #6 further stated she had seen Resident #2 self-propel into the therapy gym at the end of the North Hall around 1:40 PM on 07/04/14. CNA #6 stated she then left the North Hall to attend to her other assigned residents. She indicated Resident #2 was known to go to the therapy gym to visit with the staff. Interview with Licensed Practical Nurse (LPN) #1, on 07/08/14 at 1:13 PM, revealed he was Resident #2's nurse on 07/04/14, at the time of the resident's elopement and he did the head to toe assessment of Resident #2 when the resident was returned to the South Hall. LPN #1 stated he did not find Resident #2 to have been injured and informed the Nursing Supervisor on duty at that time. LPN #1 further stated he had seen Resident #2 at about 1:00 PM on 07/04/14 as the resident was leaving the dining room. Interview with the Quality Assurance (QA) Nurse, on 07/08/14 at 1:20 PM, revealed she was the Nursing Supervisor on duty on day shift on 07/04/14. She stated when she was made aware of Resident #2's elopement she immediately checked all of the Wander Guard door alarms and bracelets worn by elopement risk residents to ensure they were in proper working order. She also stated she was informed by LPN #1 of Resident #2's head to toe assessment which revealed no injury to the resident. The QA Nurse indicated she made calls to the Administrator, Social Services Director, Staff Development Nurse, appropriate State agencies, the resident's family and physician and started the facility's investigation into Resident #2's elopement. Further interview with the QA Nurse, on 07/17/14 at 8:59 AM, revealed a Wander Guard bracelet was placed on Resident #2 on 07/04/14 after the resident's head to toe assessment as the resident was now considered an elopement risk. She indicated the resident's picture and demographic face sheet were placed in an elopement binder at each nursing station and the resident's comprehensive care plan was updated to include the concern of elopement risk. Interview with the Maintenance Director, on 07/09/14 at 9:30 AM, revealed the exit double doors from the Therapy Gym to the patio were alarmed and should have remained closed. He stated there was a switch on the doors and when the switch was turned, it would deactivate the alarm on the doors and allow them to be propped open without sounding. He further stated he had never seen the exit doors in the Therapy Gym propped open. The Maintenance Director revealed, on 07/05/14 he removed the switch on the Therapy Gym doors which allowed the alarm to be deactivated. Further interview revealed the alarm company came to the facility to ensure the proper working order of all locked doors on 07/11/14. Telephone interview with the Director of Nursing (DON) on 07/09/14 at 1:40 PM, revealed she had never seen the exit double doors from the Therapy Gym onto the patio unlocked and propped open, but she was aware Resident #2 would sometimes self-propel into the Therapy Gym to visit with staff. The DON stated the Medical Director had been informed of Resident #2's elopement on 07/05/14. Further interview with the Administrator, on 07/17/14 at 3:37 PM, revealed he had been informed by the QA Nurse right after Resident #2 was returned to the facility. He stated he immediately became involved in the investigation of the elopement and wished he had known the therapy staff had disengaged the alarm and unlocked and propped open the exit doors from the Therapy Gym onto the patio on 07/04/14 to prevent this occurrence. He stated the Rehab Director reported to him; however, the exit doors being unlocked and propped open had never been reported as a recognized concern. The Administrator indicated the facility had a Safety Committee in the past, but the leader of the Committee stepped down and he could not find any meeting minutes, and he did not know the date of the last meeting and could not remember if there had been any previous concerns with unlocked doors. The Administrator further indicated staff was trained on resident safety on hire and had been retrained since Resident #2's elopement. He further indicated there would be a QA meeting on 07/21/14 and all actions taken would be discussed at that time with planning for future actions. The facility provided an Allegation of Compliance (AOC) on 07/15/14 alleging the Immediate Jeopardy was removed on 07/12/14; the facility took the following steps to remove the Immediate Jeopardy. 1. Resident #1 was immediately returned to the facility on [DATE] at 1:54 PM by the housekeeper who found him/her. 2. The exit double doors from the therapy gym to the patio were immediately locked by PT #1. 3. LPN #1 completed a head to toe assessment on Resident #2, on 07/04/14 at 2:20 PM, following his/her return to the facility and no injuries were found. 4. An investigation was initiated on 07/04/14 by the Quality Assurance (QA) Nurse. 5. A Wander Guard bracelet was placed on Resident #2 on 07/04/14, his/her picture and demographic face sheet were placed in the elopement binder at each nursing station and the resident's Comprehensive Care Plan was updated to include the concern of elopement risk by the QA Nurse. 6. Resident #2 was placed on hourly monitoring to be completed by the floor staff for thirty (30) days to begin on 07/09/14 by the Administrator, Staff Development, QA Nurse, Social Services, MDS Coordinator and the LPN Unit Manager. 7. On 07/09/14, a decision was made during the emergency meeting to place a directive in the Matrix (computer) of each of the six (6) residents at risk for elopement to be signed each shift by the nurse indicating the hourly check sheets for those six (6) residents were completed. 8. It was determined during the emergency meeting on 07/09/14 that Resident #2 would be reassessed for elopement risk and continued need for hourly checks in thirty (30) days (08/04/14). 9. On 07/09/14, during the emergency meeting it was determined the current Elopement policy and procedures for assessing resident's for elopement risk would be reviewed by the Administrator, Social Services, MDS Coordinator, QA Nurse and the LPN Unit Manager. The review resulted in a revision to the policy that exit door alarms would be monitored daily on the evening shift and night shift to ensure locks and alarms were intact and functioning. The locations of the elopement binders were increased to include the dietary office, therapy gym and personal care home front desk. In addition, the Charge Nurse will assume the role of coordinating the search effort for the missing resident. Any staff on break would be called back to assist with the search. An elopement checklist would be completed during the search and a safety round would be completed on all exits and doorways to investigate and identify possible routes of elopement. 10. It was determined on 07/09/14 by the Administrator and the other attendees at the emergency meeting that all residents would be re-evaluated for potential elopement risks. 11. Staff education topics of Elopement, Resident Safety, Door alarms, the new Elopement policy and hourly checks were discussed and approved by the attendees at the emergency meeting held on 07/09/14. 12. All residents (census of {81} eighty-one) were reviewed and reassessed for potential elopement risk on 07/09/14 by the QA Nurse, MDS Coordinator and Staff Development Coordinator. 13. The six (6) residents (including Resident #2) that were already identified as being at risk for elopement would continue to be monitored hourly by staff and their Comprehensive Care Plans would continue to be reviewed and updated as appropriate by the nursing staff. 14. All staff was retrained on Elopement, Resident Safety, Door Alarms, the new Elopement policy and Hourly Checks. This was completed by midnight on 07/11/14, by the Staff Development Coordinator. 15. All Wander Guard door alarms were checked by the QA Nurse for proper operation, all Wander Guard bracelets in place on residents were checked for proper working order and all locked doors were checked for proper working order by 3:00 PM on 07/04/14. 16. A newly formed Elopement Committee met on 07/14/14 and will meet weekly until the next QA meeting on 07/21/14 when it will be decided how often to have the Elopement Committee meetings. Through observation, interview and record review the State Survey Agency validated the Allegation of Compliance with removal of Immediate Jeopardy on 07/16/14 through 07/17/14 prior to exit as follows: 1. Review of the facility's investigation and Nursing Notes, dated 07/04/14 at 2:20 PM, revealed Resident #2 was returned to the facility at 1:54 PM on 07/04/14. 2. Interview with the Administrator, on 07/08/14 at 9:45 AM, revealed the exit doors were closed and locked immediately by the therapy staff when they were informed of Resident #2's elopement from the facility. Interview with PT #1, on 07/08/14 at 11:31 AM, revealed the exit doors from the therapy gym to the patio were immediately locked upon being informed of Resident #2's elopement from the facility at approximately 2:00 PM. 3. Interview with Licensed Practical Nurse (LPN) #1, on 07/08/14 at 1:13 PM, revealed he was Resident #2's nurse on 07/04/14 at the time of the resident's elopement and he did the head to toe assessment of Resident #2 when the resident was returned to the South Hall. LPN #1 stated he did not find Resident #2 to have been injured and informed the Nursing Supervisor on duty at the facility at that time. Review of the head to toe assessment by LPN #1 revealed a completion date of 07/04/14 with no injury identified. 4. Interview with the Quality Assurance (QA) Nurse, on 07/08/14 at 1:20 PM, revealed she started the facility's investigation into Resident #2's elopement. This was confirmed through review of the investigation initiated on 07/04/14. 5. Interview with the QA Nurse, on 07/17/14 at 8:59 AM, revealed a Wander Guard bracelet was placed on Resident #2 on 07/04/14 after the resident's head to toe assessment, the resident's picture and demographic face sheet were placed in an elopement binder at each nursing station and the resident's Comprehensive Care Plan was updated to include the concern of elopement risk. Review of the elopement binder revealed six (6) residents' pictures and a face sheet were in the binder and the locations were confirmed through observation on 07/15/14. 6. Interview with the Staff Development Director, on 07/16/14 at 4:20 PM, revealed the facility had initiated every fifteen (15) minute checks on Resident #2 following the resident's elopement from the facility for two (2) days and then had reverted to every two (2) hour checks. However, an emergency meeting was held on 07/09/14 at which time it was decided to start hourly monitoring of the six (6) residents assessed to be at elopement risk (to include Resident #2) and these hourly checks would continue for thirty (30) days (until 08/04/14). Review of all monitoring sheets revealed two (2) days of every fifteen (15) minute checks of Resident #2 through 07/06/14; every two (2) hour monitoring of Resident #2 from 07/06/14 at 2:00 PM through 07/09/14 at 2:00 PM; and, every hour checks of Resident #2 and five (5) other elopement risk residents from 2:00 PM on 07/09/14 through 3:00 PM on 07/16/14, and is ongoing. 7. Review of the Medication Administration Records for Resident #1, #2, #6, #7 and #8 revealed an order had been placed in the Matrix to be signed at the end of each shift by the Unit Nurse indicating the hourly check sheets had been completed and signed. Interview with the Staff Development Director, on 07/17/14 at 3:00 PM, revealed it was decided in the emergency meeting to place an order in the Matrix for all of the elopement risk residents which would be signed each shift by the Unit Nurse indicating the hourly check sheets had been completed. 8. Interview with the DON, on 07/16/14 at 3:10 PM, revealed it was also determined in the emergency meeting that Resident #2 would be reassessed for elopement risk and continued need for hourly checks in thirty (30) days (08/04/14). 9. Review of the emergency meeting notes of 07/09/14 revealed the meeting was called to review current policy and procedure for assessing (residents) for elopement risk and the attendees were the Administrator, the Social Services Director, the Staff Development Director, the Minimum Data Set (MDS) nurse, the QA Nurse and a LPN Unit Manager. 10. Interview with the Social Service Director, on 07/16/14 at 3:10 PM, revealed she attended the meeting on 07/09/14 which was called to review current policy and procedure for assessing (residents) for elopement risk and it was determined all residents would be re-evaluated for potential elopement risks. Interview with the Minimum Data Set (MDS) Nurse, on 07/17/14 at 9:20 AM, revealed she attended the meeting of 07/09/14 which was called to review current policy and procedure for assessing (residents) for elopement risk and it was determined all residents would be re-evaluated for potential elopement risks. 11. Interview with the Staff Development Director, on 07/16/14 at 3:40 PM, revealed she attended the emergency meeting held on 07/09/14 and participated in discussion and approval of education topics for staff retraining of Elopement, Resident Safety, Door Alarms, the new Elopement Policy and Hourly Checks. Interview with the Minimum Data Set (MDS) nurse, on 07/17/14 at 9:20 AM, revealed she attended the emergency meeting held on 07/09/14 and participated in discussion and approval of education topics for staff retraining. 12. Interview with the Staff Development Director, on 07/16/14 at 3:40 PM, revealed she participated in reassessing some of the facility's residents for elopement risk. Interview with the Minimum Data Set (MDS) Nurse, on 07/17/14 at 9:20 AM, revealed she participated in reassessing some of the facility residents for elopement risk. Interview with the QA Nurse, on 07/17/14 at 8:59 AM, revealed she participated in reassessing some of the facility's residents for elopement risk and all of the residents were reassessed for elopement risk on 07/09/14. Review of eighty-one (81) elopement risk assessments for all the residents was completed on 07/09/14. This revealed all were done with no new at risk residents identified, excluding Resident #2. 13. Review of all monitoring sheets revealed two (2) days of every fifteen (15) minute checks of Resident #2 through 07/06/14; every two (2) hour monitoring of Resident #2 from 07/06/14 at 2:00 PM through 07/09/14 at 2:00 PM; and every one (1) hour checks of Resident #2 and five (5) other elopement risk residents from 2:00 PM on 07/09/14 through 3:00 PM on 07/16/14 and continuing. Observations on the North Hall, on 07/16/14 at 10:00 AM and 11:00 AM revealed two staff (CNA and LPN) completed the hourly checks on Residents #6, #7 and #8. Interview with the Staff Development Director, on 07/17/14 at 3:25 PM revealed the six (6) residents identified as elopement risk would continue to be monitored hourly for thirty (30) days (08/04/14) and Comprehensive Care Plans would continue to be reviewed and updated as appropriate by nursing staff. 14. Review of staff sign in sheets for retraining/education on Elopement, Resident Safety, Door Alarms, the new Elopement Policy and Hourly Checks revealed all staff was re-trained by midnight on 07/11/14. Interview with the Staff Development Director, on 07/09/14 at 2:25 PM, revealed she had been retrained on elopement, resident safety, door alarms, the new Elopement Policy and hourly checks on 07/05/14. Telephone interview with LPN #5, on 07/12/14 at 10:55 PM, revealed she had retraining on elopement, resident safety, door alarms, the new Elopement Policy and hourly checks prior to her shift on 07/08/14. Interview with CNA #8, on 07/15/14 at 4:35 PM, revealed he had retraining on elopement, resident safety, door alarms, the new Elopement Policy and hourly checks prior to his shift on 07/09/14. Interview with LPN #3, on 07/16/14 at 11:44 AM, revealed she had retraining on elopement, resident safety, door alarms, the new Elopement Policy and hourly checks prior to her shift on 07/09/14. Interview with CNA #4, on 07/17/14 at 9:31 AM, revealed she had retraining on elopement, resident safety, door alarms, the new Elopement Policy and hourly checks prior to her shift on 07/09/14 and again on 07/10/14. One hundred and seventy-three (173) total employees received the training with twelve (12) to be trained when they return to work and before starting their shift. 15. Interview with the Quality Assurance (QA) Nurse, on 07/08/14 at 1:20 PM, revealed she was the Nursing Supervisor on duty on day shift on 07/04/14. When she was made aware of Resident #2's elopement she immediately checked all of the Wander Guard door alarms and bracelets worn by elopement risk residents to ensure they were in proper working order. She also indicated all locked doors were checked for proper working order by 3:00 PM on 07/04/14. 16. Interview with the Staff Development Director, on 07/17/14 at 3:25 PM, revealed she attended the newly formed Elopement Committee on 07/14/14 and it was decided the committee would meet weekly until the next QA meeting on 07/21/14 when it would be decided how often to have the Elopement Committee meetings. Interview with the Administrator, on 07/17/14 at 3:37 PM, revealed he was at the Elopement Committee meeting on 07/14/14 and it was decided the committee would meet weekly until the next QA meeting on 07/21/14. He stated it would be decided at the 07/21/14 QA meeting how often the Elopement Committee would continue to meet.

Based on observation, interview, record review and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to develop a comprehensive care plan for one (1) of sixteen (16) sampled residents, Resident #9. The facility staff assessed Resident #9 as at risk for falls; however, failed to develop a comprehensive care plan for Resident #9. Resident #9 sustained six falls during the month of January, 2014. On 01/16/14 the sixth fall resulted in an injury that required an acute hospital intervention of staples to the back of his/her head. The findings include: Interview with the Director of Nursing, on 05/08/14 at 3:54 PM, revealed the facility utilized Minimum Data Set (MDS) 3.0 when developing, revising and updating the care plan. Review of the Resident Assessment Instrument (RAI) Manual, MDS 3.0, Chapter 4, page 4-8, Section 4.6, revealed facilities were responsible for assessing and addressing all care issues that were relevant to individual residents, regardless of whether or not they were covered by the RAI, including monitoring each resident's condition and responding with appropriate interventions. In addition, the care plan should be revised on an ongoing bases to reflect changes in the resident and the care the resident was receiving. Observation of Resident #9, on 05/06/14 at 1:10 PM, revealed Resident #9 was in his/her room standing at the bedside. Interview at this time with Resident #9, revealed he/she was going to the bathroom unassisted. Review of Resident #9's clinical record revealed the facility admitted the resident on 10/14/13 with [DIAGNOSES REDACTED]. Review of the initial Fall Care Plan, dated 10/14/13, revealed the resident was to be toileted upon rising, before and after meals and at bed time. There was no evidence of a care plan for falls prevention to assist in the management of falls. Review of Resident #9's MDS, Admission Assessment, dated 10/23/13, revealed the facility completed a Brief Interview for Mental Status (BIMS) on Resident #9 that determined the resident was a thirteen (13). The facility identified the resident had falls since admission with no injuries. Review of Resident #9's Care Area Assessment (CAA) on falls, revealed the facility identified Resident #9 as at risk for falling related to history of falls both before and since admission. The facility decision was to initiate a Comprehensive Fall Care Plan. However, review of the resident's Comprehensive Care Plans revealed the facility did not develop a care plan for falls. Review of the facility's investigation Fall Circumstance Forms, revealed the resident sustained [REDACTED]. The resident was found wet five (5) of the six (6) falls. There was no evidence a Falls Care Plan was developed with interventions to prevent further falls, until after the sixth fall that resulted in injury. Review of the facility's investigation Fall Circumstance Form, event date 01/16/14 at 9:45 PM, revealed Resident #9 was observed on the floor with his/her head on the bedside table. The fall was unwitnessed. Resident #9 stated he/she was returning from the bathroom and fell . Resident #9 was observed to have copious amounts of blood on the floor from a laceration on the back of his/her head. The physician was notified and authorized Resident #9 be sent to the emergency room for treatment and evaluation, which included staples to the back of his/her head. Review of the resident's Comprehensive Care Plan, revealed a fall care plan was not developed until 01/16/14 on the day Resident #9 sustained an injury. Interview with South Unit Manager, on 05/08/14 at 4:50 PM, revealed a lot of Resident #9's falls were from him/her coming and going to the bathroom. The South Unit Manager stated the staff was to check on Resident #9 hourly for toileting. However, this intervention was not on the care plan. As a Manager she stated she was responsible to ensure the staff had up to date care plans. If the care plan did not contain all the pertinent issues identified for the resident with interventions to direct the staff in the care of that issue, the CNA's would not know what they were to do, and an injury could occur. Interview with the CNA #5, on 05/08/14 at 2:17 PM, revealed staff was expected to follow the care plan and without the care plan she would not know what care to provide. CNA #5 stated Resident #9 liked to get up by him/herself. She remembered when a tab alarm was used, but the resident would remove the alarm. However, review of the initial care plan and the comprehensive care plan revealed no evidence a tab alarm was ever applied. Further interview with CNA #5, on 05/08/14 at 4:21 PM, revealed she could not remember Resident #9 having to be toileted every hour. Interview with the MDS Coordinator, on 05/08/14 at 3:38 PM, revealed there was an interim care plan for falls for Resident #9 that stated beginning 10/20/13 staff was to place the resident in a wheelchair for meals; and obtain a stool culture for loose stools/[MEDICAL CONDITION]. On 10/30/13 the staff was to wake up the resident at 3:30 AM to toilet. On 11/16/13 the staff was to toilet the resident upon rising, before and after meals and at bedtime. On 12/03/13 the staff were to keep the walker in reach. However review of Resident #9's clinical record revealed there was no comprehensive care plan for falls until 01/16/14. The MDS Coordinator stated there should have been a comprehensive care plan as outlined by the CAA because it triggered on the Admission Assessment. Interview with the Director of Nursing (DON), on 05/08/14 at 3:51 PM, revealed nurses were able to initiate, revise and update the care plan and were expected to follow the plan of care. The DON felt she had done everything that needed to be done for Resident #9 though she could not ensure the staff was toileting Resident #9 every hour or that the resident had a comprehensive care plan for falls. The DON stated when discussing falls in the daily morning meetings she checked to see if there was a care plan and did not remember the resident not having a falls care plan. She stated if an intervention was not written down, then the staff would not know what was expected of them. Interview with the Administrator, on 05/08/14 at 6:30 PM, revealed he expected the staff to develop care plans for the residents as determined by the MDS . The staff not having a care plan to follow was a problem and if not given the current plan, "things" could happen to the resident and the resident would not be given proper care.

Based on observation, interview, record review and policy review, it was determined the facility failed to provide adequate supervision to prevent falls for two (2) of sixteen (16) sampled residents, Residents #6 and #9. The facility failed to track and trend Resident #9's and Resident #6's falls to determine the association with the falls and toileting. The facility failed to complete additional bladder assessments with each fall and failed to develop an individualized toileting program to assist in the management and prevention of falls. Resident #9 sustained six (6) falls in the month of January, 2014 during self transfer to the restroom. The sixth fall resulted in an injury, which required an acute hospital visit and the placement of three (3) staples to the back of his/her head. Resident #6 sustained six (6) falls from the bed without injury; however, the resident was found wet with five (5) of those falls. The findings include: The facility did not provide a policy and procedure for prevention and management of falls as requested by the State Survey Agency (SSA). Interview with the Director of Nursing (DON), on 05/08/14 at 2:08 PM, revealed the facility did not have a fall prevention and management policy and procedure. 1. Observation of Resident #9, on 05/06/14 at 1:10 PM, revealed Resident #9 was in his/her room standing at the bedside. Interview at this time with Resident #9, revealed he/she had the intention of going to the bathroom unassisted. A Certified Nursing Assistant (CNA) was located and the resident was then assisted after surveyor intervention. Review of Resident #9's clinical record revealed the facility admitted the resident on 10/14/13 with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission Assessment, dated 10/23/13, revealed the facility assessed Resident #9 with a Brief Interview for Mental Status (BIMS) score of eight (8) and was assessed to require extensive assistance of one (1) person physical assist. In addition, the MDS stated the resident had sustained falls since admission with no injuries. Review of Resident #9's Care Area Assessment (CAA) for falls, revealed the facility identified Resident #9 was at risk for falling related to history of falls both before and after admission. In addition, the facility assessed the resident as always continent. According to the CAA a comprehensive care plan was to be initiated by the Interdisciplinary Team (IDT) to address falls risk management. Review of the resident's comprehensive plan of care revealed a fall care plan was not developed. However, an initial care plan developed on admission, dated 10/14/13, revealed the resident was at risk due to an unsteady gait at times and weakness. The goal was to be no injury and this was to be achieved by: a call light in place; encourage resident to use; assist with mobility and ADLs; place personal items within reach; and a therapy screen. The initial care plan further revealed the resident had a fall on 10/20/13 without injury and staff was to place the resident in a wheelchair for meals and obtain stool samples for[DIAGNOSES REDACTED]. The resident sustained [REDACTED]. The resident fell on [DATE] without injury and staff was to start a toileting plan upon rising, before and after meals and at bedtime. In addition, the resident fell on [DATE] without injury and staff was to place the walker in reach. Review of Resident #9's Toileting Plan Monthly Progress Note, dated 12/11/13 through 05/08/14, revealed the first month assessment indicated Resident #9 would need to be toileted every hour. The Progress Note, revealed Resident #9 had increased falls related to going to the bathroom unassisted and was to begin a toileting plan. Record review revealed Resident #9 sustained six (6) falls from 01/04/14 through 01/16/14. Five (5) of the six (6) falls occurred when Resident #9 was going to or coming back from the bathroom. Review of the facility's investigation Fall Circumstance Form for Resident #9, event date 01/04/14 at 2:04 PM, revealed Resident #9 had a fall in his/her room. Staff documented Resident #9 attempted an unwitnessed self transfer to the walker to use the rest room. At the time of the fall Resident #9 was wet and assessed by staff with no injury. Per the form the resident had last been toileted at 9:00 AM. Review of the Certified Nursing Assistant plan of care, dated 03/26/14, revealed the staff was to toilet the resident at 1:00 PM, 2:00 PM, 3:00 PM and 4:00 PM. The Fall Circumstance form continued to indicate Resident #9 had a history of [REDACTED]. The facility determined the root cause analysis was the resident had reported increased weakness in legs at the time of the fall. A new intervention was staff would speak with therapy regarding plans to transfer. The Interdisciplinary Team (IDT) summary stated to place a sign on the walker telling the resident to put shoes on before walking and gripper strips on the floor. Therapy was already seeing resident under Part B. There was no evidence the facility reassessed the resident for a toileting program Review of facility's investigation Fall Circumstance Form, event date 01/05/14 at 4:50 AM, revealed Resident #9 had an unwitnessed fall in his/her room when he/she stumbled coming back from the bathroom. The resident was last toileted at 2:00 AM. He/she was found sitting on his/her bottom leaning against the wheelchair. At the time of the fall Resident #9 was found to be clean and dry. The form continued to reveal Resident #9 had been encouraged to call for standby assistance to ambulate, but Resident #9 felt he/she had to go to the bathroom right away. No injuries were observed at the time of fall. The facility determined the root cause analysis was an unsteady gait, weak and urgency of urine. A new intervention was to strongly encourage the resident to call for assistance and allow staff to stand by to prevent falls and the staff was to obtain an urine specimen for a urinalysis. There was no evidence the facility reassessed the resident for a toileting program. Review of the facility's investigation Fall Circumstance Form, event date 01/05/14 at 12:34 PM, revealed Resident #9 had an unwitnessed fall in his/her room. Resident #9 had slipped in urine and fell on his/her way to the bath room. Resident #9 was found on his/her buttocks sitting at a ninety (90) degree angle by the bathroom. Per the form the resident was last toileted at 10:00 AM. The resident was assessed with [REDACTED]. There was no new intervention identified on the form. The IDT summary on the Fall Circumstance form stated therapy was to assess the walker for appropriateness. There was no evidence the facility reassessed the resident for a toileting program. Review of the facility's investigation Fall Circumstance Form, event date 01/14/14 at 2:35 PM, revealed Resident #9 was trying to self transfer to the toilet and slid to the floor on his/her bottom unwitnessed. Resident #9 was observed to be clean and dry. The form indicated the resident was last toileted at 1:00 PM. Review of the CNA plan of care revealed the resident was to be toileted at 1:00 PM, 2:00 PM, 3:00 PM and 4:00 PM. The staff assessed the resident with no injuries. The facility determined the root cause analysis was the resident did not ask for assistance when transferring to the restroom and lost balance. The new intervention was for staff to assist the resident when ambulating to the bathroom. The IDT summary stated the staff was to ask the resident to stand one (1) to two (2) minutes before transfers. There was no evidence the facility reassessed the resident for a toileting program. Review of Resident #9's Fall Circumstance Form, event date 01/16/14 at 3:20 PM, revealed Resident #9 was observed on his/her bilateral buttocks beside his/her bed and the fall was unwitnessed. The resident was last toileted at 3:00 PM and there were no injuries identified. The root cause analysis was determined to be the resident's move to another room on 01/14/14 and the resident was adjusting to the new room. The new intervention was to allow the resident to adjust to the new room. The IDT summary stated to see other page which stated to see new fall report. However, there was no new information on the fall report. There was no evidence the facility reassessed the resident for a toileting program. Review of Resident #9's Fall Circumstance Form, event date 01/16/14 at 9:45 PM, revealed Resident #9 was observed on the floor with his/her head on the bedside table and was assessed with [REDACTED]. Resident #9 stated he/she was returning from the bathroom and fell . Per the Fall Circumstance Form the resident was last toileted at 9:40 PM; however, review of the Resident Level of Control and Bladder Function form dated 01/16/14, revealed Resident #9 was toileted at 10:25 AM and 5:01 PM. The facility determined the root cause analysis was suspect altered depth perception from recent cataract surgery. The new intervention and IDT summary revealed a new appointment would be made to follow up on vision. There was no evidence the facility reassessed the resident for a toileting program. Review of Resident #9's Progress Note, revealed on 01/16/14 at 9:45 PM, the nurse was called into the room by the CNA. Resident #9 was observed in a supine position beside the bed with his/her head resting on the corner of the bedside table. Resident #9 was observed with copious amounts of blood on the floor from a laceration on the back of his/her head. The nurse was unable to determine the length and depth due to the bleeding. A cool compress was applied. The resident did not have any complaints of pain and neurological checks were within normal limits. The physician was notified and authorized Resident #9 be sent to the emergency room for treatment and evaluation. Review of Resident #9's emergency room Summary, dated 01/16/14, revealed Resident #9 had obtained a mechanical fall (that means the resident had slipped, tripped or lost balance) which resulted in a laceration to the scalp. Interview with CNA #5, on 05/08/14 at 2:17 PM, revealed she remembered taking care of Resident #9 on 01/16/14 and found Resident #9 around 9:45 PM screaming for help. CNA #5 stated she went into Resident #9's room and then retrieved the nurse. Resident #9 was lying with his/her head facing the door, and was observed to have hit his/her head on the bottom of the bedside table. There was a lot of blood observed on the floor. She could not remember toileting the resident before the fall. CNA #5 stated she could not remember if Resident #9 was on a toileting program back in January. Interview with Licensed Practical Nurse (LPN) #6, on 05/08/14 at 2:00 PM and 5:29 PM, revealed she remembered Resident #9 had two falls on 01/16/14. LPN #6 stated Resident #9 had a fall around 4:09 PM in which he/she did not sustain any injuries and another fall at 9:45 PM in which Resident #9 needed staples. Per LPN #6, Resident #9 received three (3) staples due to the laceration. Resident #9 could walk around in his/her room and could also get up by him/herself. LPN #6 stated she remembered Resident #9 was not on an hourly toileting program during this time period. LPN #6 stated Resident #9 was dry and returning from the bathroom unassisted when he/she fell . She could not recall if she asked CNA #5 about assisting Resident #9 to the bathroom. LPN #6 stated she knew she did not assist Resident #9 to the bathroom before the fall. Interview with the South Unit Manager, on 05/08/14 at 4:50 PM, revealed to her knowledge Resident #9 was a one (1) assist to the bathroom. The South Unit Manager stated she remembered there was a time in the middle of the night that Resident #9 was toileted hourly back in January 2014; however, there was no documented evidence to validate the staff toileted Resident #9 every hour. Resident #9 was able to ambulate on his/her own to and from the bathroom. However, review of the initial care plan, dated 10/14/13, revealed the staff was to assist the resident with transfers as needed. The South Unit Manager stated she "could talk to Resident #9 a thousand times and the resident would do his/her own thing". The Unit Manager stated when the fall on 01/16/14 occurred she thought Resident #9 was having difficulties with depth perception because of his/her prior cataract surgery. The UM further stated she was not thinking of toileting as potential cause of the falls, though Resident #9 had multiple falls related to going to the bathroom. The South Unit Manager stated when she looked at the bowel and bladder assessment form she was looking for patterns, and Resident #9 should of had a new assessment completed to see if there was a new pattern to the resident's toileting. The South Unit Manager stated a lot of Resident #9's falls were from him/her going to and coming from the bathroom. Interview with the Director of Nursing (DON), on 05/08/14 at 3:51 PM, revealed when there was an accident the nurses were to fill out an event form and the next morning or Monday she would go over the falls in the morning meeting. When discussing falls she checked to see if there was a care plan. The DON stated she could not remember why Resident #9 did not have a plan of care. The DON stated she had "educated and educated Resident #9 about falls, but Resident #9 did what he/she wanted to do". Review of the initial care plan, dated 10/14/13, and the Comprehensive Care Plan, dated 01/16/14, did not reveal any reference to resident education. The DON stated the resident's falls had diminished in the last few months. Further interview with the DON, on 05/08/14 at 5:56 PM, revealed the DON felt she had done everything that needed to be done for Resident #9, though she could not ensure the staff was toileting Resident #9 as planned or that Resident #9 had a comprehensive care plan before the fall. Further interview with the DON, on 05/08/14 at 5:56 PM, revealed staff chart by exception, which meant the nursing staff charted if there were any bowel and bladder accidents, and not if the resident was continent. Interview with the Administrator, on 05/08/14 at 6:30 PM, revealed they talked about falls on a daily basis. Resident #9 had a lot of falls and they all involved the bladder. He stated he was not aware staff was not toileting the resident. He further stated he expected the staff to follow the care plan and the care plan could be a problem if not updated. 2. Observation of Resident #6, on 05/05/14 at 7:12 PM, revealed the resident was seated in a wheelchair. The resident was not oriented to person, place, or time. Review of the clinical record for Resident #6, revealed the facility admitted the resident with [DIAGNOSES REDACTED]. The facility completed an Annual MDS on 04/15/13 and a Quarterly MDS on 01/13/14 and assessed Resident #6 non-ambulatory and was extensive assistance of two person physical assist for transfers. Review of the Comprehensive Care Plan for Resident #6, initiated on 04/25/13 revealed the resident had a history of [REDACTED]. The goal for the resident was to remain free from serious injury. Interventions by the staff included: avoid use of a restraint; equip resident with a device that monitors rising; give resident verbal reminders not to ambulate/transfer without assistance; keep bed in lowest position with brakes locked; keep call light in reach at all times; observe frequently and place in supervised area when out of bed; place resident in a fall prevention program; and provide toileting assistance as needed. Review of the facility's investigative Fall Circumstance Forms for Resident #6, revealed the resident had multiple falls. The facility completed a Fall Risk Assessment on 10/07/13 that determined the resident was disoriented; required the use of assistive devices; was dependent for mobility; no referrals were necessary; and the current care plan would be continued. The facility completed a second Fall Risk Assessment on 01/09/14, which indicated the resident was at risk for falls; had a history of [REDACTED]. The facility documented that the current care plan would be continued. Review of the facility's Fall Circumstance Form revealed on 01/17/14 at 7:51 AM, the resident was found sitting on the floor beside the bed and was wet. The fall was unwitnessed. Resident #6 was toileted at 9:30 PM on 01/16/14. The facility determined the root cause of the fall was the resident was uncomfortable due to being soiled, thus attempted to transfer self out of the bed. There was a small one (1) centimeter skin tear on the resident's buttocks. The new intervention was marked not applicable. The IDT summary stated remain free of injury related to fall. There was no evidence the care plan was revised. There was no evidence the facility reassessed the resident for a toileting program. Review of the facility's investigation Fall Circumstance Form, revealed on 02/09/14 at 4:09 AM, Resident #6 was found sitting on the floor next to the bed and was wet. The fall was unwitnessed and there were no injuries. The resident was last changed at 9:26 PM on 02/08/14. The facility determined there was no injury and the root cause of the fall was documented as the resident slid out of bed. The facility documented that the resident had not sustained a fall in the last three (3) months. The new intervention was continue to monitor. The IDT summary stated continue with current care plan which was no injury from falls. There was no evidence the facility reassessed the resident for a toileting program. Continued review of the facility's investigation Falls Circumstance Form revealed on 02/17/14 at 2:02 AM, the resident was found sitting on the floor next to the bed and was wet. The last time the resident was checked and changed was 9:00 PM on 02/16/14. The fall was unwitnessed and there were no injuries. The facility determined the root cause of the fall was the resident attempted a self-transfer. The IDT summary stated possibly being awakened by roommate, will bring out of room when awake. The care plan was updated to reflect a fall on 02/16/14 the day before the fall on 02/17/14, the care plan did not reflect a fall on 02/17/14 and there were no interventions dated for 02/16/14 or 02/17/14. There was no evidence the facility reassessed the resident for a toileting program. Review of the facility's Fall Circumstance Form revealed on 03/18/14 at 3:00 PM, Resident #6 was found on the floor by the bed, wet and soiled. The fall was unwitnessed and there were no injuries. The facility documented the resident was last checked and changed at 1:34 PM. The facility documented the root cause as the resident attempted self-transfer. The care plan was updated to reflect the perimeter mattress was placed on the resident's bed on 03/20/14. The IDT summary concurred with the new intervention. There was no evidence the facility reassessed the resident for a toileting program. Review of the facility's investigative Fall Circumstance Form revealed on 04/06/14 at 4:30 PM, Resident #6 was found on the floor by the side of the bed without any injuries. The facility documented that a staff member sat the resident on the side of the bed, then turned away to get supplies, and the resident fell to the floor. The facility determined the root cause of the fall was the resident attempting self-transfer and staff was to be educated on having supplies ready. The IDT summary revealed staff was to be educated on readiness of supplies before sitting resident on the side of the bed. Review of the Annual MDS assessment completed on 04/14/14, revealed the facility assessed the resident with moderate cognitive impairment with no behaviors. The resident was rarely understood when speaking. The resident was nonambulatory and required extensive assistance of two (2) to transfer from the bed to the chair. The resident was incontinent of bladder. Review of the CAAs of the 04/14/14 MDS for Resident #6, revealed the facility determined the resident was at a high risk for falls and had a history of [REDACTED]. The resident had poor balance, Advanced Dementia and received antidepressant medication. The resident had not experienced any serious injuries from falling. The focus of the care plan would be to prevent serious injury. Review of the Comprehensive Care Plan revised on 01/10/14, and not on 04/14/14 with the Annual MDS, revealed the use of a lap buddy; verbal reminders not to rise; sensor alarm while in bed; keep the call light in reach; one-fourth (1/4) side rails; keep personal items in reach; place in supervised area when out of bed; do not awaken to change during the night; check every two (2) hours during the night; and toilet as needed. The resident had functional incontinence and required extensive assistance for transfers. The goal for the resident was not to sustain skin breakdown. Interventions included: perineal care after incontinent episodes; and take resident to the bathroom before and after meals, and at bedtime. Review of the facility's investigative Fall Circumstance Form revealed on 04/27/14 at 8:05 AM, Resident #6 was found on the floor and was wet. The fall was unwitnessed. The facility documented the last time the resident was toileted or changed was 9:00 PM on 04/26/14. The Fall Risk Assessment completed at this time determined the root cause of the fall was restlessness. The resident was agitated and orders were obtained from the physician for a urinalysis. The IDT summary stated to await evaluation and treatment. There was no evidence the facility reassessed the resident for a toileting program. Interview with CNA #1, on 05/07/14 at 10:35 AM, revealed Resident #6 fell frequently and was confused. She stated the resident was incontinent of bladder and tried to get out of bed and toilet self. She stated the resident did not use the call light. She indicated the resident was checked and changed every two hours and she was not aware the resident was on a toileting program. She stated the resident fell mostly from the bed. She stated the resident could injure him/herself from so many falls. Interview with CNA #2, on 05/07/14 at 2:15 PM, revealed Resident #6 usually fell when in the room in bed. She revealed the resident was at risk for falls according to care guide lines provided to staff. She stated the resident tried to self-transfer out of bed and could be injured from falling. She was not aware of any type of toileting program being used for the resident. Continued review of the CNA care plan revealed the resident was to wear pull ups per family request. Continued review of the Comprehensive Care Plan revealed on 03/03/13 the Functional Incontinence Care Plan was updated to include take to bathroom before and after meals, at bedtime and as needed. This was discontinued as resolved on 02/14/14. Interview with LPN #2, on 05/07/14 at 2:45 PM, revealed Resident #6 did fall from bed most of the time. She stated the facility did not like to use alarms and she was not aware of any special safety interventions to prevent the resident from falling from the bed. She stated the resident was placed at the nursing station when out of bed so staff could watch the resident. She stated she had been in-serviced several weeks ago on fall prevention; however, she could not identify how this information was put to use for Resident #6. She stated the resident could have a serious injury from frequent falling. Interview with the North Unit Manager, on 05/07/14 at 3:19 PM, revealed Resident #6 did have a history of falls and nothing more could be done to prevent the resident from falling. She could not specifically say how the facility planned to decrease the number of falls for Resident #6. She stated the resident could sustain an injury from any fall. Continued interview with the DON, on 05/08/14 at 2:08 PM, revealed she was aware of the falls for Resident #6 and added the resident had not sustained a serious injury. She indicated that the root causes for the falls of Resident #6 was the resident attempting self-transfers. She stated the resident did have a significant cognitive impairment and might not retain staff instructions to use the call light. She was not aware the resident was incontinent when found after a fall five (5) out of six (6) times or that all the falls occurred while the resident was in bed. The DON could not verbalize how this information was missed when reviewed on a daily basis. Continued interview with LPN #2, on 05/07/14 at 2:45 PM, revealed the facility tried to prevent injuries from falls and not the falls themselves. Continued interview with the North Unit Manager, on 05/07/14 at 3:19 PM, revealed the facility focused on preventing injuries from falls. She stated if a resident fell and was uninjured, there was no concern. Continued interview with the DON, on 05/08/14 at 2:08 PM, revealed the facility's fall rate had declined in the last quarter. She indicated the facility met each week day morning to review any falls. She stated falls were impossible to prevent and she had not trended the falls for Resident #6. She stated she did not know what else the facility could do to increase the safety of the resident and prevent further falls. Interview with the Administrator, on 05/08/14 at 6:30 PM, revealed he attended the morning meetings and the staff talked about falls at that time Monday through Friday. The Administrator stated the DON was tracking falls each shift and went line by line through the event reports. The Administrator stated that he was responsible to ensure residents were safe.

Based on observation, record review, review of the Bed Safety policy, and interview, the facility failed to ensure five (5) Resident's (#1, #2, #3, #4, and #11) of twelve (12) sampled residents who were restrained had medical justification, a physician's order for the restraint use, had family consent and assessed and determined the benefits of restraint use outweighed the risks for the resident. The facility failed to ensure staff was knowledgeable regarding their restraint assessment system. Furthermore, the facility's failed to ensure restraint assessments determined the benefits of restraint use outweighed the risks for the resident and failed to ensure a physician's order for the restraint use with medical justification and family/resident consent had been obtained prior to the implementation of the restraint. Furthermore, the facility failed to ensure staff was knowledgeable regarding the Bed Safety policy and were following the policy to ensure potential areas of entrapment were identified for each resident. On 04/30/11, the facility found Resident #1 entrapped between an air mattress and the side rail, which had been determined a restraint. The resident's entrapment resulted in bruising and skin tears to the chin and shins bilaterally. Based on the above findings it was determined the facility's failure to have an effective system in place to assess residents' safety when utilizing side rails as a restraint was likely to cause serious injury, harm impairment or death. Immediate Jeopardy and Substandard Quality of Care was determined to exist on 04/30/11 and is ongoing. The findings include: Review of the facility's Bed Safety policy dated 2001 with a revision date of 08/2006, revealed the Director of Nursing (DON) or designee and the Safety Officer or designee shall inspect all hospital beds at least quarterly to identify potential areas of entrapment and ensure no gaps exceed the dimensional limits established by the FDA. The facility will impose additional safety measures for residents who have been identified as high risk for entrapment. Inspection results shall be reviewed quarterly by the Quality Assurance (QA) Committee and the inspection results and the QA Committee recommendations shall be maintained in the business office. If side rails are utilized for any reason, the decision must be based on an interdisciplinary assessment of the resident, as well as the input from the resident and/or legal guardian. Consent must be obtained and the family/resident must be informed of the potential hazards prior to their use including the risk of entrapment and falls. The resident will be checked frequently for safety and if the side rails are associated with a decline in function, such as screaming or agitation, the resident's needs will be reassessed. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment. Interview with the DON, on 05/09/11 at 1:00pm, revealed she was unable to provide evidence of the bed safety checks, which the facility's policy stated should have been completed quarterly. Interview with the Maintenance Director, on 05/09/11 at 2:20pm, revealed he inspected the electrical components of the beds and did not inspect the beds for areas which could potentially result in entrapment. Interview, on 05/09/11 at 2:25pm, with the Safety Director revealed she was not aware of the Bed Safety policy or her responsibility to complete quarterly bed safety checks until after the incident with Resident #1. Therefore, the Safety Director could not provide any evidence of bed safety checks done prior to the incident. Interview with the Administrator, on 05/09/11 at 2:30pm, revealed he was not aware bed safety checks were to be done quarterly. 1. Record review revealed the facility admitted Resident #1 on 08/03/06, with the [DIAGNOSES REDACTED]. Review of the monthly summary, dated 02/02/11, revealed the facility assessed and determined side rails were a restraint for resident #1; however, the document did not detail the risks/benefits of side rail restraint use specific to Resident #1's needs, there was no documented evidence of the facility obtained consent from the family to utilize the side rails as a restraint or had determined a medical justification for utilizing the side rail restraints. Review of Resident #1's physician's orders revealed there was no physician's order for side rail use as a restraint or a medical justification for utilizing side rails as a restraint. Further clinical record review revealed there was no other documented evidence that the facility had documented their assessment of the risk/benefits of using side rail restraints, obtaining family consent for restraint use or medical justification. There was no evidence staff completed the facility ' s Restraint Assessment Form or completed a bed safety check prior to the implementation of the use of the side rails. Record review revealed the facility weighed resident #1 on 04/08/11 and detailed his/her weight as 125.2 pounds and utilized an air mattress with the use of side rails. Interview with the DON and Safety Director on 05/09/11 confirmed that there was no documented evidence that the facility had completed the Bed safety check and confirmed that the check had not been completed for Resident #1. Review of the a nurses note, dated 05/01/11 at 0010 (12:10am) and the facility's investigation report, dated 05/02/11, revealed on 04/30/11 at 11:20pm Resident #1 was heard calling for help from within his/her room. Certified Nurse Aide (CNA) #2 responded and found the resident on the floor, beside and facing the bed. The Licensed Practical Nurse (LPN) #1 entered the room to assist CNA #2 and the resident. LPN #1 found the resident on his/her knees with his/her head between the side of the mattress and the side rail. A skin assessment of the resident after being assisted to a sitting position revealed the right leg with a 2.5 x 1 cm skin tear, the left leg had a 1.5 x 1.5 x 1.5 cm skin tear, the right cheek revealed a skin tear 3.5 x 1.5 cm, a bruise was noted on the chest 10 x 7.5 cm, the left elbow had a 10 x 8.5 cm skin tear and the left forearm had a 3.5 x 4.1 x 0.5 cm skin tear and bruising was noted on the chin. Clinical record review revealed no documented evidence the facility had conducted a bed safety check, per their facility policy, despite the resident becoming entrapped between the mattress and the side rail on 04/30/11. Review of the nursing monthly summary dated 05/08/11 continued to detail side rails were a restraint for Resident #1. Further review of the monthly summary revealed the document did not detail the risks/benefits of side rail restraint use specific to Resident #1's needs, there was no documented evidence of the facility obtained consent from the family to utilize the side rails as a restraint and there was no documented evidence of a medical justification for utilizing the side rails which were considered a restraint. Review of Resident #1's physician's orders revealed there was no physician's order for side rail use as a restraint or a medical justification for utilizing side rails as a restraint. Further clinical record review revealed there was no other documented evidence that the facility had documented their assessment of the risk/benefits of using side rail restraints, obtaining family consent for restraint use or medical justification. Review of the clinical record revealed no documented evidence the facility had completed a bed safety check as of 05/08/11, eight days following the event of entrapment and continued assessment that the side rails served as a restraint for Resident #1. Furthermore, observation of Resident #1 on 05/10/11 at 5:40am, 5:45am, 5:55am, and witht the facility Administrator at 6:25am revealed the facility continued to utilize side rails for Resident #1 after being entrapped. Resident #1 was positioned on his/her right side, the fall mat was on left side of bed, the bed was in the low position, and the right side of bed was against the wall. Bilateral side rails were engaged in the one half (1/2) rail position. Interview with Certified Nursing Assistant #3 (CNA), on 05/13/11 at 2:35pm, revealed she never saw Resident #1 use the side rails for bed mobility. 2. Record review revealed the facility admitted Resident #4 on 02/03/04 with [DIAGNOSES REDACTED]. The monthly nursing summary dated 04/09/11 detailed the facility had assessed and determined the side rails were utilized as a restraint for Resident #4; however, there was no documented evidence the facility assessed the risks/benefits of side rails as a restraint, that family consent was obtained, or had medical justification for the use of side rails as a restraint. Review of the physician's orders revealed there was no evidence the physician had ordered the use of side rails as a restraint or provided medical justification for side rail restraint. Further clinical record review revealed the facility had not completed the Restraint Assessment form for Resident #4 and there was no other documented evidence that the facility had documented their assessment of the risk/benefits of using side rail restraints, obtaining family consent for restraint use or medical justification. Clinical record review and interview with the the DON and the Safety Director on 05/09/11, revealed no bed safety check had been completed. Observation of Resident #4 on 05/13/11 at 2:25pm revealed the bed with one half 1/2 rail raised on the left side and one quarter (1/4) rail raised on the right side. Interview with CNA #5 on 05/13/11 at 2:25pm revealed the resident used the side rails to roll over in bed. 3. Record review revealed the facility admitted Resident #11 on 09/17/10, with the [DIAGNOSES REDACTED]. The monthly nursing summary dated 04/14/11 revealed the facility assessed and determined the side rails were considered a restraint for Resident #11; however, the monthly summary did not detail the risks/benefits identified for Resident #11's use side rail restraint, there was no detail of medical justification, or family consent obtained. Review of the physician's orders reveled there was no evidence the physician had ordered side rails restraints or detailed a medical justification the restraint. Clinical record review revealed the facility had not completed the Restraint Assessment form for Resident #11 and there was no other documented evidence that the facility had documented their assessment of the risk/benefits of using side rail restraints, obtaining family consent for restraint use or medical justification in any other part of the record. Interview with the DON and the Safety Director on 05/09/11, and clinical record review revealed no bed safety check had been completed. On 05/12/11 at 2:20pm, observation of Resident #11 revealed the resident was in bed, with one half (1/2) rails engaged bilaterally. Interview with Certified Nursing Assistant (CNA) #4, on 05/13/11 at 11:25am, revealed Resident #11 used the side rails for transfers and to keep from rolling out of the bed. 4. Record review revealed the facility admitted Resident #2 with [DIAGNOSES REDACTED].The current comprehensive care plan for Resident #2, dated 03/22/11, stated avoid the use of restraints for this resident; however, the monthly summary dated 04/28/11determined side rails were considered a restraint for Resident #2. Further review of the summary revealed the facility did not detail the assessed risks/benefits of Resident #2's use of side rails, the medical justification for restraint use, nor family consent. Physician order review revealed there was no evidence of a physician's order or medical justification for the use of side rails as a restraint. Clinical record review revealed there was no documented evidence the facility had completed the Restraint Assessment form for Resident #2 and no other documented evidence that the facility had assessed the risk/benefits of using side rail restraints, obtaining family consent for restraint use or medical justification in any other part of the record. Clinical record review and interview with the Safety Director and DON, on 05/09/11, revealed no bed safety check had been completed. On 05/06/11 at 3:00pm, observation of Resident #2 revealed the resident in bed with one half (1/2) rails raised bilaterally. Observation on 05/10/11 at 5:40am revealed the resident in bed with one half (1/2) rails raised on both sides of the bed. Interview with CNA #5, on 05/13/11 at 2:30pm, revealed Resident #2 used the side rails to roll over in bed, to assist in keeping turned during care and to get out of bed. 5. Record review revealed the facility admitted Resident #3 on 04/20/05 with the [DIAGNOSES REDACTED].#3; however, the monthly summary did not detail the assessed risks/benefits of Resident #3 utilizing side rails as restraints, medical justfication for restraint use, or having obtained family consent. Physician order review revealed there was no evidence the physician had ordered or given medical justification for Resident #3's use of side rails as a restraint. Clinical record review revealed the facility had not completed the Restraint Assessment form for Resident #3 and there was no other documented evidence that the facility had assessed the risk/benefits of using side rail restraints, obtaining family consent for restraint use or medical justification in any other part of the record. Clinical record review and interview with the the DON and the Safety Director on 05/09/11, revealed no bed safety check had been completed. On 05/13/11 at 2:30am, observation of Resident #3revealed the resident in bed with one half (1/2) side rail engaged on the right side and the left side of the bed was against the wall. Interview with CNA #6 on 05/13/11 at 2:00pm revealed Resident #3 used the side rails to turn from side to side. Interview with South Wing Unit Manager, on 05/09/11 at 1:20pm, revealed she did the initial side rail evaluation, relying on her nursing judgment to weigh the risks and benefits of side rails for the resident; however there was no documented evidence of the risks and benefits being considered for each resident. Interview with LPN #3, on 05/12/11 at 8:15am, revealed LPN #3 stated she was not sure who was responsible to complete the side rail evaluations. According to LPN#3, the unit nurses did not complete assessments. Interview with the DON, on 05/13/11 at 11:30am, revealed the DON was not aware nursing had assessed side rails as restraints on the monthly summaries for some residents and confirmed that the facility had not completed bed safety checks, per the facility policy.

Based on observation, interview, and record review it was determined the facility failed to have an effective system to ensure residents' comprehensive care plans were reviewed and revised for three (3) (Residents #1, #2, and #3) of the twelve (12) sampled residents. The facility failed to revise the care plans to detail the required individualized air mattress settings for Residents #1, #2, #3. On 04/30/11, the facility found Resident #1 entrapped between the low air loss mattress and the side rail. The resident's entrapment resulted in bruising and skin tears to the chin and shins bilaterally. (Refer to F323) Based on the above findings, it was determined the facility's failures to review and revise residents care plans, had caused or was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on 04/30/11 and determined to exist on 05/10/11 and is ongoing. The findings include: 1. Review of the air mattress manufacturer's guidelines provided by the facility, a resident weighing one hundred twenty five (125) pounds should have a setting of four (4). Record review revealed the facility admitted Resident #1 to the facility on [DATE], with the [DIAGNOSES REDACTED]. The comprehensive plan of care, dated 09/19/10, identified the low air loss mattress as an intervention under pressure ulcer. However, the care plan did not include the required settings for the low air loss mattress based on the resident's current weight. Record review revealed the facility weighed resident #1 on 04/08/11 and detailed his/her weight as 125.2 pound which based on the guideline required an air mattress setting of four (4). Observation of Resident #1, on 05/10/11 at 5:40am, 5:45am, 5:55am, and 6:25am revealed Resident #1 was positioned on the right side, a fall mat was on left side of the bed, the bed in the low position, and the right side of the bed against the wall. Bilateral side rails were engaged in the one half (1/2) rail position. Observation of the air mattress control panel revealed all ten (10) lights were lit indicating maximum inflation, along with the float light. Interview with CNA #3, on 05/10/11 at 6:00am, revealed she was unaware of the correct settings for the low air loss mattress for Resident #1. Interview with CNA #2 on 05/10/11 at 4:25pm revealed she thought the setting for Resident #1's bed should be five (5). 2. Record review revealed the facility admitted Resident #2 on 06/29/10 with [DIAGNOSES REDACTED]. The facility assessed the resident on 03/04/11 as utilizing one quarter (1/4) side rails for bed mobility, transfers and safety. The resident was on a low air mattress for pressure reduction and the care plan did not detail the air mattress setting as deemed appropriate for the resident's weight. Observation of Resident #2, on 05/06/11 at 3:00pm revealed the resident was in bed with one half (1/2) rail raised on both sides of the bed and lying on a low air loss mattress with a setting of four (4). 3. Record review revealed the facility admitted Resident #3 on 04/20/05 with [DIAGNOSES REDACTED]. Observation of Resident #3 on 05/10/11 at 6:00am revealed the low air loss mattress setting at a six (6), the recommended setting for the resident's weight of 176. Interview with LPN #3, on 05/09/11 at 11:00am revealed she would use the low air loss mattress setting located in the care plan, but then stated "Honestly, don't know where the settings are located." Interview with the DON on 05/09/11 at 8:10am revealed the MDS Coordinator usually did the care plans. The Assistant Director of Nursing updated the CNA care plans. Further interview at 1:00 PM revealed it was the unit managers responsibility to update the care plans and the quarterly updates were completed by the interdisciplinary team. Interview with the MDS Coordinator on 05/09/11 at 8:30am, revealed she was responsible for the comprehensive care plan. Further interview with LPN #3 on 05/12/11 at 8:15am revealed she was the part time MDS Coordinator. She stated the care plans were updated by the MDS Coordinator and was the staff's responsibility to look at the care plan.

Based on observation, interview, record review, facility policy review, and low air loss mattress manufacturer ' s guideline, it was determined the facility failed to ensure adequate supervision with regard to assistive devices to prevent accidents for three (3) residents ( Resident #1, #2, and #3) of the twelve (12) sampled residents. The facility failed to ensure staff was knowledgeable with regards to the Bed Safety Policy and failed to ensure the policy was implemented as the facility had not completed quarterly bed safety inspections to identify potential entrapment risks. The facility failed to ensure staff was knowledgeable and trained for the use of the air mattress system and the appropriate settings for three (3) residents. Additionally, the facility failed to assess and ensure only residents who were safe and appropriate for the use of side rails had them engaged. On 04/30/11, the facility found Resident #1 entrapped between the low air loss mattress and the side rail. The resident's entrapment resulted in bruising and skin tears to the chin and shins bilaterally. Based on the above findings it was determined the facility's failure to have an effective system in place to assess residents' safety when utilizing half side rails with an air mattress was likely to cause serious injury, harm impairment or death. Immediate Jeopardy and Substandard Quality of Care was determined to exist on 04/30/11 and is ongoing. The findings include: Review of the side rail evaluation form revealed it would be completed upon admission to the facility and used to determine whether side rails will be utilized and if they are considered for bed mobility, transfer, rolling out of bed, or to provide a sense of security. Interview with the DON, on 05/06/11 at 2:30pm, revealed she did not have policies specific to side rails. Review of the facility's Bed Safety policy dated 2001 with a revision date of 08/2006, revealed the Director of Nursing (DON) or designee and the Safety Officer or designee shall inspect all hospital beds at least quarterly to identify potential areas of entrapment and ensure no gaps exceed the dimensional limits established by the FDA. The facility will impose additional safety measures for residents who have been identified as high risk for entrapment. Inspection results shall be reviewed quarterly by the Quality Assurance (QA) Committee and the inspection results and the QA Committee recommendations shall be maintained in the business office. If side rails are utilized for any reason, the decision must be based on an interdisciplinary assessment of the resident, as well as the input from the resident and/or legal guardian. Consent must be obtained and the family/resident must be informed of the potential hazards prior to their use including the risk of entrapment and falls. The resident will be checked frequently for safety and if the side rails are associated with a decline in function, such as screaming or agitation, the resident's needs will be reassessed. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment. Interview with the DON, on 05/09/11 at 1:00pm, revealed she was unable to provide evidence of the bed safety checks, which the facility's policy stated should have been completed quarterly. Interview with the Maintenance Director, on 05/09/11 at 2:20pm, revealed he inspected the electrical components of the beds and did not inspect the beds for areas which could potentially result in entrapment. Interview, on 05/09/11 at 2:25pm, with the Safety Director revealed she was not aware of the Bed Safety policy or her responsibility to complete quarterly bed safety checks until after the incident with Resident #1. Therefore, the Safety Director could not provide any evidence of bed safety checks done prior to the incident. Interview with the Administrator, on 05/09/11 at 2:30pm, revealed he was not aware bed safety checks were to be done quarterly. Review of the manufacturer's manual for the MaXair mattress stated each light represents approximately 30-40 pounds of body weight. Patient weight recommendations for air mattress settings 1-3 is 100 pounds or less, setting 4 is 100-140 pounds, setting 5 is 140-175, setting 6 is 175 -210, setting 7 is 210-240, setting 8 is 240-280, setting 9 is 280-315, and maximum setting 10 is 315-350. Interviews with LPN #3 (on 05/09/11 at 11:00am), LPN #2 (on 05/09/11 at 3:20pm), CNA #3 (on 05/10/11 at 6:00am), and CNA #2 (on 05/07/11 at 5:40am) revealed that these staff had not been trained on the MaXair mattress that the facility utilized for three residents. These staff was unable to detail how much body weight each light on the control panel represents. Furthermore, they were not able to detail what the appropriate settings should be for those residents who used the air mattress. While interview with the Staff Development Coordinator, on 05/12/11 at 8:45am and 3:55pm, revealed the CNA staff had been trained on the low air loss mattress, the facility could provide no documented evidence that they had tested after the training to ensure staff competence with the use of the air mattress. Observation on 05/06/11 at 3:00pm revealed only three residents had low air loss mattresses. Review of the Food and Drug Administration guidelines for Hospital Bed Dimensional Limit Recommendations are as follows: Zone 1-within the rail- (less than four and three fourths (4 3/4) inches); Zone 2-under the rail, between rail supports or next to a single rail support- (less than four and three fourths (4 3/4) inches); Zone 3-between rail and mattress- (less than four and three quarter (4 3/4) inches); Zone 4-under the rail, at the ends of the rail- (less than two and three eights (2 3/8) inches AND greater than a sixty (60) angle. Interview with the DON, on 05/06/11 at 2:30pm, revealed she was not aware of the specific measurements the FDA required for spacing between the mattress and the side rail and did not have policies for the low air loss mattress or side rails. 1.Review of the clinical record for Resident #1, revealed the facility admitted the resident on 08/31/06 with [DIAGNOSES REDACTED]. Review of the fall care plan dated 10/05/08 revealed half side rails were used for the alternating air mattress. The facility assessed the resident on 03/16/10 as a high risk for falls. On 03/16/10 the facility completed a side rail evaluation and determined quarter side rails would be used for Resident #1 due to the use of an air mattress and to avoid rolling out of bed. Resident #1 was readmitted on [DATE]. The facility reassessed the resident on 01/12/11 as a high risk for falls. On 01/12/11 upon readmission to the facility, the facility completed a side rail evaluation which determined quarter rails would continue to be used for Resident #1 due to the use of an air mattress and to avoid rolling out of bed. Review of the monthly summary, dated 02/02/11, revealed the facility determined side rails were a restraint for resident #1; however, there was no evidence staff completed the facility ' s Restraint Assessment Form or received a physician's order [REDACTED]. Review of the care plan for Resident #1, dated 09/24/10 reviewed March 2011, revealed it did not include a plan or interventions specific to the use of side rails, a restraint, or risk for falls; however, it detailed the use of the low air loss mattress but did not specify the settings specific for this resident. Record review revealed the facility weighed resident #1 on 04/08/11 and detailed his/her weight as 125.2 pounds. Record review and interview on 05/09/11 with the Director of Nursing and the Safety Director revealed the facility had no documented evidence that they had completed a bed safety review of resident #1. Review of a nursing note, dated 05/01/11 at 0010 (12:10am), revealed Resident #1 was found on the floor between the side rail and the bed. Observation by the nurse of the resident before the fall revealed the resident was positioned in bed properly. A skin assessment of the resident after being assisted to a sitting position revealed the right leg with a 2.5 x 1 cm skin tear, the left leg had a 1.5 x 1.5 x 1.5 cm skin tear, the right cheek revealed a skin tear 3.5 x 1.5 cm, a bruise was noted on the chest 10 x 7.5 cm, the left elbow had a 10 x 8.5 cm skin tear and the left forearm had a 3.5 x 4.1 x 0.5 cm skin tear and bruising was noted on the chin. Review of the facility's investigation report, dated 05/02/11, revealed on 04/30/11 at 11:20pm Resident #1 was heard calling for help from within his/her room. Certified Nurse Aide (CNA) #2 responded and found the resident on the floor, beside and facing the bed. The Licensed Practical Nurse (LPN) #1 entered the room to assist CNA #2 and the resident. LPN #1 found the resident on his/her knees with his/her head between the side of the mattress and the side rail. The resident sustained [REDACTED]. The low air loss mattress was being used for maintenance of skin integrity Review of the investigative report and the fall circumstance investigation revealed no documented evidence the facility identified the settings of the low air loss mattress settings at the time of the incident nor the type of side rail utilized by the resident or the side rail position at the time of the incident. The Certified Nursing Care Plan, with a revision date of 05/02/11, did not detail any information on the low air loss mattress, the required settings for the air loss mattress or the side rail position for the resident. Review of the monthly nursing summary dated 05/08/11 revealed the facility had assessed the resident ' s use of the side rails as a restraint; however, review of the resident #1 ' s care plan revealed no evidence of the use of side rail or interventions developed specific to their use. Review of the clinical record as of 05/09/11 revealed there was no documented evidence that the facility had determined the appropriate setting related to the low air loss mattress for Resident #1's use. Observation of Resident #1 on 05/10/11 at 5:40am 5:45am, revealed Resident #1 was positioned on the his/her right side lying in the bed. The bed was in the low position with the right side of the bed against the wall. Bilateral side rails were engaged in the one half (1/2) rail position and a fall mat was on left side of the bed. The air mattress control panel had (10) lights lit indicating maximum inflation along with the float light. A setting of ten 10 is recommended for persons who weigh 315-350 pounds; however, Resident #1 weighed 125.2 pounds, per the clinical record. Review of the MaXair Manufacturer ' s guidelines revealed persons weighing 125.2 pounds should have the air mattress set at level four (4) for persons weighing between 100 -140 pounds. Interview with LPN #1 while observing Resident #1 and the air mattress panel, on 05/09/11 at 5:45am, confirmed the air mattress control panel was set with (ten) 10 lights lit and the mattress float button was lit. She stated she did not know the correct setting of the mattress and did not know where to locate the low air loss mattress information. Interview with CNA #3, on 05/10/11 at 6:00am, revealed she was responsible for Resident #1 on the night shift. She did not change the mattress settings and did not know the setting was on ten (10). She stated she was unaware of the correct settings for the mattress specific to this resident. Interview with CNA #2, on 05/10/11 at 4:25pm, revealed she thought the setting for Resident #1's bed should be five (5). The CNA stated she had put the resident to bed the on 05/09/11 but did not change the setting of the air mattress. Continued observations of Resident #1 at 5:55am, and 6:25am revealed the resident remained in the same position with bilateral side rails engaged in the one half (1/2) rail position. All (10) lights were lit on the low air loss mattress control panel indicating maximum inflation along with the float light. On 05/10/11 at 5:40am, observation of the skin assessment performed by LPN #1 revealed Resident #1 had a bruise on the upper chest wall (midline), left elbow, right side of the cheek and skin tears on both shins and under the chin. Observation and interview with the Administrator, on 05/10/11 at 6:25am, revealed the resident's air mattress setting remained at a setting of ten (10) with side with bilateral side rails engaged in the one half (1/2) rail position, the Administrator stated the air mattress should not be on maximum inflation and he proceeded to adjust the air mattress setting to a four (4) and placed the air mattress on lock mode. Record review revealed no documented evidence that the facility reassessed for bed safety or appropriateness for the use of side rails with an air mattress until 05/10/11, ten (10) days after the entrapment. At which time the facility completed only a falls risk assessment which indicated a score of fifteen (15) which is high risk potential for falls and completed a side rail evaluation form which detailed they were used due to the air mattress, to prevent the resident from rolling out of bed and for a sense of security. There was no evidence that the facility had conducted a bed safety check, per their policy or had initiated a restraint assessment despite having four nursing monthly summaries, dated 02/08/11, 03/08/11, 04/08/11 and 05/08/11, detailing the side rails were a restraint for resident #1. Additionally, observation of Resident #1 on 05/13/11 at 11:25am revealed the facility continued to utilize one half (1/2) rails raised on both sides of the bed. 2. Record review revealed the facility admitted Resident #2 on 06/29/10 with [DIAGNOSES REDACTED]. Review of the side rail evaluation, dated 03/04/11, revealed the facility determined side rail use was necessary due to the air mattress, to prevent the resident from rolling out of bed and for a sense of security; however, there was no documented evidence the facility had completed a bed safety check prior to the implementation of the side rails. Review of the MDS Assessment, dated 03/17/11, revealed the facility assessed the resident as having severely impaired cognition. Review of the care plan, dated 03/22/11, revealed no documented evidence the care plan detailed the required settings for the low air mattress or detailed the use of side rails. Observation, on 05/10/11 at 5:40 am, revealed the resident was lying in bed with the air mattress inflated at setting four with bilateral half side rails engaged. Further review of the record revealed there was no evidence the facility had completed a bed safety check to ensure the appropriateness of the use of side rails with the air mattress. Interview with the DON and Safety Coordinator confirmed that they had no evidence that the bed safety checks had been completed per facility policy. 3. Record review revealed the facility admitted Resident #3 on 04/20/05 with the [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 08/05/10, revealed the facility assessed the resident as having impairment cognition. Review of the current care plan revised 02/11 did not include the low air mattress settings specific to the resident or include the use of side rails as an intervention. However, observation on 05/06/11 at 2:45 p.m. revealed resident #3 had an air mattress with a quarter rail engaged on the right side of the bed and the bed was against the wall on the left. However, record review revealed there was no documented evidence the facility had completed a bed safety check, per the facility policy or had completed a side rail evaluation prior to the implementation of their use. The resident was not assessed for the use of side rails until 05/10/11. Interview, on 05/12/11 at 1:00pm, with the Unit Manager of the South wing, revealed the admission nurse was responsible for completing the fall and side rail assessment on admission. She thought the MDS Coordinator was responsible to do the quarterly fall assessments and the side rail assessments should be completed quarterly. The Unit Manager stated if assessments were not completed, the care plan may not be accurate and the resident would not receive appropriate care. Interview with the DON, on 05/06/11 at 2:30pm and on 05/09/11 at 8:10am and at 1:00pm, revealed four residents had low air mattresses in the facility. The facility is responsible to ensure the low air mattress is correctly inflated. The DON stated the outcome of Resident #1 getting trapped in the assist rail could have been "disastrous". She stated the unit nurse is responsible for doing fall and side rail assessments. The Assistant DON is responsible to ensure the Certified Nursing Assistant Care Plans are updated and should include the settings for the low air loss mattress. The settings for the mattress are not written in the record but kept in a folder in the DON's office. The manual for the low air loss mattress is also kept in the DON office and not on the nursing units. She further revealed the low air loss mattress setting was not documented on the investigative report but the setting was an important piece of information that should have been included. However, staff did not have access to the settings as they were kept in her office. In addition, she was unable to provide evidence of the bed safety checks, which the facility's policy stated should have been completed quarterly.

Based on observation, interview, record review and the bed safety policy review, it was determined the facility failed to ensure all staff were trained on the proper use of the low air loss mattress, failed to ensure bed safety checks were completed quarterly on all facility beds, failed to ensure policies were followed and nursing staff completed assessments and bed safety checks to identify safe use of assistive devices/restraints for five (5) residents, (#1, #2, #3, #4, and #11) of the twelve (12) sampled residents. The facility failed to ensure care plans were updated to reflect air mattress setting needs for three (3) residents (#1, #2, #3). On 04/30/11, the facility found Resident #1 entrapped between the low air mattress and the side rail causing multiple skin tears and bruising to the resident's body. Based on the above findings, it was determined the facility's failures to implement their policies and procedures, train staff on the use of a low air loss mattress, complete bed safety checks quarterly, complete assessments, develop and revise care plans related to side rails, falls risk, air mattress settings and restraints placed the residents in a situation that was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on 05/10/11, determined to exist on 04/30/11, and is ongoing at 42 CFR 483.13, F221 at a scope and severity of a "J", 42 CFR 483.20 Resident Assessments, F280 at a scope and severity of a "J", 42 CFR 483.25 Quality of Care, F323 at a scope and severity of a "J" and 42 CFR 483.75 Administration, F490 at a scope and severity of a "J". Substandard Quality of Care was identified at 42 CFR 483.13, F221 and 42 CFR 483.25, F323. (Refer to F280, F221, F323) The findings include: The facility Bed Policy dated 2001 with a revision date of 08/2006, revealed the Director of Nursing (DON) or designee and the Safety Officer or designee shall inspect all hospital beds at least quarterly to identify potential areas of entrapment and ensure no gaps exceed the dimensional limits established by the FDA. The facility will impose additional safety measures for residents who have been identified as high risk for entrapment. Inspection results shall be reviewed quarterly by the Quality Assurance (QA) Committee and the inspection results and the QA Committee recommendations shall be maintained in the business office. The facility did not ensure five (5) Resident's (#1, #2, #3, #4, and #11) of twelve (12) sampled residents who were restrained had medical justification, a physician's orders [REDACTED]. The facility did not ensure staff was knowledgeable regarding their restraint assessment system. Furthermore, the facility did not ensure restraint assessments determined the benefits of restraint use outweighed the risks for the resident and failed to ensure a physician's orders [REDACTED]. (Refer to F221) On 03/16/10, the facility's side rail evaluation detailed that the resident used the side rail due to the air mattress and to avoid rolling out of the bed. On 02/02/11, the nursing monthly summary assessed and determined side rails were a restraint for Resident #1; however, the facility had no documented evidence that they assessed to determine the benefits outweighed the risks, had medical justification, family/resident consent for the use of the restraint or a physician's orders [REDACTED].#1 to identify potential entrapment risks related to the use of the side rails as a restraint. On 04/30/11, Resident #1's neck became entrapped between the low air loss mattress and the side rail causing bruising and skin tears to the chest, chin and legs. Observations on 05/10/11 at 5:40 a.m. revealed the facility continued to use bilateral side rails and did not ensure that the air mattress settings were appropriate to the resident's weight. Observation of the control panel detailed the resident's air mattress was set at ten (10) maximum inflation; however, review of the [MEDICATION NAME] Manufacturer's guidelines revealed the setting for a resident weighing 125 pounds should be set at four (4). Record review revealed Resident #1 weighing 125.2 pounds. Observation and interview with the Administrator, on 05/10/11 at 6:25am, revealed the resident's air mattress setting remained at a setting of ten (10) with side with bilateral side rails engaged in the one half (1/2) rail position, the Administrator stated the air mattress should not be on maximum inflation and he proceeded to adjust the air mattress setting to a four (4) and placed the air mattress on lock mode. (Refer to F323, F221, F280) Record review and interview with the Director of Nursing and the Safety Officer, on 05/09/11, revealed the facility had not followed the bed safety policy as they had not completed quarterly bed safety inspections to identify potential entrapment. Interview with the DON revealed that the manufacturer's guideline for the air mattress was maintained in her office and not available for staff to utilize. Therefore, the facility did not ensure staff was knowledgeable and trained for the use of the air mattress systems and appropriate settings for each resident's use. (Refer to F323) The facility did not have an effective system to ensure residents' comprehensive care plans were reviewed and revised for three (3) residents (#1, #2, and #3) of the twelve (12) sampled residents. The facility did not revise the care plans to detail the required individualized air mattress settings for Residents #1, #2, #3. (Refer to F280) Interview with the Administrator on 05/09/11 at 2:30pm, on 05/10/11 at 10:00am revealed he was unaware of the facility bed safety policy requirements to inspect all facility beds quarterly to ensure safety from entrapment zones. He could provide no documentation of the bed inspections. He stated Resident #1 was possibly not positioned properly on the low air loss mattress and this caused him/her to fall out of bed. He stated Resident #1 could have had a tragic outcome from this incident. Interview with the Administrator revealed the facility switched to a different company for the low air loss mattress in March of 2010. He was not aware there were concerns with the mattress. He did not review the investigative report, but relied on staff and information shared in morning meetings to keep him informed of concerns.