Every finding on record at Twin Rivers Nursing and Rehabilitation Center

Based on interview, record review, and review of facility policy, the facility failed to issue the resident or their representative a written notification of transfer when the resident was transferred to the hospital for five (5) of five (5) sampled residents reviewed for emergency transfers out of a total sample of 25 residents, Resident (R)29, R36, R48, R73, and R199. The facility did not have a system in place for sending written notification of transfer to residents or their representatives. This created the potential for the resident and/or their representative to have incomplete information related to the reason for transfer, location of transfer and/or how to appeal the transfer, if desired. The findings include: Review of the facility's policy titled, Admission, Discharge, and Transfer Standard of Practice, dated 10/2020, revealed the purpose of the policy is to ensure the process of admission, discharge, and transfer meets regulatory requirements. Discharge/Transfer: . 2. Before the facility transfers or discharges a resident, the facility shall a) Notify the resident and resident representative to include the reason in a language and manner they understand .c) Notice of transfer or discharge will be made with at least 30 days notice for a safe transition; or as soon as practicable when .iii. An immediate transfer or discharge is required due to urgent medical needs. Further review of the policy, revealed it failed to address the requirement to provide written notice to the resident and the resident's representative(s) regarding transfer. 1. Review of R29's undated Admission Face Sheet located in the resident's Electronic Medical Record (EMR) under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of R29's EMR Progress Notes, located under the Progress Notes tab, revealed the Nurse's Status Note, dated 06/12/2024, stated new orders were received to send the resident to the hospital emergency room (ER) to evaluate and treat. The Assistant Director of Nursing (ADON) and Power of Attorney (POA) were notified. Further review of R29's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 06/12/2024. 2. Review of R36's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with diagnoses which included bipolar disorder, COPD, and chronic respiratory failure. Review of R36's Nurse's Progress Note, dated 03/08/2024 and located in the resident's EMR under the Progress Notes tab, revealed, At 1500 [3:00 PM] Resident was found on floor left side of bed face down .resident had just been in bed she had been very restless and anxious unable to redirect .resident assessed no injury noted no c/o [complaints of] or s/s [signs/ symptoms] of pain. Resident assisted back into bed per staff resident refused to let nurse get vitals and obtain full set of neuros .resident taking off O2 [oxygen] wont [sic] leave it on ripping out her hair very anxious and restless .call placed to [Medical Director] gave orders to send out to ER for eval [evaluation]. Call placed to EMS [Emergency Medical Services]. EMS arrived and took the resident out of facility at 1530 [3:30 PM]. Further review of R36's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 03/08/2024. Review of R36's Nurse's Progress Note, dated 04/03/2024 and located in the resident's EMR under the Progress Notes tab, revealed, Resident arrived [readmitted ] at facility by stretcher per EMS and taken to her room . Review of R36's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During an interview, on 07/24/2024 at 12:05 PM, R36 was questioned related to what kind of paperwork she received during her most recent transfer to the hospital. R36 stated she did not remember the facility giving her any written paperwork. 3. Review of R48's undated Admission Face Sheet, located in the EMR under the Face Sheet tab, revealed the facility admitted the resident on 01/18/2024 and readmitted the resident on 06/03/2024, with diagnoses which included polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) and chronic kidney disease. Review of R48's EMR Progress Notes, located under the Progress Notes tab, revealed the Nurse's Status Note, dated 05/30/2024, stated, Resident being transported non-emergent via EMS [Emergency Medical Service] to the hospital at this time; r/t [related to] x-ray report of likely fracture to femoral head. Resident left facility at 11:15 AM. Direct admit to [room number]. All parties aware . Further review of R48's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 05/30/2024. During an interview, on 07/23/2024 at 1:50 PM, Family member (F) 48 stated, I did not receive anything in writing from the facility about her transfer to the hospital. 4. Review of R73's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included unspecified dementia and type II diabetes mellitus with hyperglycemia. Review of R73's Nurse's Progress Note, dated 06/14/2024, located in the resident's EMR under the Progress Notes tab, revealed, Resident noted with gradual decline so far this shift. Refuses to keep NC [nasal cannula] in place, O2 [oxygen] sat [saturation] declines to 75-84% [percent] on RA [room air]. Staff attempt to replace NC without success. Phoned [Medical Director] to make aware and received order for 40 mg [milligram] IM [intramuscular] Lasix [a diuretic medication]. BP [blood pressure] 100/48 so unable to administer Lasix safely. Attempted to notify [Medical Director] but on call hours had began [sic]. Phoned on call MD [medical doctor] .Order received to send resident to .ED [emergency department] for evaluation. EMS here at 12:10 [PM] to transport resident. Further review of 73's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 06/14/2024. Review of R73's readmission Nurse's Progress Note, dated 06/15/2024 and located in the resident's EMR under the Progress Notes tab, revealed Resident arrived to facility per EMS at 1500 [3:00 PM] transferred to bed per EMS and staff . During an interview, on 07/23/2024 at 12:41 PM, Family Member (F) 73 stated she had received bed hold notices and policies during R73's hospital transfers; however, she had never received anything in writing about the resident's transfer including appeal rights. 5. Review of R199's undated Admission Face Sheet located in the EMR under the Face Sheet tab, revealed the facility admitted the resident on 07/10/2024 and readmitted the resident on 07/22/2024, with diagnoses which included femur fracture and Chronic Obstructive Pulmonary Disease (COPD). Review of R199's EMR Progress Notes located under the Progress Notes tab, revealed the Nurse's Status Note, dated 07/19/2024, stated Resident ambulating from room to hallway and fell . As she attempted to ambulate around her w/c [wheelchair] she tripped on the left w/c leg/pedal . ROM [Range of Motion] severely limited, length disproportionate. MD [Medical Doctor] notified with new orders to send to ER [emergency room ] to eval [evaluate] and treat. Emergency contact- Husband [name] notified at this time . Further review of R199's EMR, revealed there was no documented evidence of a written transfer notice sent to the resident/resident representative regarding the hospital transfer on 07/19/2024. During an interview, on 07/25/2024 at 1:15 PM, the Administrator stated, We do not provide written notification of transfers to the resident or their representative. 36898

Based on observation, interview, and review of facility policies, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. These failures had the potential to affect all 95 residents in the facility who consumed food from the kitchen. The findings include: Review of the facility's policy titled, Food Storage: Cold Foods, dated 02/2023, revealed All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA [Food and Drug Administration] Food Code .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy titled, Environment, dated 09/2017, revealed All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces .All food contact surfaces will be cleaned and sanitized after each use. On 07/23/2024, the following observations in the kitchen were identified and verified by the Dietary Manager (DM) and the District Manager. 1. Observation at 8:43 AM, revealed the freezer contained one (1) bag of hamburgers, (1) bag of cookie dough and one (1) bag of dinner rolls that were not sealed. 2. Observation at 9:00 AM, revealed the sanitizer was not dispensing sanitizer from the Eco Lab dispenser; therefore, the sanitizing part of the three (3) pan sink, and red sanitizing buckets had no sanitizer in them. The Surveyor asked the Dietary Manager to test the sink and the red bucket for sanitizer. No sanitizer registered with the test strips. The DM then added the sanitizer to the sink by hand and mixed it with water and the sanitizer registered. 3. Observation at 11:00 AM, revealed 60 plastic drinking cups and coffee mugs to be used for lunch were not allowed to air dry and were wet on the inside. They were stored stacked in a plastic container beside the tray line to be used for lunch. During this observation, the Dietary Manager asked dietary staff to rewash the cups. 4. Observation at 11:00 AM, revealed there were five (5) plastic cups that had a dried milky like substance and what appeared to be dried food particles on the inside of the cups that were to be used for lunch. The plastic cups were stacked in the dish washing room. During this observation, the Dietary Manager asked dietary staff to rewash the cups. 5. Observation at 11:00 AM, revealed there were six (6) dirty plates with what appeared to be dried food particles in the plate warmer that were ready to be used for lunch. They were stacked in the plate warmer beside the tray line. During this observation, the Dietary Manager asked dietary staff to rewash the plates. 6. Observation at 11:00 AM, revealed the dirty dishes and dishwasher were in the same room with clean dishes. When the dirty dishes and trays came through a window, a dietary staff member sprayed them before sending the dishes through to the dishwasher. The dirty spray from the dirty dishes was contaminating the clean cups and dishes which were on a rack in the same room. 7. Observation at 11:00 AM, revealed the 32 kitchen trays the residents used to serve the residents their meals had plastic pieces missing from the corners and edges. Interview with the Dietary Manager during the observation revealed new trays had been ordered. During an interview on 07/26/2024 at 3:26 PM, the District Manager stated, It is my expectation for the kitchen to be fully functional, sanitary, and timely. During an interview on 07/26/2024 at 3:21 PM, the Administrator stated, It is my expectation for the kitchen to follow policies and standards.

Based on observation, interview, and record review, the facility failed to ensure the Resident Council's right to have their group meeting without staff present was honored and promoted for seven (7) of seven (7) residents reviewed for Resident Council resident rights out of a total sample of 25 residents, Resident (R)6, R12, R21, R38, R54, R56, and R63. This failure violated the residents' right to autonomy and to be able to bring up concerns without staff present. The findings include: R6, R12, R21, R38, R54 (Resident Council President), R56, and R63 attended the Group Interview conducted by the Surveyor on 07/25/2024 at 10:00 AM, in the Main Dining Room. Observation on 07/25/2024 at 10:00 AM, revealed two (2) activity staff and a dietary staff member sitting in the dining room for the meeting. When the Surveyor explained to the facility staff, the Group Interview meeting was closed to staff members of the facility unless a resident requested their presence, the staff exited the meeting. During the Group Interview, on 07/25/2024 at 10:06 AM, the group was asked if they regularly attended the Resident Council meetings. R38 stated she used to; however, she did not regularly attend anymore because staff ran the council meeting and not the residents. In continued interview, R38 stated in November 2023 or December 2023, she approached the Activity Director (AD) who ran the group, and explained to her the residents were supposed to be the ones who ran the group and not her. However, the AD informed R38, she was the one who had to conduct the meeting. R38 stated it was not a safe space if they had a concern about staff, but could not fully express it in fear of staff not keeping it confidential. All residents agreed with R38's concern. 1. Review of R6's undated Admission Face Sheet, located in the resident's Electronic Medical Record (EMR) under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R6's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated intact cognition. 2. Review of R12's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R12's quarterly MDS with an ARD of 05/30/2024, revealed the facility assessed the resident to have a BIMS score of 13 out of 15 which indicated intact cognition. 3. Review of R21's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE]. Review of R21's quarterly MDS with an ARD of 05/07/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. 4. Review of R38's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R38's quarterly MDS with an ARD of 05/10/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. 5. Review of R54's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R54's quarterly MDS with an ARD of 05/17/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. 6. Review of R56's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Review of R56's quarterly MDS with an ARD of 06/04/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. 7. Review of R63's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R63's quarterly MDS with an ARD of 06/07/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated intact cognition. During an interview, on 07/25/2024 at 10:54 AM, the AD stated she had been in her position since December 2023. When asked if residents could have the Resident Council meeting without her or other staff present, the AD stated she had been told she was required to attend the Resident Council meetings. The AD did not remember who told her she was required to attend the meetings. The AD further stated she did remember R38 telling her the meetings were to be run by the residents and not the staff and the residents did not want staff to attend. However, the AD stated she was not aware residents could hold the meetings without staff present. During an interview, on 07/26/2024 at 5:34 PM, the Administrator stated it was his expectation the facility would follow the regulatory requirement to allow residents privacy during the resident council group.

Based on interview, record review, and review of facility policy, the facility failed to ensure medication was administered according to professional standards of practice for one of 25 sampled residents, Resident (R) 81. This failure placed R81 at risk for inappropriate behavior, confusion, and disorientation. The findings include: Review of the facility's policy titled, Medication Administration Standard of Practice, dated 10/2020, revealed Medications will be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders, including any required time frame .The individual administering the medication must sign the resident's MAR/TAR [Medication Administration Record/ Treatment Administration Record] after giving each medication, along with any additional prior or follow up requested information. Review of R81's undated Admission Record located in the resident's electronic medical record (EMR) under the Resident tab, revealed the facility admitted the resident on 01/26/2024 with diagnoses which included lung cancer under Hospice care. Review of R81's Telephone Physician's order, provided by the facility, revealed orders for Ativan Intensol [anti-anxiety medication] [two] 2 mg [milligram] per [one] 1 ml, [one] 1 ml [milliliter] by mouth every [six] 6 hours for anxiety and sleep. This telephone order was undated and untimed, had no physician's signature, and was not placed into the Electronic Medical Record (EMR) order system. Review of the Patient Controlled Substance Administration Record-Liquids form, revealed Registered Nurse (RN) 3 signed as receiving 30 ml of Ativan from pharmacy on 03/14/2024. A sticker from pharmacy was attached to the controlled substance record which revealed R81's name and Lorazepam 2 mg/ml, generic for Ativan. Give 0.5 ml (1MG) by mouth every [six] 6 hours as needed for up to 10 days. Kentucky Medication Aide (KMA)1 initialed the form to indicate a 1.0 ml dose of Ativan was administered to R81 on 03/14/2024 at 0000 [12:00 AM], leaving a balance of 29 ml. [Therefore, 2 mg was administered instead of the 1 mg that was to be administered according to the sticker on the controlled substance record.] Review of R81's Medication Administration Record (MAR), dated March 2024, located in the resident's EMR under the MAR/TAR [Treatment Administration Record] tab, revealed no record of the Ativan medication being administered. Review of R81's Progress Note, dated 03/14/2024 at 6:42 AM, located in the EMR under the Documentation tab and the Progress Note tab, revealed Resident received new order for PRN [as needed] Ativan Intensol with medication delivered from pharmacy last night. First dose administered as requested. Soon after administration, the resident became very confused and disoriented. Staff entered the room to find [R81] undressed and sitting on the edge of his bed. [R81] was making multiple sexually inappropriate comments toward all staff but could be verbally redirected. Resident soon calmed and rested the remainder of the shift. Spoke with pharmacy about the directions on the medication bottle. The physician wrote an order for [one] 1 ml every [six] 6 hours PRN; however, the bottle read 0.5 ml every [eight]8 hours PRN [as needed]. Clarification from physician this morning was to follow directions as filled on script for 0.5 ml every 8 hours PRN. Review of a second telephone order provided by the facility, revealed an order clarification dated 03/14/2024, at 7:15 AM, for Ativan Intensol [two] 2 mg/ml, 0.5 ml by mouth every [six] 6 hours as needed PRN. Registered Nurse (RN)3 signed the order. During an interview, on 07/26/2024 at 6:55 AM, RN3 stated, The KMA gave the medication to the resident. I called the physician to confirm the dosage and write the new order that the physician signed. The Surveyor attempted to interview KMA1 by phone; however, the KMA did not respond to the calls. During an interview, on 07/25/2024 at 3:30 PM, the Director of Nursing (DON) stated, The order lacks the date and time as it was written, who wrote the order, and if the order was a verbal order. This is an incomplete order, and the resident was given the wrong dose according to the pharmacy label on the narcotic count sheet. During an interview, on 07/25/2024 at 4:16 PM, the Medical Director stated, I do not write a paper medication order. All orders are in the EMR. I would never write an order for Ativan. During an interview, on 07/26/2024 at 3:34 PM, the Administrator stated, My expectation for the medication administration is that nursing follows the protocols for professional standards of practice.

Based on observation, interview, and record review, the facility staff failed to administer a tube feeding as ordered by the physician for one (1) of two (2) residents reviewed for tube feeding out of a total sample of of 25 residents, Resident (R) 51. This failure had the potential for unplanned weight loss. The findings include: Review of R51's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR), revealed R51 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral aneurysm, chronic obstructive pulmonary disease, respiratory failure with hypoxia, gastrostomy status, and tracheostomy status. Review of R51's Physician's Orders located under the Orders tab in the EMR, revealed an order, dated 06/05/2024, for Glucerna 1.5 calorie 1210 ml/day (milliliters per day) at 55 cc/hour (cubic centimeters per hour) by gastrostomy for 22 hours and to have a 50 cc/hour water flush for 20 hours per day. Review of R51's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/2024, revealed the facility assessed the resident as having short term and long-term memory loss; and as never/rarely making decisions. R51 was also assessed as having a gastrostomy feeding tube. Review of R51's care plan, dated 06/30/2024 and located under the Care Plan tab of the EMR, revealed .there will be no significant weight changes and tolerate enteral feedings/flushes . with an intervention of .Enteral feedings & [and] flushes per [by] order . During an observation, on 07/26/2024 at 12:22 PM, R51's tube feeding pump was noted to be infusing Glucerna 1.5 calorie at 50 cc/hour. During an interview, on 07/26/2024 at 1:02 PM, Licensed Practical Nurse (LPN) 1 stated, I always come into work and check to make sure the feeding is infusing. But to be very honest, I don't always check to make sure the rate is correct, but I should. When asked if she checked the infusion rate this morning, LPN1 stated, I don't remember if I did. During an interview, on 07/26/2024 at 1:30 PM, the Director of Nursing (DON) confirmed the nurse should always check to make sure the enteral feeding pump was set to infuse the rate of the feeding as ordered by the physician.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure pain assessments were completed prior to and after the administration of PRN (as needed) narcotic pain medications for one (1) of two (2)sampled residents reviewed for pain management out of 25 sampled residents, Resident (R)19. R19 was ordered and administered pain medication; however, there was no documented evidence pre or post pain assessments were completed to measure if the medication was effective to ensure the resident's pain was being managed. This failure placed the resident at risk for a decreased quality of life related to uncontrolled pain. The findings include: Review of the facility's policy titled, Pain Management Standard of Practice, dated 07/2020, revealed The facility works to ensure compliance with the regulatory intent of F697, that pain management is provided to residents consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences .5. Monitoring for effectiveness and/or adverse consequences . Review of R19's undated Admission Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet tab, revealed the resident was readmitted to the facility on [DATE] with diagnoses which included chronic pain syndrome and polyneuropathy. Review of R19's Pain care plan, initiated 02/19/2020 and located in the resident's EMR under the Care Plan tab, revealed the resident's Care Plan identified the following problems: Patient has chronic pain in neck and shoulders; Dx [diagnosis] chronic pain syndrome; Dx Polyneuropathy; Resident returned to facility from pain clinic . [Pain Clinic Physician's Name] has now turned over pain management to [Resident's Attending Physician's Name] .[Resident's Attending Physician's Name] sent script at this time. Resident aware and verbalizes understanding; [R19's Name] has chronic pain r/t [related to] impaired mobility, contractures, and dx of OA [Osteoarthritis]. R19 Care Plan goal stated, Will not experience unrelieved pain through next review. R19's Care Plan included interventions of: .Administer medications as ordered and observe for effectiveness and side effects .Notify physician of any unrelieved s/s [signs/ symptoms] of pain . Review of R19's significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/2024 and located in the MDS tab of the electronic medical record (EMR), revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating intact cognition. The facility further assessed R19 as being on a scheduled pain management regimen, receiving PRN (as needed) pain medications, and frequently having pain during the assessment period. Review of R19's Physician orders located in the resident's EMR under the List tab, revealed an order, dated 05/20/2024, for Hydromorphone [narcotic pain medication] 2 mg [milligram] by mouth every [six] 6 hours as needed . Review of R19's Medication Administration Record (MAR), dated July 2024, revealed the resident was being administered the hydromorphone 2 mg tablet medication PRN (as needed). Continued review of R19's MAR revealed no documented evidence the resident's pain was being assessed prior to the administration of the pain medication, nor was the resident's pain being assessed post administration of the pain medication to measure the effectiveness of the pain medication, as of 07/24/2024. During an interview, on 07/24/2024 at 11:51 AM, R19 stated she felt like the facility could do better about controlling her pain. When asked to elaborate, the resident stated once her pain medications took effect, then her pain was better. The resident stated she just received her pain medication with her noon medications, about 30 minutes ago, and she would now rate her pain as a seven (7) out of 10 with 10 being the worse pain possible. During a subsequent interview, on 07/24/2024 at 4:00 PM, R19 stated the nurse came and explained to her she could have her pain medication every six (6) hours if she needed it. R19 further stated she thought her pain medication was scheduled and she did not know she could ask for it after six (6) hours of receiving a dose of pain medication. During record review and interview, on 07/24/2024 at 3:35 PM, Licensed Practical Nurse (LPN) 4 reviewed R19's MAR, dated July 2024, and confirmed there was no documented evidence the resident's pain was being assessed prior to the administration of the PRN pain medication of hydromorphone, nor post administration of the PRN pain medication. LPN4 stated the resident's MAR did not contain a pre or post pain level, but should have. The LPN stated normally when a resident was ordered a PRN pain medication, the MAR would automatically populate a pre and post section to document the assessments. LPN4 further stated it was important to complete a pre and post pain assessment to ensure the resident's pain was being managed appropriately. During an interview, on 07/26/2024 at 5:16 PM, the Director of Nursing (DON) stated it was her expectation R19's pain would have been assessed before and after the administration of her PRN pain medication. The DON further stated this was important to ensure the medication was effective. During an interview with the Administrator, on 07/26/2024 at 5:18 PM, he was questioned regarding the need for pain assessments before and after administration of pain medication. He stated he was not clinical and deferred to the DON.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for two (2) of six (6) residents reviewed for unnecessary medications out of a total of 25 sampled residents, Resident (R)79 and R11. This failure placed both residents at risk for side effects such as drowsiness and sedation. R79 was ordered Lorazepam (fast-acting antianxiety medication) with no stop date to reevaluate the medical necessity of the medication. Additionally, R11 was ordered and routinely administered Hydroxyzine HCI (an antihistamine medication) for itching; however, the medication was being used to control the resident's behavior. The findings include: 1. Review of R79's undated Admission Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet tab, revealed the facility admitted the resident on 05/31/2023 and most recently readmitted the resident on 02/12/2024, with diagnoses which included generalized anxiety disorder (GAD) and restless leg syndrome. Review of R79's Physician's orders located in the resident's EMR under the List tab, revealed an order, dated 03/22/2024, for Lorazepam (fast-acting antianxiety medication) Oral Concentrate two (2) MG/ML (milligram/milliliter), one (1) ml By Mouth Every four (4) hours as needed. The order did not have a stop date. Review of R79's Medication Regimen Review (MRR), dated 03/26/2024 and provided by the facility, revealed a pharmacy recommendation of Per CMS [Centers for Medicare and Medicaid Services], PRN psychotropic medications are limited to 14 days (no exceptions). If use is beyond 14 days, the rationale and an estimated duration of use must be documented. Please add an estimated duration of use to prn Lorazepam for CMS compliance. The Medical Director responded to the recommendation by marking Resident is comfort measures-90 day stop date. Review of R79's Physician's orders located in the resident's EMR under the List tab, revealed a current order dated 05/30/2024 for Lorazepam Oral Concentrate 2 MG/ML, 1.5 ml By Mouth Every four (4) hours as needed. The order did not have a stop date. This order also included for Comfort Measures Only . Review of R79's Medication Administration Record (MAR), dated July 2024 and located in the resident's EMR under the MAR/TAR [Treatment Administration Record] tab, revealed the resident was ordered and administered the PRN (as needed) Lorazepam for agitation. The MAR revealed the resident was administered the Lorazepam on 07/01/2024, 07/08/2024, and 07/09/2024. During an interview and record review, on 07/25/2024 at 3:16 PM, the Medical Director who was also R79's Attending Physician, reviewed the orders and confirmed there was no stop date on the PRN Lorazepam. The Medical Director stated R79 was on end-of-life comfort care, and she was not aware a stop date was needed for the medication since the resident was on comfort care. During an interview, on 07/26/2024 at 5:22 PM, the Director of Nursing (DON) stated it was her understanding that a stop date for a PRN antianxiety medication was needed for a resident on comfort care. 2. Review of R11's undated Admission Face Sheet, located in the resident's EMR under the Face Sheet tab, revealed the facility admitted the resident on 11/03/2016 and most recently readmitted the resident on 11/22/2022, with diagnoses which included bipolar disorder, cerebral palsy, and generalized anxiety disorder. Review of R11's Physician orders located in the resident's EMR under the List tab, revealed a current order, originally dated 10/04/2023, for Hydroxyzine HCI [an antihistamine medication with anticholinergic side effects] Oral tablet 25 mg, [one] 1 tablet via G-Tube [Gastric Tube] TID [three times a day] .for itching. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/2024 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. The assessment also revealed the resident had not engaged in any behaviors during the assessment period. Review of R11's MARs, dated October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, and July 2024 and located in the resident's EMR under the MAR/TAR tab, revealed the hydroxyzine medication was initialed as administered three (3) times a day as ordered except for the following dates: 11/16/2023 (one dose), 12/05/2023 (one dose), 01/12/2024 (two doses), 01/19/2024 (one dose), 02/22/2024 (one dose) and 06/21/2024 (one dose). An observation and interview with R11 was conducted on 07/23/2024 at 2:52 PM, in the presence of Licensed Practical Nurse (LPN) 4. When R11 was questioned if he had ever had any problems with his body itching, he stated No. Due to the resident having expressive communication deficit, LPN4 confirmed R11's answer was, No. LPN4 stated R11 had never complained to her of any itching; however, the resident did engage in the behavior of scratching his legs. Further observation revealed R11 had dressings on both legs. During a subsequent interview, on 07/24/2024 at 9:19 AM, R11 was questioned if he had any itching episodes overnight, and the resident stated, No. R11 was observed to be lying in his bed watching tv. During an interview, on 07/24/2024 at 3:48 PM, Certified Nursing Assistant (CNA) 4 stated she was often assigned to R11 and was familiar with him. CNA4 stated R11 had never complained to her about itching, and she had never observed him scratching himself from body itching. CNA4 further stated R11 used to scratch his legs a lot; however, this was a behavior when his call light was not answered quick enough. The CNA stated the resident would also engage in behaviors of yelling or putting himself on the floor. During an interview, on 07/24/2024 at 3:51 PM, CNA5 stated R11 had never complained to her about itching and she had never observed him scratching his body. During an interview, on 07/25/2024 at 3:16 PM, the Medical Director stated hydroxyzine was normally ordered and administered for itching. However, the Medical Director stated she ordered the medication for R11 more for behaviors and less for itching. The Medical Director further stated when she put the electronic order in, the drop down only had two diagnoses for hydroxyzine, anxiety and itching. In continued interview the Medical Director further stated the resident had wounds to his legs from him scratching himself, which was a behavior, and this was during a bad period of acting out. She stated she should have only ordered the medication for 10 days and stopped it after that. During an interview, on 07/26/2024 at 5:27 PM, the Director of Nursing (DON) stated it was her expectation the Medical Director would have followed the regulatory requirement for the use of the hydroxyzine medication. During an interview, on 07/26/2024 at 5:53 PM, the Administrator stated it was his expectation the Medical Director would have followed the regulatory guidance when prescribing the hydroxyzine medication.

Based on observation, interview, record review, and review of facility policy, the facility failed 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 facility failed to follow infection control guidelines and facility policy during wound care dressing changes for three (3) of three (3) residents reviewed for wound care out of a total sample of 25 residents, Resident (R) 84, R19, and R81. The findings include: Review of the facility's policy titled, Skin Care Standard of Practice, dated 07/2020, revealed, .A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing . Review of the facility's undated Clean Wound Dressing Change competency for the nursing staff, revealed .Remove old dressing .Discard soiled dressing and gloves in plastic bag. Wash hands. Don [put on] gloves .Pour sterile solution over gauze/cotton swabs using a basin or pouring over plastic bag. Cleanse wound using gauze/swabs from center outward in spiral motion with gentle pressure .Note on dressing: date, time dressing changed, and initials . 1. Review of R84's undated Face Sheet located in the resident's electronic medical record (EMR), under the Face Sheet tab, revealed the facility readmitted the resident on 05/07/2024 with diagnoses of stage IV pressure ulcers to the right and left buttocks. Review of R84's Care Plan located under the Care Plan tab of the EMR, dated 03/21/2024, revealed a Goal stating .open areas will heal without worsening or complications . Interventions put into place included: Foley catheter to assist in wound healing; Mattress - pressure reduction; Provide gentle support when turning/positioning/transferring, and Provide pressure ulcer care as ordered. Review of R84's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/2024, revealed the facility assessed the resident as having two (2) stage IV pressure ulcers that were facility acquired. Review of the Physician Orders located in the resident's EMR under the List tab, revealed an order, dated 07/25/2024 to: .Cleanse area to Right Buttocks with wound cleanser and pat dry. Pack wound with Iodoform Packing Strip and cover with border gauze daily . Review of the Physician Orders located in the resident's EMR under the List tab revealed an order dated, 07/25/2024 to: .Cleanse area to the Left Buttock with wound cleanser and pat dry. Mix collagen powder with Medi honey and apply to wound. Cover with border gauze daily. During a wound care observation, on 07/26/2024 at 9:15 AM, with Licensed Practical Nurse (LPN) 2, the following failures were noted: 1) The scissors were cleaned with an alcohol prep pads prior to cutting the Iodoform packing strip gauze; 2) The over bed table was not cleaned prior to laying the barrier down on top of it; 3) LPN2 removed the resident's right buttock dressing, then while exposed the resident was turned to the other side. She then removed the left buttock dressing; 4) LPN2 removed her dirty gloves, then without performing hand hygiene, she applied clean gloves; 5) LPN2 cleaned the left buttock wound with a 4 x 4, then folded the 4 x 4 over and cleaned the wound again using the same 4 x 4; and 6) LPN2 sprayed the wound cleanser directly into the left buttock wound prior to cleaning the wound, and then applied Medi honey into the left buttock wound using a gloved finger. During an interview on 07/26/2024 at 5:55 PM, LPN2 stated, I only know to clean my scissors with the alcohol preps before using them on a dressing change. I realized I did not clean the over bed table with a bleach wipe when I laid the barrier down. When I was performing the wound care, I remembered that I needed to dress one wound then go to the other one, but that was after I started and had already removed the dressings on both areas. I did not realize that I had used my gloved finger to apply the ointment into the left buttock wound until we started talking about it just now. I should have used a Q-Tip, and I should have sprayed the wound cleanser to the 4 x 4 instead of spraying it directly into the wound. 2. Review of R19's undated Face Sheet located under the Face Sheet tab in the EMR revealed the facility readmitted the resident on 05/17/2024 with diagnoses including an unstageable pressure ulcer to the right calf and a stage II pressure ulcer to the right heel. Review of R19's Care Plan located under the Care Plan tab of the EMR, dated 05/08/2024, revealed a Goal stating .skin impairments will show signs of healing . Interventions included: Assist with turning/positioning; Provide diet/fluids as ordered; Provide pressure redistribution cushion to chair; Pressure redistributing mattress to bed to promote skin integrity; and Provide treatments as ordered. Review of R19's significant change MDS with an ARD of 05/20/2024, revealed the facility assessed the resident as having an unstageable pressure ulcer to the right calf and a stage II pressure ulcer to the right heel which were present on admission to the facility. Review of the Physician Orders located in the EMR under the List tab, revealed an order, dated 07/25/2024, to .Cleanse area to right calf with wound cleanser and pat dry. Moisten collagen sheet with normal saline and cut to size of the wound bed. Apply collagen sheet to wound bed. Moisten calcium alginate sheet with normal saline and cut to size of wound bed. Apply calcium alginate to wound bed over collagen. Apply superabsorbent dressing and cover with ABD [abdominal gauze] pad. Wrap with Kerlix from just below the knee to ankle daily. Review of the Physician Orders located in the EMR under the List tab, revealed an order, dated 07/25/2024, to .cleanse wound to Right heel with wound cleanser and pat dry. Apply Medi honey and cover with border gauze daily. During a wound care observation, on 07/26/2024 at 9:45 AM, with Registered Nurse (RN) 1, the following failures were noted: 1) The over bed table was not cleaned prior to placing the barrier on the table; 2) The privacy curtain was touching the clean barrier on the over bed table where dressing supplies were located; 3) The bottle of wound cleanser was stored in the bedside table and was placed on the clean barrier without wiping it with a disinfectant wipe prior to wound care; 4) RN1 obtained Medi honey ointment from the original tube by using a Q-Tip and applied the ointment by spreading it to the outer edges of the wound first, then into the center of the wound on the right heel; 5) RN1 cleaned the wound to the right calf, then with the same soiled gloves, applied clean dressings as ordered with clean dressing supplies; 6) RN1 cleaned the wound to the right calf by wiping the 4 x 4 the length of the wound and did not use a circular motion; 7) RN1's dirty gloves touched the privacy curtain prior to removing them after the dressing change to the right calf; 8) The clean dressings were applied to the right heel and to the right calf with no dates documented on the dressings; and 9) RN1 took the dirty scissors back to the Medication Storage room in the rehab unit where clean supplies were kept. RN1 washed the scissors with soap and water, dried them, and placed the scissors back into the wound care cart. During an interview, on 07/26/2024 at 5:45 PM, RN1 stated, I know right off, I should have cleaned the over bed table with a wipe prior to starting. I sat the wound cleanser on the clean barrier, and I should not have. I realized when I was getting the Medi Honey out of the container that I should have placed it in a medicine cup and not brought the container into the resident's room, and I should have changed my gloves between cleaning and redressing the wound. I forgot to date the dressings that I had applied. When asked if RN1 should have taken the dirty scissors into the medication storage room where the clean dressing supplies were kept, RN1 replied, No. When asked if she should have used the disinfectant wipes to clean the scissors instead of using soap and water, RN1 replied, Yes I should have used the wipes. 3. Review of R81's undated Face Sheet located under the Face Sheet tab in the EMR revealed the facility admitted the resident on 01/26/2024 with diagnoses including an unstageable pressure ulcer of the right heel, diabetes, and peripheral vascular disease. Review of R81's quarterly MDS with an ARD of 05/03/2024, revealed the facility assessed the resident as having a stage IV pressure ulcer to the right heel which was facility acquired. Review of R81's Care Plan located under the Care Plan tab of the EMR, dated 03/04/2024, revealed a Goal stating .wounds will shoe [sic] improvement/heal . Interventions included: Float heels off mattress as resident will allow; Pressure reduction mattress; Treatment as ordered; and Provide gentle support when turning/positioning/transferring. During an observation, on 07/26/2024 at 11:15 AM with RN2, the following failures were noted: 1) The over bed table was not cleaned with a disinfectant wipe prior to placing the barrier down; 2) RN2 cleaned the wound, then used a 4 x 4 to wipe the wound twice without using a different area of the 4 x 4 for each time the wound was wiped. During an interview, on 07/26/2024 at 5:40 PM, RN2 stated, I didn't clean the over bed table with a wipe before I placed the barrier down and I should have. I should have used a clean 4 x 4 each time I wiped the wound or used a different area of the 4 x 4 each time. During an interview, on 07/26/2024 at 6:10 PM, the Director of Nursing (DON)stated, The over bed tables should have been cleaned with a disinfectant wipe prior to placing the barrier down. The nurses should change gloves after a wound is cleaned and before applying the clean dressings. The dressings should be timed and dated when the clean dressing is applied. Scissors should be cleaned with a disinfectant wipe and not soap and water before and after each dressing change. The nurse's dirty gloves should not touch the privacy curtain because you have contaminated the curtain when you do that. If the nurse is dressing two wounds, they should be treated as two different wounds. Each being dressed before the nurse moves on to the next wound. The wound cleanser should be sprayed on a 4 x 4 and not directly into the wound. When the nurse cleans a wound, they should start in the center cleaning in a circular motion and working their way out to the edges of the wound. The nurse can discard the 4 x 4 each time the wound is cleaned, or they can use a different area of the 4 x 4 to clean the wound. The wound cleanser bottle should not be placed on the clean barrier. Any type of ointment should be placed in a medicine cup and the tube or container should not be taken in the resident's room. This should be applied with a clean Q-Tip.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of five (5) sampled residents (Resident #1). The facility care planned Resident #1 to require total assistance of two (2) staff for incontinent care. However, Certified Nursing Assistant (CNA) #5 provided incontinent care for Resident #1 alone, and without the care planned assistance of two (2) staff members on 11/02/2021. During the provision of incontinent care by CNA #5 Resident #1 rolled off the bed onto the floor, hitting his/her knees on the nightstand. At approximately 12:30 PM, Resident #1 complained of pain and was assessed to have bruising and swelling to his/her left knee. Resident #1 was transferred to the hospital emergency room (ER) for evaluation, and diagnosed with a closed nondisplaced fracture of the left patella (knee) and a nondisplaced fracture of head of right radius. Resident #1 was placed in a left knee immobilizer and a right arm splint and sling, and returned to the facility on [DATE] at 9:30 PM. The findings include: Review of the facility's policy titled, Comprehensive Care Plans Standard of Practice, dated 10/2020, revealed the facility would develop an individualized comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs. Per review of the policy, the facility's Interdisciplinary Team (IDT), in coordination with the resident, family and/or representative would develop and maintain a comprehensive care plan for each resident that identified the highest level of functioning the resident might be expected to attain. Review of Resident #1's medical record revealed the facility admitted him/her on 09/18/2015, with diagnoses which included Cerebellar Stroke Syndrome, Hemiplegia, Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side, and Chronic Obstructive Pulmonary Disease. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 08/09/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated he/she was moderately cognitively impaired. Review of the MDS Assessment further revealed the facility also assessed Resident #1 to require total assistance of two (2) staff for bed mobility, toileting, and transfers. Review of Resident #1's Comprehensive Care Plan, dated 04/20/2020, revealed the facility had care planned the resident for risk of falls related to his/her impaired mobility, being non-ambulatory, and requiring assistance with transfers. Continued review revealed the interventions included: ensuring the resident had a safe environment, free of clutter with adequate lighting; mechanical lift for transfers with total assist of two (2) staff; provide the resident with a soft touch call light within reach; and notify the Physician and family as needed. Additional review of the risk for falls care plan revealed an intervention for a perimeter defined mattress dated 11/02/2021. Further review of Resident #1's care plan revealed the facility also care planned Resident #1 for his/her activities of daily living (ADLs) related to impaired mobility, diagnosis of Hemiplegia on the right side, and contractures. Review of the ADL care plan revealed interventions which included providing total assistance of two (2) staff with incontinent care and transfers, and assist with his/her daily grooming and hygiene which were initiated on 04/20/2020. In addition, further review of the ADL care plan revealed an intervention initiated on 06/13/2022, to assist the resident with turning and repositioning per assist of two (2) staff. Review of the facility's documentation dated 11/02/2021, noted by Licensed Practical Nurse (LPN) #2 revealed at 6:15 AM that morning, a Certified Nursing Assistant (CNA) changed Resident #1 resulting in the resident rolling out of his/her bed due to the head of the bed not being locked. Continued review revealed Resident #1's knees hit the nightstand during the fall. Per review, Resident #1 had been assessed to have bruising to his/her bilateral knees; however, his/her range of motion was assessed as within normal limits. Review of the hospital Emergency Department (ED) record, dated 11/02/2021, revealed Resident #1 had been diagnosed with a nondisplaced fracture of the head of the right radius, and a nondisplaced fracture of the left patella (kneecap). Review further revealed Resident #1's left knee was placed in an immobilizer and his/her right arm was splinted and placed in a sling. Interview on 08/23/2022 at 11:20 AM, with CNA #6 revealed CNA #5 had told her Resident #1 had rolled off his/her bed, and there had been only one (1) staff providing care for the resident at the time of the fall. Per CNA #6, Resident #1 was supposed to have assistance provided by two (2) staff as per his/her care plan. Interview on 08/16/2022 at 7:22 PM, with LPN #1 revealed she had been providing care for Resident #1's roommate, when CNA #5 had provided the resident's care without another staff member's assistance. LPN #1 stated she heard a noise and then CNA #5 yelled for her. Continued interview revealed when she went to Resident #1's side of the room, she observed the resident lying on the floor. LPN #1 further stated she thought Resident #1 was an assist of two (2) staff for care and did not know why CNA #5 provided the care by herself. Interview on 08/18/2022 at 4:45 PM, with LPN #2 revealed when she received report on 11/02/2021 from LPN #1 she was informed of Resident #1's fall, and she and LPN #1 went to the resident's room together to assess him/her. Per LPN #2, the resident had slight bruising and some redness to his/her knees bilaterally. Continued interview revealed around lunch time that day she was asked to check on Resident #1 and she had assessed the resident and observed increased swelling. LPN #2 stated the Advanced Practice Registered Nurse (APRN) was in the facility and assessed Resident #1, and gave an order for the resident to be sent to the hospital ED for evaluation. She stated she could not recall much about the care plan but knew Resident #1 required total care, was basically bed bound and had contractures. LPN #2 revealed she did not know what intervention had been put in place for Resient #1 as he/she went to the hospital. Further interview revealed she ensured the staff were following residents' care plans by giving them reminders about care and letting them know she was available if they needed help. Interview on 08/19/2022 at 8:40 AM, with the MDS Nurse revealed residents' care plans were how the care was personalized to each resident. She stated the admission nurse initiated the residents' care plans. Continued interview revealed the floor nurses updated residents' care plans and the interdisciplinary team (IDT) reviewed Physician's Orders daily and updated the care plans if needed during the meeting. According to the MDS Nurse, the Resident Care Profile on the Kiosk was for staff to review regarding residents' care plan interventions. She stated if a resident required assistance of two (2) staff that information should be noted on the resident's care plan. Interview on 08/18/2022 at 2:30 PM, with CNA #8 revealed residents' care profiles on the kiosk helped staff to know how to properly care for residents. She stated the profiles were residents' care plans and were for staff to review to know how to care for the residents. Per interview, Resident #1 required total assistance of two (2) staff for bed mobility and incontinent care. CNA #8 stated Resident #1 preferred to stay in bed; however, was assist of two (2) staff and a mechanical lift for transfers. Further interview revealed she knew of Resient #1's fall, but had not been working at the time of the fall. Interview on 08/15/2022 at 4:18 PM and on 08/19/2022 at 10:42 AM, with the Director of Nursing (DON), revealed at the time of Resident #1's fall she had been in the Assistant Director of Nursing (ADON) position. The DON stated initially she had identified the root cause of Resident #1's fall as CNA #5 providing the resident's care by herself. Continued interview with DON revealed however, she went back and looked at everything again and determined the root cause had been due to the Resident #1's legs sliding off the bed. According to the DON, her expectations were for all her staff to follow each resident's care plan. The DON further revealed she could not say whether or not Resident #1 would have experiened the fall from his/her bed had another staff been on the other side of the bed to assist. Interview on 08/26/2022 at 2:52 PM, with the Administrator, revealed he expected his staff to follow residents' plans of care. The Administrator stated staff should refer to the resident care profiles on the kiosk to know residents' care needs. Contined interview revealed staff should direct residents' care based on the information from the care profiles on the kiosk. The Administrator further stated multiple adverse consequences could occur if residents' care plans were not followed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of five (5) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #1). The facility assessed and care planned Resident #1 as a risk for falls and required the assistance of two (2) staff members for bed mobility and incontinent care. However, on [DATE], at 6:15 AM, Certified Nursing Assistant (CNA) #5 provided the resident incontinent care without assistance from another staff member as per the care plan. Subsequently, during the incontinent care being provided by CNA #5, Resident #1 rolled off the side of the bed onto the floor. Resident #1 sustained fractures to his/her right radius (smaller of the two [2] bones in the lower arm) and left knee. The findings include: Review of the facility's policy titled, Falls Standard of Practice, dated ,d+[DATE], revealed the facility would ensure compliance with the regulatory intent of F689. Per review, the facility would ensure the residents ' environment remained free of accident hazards as possible; and each resident received adequate supervision and assistance devices necessary to prevent accidents. Continued review revealed on admission and readmission, quarterly and annually, each resident would have a Falls Risk Assessment completed by a licensed nurse. Review further revealed on completion of the Fall Risk Assessments, immediate reasonable interventions were to be initiated to reduce the risk for falls. In addition, policy review revealed at the time of a fall or after assessing and caring for a resident after a fall, an Incident Report and Investigation were to be initiated to determine appropriate interventions. Review of Resident #1's medical record revealed the facility admitted him/her on [DATE], with diagnoses which included: Hemiplegia, following Unspecified Cerebrovascular Disease Affecting Right Dominant Side; Cerebellar Stroke Syndrome; and Chronic Obstructive Pulmonary Disease. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #1 dated [DATE], revealed the facility assessed the resident as moderately cognitively impaired, as evidenced by the Brief Interview for Mental Status (BIMS) score of eleven (11). Continued review of the MDS Assessment's, Section G. Activities of Daily Living section, revealed the facility assessed Resident #1 to require extensive assistance of two (2) staff for bed mobility and total assist of two (2) staff for toileting and transfers. Review of the facility's Fall Risk Assessment, dated [DATE] for Resident #1, revealed the document noted a resident who scored a ten (10) or higher on the Assessment was at risk for falls. Per review, Resident #1's total score was thirteen (13) indicating the resident was a high risk for falls. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed the facility had care planned the resident as at risk for falls related to impaired mobility and requiring assistance with transfers and non-ambulatory. Continued review revealed interventions which included: total mechanical lift for transfers; total assist of two (2) staff members; ensure a safe environment free of clutter with adequate lighting; clean spills up promptly; provide soft touch call light within reach; and notify Physician and family as needed. Continued review revealed on [DATE], and intervention for a perimeter defined mattress was initiated. Further review of the care plan revealed the facility also care planned Resident #1 to require total assistance with all Activities of Daily Living (ADLs) related to impaired mobility, contractures, and a diagnosis of right sided hemiplegia (one-sided paralysis). Further review of the ADL care plan revealed interventions which included: assisting the resident with daily grooming and hygiene; total assist of two (2) with incontinent care initiated on [DATE]. Review of the facility's Resident Care profile for Resident #1 dated [DATE], revealed the resident was to be transferred using a mechanical lift with assist of two (2) staff. Observation of Resident #1, on [DATE] at 8:47 AM, revealed the resident lying on his/her bed and observed to have upper extremity contractures to both arms. Interview at the time of observation with Resident #1 revealed the resident recalled sustaining the fall and stated he/she broke his/her knee and elbow. However, Resident #1 was unable to recall how many staff had provided care for him/her at the time of the fall. Review of the Progress Note dated [DATE] at 7:39 AM and signed by Licensed Practical Nurse (LPN) #1, revealed the resident rolled out of his/her bed and was lowered to the floor by Certified Nursing Assistant (CNA) #5 during care. Continued review revealed the resident hit his/her knees on the nightstand next to the bed causing some bruising. Review of the facility's Fall Management Form, dated [DATE] and initiated by Licensed Practical Nurse (LPN) #3, revealed at 6:15 AM, a Certified Nursing Assistant (CNA) #5 was changing resident and resident rolled out of the bed onto the floor, as head of bed was not locked. Further review revealed the CNA was able to lower Resident #1 to the floor, but both knees hit the nightstand. Further review revealed Resident #1 had bruising to both knees and range of motion was assessed as within normal limits. Review of CNA #5's written statement, from the facility's investigation dated [DATE], revealed the CNA had been providing care for Resident #1, with the bed locked at the end. Continued review of CNA #5's statement revealed as she was turning Resident #1 during incontinent care, the resident threw his/her leg over the side of the bed and rolled from the bed to the floor. Further review of CNA #5's statement revealed the nurse was in the room at the time; however, had been providing care for the resident's roommate. Review of LPN #1's written statement, also from the facility's investigation, dated [DATE], revealed she had been in Resident #1's room providing care for the resident's roommate when Resident #1 fell from his/her bed. Further review of LPN #1's written statement revealed the privacy curtain had been pulled between the residents' beds and therefore, she had not witnessed the fall. Review of the hospital Emergency Department (ED) medical record dated [DATE], revealed Resident #1 had sustained a closed nondisplaced fracture of the left patella (kneecap) and a nondisplaced fracture of the head of the right radius. Further review revealed Resident #1 had been placed in a left knee immobilizer and a right arm splint and sling and returned to the facility on [DATE] at 9:30 PM. Interview with CNA #5 could not be accomplished as the CNA was deceased at the time of the survey. Interview with Certified Nursing Assistant (CNA) #6, on [DATE] at 11:30 AM, revealed she received report from CNA #5 on [DATE], and CNA #5 had told her Resident #1 had rolled off the bed. She stated she was told that only one (1) staff had been providing care for Resident #1 at the time of the fall, even though the resident was supposed to be assist of two (2) staff for care. Continued interview revealed Resident #1 seemed his/her usual self that morning and had no complaints at the beginning of her shift. CNA #6 revealed however, around lunch time that day Resident #1 started complaining of knee pain, and she observed the resident's left knee was swollen. Further interview revealed she went and told the nurse, LPN #2 about Resident #1's left knee, and the nurse went and assessed the resident. Interview further revealed CNA #6 believed the Advanced Practice Registered Nurse (APRN) went to assess Resident #1 as well. In addition, CNA #6 further revealed she got Resident #1 ready to go to the ED. Interview with LPN #1, on [DATE] at 7:22 PM, revealed she had been in Resident #1's room providing care for the resident's roommate, when CNA #5 was providing care for Resident #1 without assistance from another staff person. She stated she heard a noise and CNA #5 yelled for her. LPN #3 stated she went over to Resident #1's side of the room and CNA #5 had hold of the draw sheet and Resident #1 was lying on the floor by the right side of the bed. Continued interview revealed Resident #1's knees had hit the nightstand during the fall. She stated she and CNA #5 assisted Resident #1 up off the floor, prior to assessing the resident, and back to bed where she then assessed the resident for injuries. Per LPN #1, upon her assessment Resident #1 had no swelling or bruising observed. Further interview revealed Resident #1 had upper extremity contractures and the resident had no complaints with range of motion of his/her lower extremities. She further stated she gave report to the oncoming nurse, LPN #2 and they went to Resident #1's room together and assessed the resident. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 4:45 PM, revealed she had received report from LPN #1 on [DATE], regarding Resident #1's fall. She stated they went together to Resident #1's room to assess the resident together. Continued interview revealed Resident #1 had some redness and slight bruising to both knees; however, there had been no swelling or edema. LPN #2 stated she could not recall the time, but she assessed Resident #1 again while administering medications and the resident had slight puffiness to both knees, but there had been nothing that really concerned her at the time. Per the interview with LPN #2, the puffiness appeared to be tissue trauma. Further interview revealed around lunch time staff asked her to go check on Resident #1, and she had done so. LPN #2 stated Resident #1 had increased swelling to the left knee. In addition, LPN #2 revealed the APRN had been in the facility and assessed Resident #1. Interview further revealed the APRN gave an order for Resident #1 to be sent to the hospital ED for an evaluation as she thought there could be a left knee fracture. Interview with the APRN on [DATE] at 11:42 AM, revealed she vaguely remembered Resident #1's fall and subsequent injuries. She stated she had been in the facility that day and remembered Resident #1 had some swelling and bruising to his/her knee. Further interview revealed she could not recall how much swelling or bruising; however, she thought there had been a possibility of a fracture, so she sent Resident #1 to the ED for an evaluation. Interview with the Director of Nursing (DON) on [DATE] at 10:42 AM, revealed she had been the Assistant Director of Nursing (ADON) at the time of Resident #1's fall. The DON stated the initial root cause of Resident #1's fall had been determined to be CNA #5 providing the resident's care by herself without another staff person. Continued interview with the DON revealed however, she went back and looked at everything and ultimately determined the root cause of Resident #1's fall had been due to the resident's legs sliding off the bed during care. However, review of the resident's ADL care plan revealed the resident's interventions included a total assist of two (2) with incontinent care that was initiated on [DATE]. Continued interview with the DON revealed it was her expectation that staff followed the residents ' care plans when providing care. The DON revealed she could not say whether Resident #1 would have fallen from the bed had another staff been on the other side of the bed. Interview with the Administrator on [DATE] at 2:52 PM, revealed he expected staff to follow the plans of care for the residents. He stated staff should reference the Resident Care Profiles on the Kiosk (computerized electronic record) and direct the residents' care based on the information on the profile. He further revealed there could be multiple adverse consequences if residents' care plans were not followed.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to develop a person-centered comprehensive care with specific interventions to meet the needs of one (1) of three (3) sampled residents (Resident #1). Review of Resident #1's care plan dated [DATE] revealed the facility established goal for the resident was to wander in a safe environment. The care plan revealed interventions established by the facility to meet that goal included providing supervision, and modifying the environment to ensure Resident #1 did not exit seek or wander into a situation he/she should not be in. However, on [DATE], Resident #1 removed the Wanderguard bracelet and exited the facility through an unsecured facility window. Resident #1 was gone for approximately three and one-half (3.5) hours and was found approximately four (4) miles from the facility. The facility's failure to ensure each resident had a person centered comprehensive care plan developed to meet the resident's needs has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE] at 42 CFR 483.21 Resident Assessments (F656) and CFR 483.25 Quality of Care (F689). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of Immediate Jeopardy on [DATE]. However, the State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Administrator on [DATE] at 1:58 PM revealed the facility did not have a care plan policy. Interview with the Director of Nursing (DON) on [DATE] at 12:49 PM revealed she expected care plans to be resident focused. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Elopement assessment dated [DATE], revealed Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility determined Resident #1 was at high risk for elopement, and the facility had previously placed a Wanderguard bracelet on the resident. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), indicating the resident was moderately cognitively impaired. Review of Resident #1's care plan dated [DATE], revealed the facility had identified the resident #1 required a Wanderguard bracelet related to disorientation, difficulty relating to the environment and excessive pacing. The established goal for the resident was to wander in a safe environment. Further review of the care plan revealed interventions established by the facility to meet that goal included providing supervision, and modifying the environment to ensure Resident #1 did not exit seek or wander into a situation he/she should not be in. In addition, Resident #1's care plan was updated on [DATE] to include the intervention of Staff will use care plans that are established to promote function and dignity, as well as redirecting (resident) to a safe area as needed ensuring to prevent injury. Staff will also use guidance by SS (Social Services) that has been assessing (resident) moter risk, to promote safety, and immediate responses to/for resident. Review of a facility investigation initiated on [DATE], revealed on [DATE] between 9:00 PM and 9:45 PM, Resident #1 cut off his/her Wanderguard bracelet and exited the facility without staff knowledge through a facility window. However, staff failed to identify the resident was missing until between 9:45 PM and 10:00 PM. The facility initiated a search for Resident #1, who was located approximately four (4) miles from the facility and returned to the facility on [DATE] between 2:00 AM and 2:30 AM. Observation and interview with Resident #1, on [DATE] at 1:58 PM, revealed the resident was up in his/her room able to move about independently and answer questions appropriately. Resident #1 confirmed removing the Wanderguard bracelet by using fingernail clippers to cut it off, then exiting out of the unsecured facility window. Observation on [DATE] at 5:15 PM of the window Resident #1 exited out of on [DATE], revealed the window was located between the therapy department and the nurses station. The window was double paned with sliding mechanisms on the left and right side. Attempts to open the window revealed the window would not open more than 6 inches on each side due to screws in that were placed in the window seal. Interviews on [DATE], at 9:47 AM with State Registered Nursing Assistant (SRNA) #5, 9:57 AM with SRNA #6, and 10:06 AM with SRNA #3, revealed all three of the staff were unsure of the meaning of the care plan intervention, with the exception of Resident #1 being in a safe environment. In addition, SRNA #5 stated the facility had never trained or instructed her that Resident #1 may need increased supervision, and stated Resident #1 moved about the facility at will. Interviews on [DATE] at 10:14 AM, with Registered Nurse (RN) #2, 10:33 AM with RN #3 and 11:18 AM with RN #4, revealed all the staff interpreted the care plan to mean that if Resident #1 was in an unsafe area, staff should redirect him/her to a safe area. However, none of the staff could further elaborate on specific action to take to ensure the resident's safety based on the care plan intervention, or state what defined an unsafe and safe area for Resident #1. In addition, the staff stated the care plan was not specific related to increasing supervision and environment modification for the resident or who would decide when or how staff would provide the supervision or modify the environment. Interview with RN #4, on [DATE] at 11:18 PM, revealed she interpreted the care plan intervention to mean staff were required to cover Resident #1's Wanderguard to promote dignity. She further revealed she was unsure what the intervention required of staff beyond promoting dignity. Interview with the Minimum Data Set Nurse, on [DATE] at 10:33 AM, revealed she reviewed the care plans to ensure interventions were appropriate. She revealed that she had not identified any concerns with Resident #1's care plan, and staff had not asked for clarification of any care plan interventions. The Minimum Data Set Nurse was unable to explain the meaning of the intervention added to Resident #1's care plan on [DATE], stating the SSD had developed the intervention. Interview with Social Services Director (SSD,) on [DATE] at 11:31 AM and 12:23 PM, revealed he felt like Resident #1 was in a safe environment as long as the resident remained in the facility, but the resident made the decision to leave that environment. Further interview revealed the intent of the care plan interventions listed on Resident #1's care plan was if staff observed Resident #1 wandering toward exit doors, they were to redirect the resident. Continued interview revealed he had assessed Resident #1's motor and functional ability and determined the resident had the ability to exit the facility and direct care staff was responsible to assess where the resident was in the building and provide redirection as needed. Interview with the Director of Nursing (DON), on [DATE] at 12:49 PM, revealed the facility had just recently hired her as the DON. The DON stated Resident #1's care plan intervention directed staff to provide redirection if the resident exhibited exit seeking behavior. Further interview revealed the care plan further directed staff to contact Social Service for further guidance. Continued interview with the DON, revealed resident centered care plans should be resident focused and not generalized and should address specific behaviors like wandering. Interview with the Administrator, on [DATE] at 1:58 PM, revealed his interpretation of Resident #1's care plan was for staff to contact Social Services if Resident #1 was exhibiting wandering behaviors. However, the Administrator stated the care plan did not direct staff on what to do if Social Services staff were not present in the facility or how staff would contact Social Services after hours. **The facility implemented the following actions to remove Immediate Jeopardy: 1). On [DATE], staff identified that Resident #1 removed his/her Wanderguard sensor and exited the facility out of a window. The facility conducted an extensive search of the facility, facility grounds and the community. The facility updated resident #1's elopement care plan on [DATE]. 2). The facility conducted and immediate head count of all residents at the time Resident #1 could not be located. 3). The Director of Nursing (DON) checked All exterior doors with alarming devices for proper alarming function/wander guard response on [DATE]. 4). Maintenance checked all facility windows to ensure no more than six (6) inches of opening capability. The facility identified the window located between the therapy door and exterior exit door opened greater than six (6) inches. The facility determined Resident #1 exited out of this window on [DATE]. The Maintenance Director immediately initiated the facility protocol and secured the window with a screw to prevent the window from opening no more than six (6) inches. 5). All residents identified as an elopement risk had Wanderguard bracelet placement validated by Social Services Director (SSD) and/or MDS Nurse on [DATE] and [DATE]. 6). Elopement assessments and care plans for the residents at risk for elopement were reviewed by the Administrator and DON on [DATE] to ensure the assessment was current and accurate with appropriate care plan interventions in place. 7). All residents identified as an elopement risk had their Wanderguard bracelet checked for placement and expiration date by the SSD and/or MDS Nurse on [DATE] and [DATE]. 8). The SSD checked the Elopement-risk books on [DATE], to ensure demographic information for all at-risk resident was included. 9). The medical records for all additional residents were reviewed by the DON and/or Administrator on [DATE] and/or [DATE] to ensure each had an elopement risk assessment completed within the last quarter and it contained accurate information. 10). Education was provided to the facility Administrator, DON and Assistant Director of Nursing (ADON) by the Vice President of Operations and the Chief Nursing Officer regarding the established facility elopement protocol on [DATE]. The education included instruction that staff would assess all residents on admission, readmission, and quarterly and with any change of condition for risk factors that would place the resident at risk for elopement. Those factors could include wandering, a previous history of elopement or exit seeking behavior. If staff identified a resident as an elopement risk, staff would place a Wanderguard bracelet on the resident for safety. All residents identified at risk for elopement would have their photo and corresponding biographic information placed in the Elopement book. Staff would update the Care Plan to reflect the resident's risk for elopement. 11). Education was provided to the Scheduling Supervisor, Medical Records, Maintenance Director, Social Services, Director of Rehab, Dietary Manager, Housekeeping Supervisor and Activities Director by the Administrator, DON and/or Assistant Director of Nursing (ADON) regarding the elopement protocol on [DATE]. 12). A member of the team that received the prior education provided Education to employees in all disciplines. Staff completed the education on [DATE]. All participants had to give verbal acknowledgement of understanding and sign the education. 13). All new nursing hires, including contracted/agency/employees on leave, would receive the education regarding the elopement protocol prior to assuming duties. 14). Education was provided to the facility's Administrator, DON and ADON by the Vice President of Operations and the Chief Nursing Officer regarding the regulatory intent, development and implementation of the comprehensive care plan on [DATE]. The education included the development and implementation of a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, which the resident's comprehensive assessment identified. The comprehensive care plan must describe the services provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, any services that would otherwise be required. 15). The DON and/or ADON educated the Scheduling Supervisor and Medical Records staff regarding the regulatory intent, development, and implementation of the comprehensive care plan. 16). A member of the team that received the prior education provided education to the licensed nursing staff by [DATE]. The staff provided verbal acknowledgement of understanding along with signing the education. 17). All new nursing hires, including contracted/agency/employees on leave are required to receive the education regarding the regulatory intent, development and implementation of the comprehensive care plan. 18). The facility had a Quality Assurance Process Improvement (QAPI) meeting on [DATE] to review Resident #1's elopement from the facility. The meeting included the Administrator, DON, Maintenance Director, Medical Director, Vice President of Operations and Chief Nursing Officer. 19). Licensed Nursing staff will conduct a verification of Wanderguard bracelet placement every shift. The Licensed nurse will document the verification on the resident's treatment administration record (TAR). 20). The facility implemented a second Wanderguard placement check on [DATE] to be completed every shift by the DON, ADON, and/or assigned nurse manager for all residents at risk for elopement until immediate jeopardy is determined to be abated. 21). The facility implemented an ongoing second Wanderguard bracelet placement check on [DATE] to be completed three (3) times a week for eight (8) weeks by the Administrator, DON, ADON, Social Services and/or MDS Nurse. The audit also included verification that each resident had an elopement care plan in place with appropriate interventions. 22). The facility will monitor results of the audits in the monthly QAPI meeting for a minimum of two (2) months. The Administrator, DON, ADON, Unit Manager, Social Services Director, Activities Director, Business Office Manager, Therapy Director and the Medical Director attend the monthly QAPI meeting. The QAPI meeting occurs every three month at a minimum. 23). The facility conducted a Quality Assurance Process Improvement (QAPI) meeting on [DATE] to review Resident #1 elopement from the facility, status of education and status of audits. The meeting included the Administrator, DON, Medical Director, Vice President of Operations and Chief Nursing Officer. ** The State agency verified the facility's corrective action as follows, and determined the facility removed the immediate jeopardy on [DATE] as alleged. 1). Review of Resident #1's care plan revealed on [DATE] the facility updated the care plan to include one (1) to one (1) supervision. 2). Interview with LPN #1, on [DATE] at 3:49 PM, and [DATE] at 8:45 PM, revealed she completed a head count of all residents in the facility on [DATE]. She further revealed Resident #1 was the only resident identified to be missing from the facility. Review of the facility census for [DATE], revealed the facility had 75 residents. 3). Interview with the DON, on [DATE] at 12:54 PM, and [DATE] at 4:45 PM, revealed she checked all exterior doors on [DATE], for proper alarming function and Wanderguard response. She identified no concerns. Review of door audits revealed eight (8) of eight (8) exit doors had been audited to include therapy exit, north/therapy hallway exit, dining room exit, south hall exit, west hall exit, skilled hall exit one (1), skilled hall exit two (2) and front lobby. Observation of exterior doors on [DATE], [DATE], [DATE], [DATE] and [DATE] revealed no identified concerns. 4). Interview with Maintenance Director, on [DATE] at 4:31 PM, revealed the window located between the therapy door and exterior exit door was identified to open greater than six (6) inches on [DATE]. He revealed he immediately implemented the facility protocol to insert a screw into the window seal to prevent the window from opening no greater than six (6) inches. He stated he checked all facility windows on the night of [DATE] and into the early morning of [DATE]. Further interview revealed he did not identify any other concerns with windows opening greater than six (6) inches. Observation of the window in between therapy and exterior door on [DATE], [DATE], [DATE], [DATE] and [DATE] revealed the facility had secured the window with a screw. Observation on [DATE] at 2:26 PM revealed the window did not open greater than six (6) inches. The left windowpane opened five (5) inches and the right windowpane opened three (3) inches. Observations of sample of windows on [DATE], [DATE] and [DATE] revealed no identified concerns. 5). Interview with Social Services, on [DATE] at 6:23 PM, revealed he validated on [DATE], all remaining residents in the facility at risk for elopement had a Wanderguard in place. He further revealed he did not identify any concerns at this time. Interview with MDS Nurse on [DATE] at 5:29 PM revealed she validated on [DATE], all residents (including Resident #1) had a Wanderguard in place. She revealed she did not identify any concerns. Observation on [DATE] revealed that all seventeen (17) residents, identified at risk for elopement, had a Wanderguard in place including Resident #1. 6). Interview with the Administrator and Director of Nursing on [DATE] at 12:54 PM, revealed all resident care plans who were identified at risk for elopement, were reviewed to ensure appropriate interventions were in place. The facility did not identify any concerns. The facility reviewed all residents at risk for elopement to ensure each resident had an elopement assessment completed. Review of sampled residents (Resident #2, Resident #3, Resident #5 and Resident #6) at risk for elopement revealed no identified concerns related to care plan and/or elopement assessment. 7). Interview with Social Services, on [DATE] at 6:23 PM, revealed he validated on [DATE], all remaining residents in the facility at risk for elopement had a Wanderguard in place and the device was not expired. He further revealed he did not identify any concerns. Interview with MDS Nurse on [DATE] at 5:29 PM revealed she validated on [DATE], all residents (including Resident #1) had a Wanderguard in place and the device was not expired. She revealed she did not identify any concerns. Observation on [DATE] revealed all seventeen (17) residents (assessed at risk for elopement) had a Wanderguard in place including Resident #1. Further observation on [DATE] and [DATE], revealed no concerns with sampled residents (Resident #2, Resident #3, Resident #5 and Resident #6) revealed no concerns related to expiration dates. 8). Interview with Social Services, on [DATE] at 6:23 PM, revealed he validated on [DATE], all residents who were at risk for elopement were included in the elopement-risk books. He further revealed all residents were in the books and demographic information was accurate. Review of elopement binders on [DATE] at Skilled Nursing Station, South Nursing Station and North Nursing Station revealed all seventeen (17) residents (assessed as an elopement risk) were included with demographic information. Social Services identified no concerns. 9). Interview with the Administrator and Director of Nursing, on [DATE] at 12:54 PM, revealed all residents were reviewed to ensure each resident had an elopement assessment completed. Review of sampled residents revealed no identified concerns related to elopement assessments. 10). Interview with Administrator and DON, on [DATE] at 12:54 PM and [DATE] at 4:45 PM, and the Assistant Director of Nursing (ADON), on [DATE] at 6:12 PM, revealed each member had received education and verbalized understanding. Review of educational sheet revealed no concerns. Interview with the Chief Nursing Officer (CNO), on [DATE] at 4:57 PM, revealed the Vice President of Operations and herself provided education to the Administrator, DON and ADON on [DATE]. She stated the staff verbalized understanding and signed revealing they understood the education provided. 11). Interviews on [DATE] at 3:57 PM with the Scheduling Supervisor, 4:31 PM with the Maintenance Director, 6:23 PM with Social Services, 4:09 PM with the Director of Rehabilitation and at 6:43 PM with the Dietary Manager, revealed each member had received education on [DATE] related to the facility's elopement policy. Further interview revealed each staff could demonstrate verbal understanding of the policies and procedures. Review of the education sheet dated [DATE] revealed no identified concerns. 12). Interview with State Registered Nurse Aide (SRNA) #6, on [DATE] at 1:49 PM, SRNA #7 on [DATE] at 1:55 PM, SRNA #9 on [DATE] at 5:56 PM, SRNA #10 on [DATE] at 4:12 PM, SRNA #11 on [DATE] at 7:16 PM, Licensed Practical Nurse (LPN) #1 on [DATE] at 8:45 PM, LPN #3 on [DATE] at 10:54 AM, LPN #4 on [DATE] at 6:07 PM, Registered Nurse (RN) #1 on [DATE] at 9:25 PM, RN #2 on [DATE] at 5:41 PM, RN #3 on [DATE] at 12:03 PM, and Assistant Business Office Manager on [DATE] at 5:47 PM, revealed they received education and was able to verbalized understanding of the elopement protocol. Review of education documentation revealed one-hundred percent of facility staff had received the education. 13). Review of facility employee records revealed the facility had recently hired six (6) employees since [DATE]. Review of education revealed all six (6) of the new employees had been educated on the facility's elopement protocol. Interview with the Staff Development Coordinator (SDC), on [DATE] at 6:34 PM, who was hired after [DATE], revealed she was required to complete education regarding the elopement protocol upon hire. She further revealed she would be responsible for new hire education ongoing and would include the education in new hire orientation. 14). Interview with Administrator and DON, on [DATE] at 12:54 PM, revealed each member had received education and verbalized understanding. Interview with the Chief Nursing Officer (CNO) on [DATE] at 4:57 PM revealed the Vice President of Operations and herself provided education to the Administrator, DON and ADON on [DATE]. Review of education sheets revealed no identified concerns. 15). Interview with Scheduling Supervisor, on [DATE] at 3:57 PM, revealed she had received education on [DATE] related to the regulatory intent of development and implementation of the comprehensive care plan. Review of the education sheet for [DATE] revealed no identified concerns. 16). Interview with LPN #1, on [DATE] at 8:45 PM, LPN #3 on [DATE] at 10:54 AM, LPN #4 on [DATE] at 6:07 PM, RN #1 on [DATE] at 9:25 PM, RN #2 on [DATE] at 5:41 PM and RN #3 on [DATE] at 12:03 PM, revealed they had received education and was able to verbalized understanding of the regulatory intent of development and implementation of the comprehensive care plan. Review of education documentation revealed all staff had been educated in the facility. 17). Interview with the Staff Development Coordinator (SDC), on [DATE] at 6:34 PM, who was hired after [DATE] revealed she was required to complete education regarding the regulatory intent of development and implementation of the comprehensive care plan upon hire. She further revealed she will be responsible for new hire education ongoing and will include the education in new hire orientation. 18). Review of the facility Quality Assurance and Performance Improvement (QAPI) meeting documentation revealed the facility conducted the meeting on [DATE]. The meeting included the Administrator, DON, Maintenance Director, Medical Director, Vice President of Operations and Chief Nursing Officer. Interview with the Administrator and DON on [DATE] at 12:54 PM, Maintenance Director on [DATE] at 4:31 PM, Medical Director on [DATE] at 7:05 PM, and Chief Nursing Officer on [DATE] at 4:57 PM, revealed they attended the facility QAPI meeting on [DATE]. 19). Review of Resident #2, Resident #3, Resident #5 and Resident #6's treatment administration records revealed the facility required licensed nursing staff to verify placement of the Wanderguard bracelet every shift. Interview with LPN #1, on [DATE] at 8:45 PM, LPN #3 on [DATE] at 10:54 AM, LPN #4 on [DATE] at 6:07 PM, RN #1 on [DATE] at 9:25 PM, RN #2 on [DATE] at 5:41 PM, and RN #3 on [DATE] at 12:03 PM, revealed they had to verify placement of any resident's Wanderguard every shift. Furthermore, the interviews revealed the nursing documented the verification on the treatment administration record (TAR). 20). Review of the documentation provided for the second Wanderguard placement revealed seventeen (17) of seventeen (17) residents with Wanderguard bracelets were checked on each shift (7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM) each day from [DATE]. Interview with the DON, on [DATE] at 4:45 PM, revealed she was personally completing the second Wanderguard placement check for all residents at risk for elopement. She stated she had not identified any concerns. 21). Review of the documentation provided for the audit revealed no identified concerns. Interview with the DON, on [DATE] at 4:45 PM, revealed she was participating in completing the audits and had not identified any concerns at this time. 22). Interview with the DON, on [DATE] at 4:45 PM, revealed the facility had the monthly QAPI meeting scheduled for [DATE]. Review of the QAPI meeting revealed the facility conducted the meeting on [DATE] with the attendees including the Administrator, DON, Social Services, ADON, SDC, Business Office Manager, Director of Rehab, Medical Records, Medical Director, Scheduling Supervisor, Maintenance Director, Admission and Activity Director. 23). Review of the facility QAPI meeting documentation revealed the facility conducted the meeting on [DATE]. The Administrator, DON, Medical Director, Vice President of Operations and Chief Nursing Officer attended the meeting. Interview with the Administrator and DON on [DATE] at 12:54 PM, Maintenance Director on [DATE] at 4:31 PM, Medical Director on [DATE] at 7:05 PM, and Chief Nursing Officer on [DATE] at 4:57 PM, revealed they attended the facility QAPI meeting on [DATE]. Interview with Minimum Data Set (MDS) Nurse on [DATE] at 5:29 PM and Social Service Director on [DATE] at 6:23 PM revealed they both had been educated on patient-centered care plans.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of three (3) sampled residents, (Resident #1). The facility assessed Resident #1 to be at risk for elopement on [DATE], one day after admission to the facility and placed a Wanderguard bracelet on the resident. Review of an elopement assessment conducted for Resident #1 on [DATE], revealed the resident remained at risk for elopement due to a history of elopement from a health care facility, cognitive impairment and making statements regarding leaving the facility. Based on the assessment the facility identified Resident #1 as high risk for elopement. Interviews and record reviews revealed on [DATE], sometime after 9:00 PM, Resident #1 cut off the Wanderguard bracelet and exited the facility through a window, which the facility had previously used for visitation during the COVID-19 pandemic. Interview with staff revealed the window was found open approximately twelve (12) to eighteen (18) inches after the resident was discovered missing. Although facility staff could not find Resident #1 in his/her room at approximately 9:00 PM on [DATE], after the resident had asked for pain medication. The staff took no action to locate the resident, and did not determine the resident had left the facility until approximately 9:45 PM to 10:00 PM on [DATE]. Resident #1 contacted a family member via phone and disclosed his/her location. The family member then contacted the facility and told them the resident's location. Staff located Resident #1 approximately four (4) miles from the facility and assisted back to the facility by staff on [DATE] between 2:00 AM and 2:30 AM. Interview with Resident #1 revealed he/she reported blisters bilaterally to the soles of his/her feet after return to the facility. The facility's failure to ensure residents were provided with adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE] at 42 CFR 483.21 Resident Assessments (F656) and CFR 483.25 Quality of Care (F689). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of Immediate Jeopardy on [DATE]. However, the State Survey Agency determined the Immediate Jeopardy was removed on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Resident Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Elopement Protocol, dated [DATE], revealed the facility defined elopement as a resident leaving a safe place and going to an unsafe place without supervision. Further review of the policy revealed the Facility would maintain a process to assess all residents for risk of elopement, implement prevention strategies for those identified as an elopement risk, institute measures for resident identification and conduct a missing resident procedure. The policy included procedures for staff in the event a Wanderguard alarm sounded and what action staff should take to locate a resident after an alarm sounds. However, the policy did not address other means of exit from the facility; e.g. facility windows. Interview with the Administrator, on [DATE] at 11:58 AM and 3:46 PM, revealed the facility did not have a policy related to securing the windows in the facility. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE] with diagnoses including Diabetes, Schizophreniform Disorder, Alcoholic [CONDITION(S)], Alcohol Dependence, Alcohol Induced Persisting Dementia and [MEDICATION(S)] Dependence. The record also revealed Resident #1 had a State guardian. Review of an Elopement Assessment for Resident #1, dated [DATE], revealed Resident #1 had a history of wandering, elopement from a hospital prior to being admitted to the facility, was cognitively impaired and made statements regarding leaving the facility. Based on the assessment the facility identified Resident #1 as high risk for elopement. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident was moderately cognitively impaired. The assessment also revealed the resident had not displayed wandering behaviors during the seven (7) day look back period, and indicated Resident #1 was independent and steady at all times with ambulation. Review of Resident #1's Care Plan dated [DATE], revealed Resident #1 had a Wanderguard bracelet in place related to identified patterns associated with the resident's disorientation, difficulty relating to the environment and excessive pacing. The care plan further revealed Resident #1's behavior of wandering was defined as non-goal directed wandering, wandering aimlessly and was due to the resident's very short attention span. Review of a facility investigation initiated on [DATE], revealed on [DATE] at approximately 9:00 PM, Resident #1 requested pain medication from Licensed Practical Nurse (LPN) #1, who was caring for the resident. However, when LPN #1 arrived at the resident's room to administer the medication, she was unable to locate the resident. Continued review of the investigation revealed the nurse did not find that alarming because Resident #1 routinely ambulated throughout the facility independently, and the nurse took no further action to locate the resident. Further review of the investigation revealed at approximately 9:45 PM, the nurse returned to Resident #1's room and the resident was still not present, the nurse initiated a search for the resident and subsequently determined the resident was not in the facility. Interview with LPN #1, on [DATE] at 3:49 PM, revealed she was working on [DATE], during the 7:00 AM to 11:00 PM shift, and was assigned to care for Resident #1. LPN #1 stated at approximately 9:00 PM, Resident #1 asked for pain medication and after finishing what she was doing, she proceeded to obtain the medication for the resident. LPN #1 stated approximately five (5) minutes later when she entered Resident #1's room, she was unable to locate the resident. However, she stated that was not usual for the resident to be out of his/her room, so she took no action to locate the resident at that time, and went to the other unit to assist staff with medication pass. The nurse stated at approximately 9:45 PM to 10:00 PM, she again went to Resident #1's room with the medication, but Resident #1 was still not in the room. LPN #1 stated she then initiated a search of the facility and determined Resident #1 was missing. The LPN stated during the search staff found the resident's Wanderguard bracelet in the resident's room. LPN #1 stated she left the facility at approximately 1:30 AM on [DATE], but Resident #1 had not been located. Interviews were attempted on [DATE] to reach the two (2) State Registered Nursing Assistant's who were caring for Resident #1 on [DATE], when the resident eloped. However, neither of the SRNAs could be reached via telephone. Messages were left with each SRNA, with no return call received. Both the SRNAs were agency staff. Continued review of the facility's investigation initiated on [DATE], revealed some time between 2:00 AM and 2:30 AM on [DATE], Resident #1's family member called the facility and stated that Resident #1 had contacted them and stated he/she had left the facility and told the family his/her location. Facility staff went to the location found Resident #1 and returned the resident to the facility. Further review of the investigation revealed the facility documented the resident sustained no injury while out of the facility, and was appropriately dressed with both clothing and shoes. The investigation further revealed while searching for Resident #1 on ,d+[DATE]-,d+[DATE], staff found a facility window previously used to conduct window visits during the pandemic partially open in the hallway between the therapy room and the nurse's station. Observation and interview Interview with Resident #1, on [DATE] at 1:58 PM, revealed the resident was in his/her room and able to answer questions appropriately. Resident #1 confirmed removing the Wanderguard bracelet by using fingernail clippers to cut it off, then crawled out of the window and left the facility. The resident stated there was not a screw in the window the night he/she left the facility and he/she was able to open the window fully, allowing for an easy exit out of the facility. Further interview with the resident revealed he/she was gone from the facility approximately four (4) hours and made it to an area park. Resident #1 stated it got chilly and rained some, but I had a jacket. Resident #1 stated facility staff found him/her at the park and brought him/her back to the facility. Resident #1 reported having blisters on both feet when he/she got back to the facility. Review of archived weather data from AccuWeather for [DATE], revealed a high temperature of 88 degrees Fahrenheit and a low temperature of 63 degrees Fahrenheit. Review of Google Earth Pro revealed the park where staff located Resident #1 was approximately 4 miles from the facility. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 5:33 PM, revealed she was working on [DATE], and stated she observed Resident #1 between 8:30 PM and 9:00 PM walking down the hallway. The LPN stated sometime between 9:45 PM and 10:00 PM, LPN #1 notified her that Resident #1 was missing from the facility. LPN #2 stated they immediately initiated a search and several off duty staff came to the facility to help look for the resident. Interviews with the Housekeeping Supervisor, on [DATE] at 12:17 PM, the Assistant Business Office Manager (ABOM), on [DATE] at 1:30 PM, the Social Services Director (SSD) on [DATE] at 10:14 AM, and State Registered Nursing Assistant (SRNA) #4, on [DATE] at 12:31 PM, revealed they were all called in to the facility to assist with searching for Resident #1 on ,d+[DATE]-,d+[DATE]. The SSD stated it was not the typical elopement, emphasizing that Resident #1 had devised a plan to leave the facility. All the staff interviewed stated sometime between 2:00 AM and 2:30 AM Resident #1's family called the facility and told them that the resident had called them stating he/she had left the facility and told the family member where he/she was at. Resident #1's family then called the facility and reported the resident's location. Continued interview with the Housekeeping Supervisor on [DATE] at 12:17 PM, the Assistant Business Office Manager (ABOM) on [DATE] at 1:30 PM, and SRNA #4 on [DATE] at 12:31 PM, revealed after the resident's family called and told the facility where Resident #1 was located, they went to the location disclosed by the family. The three staff stated they found Resident #1 at a convenient store across from the park, leaned up against a wall, carrying a bag with movies and a DVD player in it. The staff stated Resident #1 had no visible injuries and they transported the resident back to the facility via automobile. Further interview with LPN #2, on [DATE] at 5:33 PM, revealed sometime between 2:00 AM and 2:30 AM on [DATE], facility staff accompanied Resident #1 back to the facility. The LPN stated Resident #1 was wearing a long sleeve shirt, hat, tennis shoes, socks and jeans upon return to the facility. The nurse stated she completed a skin assessment of the resident, at which time she identified calloused areas to the resident's feet, but could not recall if the areas were reddened. However, LPN #2 did recall Resident #1 complaining of pain to the feet and she bandaged them for the resident's comfort. Interview with the Director of Nursing (DON), on [DATE] at 12:44 PM, revealed LPN #1 notified her that Resident #1 was missing from the facility sometime after 9:00 PM on [DATE]. The DON stated she arrived to the facility approximately ten (10) minutes later and immediately began searching for the resident. The DON stated the facility notified the police who assisted the facility in the search. Continued interview with the DON, revealed at some point during the search (could not recall exact time), Resident #1's family member called the facility with the resident's location. The DON stated the resident was very agitated upon arrival back to the facility with the staff members, and staff found fingernail clippers in the resident's pants pocket. The DON stated she was unaware of how the resident got out of the window. In addition, the DON stated LPN #1 should have immediately attempted to locate Resident #1 on [DATE], after the resident requested pain medication, but then left the room before receiving it. Interview with Maintenance Assistant, on [DATE] at 1:04 PM, and review of the facility's TELS system (the facility's building management software) log, revealed a routine monthly audit of facility windows was conducted which included ensuring the windows did not open more than six (6) inches. He stated the last time he had audited the windows prior to Resident #1's elopement was on [DATE]. The Maintenance Assistant stated he identified no concerns with any of the windows during the audit, including the window Resident #1 exited out of on [DATE]. Although the Maintenance Assistant was unable to recall if the window specifically had the screw in place, which prevented opening more than six (6) inches, he stated Resident #1 would not have been able to open the window wide enough to exit through it if the screw had been present. Continued interview with the Maintenance Assistant revealed that although Resident #1 had removed the Wanderguard bracelet prior to leaving the facility on [DATE], the facility windows were not equipped with Wanderguard censors and would not have alarmed even if the resident had not removed the Wanderguard bracelet. Interview with the Maintenance Director, on [DATE] at 4:15 PM, revealed he had worked at the facility for several years in another department, but had recently taken over as the Maintenance Director. The Maintenance Director stated staff observed the window between the therapy department and the nurse's station open about twelve (12) to fourteen (14) inches on the night Resident #1 eloped from the facility and he did not see a screw in the window. Observation on [DATE] at 5:15 PM of the window that Resident #1 exited from on [DATE], revealed the window was secured with screws to prevent opening of no more that six (6) inches. Interview with the Administrator, on [DATE] at 11:58 AM and 3:46 PM, revealed staff had removed the screw in the window, Resident #1 exited through on [DATE], to allow for family window visits during the pandemic. However, he was unaware if any staff had replaced the screw when window visits were no longer occurring. The Administrator stated staff notified him that Resident #1 was missing from the facility at approximately 10:00 PM on [DATE]. The Administrator stated upon his arrival to the facility, staff were searching and continued to search for Resident #1 both on and off facility grounds. Continued interview with the Administrator revealed at some point during the search of the facility for resident #1 on [DATE], a staff discovered that the window between therapy department and nurse's station was open approximately twelve (12) to eighteen (18) inches. The Administrator stated he did not observe a screw in the window to prevent opening. **The facility implemented the following actions to remove Immediate Jeopardy: 1). On [DATE], staff identified that Resident #1 removed his/her Wanderguard sensor and exited the facility out of a window. The facility conducted an extensive search of the facility, facility grounds and the community. The facility updated resident #1's elopement care plan on [DATE]. 2). The facility conducted and immediate head count of all residents at the time Resident #1 could not be located. 3). The Director of Nursing (DON) checked All exterior doors with alarming devices for proper alarming function/wander guard response on [DATE]. 4). Maintenance checked all facility windows to ensure no more than six (6) inches of opening capability. The facility identified the window located between the therapy door and exterior exit door opened greater than six (6) inches. The facility determined Resident #1 exited out of this window on [DATE]. The Maintenance Director immediately initiated the facility protocol and secured the window with a screw to prevent the window from opening no more than six (6) inches. 5). All residents identified as an elopement risk had Wanderguard bracelet placement validated by Social Services Director (SSD) and/or MDS Nurse on [DATE] and [DATE]. 6). Elopement assessments and care plans for the residents at risk for elopement were reviewed by the Administrator and DON on [DATE] to ensure the assessment was current and accurate with appropriate care plan interventions in place. 7). All residents identified as an elopement risk had their Wanderguard bracelet checked for placement and expiration date by the SSD and/or MDS Nurse on [DATE] and [DATE]. 8). The SSD checked the Elopement-risk books on [DATE] to ensure demographic information for all at-risk resident was included. 9). The medical records for all additional residents were reviewed by the DON and/or Administrator on [DATE] and/or [DATE] to ensure each had an elopement risk assessment completed within the last quarter and it contained accurate information. 10). Education was provided to the facility Administrator, DON and Assistant Director of Nursing (ADON) by the Vice President of Operations and the Chief Nursing Officer regarding the established facility elopement protocol on [DATE]. The education included instruction that staff would assess all residents on admission, readmission, and quarterly and with any change of condition for risk factors that would place the resident at risk for elopement. Those factors could include wandering, a previous history of elopement or exit seeking behavior. If staff identified a resident as an elopement risk, staff would place a Wanderguard bracelet on the resident for safety. All residents identified at risk for elopement would have their photo and corresponding biographic information placed in the Elopement book. Staff would update the Care Plan to reflect the resident's risk for elopement. 11). Education was provided to the Scheduling Supervisor, Medical Records, Maintenance Director, Social Services, Director of Rehab, Dietary Manager, Housekeeping Supervisor and Activities Director by the Administrator, DON and/or Assistant Director of Nursing (ADON) regarding the elopement protocol on [DATE]. 12). A member of the team that received the prior education provided Education to employees in all disciplines. Staff completed the education on [DATE]. All participants had to give verbal acknowledgement of understanding and sign the education. 13). All new nursing hires, including contracted/agency/employees on leave, would receive the education regarding the elopement protocol prior to assuming duties. 14). Education was provided to the facility's Administrator, DON and ADON by the Vice President of Operations and the Chief Nursing Officer regarding the regulatory intent, development and implementation of the comprehensive care plan on [DATE]. The education included the development and implementation of a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, which the resident's comprehensive assessment identified. The comprehensive care plan must describe the services provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, any services that would otherwise be required. 15). The DON and/or ADON educated the Scheduling Supervisor and Medical Records staff regarding the regulatory intent, development, and implementation of the comprehensive care plan. 16). A member of the team that received the prior education provided education to the licensed nursing staff by [DATE]. The staff provided verbal acknowledgement of understanding along with signing the education. 17). All new nursing hires, including contracted/agency/employees on leave were required to receive the education regarding the regulatory intent, development and implementation of the comprehensive care plan. 18). The facility had a Quality Assurance Process Improvement (QAPI) meeting on [DATE] to review Resident #1's elopement from the facility. The meeting included the Administrator, DON, Maintenance Director, Medical Director, Vice President of Operations and Chief Nursing Officer. 19). Licensed Nursing staff would conduct a verification of Wanderguard bracelet placement every shift. The Licensed nurse will document the verification on the resident's treatment administration record (TAR). 20). The facility implemented a second Wanderguard placement check on [DATE] to be completed every shift by the DON, ADON, and/or assigned nurse manager for all residents at risk for elopement until immediate jeopardy was determined to be abated. 21). The facility implemented an ongoing second Wanderguard bracelet placement check on [DATE] to be completed three (3) times a week for eight (8) weeks by the Administrator, DON, ADON, Social Services and/or MDS Nurse. The audit also included verification that each resident had an elopement care plan in place with appropriate interventions. 22). The facility would monitor results of the audits in the monthly QAPI meeting for a minimum of two (2) months. The Administrator, DON, ADON, Unit Manager, Social Services Director, Activities Director, Business Office Manager, Therapy Director and the Medical Director attend the monthly QAPI meeting. The QAPI meeting occurs every three month at a minimum. 23). The facility conducted a Quality Assurance Process Improvement (QAPI) meeting on [DATE] to review Resident #1 elopement from the facility, status of education and status of audits. The meeting included the Administrator, DON, Medical Director, Vice President of Operations and Chief Nursing Officer. ** The State agency verified the facility's corrective action as follows, and determined the facility removed the immediate jeopardy on [DATE] as alleged. 1). Review of Resident #1's care plan revealed on [DATE] the facility updated the care plan to include one (1) to one (1) supervision. 2). Interview with LPN #1 on [DATE] at 3:49 PM and [DATE] at 8:45 PM, revealed she completed a head count of all residents in the facility on [DATE]. She further revealed Resident #1 was the only resident identified to be missing from the facility. Review of the facility census for [DATE], revealed the facility had 75 residents. 3). Interview with the DON, on [DATE] at 12:54 PM and [DATE] at 4:45 PM, revealed she checked all exterior doors on [DATE] for proper alarming function and Wanderguard response. She identified no concerns. Review of door audits revealed eight (8) of eight (8) exit doors had been audited to include therapy exit, north/therapy hallway exit, dining room exit, south hall exit, west hall exit, skilled hall exit one (1), skilled hall exit two (2) and front lobby. Observation of exterior doors on [DATE], [DATE], [DATE], [DATE] and [DATE] revealed no identified concerns. 4). Interview with Maintenance Director, on [DATE] at 4:31 PM, revealed the window located between the therapy door and exterior exit door was identified to open greater than six (6) inches on [DATE]. He revealed he immediately implemented the facility protocol to insert a screw into the window seal to prevent the window from opening no greater than six (6) inches. He stated he checked all facility windows on the night of [DATE] and into the early morning of [DATE]. Further interview revealed he did not identify any other concerns with windows opening greater than six (6) inches. Observation of the window in between therapy and exterior door on [DATE], [DATE], [DATE], [DATE] and [DATE] revealed the facility had secured the window with a screw. Observation on [DATE] at 2:26 PM, revealed the window did not open greater than six (6) inches. The left windowpane opened five (5) inches and the right windowpane opened three (3) inches. Observations of sample of windows on [DATE], [DATE] and [DATE] revealed no identified concerns. 5). Interview with Social Services, on [DATE] at 6:23 PM, revealed he validated on [DATE], all remaining residents in the facility at risk for elopement had a Wanderguard in place. He further revealed he did not identify any concerns at this time. Interview with MDS Nurse on [DATE] at 5:29 PM revealed she validated on [DATE], all residents (including Resident #1) had a Wanderguard in place. She revealed she did not identify any concerns. Observation on [DATE] revealed that all seventeen (17) residents, identified at risk for elopement, had a Wanderguard in place including Resident #1. 6). Interview with the Administrator and Director of Nursing, on [DATE] at 12:54 PM, revealed all resident care plans who were identified at risk for elopement, were reviewed to ensure appropriate interventions were in place. The facility did not identify any concerns. The facility reviewed all residents at risk for elopement to ensure each resident had an elopement assessment completed. Review of sampled residents (Resident #2, Resident #3, Resident #5 and Resident #6) at risk for elopement revealed no identified concerns related to care plan and/or elopement assessment. 7). Interview with Social Services, on [DATE] at 6:23 PM, revealed he validated on [DATE], all remaining residents in the facility at risk for elopement had a Wanderguard in place and the device was not expired. He further revealed he did not identify any concerns. Interview with MDS Nurse on [DATE] at 5:29 PM revealed she validated on [DATE], all residents (including Resident #1) had a Wanderguard in place and the device was not expired. She revealed she did not identify any concerns. Observation on [DATE] revealed all seventeen (17) residents (assessed at risk for elopement) had a Wanderguard in place including Resident #1. Further observation on [DATE] and [DATE], revealed no concerns with sampled residents (Resident #2, Resident #3, Resident #5 and Resident #6) revealed no concerns related to expiration dates. 8). Interview with Social Services, on [DATE] at 6:23 PM, revealed he validated on [DATE], all residents who were at risk for elopement were included in the elopement-risk books. He further revealed all residents were in the books and demographic information was accurate. Review of elopement binders on [DATE] at Skilled Nursing Station, South Nursing Station and North Nursing Station revealed all seventeen (17) residents (assessed as an elopement risk) were included with demographic information. Social Services identified no concerns. 9). Interview with the Administrator and Director of Nursing, on [DATE] at 12:54 PM, revealed all residents were reviewed to ensure each resident had an elopement assessment completed. Review of sampled residents revealed no identified concerns related to elopement assessments. 10). Interview with Administrator and DON, on [DATE] at 12:54 PM and [DATE] at 4:45 PM, and the Assistant Director of Nursing (ADON), on [DATE] at 6:12 PM, revealed each member had received education and verbalized understanding. Review of educational sheet revealed no concerns. Interview with the Chief Nursing Officer (CNO), on [DATE] at 4:57 PM, revealed the Vice President of Operations and herself provided education to the Administrator, DON and ADON on [DATE]. She stated the staff verbalized understanding and signed revealing they understood the education provided. 11). Interviews on [DATE] at 3:57 PM with the Scheduling Supervisor, 4:31 PM with the Maintenance Director, 6:23 PM with Social Services, 4:09 PM with the Director of Rehabilitation and at 6:43 PM with the Dietary Manager, revealed each member had received education on [DATE] related to the facility's elopement policy. Further interview revealed each staff could demonstrate verbal understanding of the policies and procedures. Review of the education sheet dated [DATE] revealed no identified concerns. 12). Interview with State Registered Nurse Aide (SRNA) #6, on [DATE] at 1:49 PM, SRNA #7 on [DATE] at 1:55 PM, SRNA #9 on [DATE] at 5:56 PM, SRNA #10 on [DATE] at 4:12 PM, SRNA #11 on [DATE] at 7:16 PM, Licensed Practical Nurse (LPN) #1 on [DATE] at 8:45 PM, LPN #3 on [DATE] at 10:54 AM, LPN #4 on [DATE] at 6:07 PM, Registered Nurse (RN) #1 on [DATE] at 9:25 PM, RN #2 on [DATE] at 5:41 PM, RN #3 on [DATE] at 12:03 PM, and Assistant Business Office Manager on [DATE] at 5:47 PM, revealed they received education and was able to verbalized understanding of the elopement protocol. Review of education documentation revealed one-hundred percent of facility staff had received the education. 13). Review of facility employee records revealed the facility had recently hired six (6) employees since [DATE]. Review of education revealed all six (6) of the new employees had been educated on the facility's elopement protocol. Interview with the Staff Development Coordinator (SDC), on [DATE] at 6:34 PM, who was hired after [DATE], revealed she was required to complete education regarding the elopement protocol upon hire. She further revealed she will be responsible for new hire education ongoing and will include the education in new hire orientation. 14). Interview with Administrator and DON, on [DATE] at 12:54 PM, revealed each member had received education and verbalized understanding. Interview with the Chief Nursing Officer (CNO) on [DATE] at 4:57 PM revealed the Vice President of Operations and herself provided education to the Administrator, DON and ADON on [DATE]. Review of education sheets revealed no identified concerns. 15). Interview with Scheduling Supervisor, on [DATE] at 3:57 PM, revealed she had received education on [DATE] related to the regulatory intent of development and implementation of the comprehensive care plan. Review of the education sheet for [DATE] revealed no identified concerns. 16). Interview with LPN #1, on [DATE] at 8:45 PM, LPN #3 on [DATE] at 10:54 AM, LPN #4 on [DATE] at 6:07 PM, RN #1 on [DATE] at 9:25 PM, RN #2 on [DATE] at 5:41 PM and RN #3 on [DATE] at 12:03 PM, revealed they had received education and was able to verbalized understanding of the regulatory intent of development and implementation of the comprehensive care plan. Review of education documentation revealed all staff had been educated in the facility. 17). Interview with the Staff Development Coordinator (SDC), on [DATE] at 6:34 PM, who was hired after [DATE] revealed she was required to complete education regarding the regulatory intent of development and implementation of the comprehensive care plan upon hire. She further revealed she will be responsible for new hire education ongoing and will [TRUNCATED]

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to maintain a clean, comfortable, and homelike environment for three (3) of four (4) sampled residents (Resident #4, Resident #7, and Resident #8). Observations on 06/28/2021 revealed the toilet in the bathroom adjacent to Resident #4's room was clogged with feces and towels/blankets were lying on the bathroom floor to soak up the overflowed toilet water. Further observations on 06/28/2021 revealed the air conditioning unit in room 455, shared by Resident #7 and Resident #8 was set to the coldest temperature, however, the air blowing out of the unit was warm, and both residents complained of the room being hot and uncomfortable. The findings include: Review of the facility's policy Quality of Life - Homelike Environment undated, revealed residents would be provided a safe, clean, comfortable, and homelike environment. The policy stated facility staff and management would maximize to the extent possible, the characteristics of the facility which reflect a personalized homelike setting. These characteristics included cleanliness, unpleasant odors and uncomfortable temperatures. 1. Review of the medical record for Resident #4 revealed the facility readmitted the resident on 05/17/2019 with diagnoses including Hypertension, [CONDITION(S)], Chronic Pain, [CONDITION(S)], Spinal Stenosis, and Nausea/Vomiting. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 05/07/2021, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Observations of Resident #4's bathroom on 06/28/2021, at 12:15 PM, and at 4:47 PM with the Maintenance Director, revealed the toilet was clogged with feces, and towels/blankets were lying on the bathroom floor soaking up the overflow of the toilet water. Interview with Resident #4, on 06/28/2021 at 12:20 PM, revealed he/she utilized a bedpan and did not use the bathroom that was designated for occupants in his/her room and an adjoining room occupied by two additional residents. However, the resident stated the toilet backing up was an ongoing problem. The resident stated on 05/28/2021, the toilet was stopped up and the odor was terrible. The resident stated when a staff member would open the door to empty his/her bedpan the resident stated the odor would about make him/her sick. Review of a plumbing invoice revealed the facility received plumbing services on 05/31/2021, at which time the plumbing service used a sewage jetter (a powerful drain cleaning machine that uses high-pressure water jets to clear obstructions in residential and commercial drainpipes) for six (6) hours at the facility to unclog the main drain. Further review of invoices from 05/11/2012 through 06/10/2021 revealed the facility had received plumbing services nine (9) times because of clogged sewage drains. Interview with State Registered Nurse Aide (SRNA) #6, on 06/28/2021 at 1:49 PM, revealed the facility had problems with Resident #4's toilet and the shower rooms located on the same hall as Resident #4's room backing up. SRNA #6 stated she was unable to recall exact dates, but stated at times she could smell the odors in Resident #4's room herself. She stated Resident #4 had complained to her before about the room smelling bad. SRNA #6 stated when she discovered Resident #4's toilet would not flush or the shower rooms would not drain she would notify the charge nurse who would contact maintenance. Interview with Registered Nurse (RN) #1, on 06/28/2021, at 9:25 PM, and Licensed Practical Nurse (LPN) #3, on 06/29/2021 at 10:54 AM, revealed plumbers were at the facility frequently and they had smelled odors in the facility. However, the nurses stated staff tried to keep the overflow of toilets mopped up, and used an odor eliminator spray to help with the odors. Interview with the Maintenance Director, on 06/28/2021 at 3:26 PM, revealed around 05/28/2021, plumbers were in the facility for two (2) weeks working on the drainpipes, which removed the sewage from the facility. The Maintenance Director revealed he did not see any toilets overflow when the plumbers were working on the drainpipes, but had seen shower rooms overflow. Further interview revealed he did not smell any bad odors in the facility when they were working on the sewage drains. Interview with the Director of Nursing (DON), on 06/29/2021 at 4:45 PM, revealed she had not had any complaints from residents of bad odors in the facility. The DON stated when toilets were backed up she instructed staff to take continent residents to the other bathrooms which were working. The DON further revealed she did not know anything about Resident #4's toilet being clogged or the resident having complaining of foul odors in the room bad odors in his/her room. Interview with the Administrator on 06/28/2021 at 1:00 PM revealed the Administrator had just recently took over the facility and was aware the building was old and had some problems with the plumbing and sewage lines; but he was working to get them fixed. The Administrator stated plumbers were at the facility frequently. He stated he was unaware of the clogged toilet in Resident #4's room. 2. Review of the medical record for Resident #7 revealed the facility admitted the resident on 09/14/2013 with diagnoses including Major Depressive Disorder, Chronic Pain, [CONDITION(S)] Disorder, Anxiety disorder, Guillain-Barre Syndrome, and Restless Leg Syndrome. Review of Resident #7's quarterly MDS assessment, dated 06/01/2021, revealed Resident #7 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of the medical record for Resident #8 revealed the facility admitted the resident on 03/03/2018 with diagnoses including Diabetes, Pain, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, and [CONDITION(S)]. Review of Resident #8's quarterly MDS assessment, dated 06/04/2021, revealed Resident #8 had a BIMS score of nine (9), which indicated the resident was moderately impaired cognitively. Observations of Room 455 where Resident #7, and Resident #8 were roommates, on 06/28/2021 at 1:00 PM, 1:25 PM, and 8:23 PM, revealed both residents lying in bed voicing complaints of it being hot in their room. Further observation revealed the room was equipped with a single unit air conditioner mounted through the wall to the outside to allow for drainage. The room's temperature obtained on 06/28/2021 at 1:25 PM, utilizing an infrared thermometer revealed the room temperature was 78 degrees Fahrenheit. Further observation at that time revealed the air conditioning unit setting was as cold as it would go, but the unit was blowing out warm air into the room. Subsequent observation of room 455, on 06/28/2021 at 8:23 PM, revealed the temperature was 80.3 degrees Fahrenheit, and both residents complained of being very hot and uncomfortable. Interviews with Resident #7 and Resident #8, on 06/28/2021 at 1:25 PM and at 8:23 PM, revealed both residents had complained to direct care staff and maintenance staff about the air conditioning unit not working and the room being uncomfortably warm. In addition, Resident #7 stated his/her Responsible Party had also complained about the room being too hot and uncomfortable. Interview with Resident #7's the Responsible Party (RP) on 06/29/2021 at 4:09 PM, revealed she had complained to staff for approximately one (1) month concerning the broken air conditioning unit in room 455. The RP stated she was even supplied with a Maintenance Work Order form to fill out and route to the maintenance department. The RP stated she filled the form out and returned the slip to staff who gave it to her and they forwarded it to the maintenance department. Interview with SRNA #6, on 06/28/2021 at 1:49 PM, revealed approximately one (1) month ago, she attempted to fix the air conditioner in room 455, but was unsuccessful. SRNA #6 stated the room was hot and the residents complained. Interview with Registered Nurse #1, on 06/28/2021 at 9:25 PM, revealed both Resident #7 and Resident #8 had complained of their room being too hot. RN #1 further stated, last weekend the hallways were hotter than heck and stated residents also complained of their rooms being too hot. Interview with the Maintenance Director (MD), on 06/28/2021 at 3:26 PM, revealed he could not recall if he received a work order slip filled out by Resident #7's RP or not. The MD stated he checked resident room temperatures daily, but does not document any of the temperatures or keep any log. The MD stated he often cleaned or worked on air conditioning units, if they needed it or when he received complaints; but could not recall if he had worked on room 455's unit recently. Further interview revealed approximately two (2) weeks ago, he and an outside company worked on the common area air conditioning units in the facility until midnight because the evaporating coils were freezing up. The Maintenance Director revealed the hallways in the facility were warm, and he instructed staff to keep resident room doors closed to keep them from getting any warmer. The MD stated he had not been aware of the recent complaints made by Resident #7 and Resident #8. Interview with the Director of Nursing (DON), on 06/29/2021 at 4:45 PM, revealed she was only aware of one (1) time Residents #7 and Resident #8 had complained of their room being too hot (could not recall exact date) and to her knowledge the MD had fixed the problem. Further interview with the DON revealed she did expect the resident's room to have comfortable room temperatures. Interview with the Administrator, on 06/28/2021 at 1:00 PM, revealed the MD was responsible to maintain and monitor equipment in the facility including air conditioners in resident rooms. The Administrator stated the air conditioner that services the common areas in the facility had problems, but that it should have no effect on resident room temperatures. The Administrator stated he expected the MD to repair or replace any air conditioner in a resident room that was not working, and was unaware of the complaints of Resident #7 and Resident #8.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to notify the physician for one (1) of three (3) sampled residents, Interview and record review revealed on 06/05/2021, Resident #1 eloped from the facility and walked approximately four (4) miles. After returning to the facility the Resident #1 stated he/she sustained blisters to the soles of both feet as the result of walking four miles. Interviews revealed staff bandaged Resident #1's feet, but failed to notify the physician of the injuries. The findings include: Review of the facility's policy, Change of Condition Standard of Practice, reviewed July 2020, revealed the facility would immediately (as soon as possible/no longer than 24 hours) inform the resident, consult the resident's physician, nurse practitioner or physician assistant, and the resident representative (if applicable and consistent with his/her authority) when there was an accident involving the resident which results in injury and has potential for requiring physician intervention, significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly. Review of the facility's policy titled Skin Care Standard of Practice, reviewed July 2020, revealed a licensed nurse on admission/readmission and minimum of weekly would assess all residents. The policy further revealed upon identification of a skin/wound impairment the nurse would notify the physician, obtain new orders for treatment, notify the responsible party, note the change in condition on the 24-hour report and notify the nurse manager of the change in the resident's skin condition, requiring additional oversight and monitoring. Review of Resident #1's medical record revealed the facility admitted the resident on 11/11/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also revealed Resident #1 had a State guardian. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident was moderately cognitively impaired. The assessment also revealed the resident did not have any skin conditions. Review of Resident #1's Care Plan, dated 11/03/2020, revealed Resident #1 was at risk for skin breakdown related to Diabetes. The care plan included interventions to monitor the resident's skin and report changes. Review of a facility Investigation Report initiated, on 06/05/2021, and interview with Resident #1 on 06/15/2021 at 1:58 PM, revealed the resident eloped from the facility on 06/05/2021, and walked approximately four (4) miles, prior to being located and assisted back to the facility by staff. Resident #1 stated he/she sustained blisters to the soles of both feet as the result of walking after leaving the facility. Further interview with the resident revealed Licensed Practical Nurse (LPN) #2 bandaged his/her feet after returning to the facility on [DATE], between 2:00 AM and 2:30 AM. However, continued review of the investigation report revealed it was documented Resident #1 sustained no injuries while out of the facility, on 06/05-06/06/2021. Observation of Resident #1's skin, on 06/17/2021 at 1:28 PM with LPN #3 and the Director Of Nursing, revealed healing areas to both feet. The sole of the resident's left foot had a reddened area and the sole of the right foot had two healing areas. The areas appeared to be healing blisters. On 06/15/201 5:33 PM and 06/17/2021 at 1:37 PM, interview with Licensed Practical Nurse (LPN) #2, revealed she completed a skin assessment with the Director of Nursing (DON) on 06/06/2021 when Resident #1 returned to the facility. LPN #2 stated she did not identify any injuries during the assessment, however, later in the interview stated she had bandaged the resident's feet on 06/06/2021, after the resident returned to the facility because the resident was complaining of pain. The LPN stated the areas were reddened and callous like. LPN #2 stated she did not notify the resident's physician or nurse practitioner of the injuries to obtain a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN #3, on 06/17/2021 at 1:47 PM, revealed she denied LPN #2 notifying her of the injuries to Resident #1's feet on 06/06/2021. Further interview revealed the LPN stated she had performed a skin assessment on Resident #1, on 06/03/2021 (prior to elopement), and the resident skin was intact with no injuries or impaired skin areas. Interview with Nurse Practitioner #1, on 06/29/2021 at 2:20 PM, revealed the facility did not notify her that Resident #1 injured his/her feet during an elopement on 06/05-06/2021. Further interview revealed she expected facility staff to notify her when a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Physician #1, on 06/28/2021 at 7:05 PM, revealed the facility did not notify her that Resident #1 sustained injury related to the elopement. She further revealed that she expected staff to notify her when a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/17/2021 at 12:49 PM and 06/29/2021 at 4:45 PM, interview with the DON, revealed, she was present when LPN #2 assessed Resident #1 upon arrival back to the facility on [DATE], and she did not identify any concerns. She further stated she was unaware Resident #1 had sustained an injury during the elopement until 06/17/2021. Continued interview with the DON revealed she expected staff to notify the physician of any injury sustained by a resident and obtain a new order if indicated. On 06/17/2021 at 1:58 PM, interview with Administrator, revealed he was unaware Resident #1 had sustained and injury to the feet during the elopement. He further revealed he expected staff to notify the physician, nurse practitioner or physician assistant when a resident is injured or a change in condition occurs.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure one (1) of three (3) sampled resident's comprehensive care plan was reviewed and revised when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the staff failed to add the injury to the resident's comprehensive care plan. The findings include: Interview with the Administrator on 06/17/2021 at 1:58 PM revealed the facility did not have a care plan policy related to care plans. However, interview with the Director of Nursing (DON) on 06/17/2021 at 12:49 PM revealed if a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record revealed the facility admitted the resident on 11/11/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also revealed Resident #1 had a State guardian. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident was moderately cognitively impaired. The assessment also revealed the resident did not have any skin conditions. Review of Resident #1's care plan dated 11/03/2020 revealed Resident #1 was at risk for skin breakdown related to Diabetes. Review of a facility investigation revealed on 06/05/2021, sometime between 9:00 PM and 9:45 PM, Resident #1 exited the facility through an unsecured facility window without staff knowledge. Facility staff located Resident #1 sometime between 2:00 AM and 2:30 AM on 06/06/2021, approximately four (4) miles from the facility. Interview with Resident #1, on 06/15/2021 at 1:58 PM, confirmed the resident had left the faciity on [DATE] sometime after 9:00 PM and walked approximately four (4) miles to a park area before staff located and returned him/her to the facility. Further interview with Resident #1 revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview with Resident #1 revealed Licensed Practical Nurse #2 bandaged his/her feet on 06/06/2021 after return to the facility. Interview with LPN #2 on 06/15/2021 at 5:33 PM and 6/17/2021 at 1:37 PM revealed she completed a skin assessment with the DON on 06/06/2021 when Resident #1 returned to the facility. LPN #2 stated she did not identify any skin areas on Resident #1, but later stated she was aware that Resident #1 had sustained blisters to the feet, and she bandaged them on 06/06/2021. LPN #2 stated the areas were red and appeared to look like calluses. Review of Resident #1's comprehensive care plan in effect on 06/15/2021, revealed no evidence the injuries sustained by Resident #1 were added to the resident's care plan. Interview with the Mininum Data Set Nurse, on 06/16/2021 at 10:33 AM, revealed she reviewed care plans to ensure interventions were appropriate. She revealed that she had not been aware that Resident #1 had sustained injuries during the elopement and therefore she had not added that to the resident's care plan. Observation of Resident #1's skin on 06/17/2021 at 1:28 PM, revealed a red area to the anterior sole of the left foot and a red area on the anterior sole and arch of the right foot. The areas appeared to healing blisters. Interview with the Director Of Nursing, on 06/17/2021 at 12:49 PM and 06/29/2021 at 4:45 PM, revealed she assessed Resident #1 upon arrival back to the facility on [DATE] with LPN #2, but did not see any injuries to the resident. However, she stated if LPN #2 bandaged the resident's feet, there must have been injury to them. She stated she was unaware of Resident #1's injuries until 06/17/2021. The DON stated any injury sustained by a resident should be included on the resident's plan of care. Interview with Administrator, on 06/17/2021 at 1:58 PM, revealed he was unaware that Resident #1 had injuries to the feet. He further stated that each care plan was supposed to be reviewed and revised by the interdisciplinary team and would be updated by nursing administrative staff. However, the Administrator stated that due to LPN #2 not documenting or reporting the injuries, the staff did not update the care plan.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide necessary care and treatment in accordance with professional standards for one (1) of three (3) sampled residents (Resident #1). Interview with Resident #1, on 06/15/2021 at 1:58 PM, revealed he/she eloped from the facility on 06/05/2021, and walked four (4) miles to a park area prior to staff locating him/her. The resident stated upon return to the facility he notified staff of the blisters he/she had got from walking and they bandaged both feet. However, further review of the facility's investigation initiated on 06/05/2021, revealed staff documented Resident #1 sustained no injuries as a result of the elopement. Observation of Resident #1's skin, on 06/17/2021 at 1:28 PM, revealed the resident had reddened areas to soles of both feet. Record review revealed the facility failed to obtain a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled Skin Care Standard of Practice, reviewed July 2020, revealed a licensed nurse on admission/readmission and a minimum of weekly thereafter, would assess all residents for skin impairment. The policy further revealed upon identification of skin impairment the nurse would notify the physician, obtain new orders for treatment, notify the responsible party, note the change in condition on the 24-hour report and notify the nurse manager of the change in the resident's skin condition. Review of Resident #1's medical record revealed the facility admitted the resident on 11/11/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also revealed Resident #1 had a State guardian. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident was moderately cognitively impaired. The assessment also revealed the resident did not have any skin conditions. Review of Resident #1's care plan dated 11/03/2020 revealed Resident #1 was at risk for skin breakdown related to Diabetes. The care plan included interventions to monitor the resident's skin and report changes. Review of a facility investigation initiated on 06/05/2021, reveled Resident #1 exited the facility without staff knowledge on 06/05/2021, through an unsecured window. Staff located the resident approximately four (4) miles from the facility approximately (4) hours later. Interview with Resident #1 on 06/15/2021 at 1:58 PM confirmed he/she eloped from the facility on 06/05/2021, and walked four (4) miles to a park area prior to staff locating him/her. The resident stated upon return to the facility he/she notified staff of the blisters he/she had got from walking and the staff bandaged both feet. However, further review of the facility's investigation initiated on 06/05/2021, revealed staff documented Resident #1 sustained no injuries as a result of the elopement. Observation of Resident #1's skin, on 06/17/2021 at 1:28 PM, revealed the resident had reddened areas to soles of both feet. One area was to the anterior sole of the left foot and two areas were located on the resident's right foot, one to the anterior sole of the right foot and one area to anterior arch of right foot. All the areas observed appeared to be healing blisters. Review of Progress Notes for Resident #1 dated 06/06/2021 at 3:19 AM, revealed Licensed Practical Nurse #2 performed a skin assessment on Resident #1 when the resident was returned to the facility after the elopement. The note stated the nurse observed no areas of skin breakdown when the skin assessment was completed. Further review of Resident #1's medical record revealed a skin assessment was documented on 06/10/2021 for Resident #1 which stated Resident #1's skin was intact and had no areas of skin breakdown. Review of Resident #1's bath sheets for 06/05/2021, 06/09/2021 and 06/16/2021 revealed staff documented the resident's skin was intact with no areas of skin breakdown. Interview with LPN #2 on 06/15/2021 at 5:33 PM and 6/17/2021 at 1:37 PM revealed she completed a skin assessment with the Director of Nursing (DON) on 06/06/2021 after Resident #1 returned to the facility. LPN #2 stated she did not identify injuries sustained by Resident #1. However, after further interview, LPN #2 stated she was aware that Resident #1 had impaired skin areas to his/her feet. She revealed she assessed the areas on 06/06/2021, to be reddened and callous like. LPN #2 stated Resident #1 told her the areas were the result of walking that night and they were painful. LPN #2 stated she bandaged both of the resident's feet, but did not notify the resident's physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #1's medical record revealed no further treatment, documentation, or assessment of the areas on Resident #1's feet until 06/17/2021, when LPN #3 discovered the areas to the resident's feet during a skin assessment. Interview with LPN #3 on 06/17/2021 at 1:47 PM revealed she performed a skin assessment on Resident #1 on 06/03/2021, two (2) days prior to elopement, and Resident #1's skin was intact with no skin breakdown. LPN #3 denied LPN #2 notified her of the areas to the resident's feet on 06/06/2021 during shift change. The LPN stated she had no knowledge of the areas to the resident's feet until she completed the resident's skin assessment on 06/17/2021. She stated when she conducted the skin assessment she observed an area to the anterior sole of left foot and two areas on the right foot located on the anterior sole and arch of right foot. LPN #3 stated the areas appeared to be healing blisters. LPN #3 stated at that time she notified the resident's physician. Interview with State Registered Nurse Aide (SRNA) #10 on 6/29/2021 at 4:12 PM revealed Resident #1 was independent with bathing and therefore she did not identify any areas of skin breakdown. Interview with the Director of Nursing, (DON), on 06/17/2021 at 12:49 PM and 6/29/2021 at 4:45 PM revealed, she assessed Resident #1 upon arrival back to the facility on [DATE] with LPN #2. She stated she did not identify any concerns during the skin assessment, and was unaware of the areas to Resident #1's feet until 06/17/2021. The DON stated she was unable to determine why LPN #2 did not notify Resident #1's physician and obtain a treatment order for the areas to the resident's feet on 06/06/2021. The DON stated she expected nursing to perform a full head to toe assessment when any skin assessment was performed or if a resident had an accident or injury, including being out of the facility without staff knowledge. The DON further stated that any skin breakdown should be documented so follow-up assessments could be conducted to ensure the area was healing and did not decline. Interview with the Administrator, on 06/17/2021 at 1:58 PM, revealed he was unaware that Resident #1 had sustained an injury to his/her feet while out of the facility. The Administrator stated he expected staff to perform established guidelines and seek treatment orders from the physician when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interviews, record review, and facility policy review it was determined the facility failed to ensure residents' care plans were being implemented for one (1) of three (3) sampled residents (Resident #2) Resident #2's care plan interventions included to anchor tubing, keep drainage bag below level of bladder and provide catheter care every shift. However, the facility failed to ensure these interventions were implemented. The findings include: Review of the facility's documents provided on 06/04/2021, revealed the facility did not have the following policies: Incontinent Care, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's policy titled, Comprehensive Care Plans Standard of Practice with a revision date of 2017, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the resident's comprehensive assessment. Person centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. The care planning process will include an assessment of the resident's personal and cultural preferences in developing goals of care. Record review revealed the facility admitted Resident #2 on 05/11/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission Minimum Data Set (MDS) revealed Resident #2 to have a Brief Interview for Mental Status (BIMS) SPELL OUT score of (15) fifteen signifying the resident was cognitively intact. The facility assessed the resident to require the extensive assistance with Activities of Daily Living (ADLs). The facility also assessed the resident to have an indwelling catheter. The resident used taking opioids for occasional pain 4/7 days with a pain rating of 6/10. Review of Resident #2's care plan revealed an order dated 05/12/2021 for indwelling catheter care (every shift) with start date of 05/22/2021, related to Urinary Tract Infection, and Neuromuscular dysfunction of the bladder. Problems included: potential for complications related to indwelling Foley (brand of indwelling catheter) catheter. Care plan goals included: the resident will not experience complications/infections through next review and UTI will resolve. Interventions included: Anchor tubing, keep drainage bag below level of bladder and provide catheter care every shift. Review of June 2021 CNA Care Plan Card Profile revealed no interventions related to catheter care. Observation on 06/07/2021 at 1:22 PM revealed the catheter tubing and dignity drainage bag were lying on the floor beside Resident #3. The resident was sitting in his/her wheelchair (w/c). Interview with the resident, at that time, revealed staff had left the catheter on the floor and it was not supposed to be on the floor. Interview on 06/09/2021 at 12:07 PM, with Physical Therapy Assistant (PTA) and on 06/09/2021 at 12:11 PM with Occupational Therapy Assistant (OTA) revealed the catheter was anchored when they had left the room after providing therapy that morning about 9:30 AM-10:30 AM and both had left the room at the same time and the catheter was anchored when they left the resident. Interview on 06/07/2021 at 1:31 PM with Certified Nursing Aide (CNA) #1 and (CNA) #2 revealed they had been in the room previously and the catheter must have fallen on the floor. Interview on 06/09/21 at 1:10 PM with CNA #1 revealed everyone followed the residents' care plans and she provided catheter care and cleaned the catheter to prevent infection. Additionally, CNA #1 stated the purpose of the care plan was to provide the best care for the resident. She stated the catheter should have been anchored to the wheelchair. CNA #1 reported things happen and therapy had been in the room prior and should have picked it up. However, it should have been on the chair because of infection control. Interview on 06/09/2021 at 1:30 PM with Licensed Practical Nurse (LPN #3) revealed all staff were to follow the care plans. The LPN stated the tubing and catheter lying on the floor could cause infection. Interview on 06/07/2021 at 2:00 PM and on 06/09/2021 at 2:25 PM with Registered Nurse (RN) #2 revealed that nursing was to ensure the tubing and catheter were anchored for the resident related to the care plan. Interview on 06/09/2021 at 3:46 PM with the Assistant Director of Nursing (ADON) revealed everyone should follow the care plan because it directed resident care, and she expected the tubing and catheter to be anchored on a non-moveable object. Interview on 06/09/2021 at 4:02 PM with the Director of Nursing (DON), revealed everyone followed the care plans specific for the resident and that was the responsibility of everyone. The DON stated that the anchor tubing on the care plan interventions should have been implemented. The DON stated the outcome for the catheter and tubing on the floor would be that it could come and it presented a greater chance of a (UTI) urinary tract infection.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to ensure the environment remained as free from accident hazards as possible for 1 (one) of three (3) sampled residents (Resident #3). Resident #3's [MEDICATION(S)] pain patch was left on his/her overbed table, all night, unsecured. Staff failed to place the new patch on the resident; and, failed to remove the old patch from the resident's back. The findings include: Review of facility's documents provided on 06/04/2021 revealed the facility did not have the following policies: Medication Administration, Physician's Orders, or an Accident/Hazards. Interview with the Administrator and Director of Nursing (DON) on 06/09/2021 at 4:56 PM revealed the facility followed State and Federal guidelines. Record review revealed the facility admitted Resident #3 on 04/14/2021 with the following diagnoses: [CONDITION(S)], Type II Diabetes Mellitus without complications, [CONDITION(S)], [CONDITION(S)] Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, Mild Cognitive Impairment, Pain, and Unstable Burst Fracture of T 5-T 6 Vertebrae. Review of the 06/03/2021 Quarterly Minimum Data Set (MDS) revealed the facility assessed Resident #3 to have a Brief Interview for Mental Status (BIMS) of (15) fifteen which indicated the resident was cognitively intact. Further review revealed the facility assessed Resident #3 to require the extensive assistance with activities of daily living (ADLs). Observation on 06/03/2021 at 8:40 AM, during Resident #3's incontinent care, revealed a [MEDICATION(S)] 5% pain patch lying on the overbid table beside the resident's bed. Further observation revealed the backing was still on the pain patch. Observation revealed the following information was noted on the patch: 06/02/2021 7:00 PM and initials on the patch. Review of the [MEDICATION(S)] 5% Pain Patch facts document provided by facility, revealed the following: when using this product use only as directed; avoid contact with eyes, dispose of used patch in manner that always keeps product away from children and pets. Used patches still contain the drug product that can produce serious adverse effects if a child or pet chews or ingests the product. Interview with Certified Nursing Assistant (CNA) #12, on 06/03/2021 at 8:55 AM revealed that the patch was not supposed to be on the overbed table and it had not been used. CNA #12 stated she was not a medication aide and she would give it to the nurse. Observation revealed CNA #12 handed the 5% [MEDICATION(S)] pain patch to the Assistant Director of Nursing (ADON). Interview with the ADON and DON, on 06/03/2021 at 9:00 AM, revealed the patch should have been placed on the resident. During the interview the ADON handed the 5% [MEDICATION(S)] pain patch to the Director of Nursing (DON). The DON read the writing on the pain patch, then stated it was a 5% [MEDICATION(S)] patch usually utilized for pain for a certain area of the body, and it belonged to Resident #3. The DON stated she did not know if the patch was for 12 hours or for a 24 hour period. Additionally, the DON asked Resident #3 if a patch was on his/her back with the resident stating he/she did not think one had been placed to the middle of his/her back last night and his/her back hurt. Observation on 06/03/2021 at 9:20 AM, revealed Kentucky Medication Aide (KMA) #1 brought in a 5% [MEDICATION(S)] pain patch to place on the resident. Additionally, KMA #1 then pulled off an old patch on the small of the back of Resident #2 and stated that it was dated 06/02/2021 and had her initials on it. KMA #1 then placed the new 5% [MEDICATION(S)] patch to Resident #3's back. Interview with KMA #1, on 06/02/2021 at 9:25 AM, revealed the patches were twelve (12) hour patches. KMA #1 stated Resident #3 should receive a 5% [MEDICATION(S)] patch during the day and one at night, but the one left on the overbed table was not hers, because she only works days. Interview with Licensed Practical Nurse (LPN) #2, on 06/04/2021 at 7:37 AM, revealed [MEDICATION(S)] Pain Patches 5% were ordered to go on at night and come off during the day. LPN #2 stated they switched the Physician's Order to go on during day shift and off during the night shift. She stated it was changed 06/03/2021. Additionally, LPN #2 stated she was to put the [MEDICATION(S)] patch on Resident #3, and the CNAs usually called her when doing incontinent care, but she had forgotten to put the pain patch on Resident #3 and left it on the table. LPN #2 stated she would usually put it on around 9:00 PM. Continued interview revealed the outcome of leaving the pain patch on the overbed table could be a medication error, but she didn't think Resident #3 would bother the pain patch on the table. However, they do have wanderers on the hall that go into other residents' rooms, but they were not usually up at night. Review of list provided by facility revealed there were eighteen (18) residents that were wanderers. Interview with Licensed Practical Nurse #3 (LPN #3), on 06/09/2021 at 1:30 PM, revealed all staff should follow the residents' care plans. She stated another resident could pick the patch up, or it could get thrown away if left out overnight on Resident #3's overbed table. Interview with Registered Nurse (RN) #2, on 06/09/2021 at 2:25 PM, revealed nursing was to ensure the care plan was followed related to dispensing of the medication according to the Physician's Orders. RN #2 stated the outcome could be Resident #3 not getting pain relief, or it could be ingested by an incoherent resident. Interview on 06/09/2021 at 12:14 PM with Registered Nurse #4, revealed it was the nurse responsibility to ensure proper placement and administration of medication related to (r/t) pain patch. Interview with Assistant Director of Nursing (ADON), on 06/09/2021 at 3:46 PM, revealed the outcome of the [MEDICATION(S)] Pain Patch lying out in the room could be a resident received more medication than they were supposed to. She stated if another resident went into the room they could pick the patch up. The ADON stated there were residents that wandered in the facility. Interview with Director of Nursing (DON), on 06/09/2021 at 4:02 PM, revealed Physician's Orders and care plans should be followed. She stated the [MEDICATION(S)] Pain Patch (medication) was supposed to be taken off and applied according to the care plan and the Physician's Order. The DON stated she expected the patch to be given to her, the event investigated, notification made to family and the doctor due to the [MEDICATION(S)] Pain Patch being on too long as it could have irritated the skin of Resident #3. She further stated the patch should have been disposed of when found and she would not want to use it since it was out overnight.

Based on observation, interviews, record review, and facility policy review it was determined the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (1) of three (3) sampled residents (Resident #2). Resident #2's catheter and tubing was found lying on the floor, beside the resident who was sitting in the wheelchair. The tubing was not anchored off the floor. The findings include: Review of the facility's documents provided on 06/04/2021 revealed the facility did not provide a policy on catheters. Interview with Administrator and Director of Nursing (DON on 06/09/2021 at 4:56 PM revealed State and Federal guidelines were followed. Record review revealed the facility admitted Resident #2 on 05/11/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status score of (15) fifteen which indicated the resident was cognitively intact. Further review revealed the facility assessed the resident as requiring the extensive assistance with ADLs (activities of daily living), had an indwelling catheter and had opioids for occasional pain four of seven (4/7) days with a pain rating of six on a scale of ten (6/10). Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's care plan revealed an order dated 05/12/2021 for indwelling catheter care (every shift) with a start date of 05/22/2021 related to the following medical Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed care plan problems included: potential for complications related to indwelling Foley catheter, 16 French 10 cc (cubic centimeters), admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2021 CNA (certified Nurse Aide) CNA Careplan Card Profile revealed no interventions related to catheter care. Observation on 06/07/2021 at 1:22 PM revealed the resident's catheter tubing and dignity bagged catheter lying on the floor. Interview with Resident #2, at that time, revealed staff had left the catheter on the floor and it was not supposed to be on the floor. Interview on 06/09/2021 at 12:07 PM with the Physical Therapy Assistant (PTA); and, on 06/09/2021 at 12:11 PM with the Occupational Therapy Assistant (OTA) revealed the catheter was anchored when they left the room after providing therapy. Further interview revealed they both left the room at the same time and catheter was anchored when they left the resident. Interview on 06/07/2021 at 1:31 PM with Certified Nursing Aide (CNA) #1 and (CNA) #2 revealed that they had previously been in the room and the catheter must have fallen on the floor. Interview on 06/09/2021 at 1:10 PM with CNA #1 revealed the catheter should have been anchored to the wheelchair (w/c), but things happen and therapy had been in the room prior and should have picked it up. Additionally, CNA #1 stated just because the catheter and tubing was on the floor did not mean not it was not anchored correctly. However, it should have been on the chair until the resident was transferred because of infection control. Attempts to contact CNA #2 on 06/09/21 at 2:43 PM, at 2:57 PM, and at 4:24 PM were unsuccessful. Interview on 06/09/2021 at 1:30 PM with Licensed Practical Nurse (LPN #3) revealed tubing and catheter lying on the floor could cause infection. Interview on 06/09/2021 at 2:25 PM with Registered Nurse (RN) #2 revealed nursing was to ensure the tubing and catheter were anchored for the resident. RN #2 stated the outcome of the tubing being on the floor could be an infection risk or fall risk. Interview on 06/09/2021 at 3:46 PM with ADON (Assistant Director of Nursing) revealed she expected the tubing and catheter to be anchored on a non-moveable object. The ADON stated if it was lacking a clip then staff should get one to replace it. She stated if the catheter was not handled properly a resident could get an infection. Interview on 06/09/2021 at 4:02 PM with the DON revealed the care plan interventions included to anchor the tubing. The DON stated she expected the staff to keep the tubing and catheter off the floor. Continued interview revealed the tubing should still be able to drain. She stated the outcome for the catheter and tubing on floor would be a greater chance of (UTI) urinary tract infection.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to 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 related to one (1) resident of three (3) sampled residents (Resident #2). Resident #2's catheter and tubing was found lying on the floor unanchored to the wheelchair or a stationary object in the room. The findings include: Review of facility's documents provided on 06/04/2021 revealed the facility did not have the following policies: Medication Administration, Incontinent Care, Physician Orders, or a policy on catheters. Interview with Administrator and Director of Nursing (DON), on 06/09/21 at 4:56 PM, revealed they followed State and Federal guidelines. Review of the facility's policy entitled Infection Prevention and Control Program, undated revealed an infection prevention and control program (IPCP) was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program was developed to address the facility's specific infection control needs and requirements identified in the facility's assessment and the infection control risk assessment, and based on accepted national infection prevention and control standards. Prevention of Infection: identifying possible infections or potential complications of existing infections; instituting measures to avoid complications or dissemination and educating and ensuring that staff adhere to proper techniques and procedures. Review of the facility's policy entitled, Monitoring Compliance with Infection Prevention, undated, revealed routine monitoring and surveillance of the workplace was conducted to determine compliance with infection prevention and control policies and practices. Record review revealed the facility admitted Resident #2 on 05/11/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status score of (15) fifteen which indicated the resident was cognitively intact. Further review revealed the facility assessed Resident #2 to require the extensive assistance with ADLs (activities of daily living). Resident #2 has an indwelling catheter and was taking opioids for occasional pain four (4) of seven (7) days with a pain rating of six (6) on a scale of ten (10). Review of Resident #2's care plan with an order dated 05/12/2021 for indwelling catheter care (every shift) with a start date of 05/22/2021 related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed goals that included the resident will not experience complications/infections through next review and the UTI will resolve, with the treatments/interventions. Also anchor the tubing, keep drainage bag below level of bladder, provide catheter care every shift. Review of the June 2021 Certified Nurse Aide (CNA) Card Profile (CNA care plan), which guides the resident's care by the CNA revealed no interventions related to catheter care. Observation on 06/03/2021 at 1:22 PM revealed Resident #2 sitting in wheelchair (w/c) with a dignity drainage bag and catheter tubing lying on the floor beside the resident's w/c. Resident #2 stated the catheter was not supposed to be on the floor. Continued observation revealed CNA #1 and CNA #2 entered the room at 1:31 PM. The CNA's picked the tubing and catheter up off the floor with gloved hands and placed the tubing in the resident's waistband of his/her pants. CNA #1 then placed the catheter on the bed frame. Further observation revealed CNA #1 with the help of CNA #2 placed the resident in bed. CNA #2 retrieved a trash bag from the trash can beside the bed to place the wet brief. CNA #1 (with the same gloves) removed the resident's pants, taking the catheter and tubing through the resident's pant leg and hanging the catheter back on the bed frame. CNA #1 then provided incontinent care to resident (frontal) displacing the catheter tubing as she provided care to the resident and cleaned the posterior buttocks of Resident #3; removed the wet brief with gloved hands and placed the wet brief in a trash bag. CNA #1 and #2 then placed a clean brief on Resident #3 with the same gloves. CNA #1 then obtained a graduate from the bathroom and emptied the drainage bag with same gloves. She then emptied and rinsed the graduate and wiped it graduate out with the same pair of gloves. Interview with CNA #2, on 06/03/2021 at 1:40 PM, revealed her gloves should have been changed when she retrieved the trash bag from the trash can in the room. CNA #2 stated when she provided perineal care, her gloves should have been changed, and after touching the catheter. Interview with CNA #1, on 06/03/2021 at 1:50 PM and 06/09/2021 at 1:10 PM, revealed that she had thought about changing the gloves after picking the tubing and drainage bag up off the floor. She stated she probably should have changed her gloves when cleaning the graduate. Additionally, CNA #1 stated just because the catheter and tubing were on the floor did not mean not it was not anchored correctly. Attempts to contact CNA #2 on 06/09/2021 at 2:43 PM, 2:57 PM and 4:24 PM were unsuccessful. Interview with Licensed Practical Nurse (LPN #3), on 06/09/2021 at 1:30 PM, revealed the tubing and catheter lying on the floor could cause infection. Interview with LPN #3, on 06/09/2021 at 1:30 PM, revealed the catheter and tubing should not be on the floor because it was an infection issue. LPN #3 stated staff should have made sure that the tubing and the catheter were cleaned and placed in a secure position and then remove their gloves, wash their hands and dry them. She stated staff should have the items needed for the perineal care ready and then put on gloves. LPN #3 stated she would change her gloves between picking up the catheter and tubing and providing perineal care. Interview with LPN #4, on 06/09/2021 at 10:12 AM, revealed the tubing for catheter was to be below the bladder, and if the resident was in a wheel chair it should be behind the resident under the chair with the privacy bag. LPN #4 stated the catheter and tubing should not be on the floor, not touching anytime because of germs. She stated the outcome could be that it would affect the resident by making them sick and cause an infection. Continued interview revealed the gloves should be changed because going from two different procedures, the gloves were dirty and should be changed before perineal care. She stated you should change gloves after perineal care before putting on a clean brief, as it was a different procedure. LPN #4 stated if the Foley (brand of indwelling catheter) was touched, then change your gloves as well as after pericare. She stated you should not touch a clean area with dirty gloves. Interview with Registered Nurse (RN) #2, on 06/07/2021 at 2:00 PM and 06/09/2021 at 2:25 PM, revealed that staff should change gloves when picking a catheter and tubing off the floor and before going on to do perineal care (incontinent care). She stated that was the expectation for herself and her staff. RN #2 stated a catheter on the floor was an infection risk or a fall risk. She stated the staff should change gloves before doing any care, after perineal care, because they could be a risk for infection. Interview with the Assistant Director of Nursing (ADON), on 06/09/2021 at 3:46 PM, revealed she expected catheter tubing and catheters to be anchored on a non-moveable. The ADON stated that if not handled properly the resident could get an infection. Additionally, the ADON stated with touching the tubing and catheter then providing perineal care, she expected staff to change gloves. Interview with the Director of Nursing (DON) on 06/09/2021 at 4:02 PM, revealed the tubing from the catheter to the bag should be free flowing with urine, the catheter and tubing should be clipped if they had clips. The DON stated she would not expect the tubing to be on the floor, as it should be anchored on the wheel chair. The DON stated with the tubing and catheter on the floor, the catheter could come out and urine backed up into the bladder which could provide a greater chance of UTI. Continued interview with the DON revealed stated she expected staff to pick up catheter and tubing, then change gloves before providing perineal care, as this could lead to infections. The DON stated she expected gloves to be changed between cleaning the front perineal area and the posterior area and, providing the clean brief.

Based on interview, record review, facility policy review, and hospital record review, it was determined the facility failed to notify the Physician of a significant change in the resident's physical status or possible need to alter treatment until resident's family requested transfer to the hospital for one (1) of three (3) sampled residents (Residents #1). Closed record review revealed the facility admitted Resident #1 on [DATE], for rehabilitation and assessed the resident to be alert. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Speech and Physical Therapy staff were unable to arouse Resident #1, on [DATE] and [DATE]. Interviews revealed the resident's change in condition was reported to nursing staff; however, there was no documented evidence the resident's physician was notified. On [DATE] around 7:00 AM, Certified Nursing Assistant #7 reported to nursing that Resident #1 was not acting right; would not react to talk, touch, or a sternum rub. However, there was no documented evidence the physician was notified and interviews with nursing revealed staff did not notify the physician of the change in condition. Continued interviews, revealed the resident was transferred to the emergency room , upon request of the family around 10:40 AM. Review of the hospital records, dated [DATE], revealed Resident #1 was admitted to the Intensive Care Unit (ICU) and was diagnosed with [CONDITION(S)], Diabetic Ketoacidosis, [CONDITION(S)] due to a Urinary Tract Infection, and altered mental status. Further review of the hospital record, revealed upon entry to the Emergency Department, the resident was non-responsive even with deep pain and had a blood glucose level of 446 mg/dl(milligrams/deciliter). The facility failed to follow facility policy regarding physician notification. Although, the physician was notified on [DATE], after request from family, nursing did not provide specific information related to Resident #1's decline in food/fluid intake, lethargy and unresponsiveness. In addition, the physician was not immediately notified, per policy, of the resident's change in condition to unresponsive, reported to nursing at 7:00 AM on [DATE]. The facility's failure to ensure the physician was notified when there was a change of condition or need to alter treatment has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. 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 (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Change in Condition: When to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician's Assistant), dated 2003, revealed Immediate notification is to be made when any symptom, sign or apparent discomfort that is: acute or sudden in onset, and a marked change (i.e. more severe) in relation to usual symptoms and signs or unrelieved by measures already prescribed. Non-Immediate Notification is made when new or worsening symptoms that do meet above criteria. Closed record review revealed the facility admitted Resident #1 on [DATE] with diagnoses, which included Displaced Supracondylar Fracture with Intracondylar Extension of the lower end of right femur, Type 2 Diabetes Mellitus, and Dementia. Resident #1 was discharged on [DATE]. Review of the five (5) day scheduled Minimum Data Set (MDS) assessment, dated [DATE] revealed the facility had no assessment of Resident #1's cognition. Review of the Clinical Admission Documentation, dated [DATE] at 7:32 PM, revealed staff assessed Resident #1 to be alert. Review of the Speech Therapy Notes, dated [DATE], and Occupational Notes dated [DATE], revealed the resident was unable to be aroused by staff on three (3) separate visits. Interview with the Speech Therapist, on [DATE] at 10:01 AM, revealed she had been in Resident #1's room a few times on [DATE], and noted the resident was lethargic. She stated when speaking to him/her, the resident's jaw would tremble. She stated she had an aide assist her in repositioning Resident #1, but the resident still did not engage. The Speech Therapist stated she made the nursing staff aware of the resident's lethargy. Interview on [DATE] at 10:18 AM, with Certified Nursing Assistant (CNA) #5, revealed she worked on [DATE], and helped speech therapy attempt to wake Resident #1, but they were unsuccessful. She stated this was not the resident's normal behavior; so she reported it to the nurse on the unit. CNA #5 stated she did not remember who the nurse was as her days were all jumbled up. Interview with the Occupational Therapist (OT), on [DATE] at 11:20 AM, revealed she had briefly seen Resident #1, on [DATE] and [DATE], and noticed the resident to be sleepy, keeping his/her eyes closed. She stated she told the aides and she believed the aides said the nurse already knew. Review of Resident #1's Meal Intake Record, from [DATE]-[DATE], revealed fair (,d+[DATE]%) to good (,d+[DATE]%) intake for all meals. On [DATE], the resident consumed ,d+[DATE]% of breakfast, refused the lunch meal and consumed ,d+[DATE]% of supper. However, further review of the Meal Intake Record revealed the resident's intake had decreased to not consuming breakfast, lunch, or dinner on [DATE]; and breakfast on [DATE]. In addition, review of Resident #1's Fluid Intake Record revealed the resident consumed an average of 960 milliliters (ml) of fluids per day on [DATE]-[DATE]. However, further review of the Fluid Intake Record, revealed there was no documented evidence the resident consumed liquids on [DATE] or [DATE]. Interview with CNA #3, on [DATE] at 2:45 PM, and on [DATE] at 4:30 PM, revealed on [DATE], she tried to feed the resident both breakfast and lunch but he/she would not open his/her mouth. She stated she told Licensed Practical Nurse (LPN) #1 and the LPN stated, Okay, thank you, we will look into it. However, there was no documented evidence LPN #1 assessed the resident. Interview on [DATE] at 10:29 AM, with Licensed Practical Nurse (LPN) #1, revealed she could not recall staff reporting Resident #1 had not ate or drank during her shift on [DATE], or staff reports of the resident being lethargic during therapy. Interview with LPN #2, on [DATE] at 9:25 AM, revealed she could not recall receiving reports from other staff that Resident #1 had not eaten or was unresponsive during care/therapy. Further review of the Nursing Progress Notes, dated [DATE]-[DATE], revealed there was no documented evidence the physician was notified of Resident #1's increased lethargy, or decrease in meal and fluid intake. Interview with CNA #8, on [DATE] at 6:19 PM, revealed during breakfast tray pass, on [DATE], she noticed the resident was unresponsive. She stated when the resident's condition was reported to LPN #2, the LPN told her the resident probably had been given a sleeping pill. Interview with CNA #7, on [DATE] at 6:06 AM, revealed she worked on [DATE], and reported to LPN #2, Resident #1 was not acting right shortly after she arrived for her shift at 7:00 AM. She stated the resident would not react to talk, touch, or a sternum rub. CNA #7 stated the resident was sent out to the hospital before lunch. Interview with LPN #2, on [DATE] at 9:25 AM, revealed a nurse aide reported Resident #1 was unresponsive on [DATE]. LPN #2 stated the resident was sluggish to respond and she did not see any changes in the resident from the previous day. She stated she did not think anything was wrong with Resident #1. She further stated the residents daughter had called, at 5:07 AM on [DATE], and stated she knew the resident was dying and she did not want him/her to die in the facility. LPN #2 stated the residents family member called back at 5:32 AM, 7:49 AM and again at 10:40 AM, with concerns related to the residents medication regimen and to check on the resident's status. LPN #2 stated she sent Resident #1 out, on [DATE] around 10:40 AM, because the family asked the resident be evaluated. LPN #2 stated if she felt the resident's condition had declined or the resident was unresponsive she would have notified the doctor for new orders. Interview with Resident #1's Family Member, on [DATE] at 11:00 AM, revealed she had a window visit with Resident #1, on [DATE], and the resident spoke to her and waved. However, further interview revealed, on [DATE] at 11:32 AM, during a window visit on [DATE], she noticed the resident was very lethargic with labored abdominal breathing. She stated she asked the activity staff to get a nurse to check on the resident, and was told by LPN #1, the resident was fine. She further stated she asked the nurse to call the doctor and get orders for labs because something was wrong with the resident. She revealed she was very worried about the resident and each time she would call the facility she was told the resident was fine. The Family Member stated on the morning of [DATE], she called the facility and asked that the resident be sent out for an evaluation. The Family Member stated she felt no one was taking her concerns seriously. She further stated the resident was placed on Hospice care and had recently expired after transfer to the hospital. Review of the hospital records, dated [DATE], revealed Resident #1 was admitted to the Intensive Care Unit (ICU) and diagnosed with Diabetic Ketoacidosis, [CONDITION(S)] due to a Urinary Tract Infection, and altered mental status. Further review of the hospital record, revealed upon admission to the Emergency Department the resident was non-responsive even with deep pain and had a blood glucose level of 446 mg/dl (milligrams/deciliter). Interview with the Medical Director/Physician, on [DATE] at 3:43 PM, revealed she expected staff to make her aware of any acute or emergent changes in condition. She stated upon admission the resident was alert, awake in the bed, but nonverbal most of the time. Further interview revealed the nursing contacted her on [DATE]; but did not provide any specific details related to the resident's condition. She stated nursing told her the family wanted to have some lab work done; because the family had concerns and thought something was wrong with the resident. The Medical Director stated she ordered [MEDICATION(S)] and Magnesium levels to be drawn the next morning. She stated she was not notified about a change in condition, at 7:00 AM on [DATE], when the Certified Nursing Assistant identified Resident #1 was unresponsive. Interview with the Director of Nursing (DON), on [DATE] at 2:15 PM, revealed she expected the nurses to notify the physician if there was a significant change in a resident. The DON revealed the resident was sent out due to the family demanding the resident be evaluated. Interview with the Administrator, on [DATE] at 9:40 AM, revealed he expected the nurses to notify the doctor if there was a change noticed in the resident's condition. He stated he felt the nursing staff assessed the resident properly during the window visit and the resident had a decline due to his/her diagnosis. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility transferred Resident #1 to the hospital on [DATE]. Resident #1 was discharged from the facility on this date per family request. 2. Physical assessments were completed for all in-house residents by licensed nurses. This assessment included vital signs and skin integrity audits. The DON, ADON and/or licensed wound nurse completed a second lookback sample of ten (10) residents. For any identified concern, the nursing IDT (DON, ADON, wound nurse) verified physician notification and that the concern was care planned with interventions for prevention/treatment. This was completed by [DATE]. 3. The Chief Nursing Officer (CNO) provided education to the Interim Administrator (Adm), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on [DATE] regarding F580, F656, F684, and F686. The education included: A. Education on immediately informing the resident; consulting with the resident's physician; and notifying the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status and/or a need to alter treatment significantly. This included, but was not limited to decreased meal intake; change in level of consciousness; and new or worsening skin condition/integrity. B. Education on developing and implementing a comprehensive person-centered care plan for each resident. An example of interventions that would be required on the care plan would include (but not limited to) interventions to prevent pressure wounds for the risk of skin breakdown. C. Education on ensuring that the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices; which included Quality of Care, but was not limited to nursing assessments for cause or need for additional care and services to prevent further decline at the time of notification; and obtaining labs/diagnostics for residents as ordered by physician. D. Education on ensuring a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable ulcers/injuries were placed on the plan of care and implemented. 4. The education related to Physician Notification (F580), Care Plan Development and Implementation (F656), and Pressure Sores (F686) was provided to the licensed nursing staff (including contracted/agency nursing staff) and CNA's (including contracted/agency nursing) by the DON, ADON, or assigned licensed nurse that had previously been educated by the DON and/or ADON. Education provided to the CNA's also included the importance of implementing the interventions specified in the plan of care. This would be completed by [DATE]. Verbal acknowledgement of understanding along with signed education was received for the CNA's, and a post-test was conducted after the education for licensed nurses. Any new nursing hire (including contracted/agency) would receive this education prior to assuming duties. 5. The education related to Quality of Care (F684) was provided to the licensed nursing staff (including contracted/agency nursing staff) by the DON, ADON, or assigned licensed nurse that had previously been educated by the DON and/or ADON. This would be completed by [DATE]. A post-test was conducted after the education for licensed nurses. Any new nursing hire (including contracted/agency) would receive this education prior to assuming duties. 6. Any nursing staff member that has not completed the education by [DATE], will receive the education prior to assuming duties at the facility. 7. An ad hoc Quality Assurance Process Improvement (QAPI) meeting was held [DATE] to review the summary of Immediate Jeopardy findings and discussed the development of the action items to be completed. This meeting included the Interim Administrator, Director of Nursing, Assistant DON, the Chief Nursing Officer, and the Medical Director via phone. 8. Effective [DATE] and continuing on-going, the prior 24- hour nursing notes would be reviewed in the morning daily clinical meeting by the DON/ADON/the assigned licensed nurse to ensure that physician notification has been made for any identified changes in condition, and that the care plan has been updated to reflect the change with interventions. This would include, but not limited to, any concern with nutritional intake, changes in skin integrity, or changes in level of consciousness/mental status change. 9. The assigned licensed nursing supervisor would be responsible to review on weekends. During the Monday morning clinical meeting, a second lookback of the weekend nursing notes would be completed. 10. Beginning [DATE], the DON and/or ADON would receive a daily shift report from a selected nurse and a selected CNA, on a rotating basis, five (5) x a week for four (4) weeks, then two (2) x a week for four (4) weeks to get the direct nursing/nursing assistant report to validate that any change of condition has been reported to the nurse and physician, with interventions being followed, and the care plan updated as indicated. 11. Beginning [DATE], the DON and/or ADON would review a minimum of five (5) residents weekly with skin integrity care plans to validate that interventions are being implemented as directed in the plan of care. This would include walking rounds with the CNA's to validate residents' care plan interventions are being implemented. This would continue for four (4) weeks. 12. Beginning [DATE], the DON and/or ADON would audit a minimum of ten (10) residents weekly with ordered blood sugars to ensure that this was completed and documented as ordered. This would continue for four (4) weeks. 13. A second ad hoc QAPI meeting was held [DATE] to review the status of education and audits. This meeting included the Interim Administrator, Director of Nursing, Assistant DON, the Chief Nursing Officer, and the Medical Director via phone. 14. The monitoring results would be followed in the facility's monthly QAPI monthly for a minimum of two (2) months for review and recommendation, if indicated. The monthly QAPI is attended by, but not limited to, the Administrator, Director of Nursing, Assistant DON, Unit Manager, Social Services Director, Activities Director, Dietary Manager, Business Office Manager, Therapy Director, and the Medical Director a minimum of quarterly. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of a facility Census Activity form revealed Resident #1 was discharged to a Regional Hospital on [DATE] with no bedhold and no return anticipated. 2. Review of a Twin [NAME] Nursing and Rehab Center Bed listing by resident, dated [DATE] related to Physical Assessments, revealed all residents' names were checked indicating assessments to include vital signs and skin assessments were completed for each resident. Review of skin assessment sheets revealed all residents received a skin assessment. Review of Skilled B Unit's and Skilled A Unit's resident lists and vital sign sheets revealed all residents' vital signs were checked, to include O2 sats on [DATE]. Any concerns identified were reported to the physician and the concern was care planned with interventions for prevention/treatment. In addition, review of a skin assessment lookback by the DON, ADON, and Wound Nurse, revealed ten (10) residents received skin assessments on [DATE] with no concerns identified. Interviews on [DATE] with the DON at 11:17 AM and ADON at 11:45 AM revealed all residents received an assessment to include vital signs and skin by the licensed nurses. The DON and ADON stated the residents' physicians were notified of any concerns and care plans were revised. The DON and ADON also revealed they completed skin assessments of ten (10) residents and validated their skin assessments were accurate and their physicians were notified and care plans revised with any change in condition identified. They stated no concerns were identified. 3. Review of the F580 Notification of changes, F656 Develop/Implement Comprehensive Care Plan, F684 Quality of Care, and F686 Treatment Services to prevent/heal pressure ulcers education sign in sheets, revealed the CNO, Regulatory Risk Manager, provided education to the prior Administrator, DON and ADON on [DATE]. Interviews on [DATE], with the Administrator at 1:15 PM, the DON at 11:17 AM. and ADON at 11:45 AM revealed the CNO educated them on change in condition, implementing the care plans, and providing care and services related to prevention/healing of skin breakdown to include CNA's reporting to a nurse when redness was identified. 4. Review of the F580 Notification of Change, F656 Develop/Implement Comprehensive Care Plan, and F686 Treatment Services to Prevent/Heal Pressure Ulcers education sign in sheets, revealed all nursing staff to include agency staff were educated by [DATE]. Review of sign in sheets revealed the CNA's validated they received education and review of post tests revealed all licensed staff scored 100%. Interviews on [DATE] with the DON at 11:17 AM and ADON at 11:45 AM, revealed they provided education to all nursing staff and agency staff on F580 Notification of Change, F656 Develop/Implement Comprehensive Care Plan, and F686 Treatment Services to Prevent/Heal Pressure Ulcers. Interviews on [DATE] with Registered Nurse (RN) #3 at 9:09 AM, Licensed Practical Nurse (LPN) #1 at 9:04 AM, LPN #3 at 9:36 AM, Certified Medication Aide at 9:25 AM, Certified Nurse Aide (CNA) at 9:14 AM, and CNA #8 at 9:20 AM, revealed they were educated on notification of the physician, family, and/or nurse if they identified a resident with a change in condition, implementation of the care plan, and reporting if they identified any redness for skin breakdown. 5. Review of the F684 sign in sheet revealed licensed staff were provided education on assessments by [DATE]. Review of post tests revealed the licensed staff scored a 100%. Interviews with Registered Nurse (RN) #3 at 9:09 AM, Licensed Practical Nurse (LPN) #1 at 9:04 AM, LPN #3 at 9:36 AM, and the RN Weekend Supervisor at 1:07 PM, revealed they were educated related to assessing residents when identified to have any change in condition to include changes in vital signs, cognition, alertness, food and fluid intake etc. Interviews on [DATE] with the DON at 11:17 AM and ADON at 11:45 AM, revealed they provided education to the licensed staff related to assessments and all licensed staff completed post tests. 6. Further review of the sign in sheets revealed four (4) licensed nurses were educated ,d+[DATE]-,d+[DATE] prior to working. Interviews on [DATE] with the DON at 11:17 AM and ADON at 11:45 AM, revealed the staff who were not educated by [DATE], were educated prior to returning to work. 7. Review of an Emergency AD HOC QAA Committee minutes, revealed the QAA met on [DATE], to discuss the IJ received, the plan developed; and, the audits to be completed. The Interim Administrator, CNO, DON, ADON, and visiting Administrator from a sister facility attended the meeting. Interviews on [DATE] with the DON at 11:17 AM, ADON at 11:45 AM, and Administrator at 1:15 PM, revealed they attended the Emergency Ad HOC QAA meeting. 8. Review of Daily Clinical Meeting sheets dated [DATE] - [DATE], revealed the prior 24 hour Nursing Notes were reviewed in the morning daily clinical meetings by the DON/ADON/assigned licensed nurse to ensure that physician notification has been made for any identified changes in condition, and that the care plan has been updated to reflect the change with interventions. Interviews on [DATE] with the DON, at 11:17 AM and ADON at 11:45 AM, revealed the prior 24 hours nursing notes for all resident were reviewed daily in morning meeting so they could ensure the physician was notified of any identified changes and care plans were updated. They stated no concerns were identified. 9. Review of Daily Clinical Meeting sheets, dated [DATE], [DATE], [DATE], and [DATE], revealed the prior 24 hour Nursing Notes were reviewed by the Weekend Supervisor on the weekends to ensure the physician was notified and care plans updated for any change in condition, Interview with the Weekend Supervisor, on [DATE] at 12:40 PM, revealed he reviewed the prior 24 hour Nursing Notes on Saturdays and Sundays to ensure the physician was notified and the resident's care plans was updated for any change in condition. He stated no concerns were identified. Interviews on [DATE], with the DON at 11:17 AM and ADON at 11:45 AM, revealed they did a follow-up review on Monday mornings of the Nursing Notes for the weekend to ensure the physicians were notified and care plans updated. 10. Review of the shift review forms, revealed five (5) nurses and five (5) CNA's were interviewed daily at shift change to validate any change in condition was identified and physician notification was completed. These were completed by the DON and ADON the week of [DATE] and [DATE]. Interviews on [DATE] with the DON, at 11:17 AM and ADON at 11:45 AM, revealed five (5) nurses and five (5) CNA's were interviewed daily at shift change to ensure all changes in condition were identified and physician notification completed. 11. Review of the form titled, Five (5) skin integrity care plans to validate interventions being implemented by CNA, revealed they were completed by the DON and ADON the week of [DATE] and the week of [DATE]. The form included the date completed, resident's name, interventions in place, concerns identified, and the nurse completing the form. Further review of the form revealed this was completed for five (5) different residents a week and different CNA's. Interviews on [DATE] with the DON, at 1:17 PM and ADON at 11:45 AM, revealed they reviewed five (5) residents' skin integrity care plans and ensured the CNA's were implementing the care plan. They stated they ensured this was completed for different residents and CNA's. 12. Review of the blood sugar audits forms, revealed ten residents blood sugars were reviewed the weeks of [DATE] and [DATE]. The form had an area to document the date completed, blood sugar value, if it was within parameters, any concerns identified, and the nurse completing the form. No concerns were identified. Interviews on [DATE], with the DON at 11:17 AM, and ADON at 11:45 AM, revealed they audited ten (10) residents weekly to ensure the residents' blood sugars were checked; if they were within parameters; and, if not, appropriate action was taken. 13. Review of the minutes of the Ad HOC QA Committee meeting, dated [DATE], revealed the current AOC, status of education, post tests and monitoring were discussed. Further review revealed the Administrator, CNO, Regional Quality Manager (RQM), DON, ADON attended the meeting and the Medical Director participated by phone. Interviews on [DATE], with the Administrator at 1:15 PM, DON at 11:17 AM, and ADON at 11:45 AM, revealed they attended the Ad HoC meeting and discussed the progress made related to the AOC to include education and monitoring. Interview with the Medical Director, on [DATE] at 12:30 PM, revealed she participated in the AD HoC meetings by phone. The Medical Director stated he thought the facility had done a good job in addressing the deficient practice identified and they were continuing to monitor to ensure the AoC was effective. 14. Review of the QAPI meeting minutes, revealed a meeting was held on [DATE], to go over the monitoring that had been completed. Further review revealed the Administrator, DON, ADON, RQM, and RDO attended the meeting, with the Medical Director attending by phone. Interviews on [DATE], with the Administrator at 1:15 PM, DON at 11:17 AM, ADON at 11:45 AM, and Medical Director at 1:00 PM, revealed they reviewed the monitoring that had been completed through [DATE] to identify if any further actions were needed at that time. No concerns were identified.

Based on interview, record review, facility policy review, hospital record review, and the Kentucky Board of Nursing (KBN) Revised Statute 314.021(2), it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received necessary care and treatment in accordance with professional standards. Record review revealed Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 refused or had decreased meal intake from [DATE] thru [DATE], without a nursing assessment for the cause or need for additional intervention. In addition, Speech and Physical Therapy staff were unable to arouse Resident #1, on [DATE] and [DATE], and reported to nursing. However, there was no documented evidence nursing assessed the resident. On [DATE] at 7:00 AM, Certified Nursing Assistants identified Resident #1 as unresponsive, which was a change in condition for the resident, and notified nursing. However, there was no evidence nursing completed an assessment. Resident #1's family member requested Resident #1 be sent to the emergency room (ER) for evaluation on [DATE] at 10:40 AM, after feeling staff were not able to identify a change in the resident's condition. Resident #1's blood sugar in route to the hospital was 465 mg/dl (milligrams/deciliter). Record review revealed normally at 7:00 AM, prior to [DATE], the resident's blood sugar ranged from ,d+[DATE] mg/dl. However, the facility failed to obtain Resident #1's morning blood sugar at 7:00 AM, per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Upon admission to the ER, the resident responded only to painful stimuli and had a Glasgow Coma Scale score of three (3) (minimum score is 3, which indicated the worst prognosis) with pupils fixed at 5 millimeters. The hospital diagnosed the resident with [CONDITION(S)], [CONDITION(S)] due to a Urinary Tract Infection, Diabetic Ketoacidosis. The resident was admitted to the ICU (intensive care unit), then discharged to a Hospice Unit. The facility's failure to ensure residents received care and treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. 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 (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility provided document not dated, revealed according to the Kentucky Board of Nursing (KBN) Revised Statute 314.021(2), All Nurses are responsible and accountable for making decisions that are based upon the individual's educational preparation and current clinical competence in nursing and requires licensees to practice nursing with reasonable skill and safety. Closed record review revealed the facility admitted Resident #1 on [DATE] and discharged the resident on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five (5) day scheduled Minimum Data Set (MDS) assessment, dated [DATE] revealed the facility had no assessment of Resident #1's cognition. Further review of the MDS revealed the resident required an assist of one (1) staff for eating, and extensive assist of two (2) staff with transfers, bed mobility, and toileting. The MDS further revealed the resident was at risk for developing pressure ulcers/injuries. Review of the Clinical Admission Documentation dated [DATE] at 7:32 PM, revealed staff assessed Resident #1 to be alert. Review of Progress Notes, dated [DATE] at 2:38 AM, revealed the resident's Daughter came here tonight and nurse walked daughter to the window so she could see the resident. Resident spoke through window and waved at daughter and said bring me dinner tomorrow and smiled. Review of Care Plan Meeting Notes dated [DATE], revealed Resident's speech was limited related to dementia, confusion was high, resident was disoriented to person, place, and time, and unaware of (his/her) surroundings and where (he/she) was. Review of the Speech Therapy Notes dated [DATE], revealed, Initiated evaluation on this date, however, unable to complete in entirety due to patient (resident) unable to be aroused after increased volume of verbal cues and tactile cues. Further review of the Speech Therapy Notes dated [DATE], revealed, Patient asleep and unable to be aroused x 2 visits. Interview with the Speech Therapist, on [DATE] at 10:01 AM, revealed she was in the resident's room a few times on [DATE], and the resident was lethargic. She stated she had a Certified Nurse Aide (CNA) assist her in repositioning the resident, but the resident still did not engage. She further revealed she made nursing staff aware of the resident's lethargy. Interview with CNA #5, on [DATE] at 10:18 AM, revealed she had worked on dayshift twelve hours, on [DATE], and had helped the Speech Therapist attempt to wake Resident #1. She stated normally the resident would mumble when repositioned; however, the resident was not doing anything, so she reported it to the nurse on the unit. CNA #5 stated she could not recall the nurse to whom she reported it to because her days were all jumbled up. Review of the Occupational Therapy Note, dated [DATE], revealed, Patient demonstrated lethargy this date, unable to fully arouse despite bilateral upper/lower extremity mobility being provided. On [DATE] at 11:20 AM, interview with the Occupational Therapist, revealed she had briefly seen Resident #1, on [DATE] and [DATE], and noticed the resident was sleepy, keeping his/her eyes closed. She stated she told the aides and she believed the aides said the nurse already knew. Review of Resident #1's Fluid Intake record, for [DATE] and [DATE], revealed no documented evidence the resident consumed liquids during meals. In addition, review of Resident #1's Meal Intake record revealed no documented evidence the resident consumed breakfast, lunch, or dinner on [DATE]; and breakfast on [DATE]. Review of an Activities of Daily Living (ADL) Flow Record for Resident #1, revealed the resident had consumed 75 percent of his/her meals for the day and evening section of the form, for [DATE]. However, interview with Certified Nurse Aide (CNA) #3, on [DATE] at 4:30 PM, revealed she had worked dayshift, from 7:00 AM to 3:00 PM, on [DATE], and attempted to feed the resident breakfast and lunch. She stated she could not get Resident #1 to eat and told LPN #1. CNA #3 stated that LPN #1 stated, Okay, thank you, we will look into it. CNA #3 further revealed the Kiosk had been down at times but the resident did not eat or drink anything for breakfast or lunch on [DATE]. Review of a Progress Note, dated [DATE] at 6:25 PM, revealed, Resident's family here for a window visit were upset because resident was not quick to respond to them, resident was aroused by charge nurse, and (he/she) spoke a few words to (spouse) and daughter. Resident's daughter kept saying something was wrong with the resident. Vital signs were obtained, and resident denies pain. The Physician was called and received orders for [MEDICATION(S)] and Magnesium level in the AM. Interview with CNA #10, on [DATE] at 12:00 PM, revealed she was present in the room during the window visit on [DATE] and the resident stared off into space, looked over at the window, called daughter by a different name; and smiled a couple of times. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 10:29 AM, revealed she worked from, 7:00 AM to 7:00 PM on [DATE], and the resident's family felt he/she was not responding during a window visit. LPN #1 revealed she assessed the resident by obtaining vital signs after the family expressed concerns that the resident did not seem right. She stated the resident's vitals were within normal range. LPN #1 further stated she called the physician and told the doctor the family was concerned but she did not see anything abnormal. She stated the physician ordered [MEDICATION(S)] and Magnesium levels drawn the following morning. LPN #1 revealed she did not see a significant change or a cause for alarm during the window visit. She stated if she had noticed something out of the norm she would have notified the doctor. LPN #1 further revealed she did not recall any staff reporting the resident not eating or drinking during her shift on [DATE], or being made aware of the resident being lethargic during therapy; because that was to long ago. Review of Resident #1's [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes, dated [DATE] at 10:40 AM, revealed Resident's daughter called demanding the resident go to the hospital emergency room (ER) for evaluation and treatment. Resident was sleeping this AM, and will open eyes when stimulated with chest rub, and respirations even. Blood pressure ,d+[DATE] (,d+[DATE] normal range), Respirations 18, Pulse 93, Temperature 97.5 Fahrenheit and Oxygen Saturation of 97%. Further review of the Progress Notes, dated [DATE] at 10:53 AM, revealed, EMS (Emergency Medical Service) here to transport resident to emergency roiagnom on stretcher via ambulance. Review of the Hospital Record dated [DATE] at 11:09 AM, revealed, Upon arrival the patient was unresponsive, pupils fixed at 5 mm bilaterally, and minimal motor tone to upper extremities bilaterally. Further review revealed the resident's white blood count was 23.8 High (4.,d+[DATE].8 normal reference range), Glucose 446 ml/dl (milligrams/deciliter) which was High (,d+[DATE] ml/dl normal reference range), The resident was diagnosed with Diabetic Ketoacidosis, and [CONDITION(S)] due to a Urinary Tract Infection. Continued review revealed the facility advised EMS that the patient had not had any changes and his/her current condition was normal. Patient was not verbal and only responsive to pain during triage. Resident #1 was admitted to the Intensive Care Unit (ICU). Interview with the Family Member, on [DATE] at 11:00 AM and [DATE] at 11:32 AM, revealed during a window visit on [DATE], she noticed the resident to be very lethargic with labored abdominal breathing. She stated when she visited the resident on [DATE], the resident spoke to her and waved. She stated she asked the activity staff to get a nurse to check on the resident. The family member revealed she never saw the nurse listen to the resident's lung sounds but she was told the resident was fine. She stated she was very worried about the resident and each time she would call the facility she was told the resident was fine. Further interview revealed on the morning of [DATE], she called the facility several times and finally asked that the resident be sent out for an evaluation because she felt no one was taking her concerns seriously. She stated after the resident was transferred to the hospital the resident was placed on Hospice care and recently expired. Interview with CNA #7, on [DATE] at 6:06 AM, revealed she worked twelve hours dayshift on [DATE] and reported to LPN #2 that Resident 1 was not acting right shortly after the beginning of her shift at 7:00 AM. She stated the resident was not responding to talk, touch, or a sternum rub. CNA #7 stated when she arrived to work she had not heard anything about the resident having a change in condition. However, after she noticed the change in Resident #1's condition, she made LPN #2 aware and the resident was sent out before lunch. Interview with CNA #8, on [DATE] at 6:19 PM, revealed during the breakfast tray pass on [DATE], she noticed Resident #1 was unresponsive and reported this to LPN #2. She stated LPN #2 stated, The resident probably had a sleeping pill. CNA #8 stated LPN #2 did not assess the resident right away. CNA #8 further revealed the resident was not able to eat breakfast, because he/she was sleepy. She stated the resident was sent to the hospital shortly before lunch on [DATE]. Interview with LPN #2, on [DATE] at 9:25 AM, revealed she had sent Resident #1 out on [DATE]; because the family had asked that the resident be evaluated. LPN #2 stated the resident was sluggish to respond and she had given the resident a bed bath prior to the hospital transfer. LPN #2 revealed the resident's bottom was red, but she did not see any changes in the resident from the previous day, and nothing uncommon had occurred to make her think anything was wrong. LPN #2 stated if she felt the resident's condition had declined or the resident was unresponsive she would notify the doctor for new orders. She further stated she had checked the resident's blood sugar on the morning of [DATE] and believed it was 118, however, she failed to document the result on the MAR. Interview withe the Director of Nursing, on [DATE] at 2:15 PM, revealed she expected the nurses to notify the physician if there was a significant change in a resident. The DON stated the nurse called the doctor on [DATE], and received orders to draw [MEDICATION(S)] and Magnesium levels. She stated she felt the nurse addressed the family's concerns when she obtained vital signs and called the doctor. The DON stated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the resident had been transferred to the hospital because the family demanded that he/she be sent to the hospital to be evaluated. Interview with the Administrator on [DATE] at 9:40 AM, revealed he felt the nursing staff assessed the resident properly during the window visit and the resident had a decline due to his/her diagnosis. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility transferred Resident #1 to the hospital on [DATE]. Resident #1 was discharged from the facility on this date per family request. 2. Physical assessments were completed for all in-house residents by licensed nurses. This assessment included vital signs and skin integrity audits. The DON, ADON and/or licensed wound nurse completed a second lookback sample of ten (10) residents. For any identified concern, the nursing IDT (DON, ADON, wound nurse) verified physician notification and that the concern was care planned with interventions for prevention/treatment. This was completed by [DATE]. 3. The Chief Nursing Officer (CNO) provided education to the Interim Administrator (Adm), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on [DATE] regarding F580, F656, F684, and F686. The education included: A. Education on immediately informing the resident; consulting with the resident's physician; and notifying the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status and/or a need to alter treatment significantly. This included, but was not limited to decreased meal intake; change in level of consciousness; and new or worsening skin condition/integrity. B. Education on developing and implementing a comprehensive person-centered care plan for each resident. An example of interventions that would be required on the care plan would include (but not limited to) interventions to prevent pressure wounds for the risk of skin breakdown. C. Education on ensuring the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Which included Quality of Care, but was not limited to nursing assessments for cause or need for additional care and services to prevent further decline at the time of notification; and obtaining labs/diagnostics for residents as ordered by physician. D. Education on ensuring a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable ulcers/injuries are placed on the plan of care and implemented. 4. The education related to Physician Notification (F580), Care Plan Development and Implementation (F656), and Pressure Sores (F686) was provided to the licensed nursing staff (including contracted/agency nursing staff) and CNA's (including contracted/agency nursing) by the DON, ADON, or assigned licensed nurse that had previously been educated by the DON and/or ADON. Education provided to the CNA's also included the importance of implementing the interventions specified in the plan of care. This would be completed by [DATE]. Verbal acknowledgement of understanding along with signed education was received for the CNA's, and a post-test was conducted after the education for licensed nurses. Any new nursing hire (including contracted/agency) wouold receive this education prior to assuming duties. 5. The education related to Quality of Care (F684) was provided to the licensed nursing staff (including contracted/agency nursing staff) by the DON, ADON, or assigned licensed nurse that had previously been educated by the DON and/or ADON. This would be completed by [DATE]. A post-test was conducted after the education for licensed nurses. Any new nursing hire (including contracted/agency) would receive this education prior to assuming duties. 6. Any nursing staff member that has not completed the education by [DATE], would receive the education prior to assuming duties at the facility. 7. An ad hoc Quality Assurance Process Improvement (QAPI) meeting was held [DATE] to review the summary of Immediate Jeopardy findings and discussed the development of the action items to be completed. This meeting included the Interim Administrator, Director of Nursing, Assistant DON, the Chief Nursing Officer, and the Medical Director via phone. 8. Effective [DATE] and continuing on-going, the prior 24- hour nursing notes would be reviewed in the morning daily clinical meeting by the DON/ADON/the assigned licensed nurse to ensure that physician notification has been made for any identified changes in condition, and that the care plan had been updated to reflect the change with interventions. This would include, but not limited to, any concern with nutritional intake, changes in skin integrity, or changes in level of consciousness/mental status change. 9. The assigned licensed nursing supervisor would be responsible to review on weekends. During the Monday morning clinical meeting, a second lookback of the weekend nursing notes would be completed. 10. Beginning [DATE], the DON and/or ADON would receive a daily shift report from a selected nurse and a selected CNA, on a rotating basis, five (5) x a week for four (4) weeks, then two (2) x a week for four (4) weeks to get the direct nursing/nursing assistant report to validate that any change of condition has been reported to the nurse and physician, with interventions being followed, and the care plan updated as indicated. 11. Beginning [DATE], the DON and/or ADON would review a minimum of five (5) residents weekly with skin integrity care plans to validate that interventions are being implemented as directed in the plan of care. This would include walking rounds with the CNA's to validate residents' care plan interventions are being implemented. This would continue for four (4) weeks. 12. Beginning [DATE], the DON and/or ADON would audit a minimum of ten (10) residents weekly with ordered blood sugars to ensure that this was completed and documented as ordered. This would continue for four (4) weeks. 13. A second ad hoc QAPI meeting was held [DATE], to review the status of education and audits. This meeting included the Interim Administrator, Director of Nursing, Assistant DON, the Chief Nursing Officer, and the Medical Director via phone. 14. The monitoring results would be followed in the facility's monthly QAPI monthly for a minimum of two (2) months for review and recommendation, if indicated. The monthly QAPI was attended by, but not limited to, the Administrator, Director of Nursing, Assistant DON, Unit Manager, Social Services Director, Activities Director, Dietary Manager, Business Office Manager, Therapy Director, and the Medical Director a minimum of quarterly. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of a facility Census Activity form revealed Resident #1 was discharged to a Regional Hospital on [DATE] with no bedhold and no return anticipated. 2. Review of a Twin [NAME] Nursing and Rehab Center Bed listing by resident, dated [DATE], related to Physical Assessments, revealed all residents' names were checked indicating assessments to include vital signs and skin assessments were completed for each resident. Review of skin assessment sheets revealed all residents received a skin assessment. Review of Skilled B Unit's and Skilled A Unit's resident lists and vital sign sheets revealed all residents' vital signs were checked, to include O2 sats on [DATE]. Any concerns identified were reported to the physician and the concern was care planned with interventions for prevention/treatment. In addition, review of a skin assessment lookback by the DON, ADON, and Wound Nurse, revealed ten (10) residents received skin assessments on [DATE] with no concerns identified. Interviews on [DATE], with the DON at 11:17 AM, and ADON at 11:45 AM, revealed all residents received an assessment to include vital signs and skin by the licensed nurses. The DON and ADON stated the residents' physicians were notified of any concerns and care plans were revised. The DON and ADON also revealed they completed skin assessments of ten (10) residents and validated their skin assessments were accurate and their physicians were notified and care plans revised with any change in condition identified. They stated no concerns were identified. 3. Review of the F580 Notification of changes, F656 Develop/Implement Comprehensive Care Plan, F684 Quality of Care, and F686 Treatment Services to prevent/heal pressure ulcers education sign in sheets, revealed the CNO, Regulatory Risk Manager, provided education to the prior Administrator, DON and ADON on [DATE]. Interviews on [DATE], with the Administrator at 1:15 PM, the DON at 11:17 AM, and ADON at 11:45 AM, revealed the CNO educated them on change in condition, implementing the care plans, and providing care and services related to prevention/healing of skin breakdown to include CNA's reporting to a nurse when redness was identified. 4. Review of the F580 Notification of Change, F656 Develop/Implement Comprehensive Care Plan, and F686 Treatment Services to Prevent/Heal Pressure Ulcers education sign in sheets, revealed all nursing staff to include agency staff were educated by [DATE]. Review of sign in sheets revealed the CNA's validated they received education and review of post tests revealed all licensed staff scored 100%. Interviews on [DATE], with the DON at 11:17 AM and ADON at 11:45 AM, revealed they provided education to all nursing staff and agency staff on F580 Notification of Change, F656 Develop/Implement Comprehensive Care Plan, and F686 Treatment Services to Prevent/Heal Pressure Ulcers. Interviews on [DATE], with Registered Nurse (RN) #3 at 9:09 AM, Licensed Practical Nurse (LPN) #1 at 9:04 AM, LPN #3 at 9:36 AM, Certified Medication Aide at 9:25 AM, Certified Nurse Aide (CNA) at 9:14 AM, and CNA #8 at 9:20 AM, revealed they were educated on notification of the physician, family, and/or nurse if they identified a resident with a change in condition, implementation of the care plan, and reporting if they identified any redness for skin breakdown. 5. Review of the F684 sign in sheet, revealed licensed staff were provided education on assessments by [DATE]. Review of post tests revealed the licensed staff scored a 100%. Interviews with Registered Nurse (RN) #3 at 9:09 AM, Licensed Practical Nurse (LPN) #1 at 9:04 AM, LPN #3 at 9:36 AM, and the RN Weekend Supervisor at 1:07 PM, revealed they were educated related to assessing residents when identified to have any change in condition to include changes in vital signs, cognition, alertness, food and fluid intake etc. Interviews on [DATE], with the DON at 11:17 AM, and ADON at 11:45 AM, revealed they provided education to the licensed staff related to assessments and all licensed staff completed post tests. 6. Further review of the sign in sheets revealed four (4) licensed nurses were educated ,d+[DATE]-,d+[DATE] prior to working. Interviews on [DATE] with the DON at 11:17 AM and ADON at 11:45 AM revealed the staff who were not educated by [DATE] were educated prior to returning to work. 7. Review of an Emergency AD HOC QAA Committee minutes, revealed the QAA met on [DATE], to discuss the IJ received, the plan developed; and, the audits to be completed. The Interim Administrator, CNO, DON, ADON, and visiting Administrator from a sister facility attended the meeting. Interviews on [DATE], with the DON at 11:17 AM, ADON at 11:45 AM, and Administrator at 1:15 PM, revealed they attended the Emergency Ad HOC QAA meeting. 8. Review of Daily Clinical Meeting sheets, dated [DATE] - [DATE], revealed the prior 24 hour Nursing Notes were reviewed in the morning daily clinical meetings by the DON/ADON/assigned licensed nurse to ensure that physician notification has been made for any identified changes in condition, and that the care plan has been updated to reflect the change with interventions. Interviews on [DATE], with the DON at 11:17 AM, and ADON at 11:45 AM, revealed the prior 24 hours nursing notes for all resident were reviewed daily in morning meeting so they could ensure the physician was notified of any identified changes and care plans were updated. They stated no concerns were identified. 9. Review of Daily Clinical Meeting sheets, dated [DATE], [DATE], [DATE], and [DATE], revealed the prior 24 hour Nursing Notes were reviewed by the Weekend Supervisor on the weekends to ensure the physician was notified and care plans updated for any change in condition, Interview with the Weekend Supervisor, on [DATE] at 12:40 PM, revealed he reviewed the prior 24 hour Nursing Notes on Saturdays and Sundays to ensure the physician was notified and the resident's care plans was updated for any change in condition. He stated no concerns were identified. Interviews on [DATE], with the DON at 11:17 AM, and ADON at 11:45 AM, revealed they did a follow-up review on Monday mornings of the Nursing Notes for the weekend to ensure the physicians were notified and care plans updated. 10. Review of the shift review forms revealed five (5) nurses and five (5) CNA's were interviewed daily at shift change to validate any change in condition was identified and physician notification was completed. These were completed by the DON and ADON the week of [DATE] and [DATE]. Interviews on [DATE], with the DON at 11:17 AM and ADON at 11:45 AM, revealed five (5) nurses and five (5) CNA's were interviewed daily at shift change to ensure all changes in condition were identified and physician notification completed. 11. Review of the form titled, Five (5) skin integrity care plans to validate interventions being implemented by CNA, revealed they were completed by the DON and ADON the week of [DATE] and the week of [DATE]. The form included the date completed, resident's name, interventions in place, concerns identified, and the nurse completing the form. Further review of the form revealed this was completed for five (5) different residents a week and different CNA's. Interviews on [DATE], with the DON at 1:17 PM, and ADON at 11:45 AM, revealed they reviewed five (5) residents' skin integrity care plans and ensured the CNA's were implementing the care plan. They stated they ensured this was completed for different residents and CNA's. 12. Review of the blood sugar audits forms revealed ten residents blood sugars were reviewed the weeks of [DATE] and [DATE]. The form had an area to document the date completed, blood sugar value, if it was within parameters, any concerns identified, and the nurse completing the form. No concerns were identified. Interviews on [DATE], with the DON at 11:17 AM and ADON at 11:45 AM, revealed they audited ten (10) residents weekly to ensure the residents' blood sugars were checked; if they were within parameters; and, if not, appropriate action was taken. 13. Review of the minutes of the Ad HOC QA Committee meeting, dated [DATE], revealed the current AOC, status of education, post tests and monitoring were discussed. Further review revealed the Administrator, CNO, Regional Quality Manager (RQM), DON, ADON attended the meeting and the Medical Director participated by phone. Interviews on [DATE] with the Administrator at 1:15 PM, DON at 11:17 AM, and ADON at 11:45 AM revealed they attended the Ad HoC meeting and discussed the progress made related to the AOC to include education and monitoring. Interview with the Medical Director on [DATE] at 12:30 PM revealed she participated in the AD HoC meetings by phone. The Medical Director stated he thought the facility had done a good job in addressing the deficient practice identified and they were continuing to monitor to ensure the AoC was effective. 14. Review of the QAPI meeting minutes, revealed a meeting was held on [DATE] to go over the monitoring that had been completed. Further review revealed the Administrator, DON, ADON, RQM, and RDO attended the meeting, with the Medical Director attending by phone. Interviews on [DATE] with the Administrator at 1:15 PM, DON at 11:17 AM, ADON at 11:45 AM, and Medical Director at 1:00 PM revealed they reviewed the monitoring that had been completed through [DATE] to identify if any further actions were needed at that time. No concerns were identified.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop a baseline care plan within 48 hours for one (1) of six (6) sampled residents (resident #4) that includes instructions needed to provide effective and person centered care and meets professional standards of quality care. Resident #4 was admitted on [DATE], after a recent hospitalization for complications of amputation stump and [CONDITION(S)]. Review of the Hospital Discharge Summary (to home) dated 06/22/2020, revealed the resident was to continue to receive Oxycodone 5 mg, one (1) tablet every six (6) hours as needed for pain, after discharge. The facility assessed and identified the resident was in pain; however, the facility failed to develop a baseline care plan with interventions to address the resident's pain management. Review of Nurse's Notes revealed Resident #4's script for Oxycodone was not requested until 06/26/2020 at 4:52 AM. On 06/27/2020 at 9:00 PM, the resident was crying with complaints of pain. The Nurse explained the Oxycodone had not been delivered yet and spoke to pharmacy and requested medication be sent stat and was instructed that the prescription was being filled presently and that they would send stat. Further review of the Nursing Notes revealed the Oxycodone was administered to resident, on 06/27/2020 at 11:42 PM. The findings include: Review of the policy titled, Clinical Standards of Practice Manual- Comprehensive Care Plans Standard of Practice, revised November 2017, revealed it was the practice of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the resident's comprehensive assessment. Review of facility policy, titled Pain- Clinical Protocol not dated, revealed the physician and staff would identify individuals who have pain or who were at risk for having pain to include a review of each person's known diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing staff would assess each individual for pain upon admission to the facility using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The nursing staff would identify any situations or interventions where an increase in the resident's pain may be anticipated. The staff and physician would also evaluate how pain was affecting mood, activities of daily living, sleep and the resident's quality of life. The physician would help identify causes of pain. A hospital discharge summary may indicate that the resident had a painful condition or was receiving medications that may cause or exacerbate pain. As part of the medical assessment, the physician would help identify the extent to which underlying causes of pain could be addressed or reversed. With input from the resident and/or advocate, the physician and staff would establish goals of pain treatment. The staff would evaluate and report how much and how often the individual asked for as needed, pain medication. Record review revealed the facility admitted Resident #4 to the facility from home on 06/25/2020, at approximately 9:00 PM with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospital Discharge Summary (to home) dated 06/22/2020 revealed the resident was to continue to receive [MEDICATION(S)] (chronic pain) 400 milligrams (mg) three (3) times a day (TID) , [MEDICATION(S)] (Flexeril) 10 mg TID as needed (PRN) for muscle spasms, and Oxycodone 5 mg, one (1) tablet every six (6) hours PRN for pain after discharge. Review of Admission Pain Evaluation Documentation, revealed Resident #4's pain assessment was was initialed, on 06/25/2020 at 2:11 PM, and completed on 06/26/2020 at 9:17 AM, by Licensed Practical Nurse (LPN) #3. Resident #4 described he/she had daily pain related to post-surgical procedure and phantom pain, which he/she said was eight (8) on pain scale of one to ten (1-10) without medication and medication relieved it to a three (3). The resident's expected tolerable pain rating was 3. Further review of the evaluation revealed the resident stated pain affected ability to do activities of daily living (ADL's), mental status and sleep. Resident stated a calm environment and distraction helps a small amount. However, review of Resident #4's Baseline Care Plan, dated 06/25/2020, revealed there were no individualized interventions put in place to address the resident's surgical pain and phantom pain and no interventions to address what medications needed to be available to address resident's pain. Review of Nurse's Notes revealed Resident #4's script for Oxycodone was not requested until 06/26/2020 at 4:52 AM. On 06/27/2020 at 9:00 PM, the resident was crying with complaints of pain. The Nurse explained the Oxycodone had not been delivered yet and spoke to pharmacy and requested medication be sent stat and was instructed that the prescription was being filled presently and that they would send stat. Further review of the Nursing Notes revealed the Oxycodone was administered to resident, on 06/27/2020 at 11:42 PM. Post survey interview with Director of Nursing (DON), on 10/15/2020 at approximately 8:40 AM, revealed the interim care plan was initiated by admitting floor nurse, and other departments were notified and responsible for their input and then completed by MDS Nurse and administration. All interim care plans should entail the resident's immediate needs, and pain medications that were an immediate need. The DON stated the interim care plan was automatically generated in the EMR software but she could not find a policy on interim care plans, only the comprehensive care plan policy. She expected the nursing staff to have interim care plans completed and followed with in 48 hours. The facility did not have a lot of policies in writing, and staff development would be doing education on documentation, interim care plans and the expectations that federal and state regulations mandate regarding interim care plans and pain management. She stated there were plans to develop a policy on baseline care plans; ensuring every item on the interim care plan was in place. Interview (Post Survey) with Licensed Practical Nurse (LPN) #3, on 10/15/2020 at 12:01 PM, revealed the care plan was auto generated in computer system, then administration and MDS Nurses followed up. She stated care plans were meant to address basic level of care required to ensure best interest of resident was provided for, such as pain management, ADL's, therapy, and dietary. She stated she expected to see pain medication addressed in interim care plan, although she did a pain evaluation, it did not carry over to the interim care plan. LPN #3 stated the oncoming nurses, administration and MDS staff should have taken over to finish the interim care plan to ensure it was complete. She stated she thought the facility had 24 to 48 hours to complete the interim care plan. LPN #3 revealed no documentation in the pharmacological pain regimen of the interim care plan would infer that the assessment was not done. Pain management and missing care plans information should have been followed up continually to ensure complete communication for best interest of resident. She stated it was possible for resident to experience harm or decline if nursing did not fully develop and implement base line care plan. Interview (Post Survey) with Licensed Practical Nurse (LPN) #7, on 10/15/2020 at 11:20 AM, revealed the facility had a policy on interim care plans, not necessarily written but more of expectation. She stated the facility expected nurses to initiate an interim care plan when a resident was admitted and it should be completed within forty-eight (48) hours, however the facility administration encouraged completion within four (4) hours. She revealed administrative staff was responsible for completing and finishing the care plan. She stated the interim care plan was initiated on paper and she was not sure who entered it in Electronic Medical Record (EMAR). She further revealed the interim care plan should include ADL care, dietary, assistance needed with toileting, bathing, eating and pain. She stated missing pain interventions could affect residents ability with ADL's, therapy and sleep and any missing communication could leave the resident vulnerable. She stated that no entries on interim care plan for Resident #4 for pharmological interventions made the interim care plan incomplete and that was a very important part of care plan. She did not remember being the admitting nurse and was not responsible for initiating Resident #4's interim care plan, but if she had seen missing info, she should have added it. Interview (Post Survey) with Minimum Data Set (MDS) Coordinator, on 10/15/2020 at 9:50 AM, revealed interim care plans were initiated by admitting staff nurse and facility had up to forty-eight (48) hours to complete. The purpose of an interim care plan was to give a baseline working plan to care for resident on physical, medical, and spiritual level. Nursing staff was responsible for initiating and nursing administration was responsible for completing along with all departments that make up the Interdisciplinary team (IDT), including the resident. The facility used the baseline care plan to complete the comprehensive. She stated if nurses failed to document entry under the pharmacological pain regimen section of the care plan, then she would consider it an incomplete care plan. She would have expected the nurse to document one way or other of addressing pharmacological pain management. She stated the facility does not have any written policy related to an interim care plan to her knowledge and she followed the comprehensive care plans standard of practice policy. Interview with Administrator, on 10/15/2020 at 3:10 PM, revealed he expected the staff to have interim care plans completed and followed with in 48 hours. The facility does not have a lot of policies in writing, will be doing education on documentation, interim care plans and the expectations that federal and state regulations mandate regarding interim care plans and pain management.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide pain management to one (1) of six (6) sampled residents (Resident#4). Resident #4 was admitted to the facility on [DATE] at approximately 9:00 PM with orders for [MEDICATION(S)] (nerve pain), [MEDICATION(S)] (muscle spasms) and Oxycodone; however, the facility failed to ensure the resident's pain medication was ordered or available to control his/her pain for approximately forty-eight (48) hours after admission. In addition, the facility failed to assess the residents pain prior to and after as needed pain medication was given. The findings include: Review of facility policy, titled Pain- Clinical Protocol not dated, revealed the physician and staff will identify individuals who have pain or who are at risk for having pain to include a review of each person's known diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing staff would assess each individual for pain upon admission to the facility using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The nursing staff would identify any situations or interventions where an increase in the resident's pain may be anticipated. The staff and physician would also evaluate how pain was affecting mood, activities of daily living, sleep and the resident's quality of life. The physician would help identify causes of pain. A hospital discharge summary could indicate that the resident had a painful condition or was receiving medications that may cause or exacerbate pain. As part of the medical assessment, the physician would help identify the extent to which underlying causes of pain can be addressed or reversed. With input from the resident and/or advocate, the physician and staff would establish goals of pain treatment. The staff would evaluate and report how much and how often the individual asked for as needed (PRN) pain medication. Interview with the Director of Nursing (DON), on 10/14/2020 at approximately 1:10 PM, revealed there was no facility policy that addressed assessing for pain prior to administration of pain medication and after to determine if medication effective. However, she stated she expected nursing staff to use professional standards of practice for assessing pain, and reassessing for pain medication and intervention effectiveness. Record review revealed the facility admitted Resident #4 to the facility, on 06/25/2020 at approximately 9:00 PM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Hospital Discharge Summary, dated 06/22/2020, revealed the resident was admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident was to continue to receive [MEDICATION(S)] (chronic pain) 400 milligrams (mg) three (3) times a day (TID) , [MEDICATION(S)] ([MEDICATION(S)]) 10 mg TID as needed (PRN) for muscle spasms, and Oxycodone 5 mg, one (1) tablet every six (6) hours PRN for pain. Review of Pain Evaluation Documentation, revealed Resident #4's Admission pain assessment was initiated, on 06/25/2020 at 2:11 PM, and completed, on 06/26/2020 at 9:17 AM, by Licensed Practical Nurse (LPN) #3. The nurse documented Resident #4 described he/she had daily pain related to post-surgical procedure and phantom pain, which was an (eight) on scale of one to ten (1-10), without medication; and medication relieved it to a three (3). Pain type described as chronic, constant frequency, with an expected tolerable pain rating of three (3) and a pain goal of no pain (0). Further review of the documentation revealed the Resident stated he/she had continual pain at this time related to surgical wound and phantom pain and described pain as aching. The resident stated his/her pain affected ability to do activities of daily living (ADL's), mental status, and sleep and a calm environment and distraction helped a small amount. Review of the Physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, further review of the orders revealed there was no order for the Oxycodone 5 mg that was listed on the Hospital discharge orders or identified in the pain evaluation. Review of Baseline Care Plan, dated 06/25/2020, revealed Resident complained of daily pain, related to post-surgical procedure and phantom pain, and described to nurse pain was an eight (8) on scale of 1-10 without medication and that medication relieved it to a three (3). However, further review of the care plan revealed there were no interventions put in place to address assessments for pain; or, what to do to relieve the resident's pain. Review of Resident #4's Physical Therapy evaluation and Plan of Treatment, dated 06/26/2020 at 12:29 PM, revealed Resident was referred to facility due to recent exacerbation of left resident limb that required surgery and debridement of bone fragments in order to facilitate ambulation with prosthetic limb and was admitted for further rehab. Short term goals included the resident to report pain pre/post treatment sessions at or below a five (5) on a pain scale of 1 to 10 to facilitate improved participation in functional activities. The initial assessment from physical therapy revealed resident had complaints of pain at rest intensity to be at 5/10 and with pain with movement assessment to be 10/10 with the method of assessment as Patient verbalized pain level. Resident revealed pain does limit patient's functional activities with interventions as patient receives medications on schedule program and PRN. Review of Resident #4's vital signs that included pain assessments and his/her June 2020 Medication Administration Record (MAR), revealed Resident #4's pain level was a five (5), at 7:00 PM on 06/25/2020, and a nurse administered [MEDICATION(S)] PRN on 06/25/2020 at 11:53 PM. However, further review of the MAR and Nurse's Notes, revealed there was no documented evidence the resident's pain was assessed prior to administering the Fleer PRN and after, to determine the effectiveness of the medication, on 06/25/2020 per facility policy Review of Resident #4's Nurse's Notes, revealed LPN #7 requested a script for pain medication on 06/26/2020 at 4:52 AM. Further review of Resident #4's Vital Signs that included pain assessments revealed Resident had no pain, on 06/26/2020 at 7:00 AM, and his/her pain level was a six (6) at 7:00 PM. The nurse administered [MEDICATION(S)] PRN, on 06/26/2020 at 9:13 PM. On 06/27/2020 at 7:00 AM, it was documented the resident stated he/she had no pain and at 7:00 PM, the resident stated pain level was 6. The nurse administered [MEDICATION(S)] PRN, on 06/27/2020 at 8:51 PM. However, further review of the MAR and Nurse's Notes revealed there was no documented evidence the resident's pain was assessed prior to administering the [MEDICATION(S)] PRN and after, to determine the effectiveness of the medication, on 06/26/2020 and 06/27/2020, per facility policy. Review if a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nurse's Notes revealed, on 06/27/2020 at 9:00 PM, Registered Nurse (RN) #2 documented Resident #4 was sitting on side of bed on cell phone, and a few minutes later was crying and stated he/she was in pain when nurse entered the room. Nurse documented she explained to resident what medication the nurse had and that the Oxycodone had not arrived as of yet. Further review of note revealed resident had been on Oxycodone routinely for years at home and was in pain. Further review of note, revealed RN #2 spoke to pharmacy and requested medication be sent stat and was instructed that it was being filled presently and that they would send stat. Review of Resident #4's June 2020 MAR, revealed the resident's first dose of Oxycodone was administered to resident, on 06/27/2020 at 11:42 PM. However, further review of the MAR and Nursing Notes revealed there was no documented evidence the resident's pain was assessed prior to or after the administration of the as needed (PRN) pain medication per facility policy and professional standards of practice. Review of Resident #4's Controlled Drug Record from Pharmerica revealed Oxycodone HCL 5 mg tablets were dated 06/27/2020 with the first dose signed out by staff on 06/27/2020 at 11:30 PM. Further review of the vital sign assessment, on 06/28/2020 at 7:00 AM, revealed the Resident had no pain; however, further review of the June 2020 MAR revealed the nurse administered Oxycodone 5 mg PRN, on 06/28/2020 at 8:00 AM. Review of MAR and Nursing Notes, revealed there was no documented evidence the nurse assessed the resident's pain before or after administering the PRN medication, per facility policy. Phone interview with Licensed Practical Nurse (LPN) #3, on 09/28/2020 at 11:20 AM, revealed she worked 7:00 AM to 7:00 PM, the day Resident #4 came from hospital, but the resident did not come with any scripts. LPN #3 revealed she should have notified the hospital or doctor immediately to get pain medications. She revealed she called the doctor and completed a Situation, Background, Assessment, Recommendation (SBAR) sheet; however, review of the resident's record revealed there was no SBAR in the resident's chart. She stated she could not remember if contact was made by phone with Physician or if a response was received because her shift was over at 7:00 PM and she had stayed over to help get patient settled and handed off to next nurse (LPN #7). She revealed that facility policy was to assess residents then contact hospital or MD for obtaining order for pain medication. If facility did not have the dose in Emergency Drug Kit (EDK), then nurse should call the MD for one time order, then call pharmacy to administer from the EDK. She stated it was unacceptable for facility to fail to ensure pain management was provided to Resident #4. She stated assessment of pain prior to administration of pain medication along with reassessment after pain medication given should have been documented in the resident's chart under nursing notes; but she could not recall if she charted them. She revealed she could not recall if the resident complained of pain, but would have documented in pain scale assessment under the vital sign tab. Phone interview with LPN #7, on 09/29/2020 at 1:58 PM, revealed she could not recall if Resident #4 had orders for pain medications on admission. She acknowledged that facility policy on obtaining pain medication would have been the admitting nurse's responsibility and she should have written something in the nurses note about contacting doctor about getting a script. LPN #7 stated the nurse following her should have followed up about getting an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the facility failed to ensure pain medication was provided for 48 hours without pain relief for Resident #4, was unacceptable, and should have never happen. She stated all residents should be assessed every shift for pain and the nurse should document the assessment in the vital sign tab in electronic record. She stated when interventions were used for pain management a reassessment should also be entered in a nursing note documenting whether intervention was effective. She was unable to recall if resident complained of pain but stated if she documented that she called the MD requesting pain medication, the resident would have complained. Phone interview with Registered Nurse (RN) #2, on 09/28/2020 at 2:12 PM, revealed it was facility policy that residents should have pain medication available upon admission, and that nurses should call the physician for an order if patient was in pain. She stated she called the Nurse Practitioner on 09/27/2020, to request pain medication. The RN stated the resident should receive pain medication upon first request and complaint of pain. She revealed it was unacceptable for any resident to be admitted without pain medication. She stated it was nursing's responsibility to call the physician for a prescription for pain relief, and to anticipate the need for pain relief for resident. The nurse should have contacted someone on 09/25/2020 to get script for emergency relief while waiting for script to arrive from pharmacy. She stated assessment of pain and administration of pain medication along with reassessment after interventions should have been documented in the resident's chart under nursing notes but she could not recall if she charted them. Phone interview with LPN #6 on 09/29/2020 at 9:59 AM, revealed she did not remember Resident #4, however it was facility policy to assess residents upon admission and then contact hospital or MD for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed that if the facility did not have the dose in EDK, the nurse should have called the MD for a one-time order. If a one-time order was obtained then the nurse had to call Pharmerica for access code to get into EDK. She stated assessment of pain and administration of pain medication along with reassessment after interventions should have been documented in the resident's chart under nursing notes, but she could not recall if she charted them. Phone interview with Pharmacy Assistant, on 09/28/2020 at 10:51 AM, revealed a prescription for Oxycodone was received via e-script, on 06/27/2020 at 5:14 PM, from prescriber and pharmacy sent medication stat per request from RN #2, and the medication would have been delivered to the facility within four (4) hours of time requested. She stated the facility did not have the Oxycodone 5 mg in the Emergency Drug Kit (EDK) at the facility; however, they should have a list of available narcotics in the facilities EDK and could have requested the prescriber for alternate pain relief available in the EDK until script arrived. Phone interview with Weekend Supervisor, on 09/29/2020 at 12:59 PM, revealed when any resident complained of pain, many prescribers gave [MEDICATION(S)], which was a muscle relaxer, and the oxycodone. At times when residents were sent from hospital, orders would come as a continued medication, but Resident #4 did not have a script from the hospital, therefore the admitting nurse should have contacted the hospital or MD and documented in nursing notes. Interview with Resident #4's Physician (Post Survey), on 10/15/2020 at 1:05 PM, revealed she does not remember all contact with staff from June regarding Resident #4, but would have expected continued attempts until they reached her and documentation of attempts and conversations. She stated she was in the facility every Thursday to participate care planning and they should have documented the communication in the medical records. Phone interview with the Director of Nursing (DON), on 09/28/2020 at 3:57 PM, revealed she expected nurses to clarify orders upon resident admission or to call the hospital or MD for further directions. The DON stated it does not appear that pain management was addressed appropriately at Resident #4's admission per facility policy. She revealed she expected the resident's pain be addressed when vital signs were taken and that it does not appear the staff nurse addressed pain appropriately from the documentation of complaints of pain on vital signs on 09/25/2020, 09/26/2020 and 09/27/2020. She revealed on 06/27/20, RN #2 should have asked doctor for another order for something in facility's Emergency medications supply to address Resident #4's pain immediately while waiting for pharmacy to fill the prescription for the Oxycodone 5mg. She stated nurses should reassess residents within an hour, and if still in pain should contact the MD if extreme pain persists. She revealed she could not locate any SBAR communication sheets for contacting the physician for pain meds in Resident #4's medical records. She expected nursing staff to follow facility policy by assessing each individual for pain upon admission to the facility using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. She stated the nursing staff should identify any situations or interventions where an increase in the resident's pain may be anticipated and document in resident medical record, MAR, vital sign assessment and do a re-assessment after interventions to ensure pain was controlled to resident's comfort. She expected nursing staff to use professional standards of practice with assessing residents for pain and for administering PRN pain medications, which include before and after assessments and to document the results in the resident's nursing notes and MAR.

Based on observation, interview, record review, facility policy review, and review of the facility's Weekly/Daily Direct Supply Tels. Alarm Log instructions, it was determined the facility failed to ensure the residents' environment was free from accident hazards for one (1) of three (3) sampled residents (Resident #1). The facility failed to ensure Resident #1 received adequate supervision and monitoring to prevent elopement. The facility assessed and care planned Resident #1 as an elopement risk. However, Resident #1 exited the building, unsupervised; and without staff knowledge on 09/12/19 between 6:15 PM and 6:45 PM. Staff left a door to the Therapy Gym propped open and unsupervised which enabled Resident #1 to enter the Therapy Gym doors and exit the facility through the Therapy Gym Exit door to the parking lot. The exit door alarm sounded; however, the alarm failed to sound at the North Nurse's station. In addition, staff failed to follow the facility's policy and identify what caused the alarm to sound; and, failed to leave the alarm sounding until the cause was determined. Staff also failed to call a Code[NAME]to ensure staff were aware of a possible elopement so staff would check the entire outside perimeter of the facility for a resident, and complete a count of all residents to determine there was no resident missing, per facility policy. Resident #1 was found by Resident A's family member in the facility's parking lot. The facility's failure to ensure adequate supervision and monitoring for Resident #1 has caused or is likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on 09/20/19 and determined to exist on 09/12/19. The facility was notified of the Immediate Jeopardy on 09/20/19. An acceptable Allegation of Compliance (AoC) was received on 09/30/19. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 10/03/19. 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 (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Resident Elopement Policy, revealed the facility's Process for Elopement was as follows: Go to alarming doors, leave alarm sounding, and determine the cause of the alarming door. If the cause is not evident, initiate the following: Alert other staff to the potential of an elopement attempt, check the entire outside perimeter of the building, initiate elopement procedures and announce a potential elopement, complete a facility count of all residents to assure residents are accounted for, and initiate the missing persons procedure if any resident is unaccounted for. Review of the Weekly/Daily Direct Supply Tels. Alarm Log instructions (this is the facility alarm system for exit doors) under the section, Check delayed egress operation, revealed to Confirm security panels at nurse's station activate when door is opened and that it properly indicates the location of the door released. Record review revealed the facility admitted Resident #1 on 08/02/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/02/19, revealed the facility assessed Resident #1's Brief Interview for Mental Status (BIMS) score as a ninety-nine (99), which indicated this resident was not cognitively intact and was not interviewable. Review of Resident #1's Comprehensive Care Plan for Elopement Risk dated 08/02/19, revealed Resident #1 was at risk for elopement due to exit seeking behaviors, and impaired cognition due to [DIAGNOSES REDACTED].#1 often looked for his/her spouse when wandering or would look for his/her vehicle because he/she believed he/she needed to go to work. The plan stated the goal was that Resident #1 would not exit the facility without supervision through the next review: and the resident would be redirected if wandering. Further review revealed interventions for a wander-guard device as ordered; check placement every shift, and check the function every shift. In addition, review of Resident #1's Comprehensive Care Plan for Alteration in Mood/Behavior, dated 08/02/19, revealed resident often asks where things are including his room, resident has a [DIAGNOSES REDACTED]. Resident will go up to the door but states he likes looking out the window. Resident has a history of wondering and getting lost per wife. Further review revealed an intervention to observe resident whereabouts when wandering and redirect back to room as needed, approach in calm manner. Review of a facility Elopement/Wandering Risk Data Assessment completed on 08/07/19 revealed the facility assessed Resident #1 as oriented to person only, wad increased confusion in the PM, and a history of elopements in the past six (6) months. The resident was required to wear a wander-guard. Review of a Nursing Progress Note, dated 09/12/19 at 8:52 PM revealed the Assistant Director of Nursing (ADON) was notified Resident A's family member observed Resident #1 in the parking lot of the facility. One of the family members assisted Resident #1 inside the facility and staff assisted Resident #1 to his/her room and checked to see if he/she was okay. Staff did a skin assessment and there were no injuries identified. Further review revealed staff assisted Resident #1 into his/her pajamas and checked the wander-guard and it was working. Review of the weather report on Accuweather.Com Owensboro, for 09/12/19 at 6:00 PM indicated the temperature was 91 degrees Fahrenheit and the humidity was 43% around the time the elopement occurred. Interview of Resident A's family member on 09/18/19 at approximately 11:11 AM, revealed on 09/12/19 at approximately 6:45 PM, she and her family members were leaving the facility after visiting with Resident [NAME] The family member stated as they were backing their vehicle out of their parking space to leave, she observed Resident #1 walking in the parking lot towards the road. She stated Resident #1 was stumbling and having difficulty maintaining his/her balance. Further interview revealed she observed that Resident #1 was wearing a [NAME]et even though it was hot outside, and the resident appeared to be flushed with sweat beads visible on his/her head, and dripping down from his/her forehead. The family member stated she was concerned and asked the other family member in the car to sit in front of the facility with the resident while she alerted staff. Interview with Certified Medication Technician (CMT) #1 on 09/17/19 at 2:00 PM, revealed around 6:50 PM on 09/12/19 a family member came to the locked skilled unit door and reported they had observed Resident #1 walking in the parking lot and the resident was now sitting in the front of the facility with his/her mom. CMT #1 stated she did not hear any alarms sounding in the building and she never heard staff call a Code[NAME]to inform staff there was a possible elopement so staff could immediately start a head count on all units. The CMT stated since the incident occurred, the facility had provided education in regards to the Elopement protocol, Code[NAME]and not leaving the Therapy Gym Doors propped open for any reason. Interview with Licensed Practical Nurse (LPN) #1 on 09/17/19 at 2:55 PM revealed on 06/12/19 she walked Resident #1 from the dining room after dinner to the doorway of his/her room at approximately 6:15 PM. She stated the reason she was able to validate the time was that she administered another resident an as needed medication, which was documented that it was administered at 6:23 PM, which was right after she had left Resident #1. LPN #1 stated she then returned to the North Nurses station and completed her Insulin protocol with residents. The LPN stated that at no time did the alarm sound at the North Nurses' station. LPN #1 stated she thought she heard an alarm in the background that was coming from the Therapy gym and she asked two (2) Certified Nurse Aides (CNA's) who arrived early for their 7 PM shift to go and check that door. LPN #1 stated when the CNA's returned they confirmed the Therapy gym exit door was sounding and told her they turned off the alarm and looked outside but did not see anything. LPN #1 stated she did not hear a Code[NAME]called at any time during this period. She further stated it was around this time she became aware that staff from the Skilled Unit were alerted by another resident's family that Resident #1 had exited the building without staff supervision. LPN #1 stated that since the incident occurred, the facility has provided education in regards to the Elopement protocol, Code[NAME]and not leaving the Therapy Gym Doors propped open for any reason. Interview with CNA #1 and CNA #2 on 09/18/19 at approximately 7:30 AM revealed they worked the night shift starting at 7:00 PM and on 09/12/19 when they came into the building and walked to the North Nurses' station. Further interview revealed LPN #1 told them to check the Therapy Room Gym doors. CNA #1 and CNA #2 stated they found the entrance door to the Therapy Gym propped open and when they entered the Therapy Gym, and they found the Therapy Gym Exit door alarm sounding. The CNA's stated they looked outside but did not see anything and turned the alarm off. They reported they did not know what caused the alarm to sound. They stated they went back to LPN #1 and reported what they found and then left to go clock in to work. Further interview with CNA #1 on 09/26/19 at approximately 10:35 AM revealed when she came into work that evening she could hear an alarm sounding at the North nurses' station but she did not mention the alarm to LPN #1 or ask what caused the alarm to sound. CNA #1 stated she walked with CNA #2 to the Therapy Gym exit door, looked outside and did not see anything, and put in the reset code to stop the alarm from sounding. The CNA stated she did not know what caused the alarm to sound prior to her entering the reset code to turn off the alarm. During further interview related to the why they turned off the alarm before verifying what caused the alarm (per facility policy), CNA #1 became upset and was unable to explain why she turned off the alarm. Interview with CNA #3 on 09/18/19 at approximately 11:20 AM revealed that on the evening of 09/12/19 around 5:30 PM, she was on North Hall passing dinner trays to residents in their rooms. CNA #3 stated after dinner she picked up the trays from each of the resident's rooms, took them to the dining room, and then went back to the North Hall and did bed checks and checked call lights. CNA #3 stated she took the trash out, went back to the North nurses station, and charted around 6:30 PM, but she never heard an alarm sounding from the monitor at the North nurses station. CNA #3 stated she never heard a code[NAME]called to alert staff that there was a potential elopement. CNA #3 stated when she completed her charting; she did another bed check before her shift ended at 7 PM that evening. CNA #3 stated up to the time she clocked out she never heard an alarm going off at the North nurses' station. CNA #3 stated since the elopement occurred the facility has provided education on Code[NAME] the Elopement Protocol and not leaving the Therapy gym door propped open. Interview with Physical Therapist (PT) #1 on 09/17/19 at approximately 2:30 PM revealed he was with Resident #1 in the Therapy Gym prior to dinnertime on 09/12/19 before the elopement incident occurred. PT #1 stated he worked with Resident #1 on his/her gait from 4:30 PM to 5:15 PM and he walked with Resident #1 to the dining room and left Resident #1 there in the dining room. PT #1 further revealed when he left the Therapy gym he shut the door and locked it. Further interview with PT #1 revealed he did not go back to the Therapy Gym because the other residents he provided therapy for received it in their rooms. Pt #1 stated there were times during the day that the Therapy Gym door was left open and unlocked when staff were in the gym area, but it should not be open and unlocked if there were no staff in the gym to supervise and monitor residents. Interview with Maintenance Director on 09/18/19 at approximately 9:30 AM revealed he checked the alarms twice a day to ensure they were functioning properly and he logged the checks daily on the Weekly/Daily Direct Supply Tels. Alarm log. The Maintenance Director stated he did not check the monitors at the Nurses station because his Corporate Life Safety person informed him that since the monitors were the power source for the alarms at the doors, the monitors worked if the doors were working. The Maintenance Director stated he has not found any malfunction in the alarm system but, he did not check the monitor two (2) times daily as he does the door alarms. He stated he had only verified that the monitors worked during elopement drills, but they were completed once a month. The Maintenance Director also stated that no outside source had looked at or checked the monitors at the nurses station since the elopement. Interview with Charge Nurse/RN (Registered Nurse) #1 on 09/26/19 at approximately 10:45 AM revealed she was on the South Hall when the incident occurred with Resident #1 on 09/12/19. RN #1 stated she was on the phone when CMT #1 came down the hall and reported that Resident #1 had gotten out of the building, and that another resident's family member brought him/her back to the facility. She stated the CMT said to make sure all the residents were on the hall and that none were missing. RN #1 stated she remembered hearing a bell going off in the background but she was not sure where the sound was coming from and she did not hear a Code[NAME]called. Interview with Resident #1's Family Member on 09/18/19 at approximately 2:00 PM revealed staff did not make her aware Resident #1 had exited the facility on 09/12/19 unsupervised. The Family Member stated staff contacted her and told her that staff found Resident #1 pushing on the doors of the facility in an attempt to open the door but was not successful in opening the door. Observation of the Therapy Gym room on 09/18/19 at approximately 12:05 PM revealed the room contained rehabilitation equipment. Observation of the gym room exit door (to outside) revealed that when a wander-guard device came within range of the door it disabled the key pad by the door preventing anyone from entering the code to open the door. Further observation revealed when the door release was held down, the door immediately started to sound an alarm that was an intermittent beeping alarm for about fifteen (15) seconds before the door released automatically due to the egress. At this time, a loud continuous alarm sounded and remained alarming until the reset code was entered to stop it. In addition, an observation of the North nurses station revealed that when the Therapy Gym door alarm sounded, a loud continuous alarm sounded at the North nurses station and a red light lit up on the monitor on the wall behind the nurse's station indicating the Therapy Gym door alarm sounded. The alarm was heard down the North nurse's station hallway. Interview with Administrator on 09/18/19 at approximately 3:45 PM revealed staff regularly leave the Therapy Gym doors propped open and there was no regulation that says he cannot do that. The Administrator stated staff followed their Elopement protocol and even though staff never called a Code[NAME] staff went through the Code[NAME]steps in an attempt to ensure that no other residents were unaccounted for after the family member made staff aware Resident #1 was in the parking lot. He revealed education was provided to staff after the incident on the facility's Code[NAME]Protocol and the facility Elopement Policy. Further interview revealed there was nothing wrong with the alarm system or the monitor at the North nurses station; however, the Administrator stated that no outside source had checked the North nurse's station alarm to ensure there were no glitches in the system. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 09/12/19, a licensed nurse assessed Resident #1 and verified the wander guard was on and functioning as ordered. No concerns identified. 2. On 09/12/19, Resident #1's Care Plan was updated to provide one to one (1:1) supervision. 3. On 09/12/19, the Physician and Resident representative for Resident #1 were notified. 4. On 09/12/19, the ADON checked all exits and determined that all alarms were sounding appropriately. 5. On 09/13/19, nursing decreased supervision for Resident #1 to fifteen (15) minute checks and the care plan was updated to reflect the change. 6. On 09/12/19 and 09/13/19, the ADON and Wound Nurse audited all residents at risk for elopement to determine that all wander guards were in place and functioning and documented on the Treatment Administration Record (TAR). No concerns identified. 7. Licensed Nurses completed a head count on 09/13/19 and verified all residents were accounted for. 8. Resident #1's wander guard has been checked for placement daily by ADON and RN weekend supervisor to ensure it was on and functioning. 9. On 09/13/19, the ADON, DON and RN Supervisor completed an audit of all elopement risk residents to determine their elopement risk and that the care plan reflected the resident's elopement risk and that the plan of care included person centered interventions with appropriate supervision. 10. On 09/13/19, the door leading to the therapy gym from the hallway was changed from a key entry to a code entry by Maintenance; this change will prevent the door from remaining open and that it is closed at all times. 11. On 09/13/19, the Staff Development Coordinator, Business Office Manager, Assistant Business Office Manager, Social Services Director, and Social Services Assistant, completed an inspection of the door alarm system, including boxes at the nurses' stations. The Administrator assigned staff to sit at the North Hall nursing station twenty-four (24) hours a day, seven (7) days a week to observe the camera and monitors and listen for door alarms connected to the North Hall nursing station box. All door alarms connected to the North Hall nursing station box could be heard at the North Hall nursing station. These 24/7 door monitors remain in effect. 12. On 09/14/19, the ADON and Weekend Supervisor led an elopement drill on each shift to evaluate staff response to the wander guard alarms. No concerns were identified. 13. On 09/13/19, all staff (from every department including, but not limited to , nurses, aides, dietary, etc.) were educated by the Nurse Administrator Team (DON, ADON, SDC and MDS) to the Elopement Process which included checking wander guard placement/function per care plan, response to door alarm, and assessing for further interventions to prevent elopement for residents who exhibit elopement attempts. As of 09/14/19, no staff worked without being educated. Signs were posted by the time clock and a master list generated by payroll was utilized by the SDC to ensure all staff were educated by 09/13/19 and none worked until receiving the training. The facility has no agency staff. 14. On 09/25/19, the Maintenance Director and Administrator were educated by the Plant Operations Manager that when checking the door alarm system the boxes at the nurses' station must also be checked. This is to be achieved by having staff members posted at each nurses station with walkie talkies to confirm that the door was alarming at the nurse's station. Each staff member involved will then sign the testing audit. 15. On 09/25/19, Department Heads and licensed nurses were educated by the Administrator, Staff Development Coordinator, DON, ADON's and MDS Nurse that when checking the door alarm system the boxes at the nurses' station must also be checked. This is to be achieved by having staff members posted at each nurses station with walkie talkies to confirm that the door was alarming at the nurses station. Each staff member involved will then sign the testing audit. 16. On 09/20/19, a third party vender checked the alarm system for functionality and provided maintenance as needed. 17. On 09/25/19, another third party vendor was engaged to update the system so that every door alarm sounds at every nurses' station. Until the work is competed the monitor will continue at the North Hall nursing station, twenty-four (24) hours a day/seven (7) days a week. 18. The Administrator, ADON, DON, Staff Development Coordinator, or RN weekend supervisor will complete an elopement drill on each shift weekly for two (2) weeks and them monthly times three (3) months and will assess the staff response then provide additional education and guidance based on that response. 19. The Nurse Management Team, which consists of the DON, ADON's, Staff Development Coordinator, RN Weekend Supervisor and MDS will audit each resident with a wander guard for placement and function daily beginning on 09/13/19. 20. The DON, ADON, or RN Weekend Supervisor will verify that wander guards are in place and functioning by observing all residents with a wander guard and comparing that observation to the resident care plan daily for two (2) weeks, weekly times three weeks, and then monthly times two (2) months. The results of the audits will be submitted to the Administrator and DON upon completion for review and presentation to Quality Assurance (QA). 21. Door alarms, including alarms at nurses station, will be audited by members of the departmental head team which includes the Administrator, Maintenance Director, Maintenance Assistant, DON, ADON, MDS Nurse, Staff Development Coordinator, Central Supply, Medical Records, AP/Payroll Clerk, Business Office Manager, Assistant Business Office Manager, Social Service Director and Social Services Assistant, weekly times twelve (12) weeks to ensure that alarms at doors and at boxes at the nurses station are functioning properly. Results are report to the Administrator for presentation to Q[NAME] 22. On 09/25/19, an internal QA meeting was held to discuss all audit results and corrective action with no concerns noted. 23. A full Quality Assurance Meeting was held on 09/13/19 and was attended by the Administrator, DON, Nursing, Social Services, and the Medical Director to review the plan for further recommendations. Another full QA meeting was held on 09/26/19. All audit results were presented by the Maintenance Director and ADON. No concerns noted. The Administrator addressed any follow up needed. QA meetings will continue weekly until the facility obtains substantial compliance and then will occur monthly for three (3) months, then quarterly. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Resident #1's Departmental Notes dated 09/12/19 at 8:52 PM, revealed Resident #1 was assessed by Assistant Director of Nursing (ADON) #1 and another nurse after elopement from the facility with no injury noted. Interview on 10/02/19 at 4:00 PM with ADON #1 revealed Resident #1's wanderguard was working when he/she returned to the facility and no injury was noted. 2. Review of Resident #1's Risk for Elopement Care Plan revealed an intervention was added to provide 1:1 supervision on 09/12/19. Review of Departmental Notes (nursing) dated 09/12/19 at 8:52 PM revealed Resident#1 was placed on 1:1 supervision. Review of the 1:1 Resident Safety Check Sheets revealed the resident remained on 1:1 monitoring from 09/12/19 to 09/13/19. Interview on 10/02/19 at 11:22 AM with CNA #4 revealed she had provided 1:1 supervision to Resident #1. 3. Review of Departmental Notes (nursing) dated 09/12/19 at 8:52 PM revealed Resident #1's family member was notified of the elopement at this time. Review of Note dated 09/12/19 at 7:16 PM, revealed notification to the physician which was signed by the Director of Nursing (DON). Interview on 10/03/19 at 1:05 PM with Resident #1's Physician/Medical Director revealed she was immediately notified of Resident #1's elopement. 4. Review of a statement dated 09/12/19, written by ADON #2 revealed all exit doors were checked with the alarm sounding appropriately and staff responding to alarms. In addition, all wanderguards were functioning. Interview on 10/02/19 at 11:54 PM with ADON #2 revealed the exit door alarms and all wanderguards were checked and were functioning. 5. Review of Resident #1's Risk for Elopement Care Plan revealed the resident was placed on 15 minute checks on 09/13/19. Review of the Resident Safety Checks dated 09/13/19 through 10/03/19 revealed Resident #1 remained on 15 minute checks. Interviews on 10/02/19 with CNA #5 at 10:21 PM, Certified Medication Technician at 10:46 PM, and CNA #4 at 11:22 PM, revealed they had provided 1:1 supervision and every 15 minute checks for Resident #1 after elopement. 6. Review of the Wanderguard Checklist Sheet and TAR's for all residents with wanderguards revealed the wanderguards were checked daily from 09/12/19 through 10/03/19 for functioning. Interviews on 10/02/19 with ADON #1 (wound care nurse) at 4:00 PM and ADON #2 at 11:54 PM revealed they helped with the wanderguard audits. 7. Review of hall census sheets revealed a head count audit of residents was completed on 09/13/19. Interview on 10/02/19 at 4:00 PM with ADON #1 (wound care nurse) verified she had helped with the head count. 8. Review of Resident #1's Treatment Administration Records (TARs) revealed his/her wanderguard was checked for placement and function every shift. Interview on 10/02/19 at 4:00 PM with ADON #1 revealed she helped check placement and function of Resident #1's wanderguard daily. 9. Review of all residents with wanderguards care plans and assessments revealed assessments were conducted on 09/13/19 and care plans were updated to include supervision and wanderguard placement. Interview on 10/02/19 at 4:00 PM with ADON #1 (wound care nurse) revealed she was involved in audits of all elopement risk residents and ensured the care plans reflected supervision and person centered interventions. 10. Observation on 10/02/19 at 1:17 PM, revealed there was a keypad entry at the door to the therapy gym. Observation of the Staff Alert Box at nursing stations revealed the therapy door was listed on the alarm box. Interview on 10/03/19 at 8:39 AM with the Maintenance Director revealed there was a new code box installed at the therapy door and he had also moved a large magnet that had been utilized previously to prop the therapy door open. He stated the therapy door was now on the staff alert box at all nurses stations. 11. Review of a 09/13/19 document revealed Department Heads were posted at each nursing station with walkie talkie to verify that each door alarm was tested on e by one to ensure they were working properly and that the alarm box at the nursing station worked properly. Further review revealed the SDC signed the document verifying five (5) staff members were involved in the process. Interview on 10/02/19 at 11:40 PM with LPN #3 revealed the Maintenace Director set the alarm off at the door while she was at the skilled nurses station checking to see what alarm was showing to be off on the staff alert box, She would then go to the door to see the alarm going off and if anyone was around the door or outside the door. Interview on 10/03/19 at 11:29 AM with the BOM revealed she had been involved in the door alarm inspections. Review of the door monitoring sheets revealed a schedule with designated time frames of monitoring by staff. Observation on 10/02/19 at 1:00 PM and 6:00 PM and on 10/03/19 at 9:00 AM, 11:38 AM, and 4:30 PM revealed staff were sitting at the North Hall nursing station with 1:1 observation of the door monitors. 12. Review of the Logbook Documentation dated 09/14/19 revealed an elopement drill was completed on each shift and further review revealed the signatures of staff who were involved in the drills. 13. Review of the Inservice Training of Code[NAME](drills for elopement of residents and residents on wanderguards) dated 09/13/10-09/15/19 revealed staff was educated on Code[NAME](elopement drill process). Interviews on 10/02/19 with RN #1 and RN #2 at 1:50 PM, LPN #1 at 2:10 PM, CNA #2 at 1:33 PM, LPN #3 at 11:40 PM, Activities Assistant at 1:45 PM, revealed they were educated on Code Wanda. Inteviews on 10/03/19 with Social Service at 10:40 AM, and with Housekeeper #1 at 9:45 AM revealed they had been educated on the elopement process and care plans. Interview on 10/03/19 at 12:28 PM with the SDC revealed all staff had been educated except for one that was on Family Medical Leave. Interview on 10/03/19 at 11:29 AM with BOM and ABOM revealed they had been educated on the elopement process. Observations on 10/03/19 at 9:53 AM revealed two (2) signs at two (2) time clocks in the staff break room which stated Do not clock in unless educated on elopement/wanderguard process. Interview with Housekeeper #2 on 10/03/19 at 9:45 AM revealed this was her first day at work and she had not received any elopement training. 14. Review of an inservice training record revealed on 09/20/19, the Maintenance Director and Administrator were educated that the door alarms boxes located at the nurses station must be checked when checking the function of the door alarms to ensure functioning. Interviews on 10/03/19 with Maintenance Director at 8:39 AM and Administrator at 2:08 PM revealed they were educated on how the door alarms needed to be checked. 15. Review of Inservice training dated 09/25/19 revealed Department Heads and licensed nurses were educated on the door alarms being tested to ensure the alarm was sounding and lighting up at the nurses station with signatures of staff inserviced. Interviews on 10/02/19 at 4:12 PM with Housekeeping Supervisor/Dietary Manager and Accounts Manager/Laundry Manager revealed they were educated on how to test the alarms; and, to ensure the alrms lighted up at the nurse's station. 16. Review of the letter received by the Administrator from the first third party vendor dated 09/20/19 revealed the vendor tested eight (8) doors monitored by the Code Alert System and one (1) of the eight (8) doors did not relay the alarm to the annunciator at the nurse's station. The door was the Therapy Hall door leading to a parking lot. Further review revealed the vendor made the facility aware they were not a Code Alert distirbutor so the facility would have to order the part and the vender could return and install the keypad. The letter was signed by the Administrator and dated received 09/20/19. 17. Observation on 10/02/19 and 10/03/19 of third party vendor working on the alarm system of the facility doors. Interview on 10/03/19 at 8:29 AM with the Maintenance Director revealed a new alarm system with new boxes was being installed so that every door will alarm at the nursing station. Interview with the Third party Vendor Technician (TPVT) on 10/03/19 at 10:46 AM revealed the purpose of the staff alert monitor was to alert staff to when doors were opened. He stated the egress signal goes from the door to the staff alert box at the nurse's station to tell what door had been opened. He further revealed the keypad in place was used to prevent residents with wanderguards from going out the doors and the only way out was with a code. He stated maintenance was being completed on the door alarms and the keypad systems with projected completion to be late the evening of 10/03/19. 18. Review of the Elopement Drill Log documentation revealed drills

Based on interview, record review, and review of the Lippincott Manual of Nursing Practice 10th Edition, it was determined the facility failed to notify the Physician of a significant change in the resident's physical status or possible need to alter treatment for two (2) of twenty-one (21) sampled residents (Residents #1 and #4). Resident #4, who also had a trach, was to receive Chest Percussion Treatment (CPT) vest every six (6) hours for twenty (20) minutes. There was no documented evidence the treatments were completed seven (7) times between [DATE] to [DATE]. Two (2) of the treatments ([DATE] at 12:00 PM and 6:00 PM) were documented as Not Administered due to vest not available; and, the [DATE], 12:00 AM treatment was not given per interview with no reason given. However, the facility failed to notify the physician that the treatments were not provided to determine if there was a need to alter treatment. On [DATE], Resident #4 was found in Respiratory Arrest and Cardiopulmonary Resuscitation (CPR) was initiated. The resident was sent to the hospital and mechanically ventilated. The resident passed away on [DATE]. On [DATE] to [DATE], Resident #1's tracheal secretions increased, thickened and went from white to green. However, the facility failed to follow its policy and, did not notify the Physician of the change in condition for Resident #1. On [DATE], Resident #1 pulled out his/her trach, was sent to the hospital, and was diagnosed with [REDACTED]. The facility's failure to ensure the physician was notified when there was a change of condition or need to alter treatment has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. 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 (QA) monitors the effectiveness of the systemic changes. The findings include: Interview with the Director of Nursing (DON) on [DATE] at 2:00 PM revealed the facility did not have a policy regarding when to call the physician or documentation. She stated the facility used the Lippincott Manual of Nursing Practice. Review of the Lippincott Manual of Nursing Practice 10th Edition dated 2014, revealed in the Follow-up Phase of [MEDICAL CONDITION] Care to document procedure performance, observations of stoma (irritation, redness, [MEDICAL CONDITION], subcutaneous air), and character of secretions (color, purulence). Report changes in stoma appearance or secretions. 1. Record review revealed the facility admitted Resident #1 on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Minimum Data Set (MDS) assessment, dated [DATE] revealed no Brief Interview of Mental Status (BIMS) was attempted because the facility assessed the resident to be severely cognitively impaired and was not interviewable. Review of Departmental Notes (Progress Notes), revealed on [DATE] at 1:50 PM and, on [DATE] at 4:44 AM, Resident #1's tracheal suctioning was completed numerous times with white, thick mucous in large amounts. On [DATE] at 1:35 AM, Resident #1's tracheal suctioned sputum was thick and white; on [DATE] at 10:17 AM, the resident had copious amounts of thick yellow sputum, and required suctioning frequently and drain sponge changes. Further review revealed on [DATE] at 11:35 PM, the resident was suctioned many times with thick white sputum noted. On [DATE] at 6:59 PM, the resident was suctioned multiple times with copious amounts of thick yellow sputum and the resident's oxygen saturation was 90% on O2 as ordered. On [DATE] at 4:13 AM, after several times of tracheal suctioning there was thick green sputum and at 12:27 PM (same day), the resident was suctioned often due to thick yellowish white secretions; and, on [DATE] at 5:50 PM, it was noted Resident #1 pulled his/her oxygen off several times. However, further review of the Departmental Notes revealed there was no documented evidence the Physician was made aware of the change in the amount, consistency, and color of Resident #4's tracheal secretions, per facility policy. Review of the Departmental Note, dated [DATE] at 12:59 PM, revealed at 12:38 AM, the resident was heard calling out, and was found with his/her [MEDICAL CONDITION] and oxygen pulled out with bloody drainage noted coming out of [MEDICAL CONDITION] site. The resident was in respiratory distress and cyanotic in color. The resident'[MEDICAL CONDITION] replaced and O2 reapplied. The resident's oxygen saturation was 84% (normal: 96% average). 911 (Emergency Medical Services) was called related to the resident's respiratory distress. Resident #4 was sent to the local Emergency Department. Review of the Emergency Department Record dated [DATE], revealed Resident #1 was in respiratory distress on arrival. Resident #1 was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. The resident was discharged back to the facility on [DATE]. Interview (Post Survey) with Licensed Practical Nurse (LPN) #11, on [DATE] at 9:27 PM revealed she had taken care of Resident #1 on [DATE] and she suctioned Resident #1 several times and obtained thick green sputum with no shortness of air noted. She stated she should have filled out an incident report and contacted the physician about the green sputum but did not. Interview (Post Survey) with LPN #4, on [DATE] at 9:17 PM, revealed Resident #1 pulled out his/her [MEDICAL CONDITION] on [DATE]. She stated there was a lot of blood, and the resident was cyanotic in color. LPN #4 stated she was unable to obtain a good O2 sat. She stated Emergency Medical Service (EMS) was called. She revealed she did not normally work with this resident but green secretions usually meant that the resident had some sort of infection. She stated she would call the doctor if she were to see green secretions. However, she stated she would not call the doctor immediately since she works the night shift, unless the resident exhibited shortness of breath or a fever with the secretions, but she would fill out an incident report and call the physician in the morning. Interview with Resident #1's Physician revealed he knew that the resident had been pulling at his/her [MEDICAL CONDITION], however, he was not aware of the changes in the color and consistency of secretions and he expected nursing staff to call him and advise of these changes. He stated an increase of thickness of secretions would cause the resident to want to pull his/her [MEDICAL CONDITION] out. He revealed if the resident could not clear his/her airway, it would cause him/her to fight it and want to pull it out. 2. Interview (Post Survey) with the DON on [DATE] at 4:30 PM, revealed the facility used Lippincott Manual of Nursing Practice 10th Edition for their Professional Standards of Practice related to concerns for medications or treatments not being available or missed. Review of Lippincott Manual of Nursing Practice ,[DATE]th Edition revealed the Linppincott manual did not address what the licensed nurse should do when a medication or treatment was not available. Review of the Specialized Medical Services for Percussion Vest used by Resident #4 revealed the percussion vest system consists of an inflatable vest which is worn over the torso, and an air pulse generator that delivers air pulses to the vest. These air pulses produce a high frequency chest wall oscillation that creates air flow throughout the lungs. The pulsed air acts much like a cough to shear secretions away from the airway wall and move them upward where they can be coughed or suctioned out. Record review revealed the facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed a BIMS was not attempted due to the resident being assessed as severely cognitively impaired and was not interviewable. Review of Resident #4's (MONTH) (YEAR) Physician order [REDACTED]. Settings as tolerated. Review of Resident #4's Medicare Notes and Departmental Notes revealed on [DATE], [DATE], and [DATE], the resident was suctioned and staff obtained moderate amounts of secretions yellow to yellow green in color. On [DATE], the resident was suctioned with small amounts of thick whitish yellow secretions obtained and further review revealed there was no description of Resident #4's secretions on [DATE]. Further review revealed there was no documented evidence the physician was made aware of the yellow green secretions or the decline in the amount of secretions. Review of the Resident #4's (MONTH) (YEAR) Treatment Administration Record (TAR) revealed to apply the CPT Vest every six hours (6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM) for twenty minutes, but there was no documentation to indicate whether the CPT Vest was applied or not on [DATE] at 6:00 PM, on [DATE] at 6:00 AM and 12:00 PM; and on [DATE] at 6:00 AM and 6:00 PM. However, review of the Departmental Notes for [DATE] through [DATE] revealed there was no documented evidence staff made the Physician aware the treatments were not provided, per facility policy. Interview with LPN #3 on [DATE] at 2:08 PM, revealed she came in to work on [DATE] and went to Resident #4's room and found the vest was missing. She stated she obtained the vest from the laundry room which had been placed there because tube feeding had been spilled on the vest. She stated she cleaned the vest and hung it up to dry in the shower room. LPN #3 stated she thought she must have missed documenting the treatment on [DATE] at 6:00 PM. She stated if the vest was not available she would chart that the vest not available and would call the physician just as if a medication was missing. Review of Departmental Notes dated [DATE] at 1:37 AM (late entry for 1:00 AM) revealed the resident was found with his/[MEDICAL CONDITION] on his/her chest and staff were unable to re-insert trach. The Physician was called and an order was received to send the resident to the emergency room (ER). Review of the Emergency Medical Services Report dated [DATE], revealed the Emergency Medical Technician (EMT) found the resident fighting care when he arrived at the facility; he intubated the resident's [MEDICAL CONDITION] stoma, and the resident immediately improved. Further review revealed the resident was suctioned with a copious amount of secretions obtained, and then the resident coughed up a bloody sputum mucous plug and went into [MEDICAL CONDITION]. The paramedic immediately ventilated the resident and he/she improved. Review of the Emergency Department Records dated [DATE] revealed the emergency room Physician replaced the resident's [MEDICAL CONDITION] at the bedside. The resident left the Emergency Department on [DATE] at 7:22 AM and was returned to the nursing facility. Further review of the (MONTH) (YEAR) TAR and review of Departmental Notes dated [DATE] at 6:45 PM, revealed LPN #2 documented the vest was not administered on [DATE] at 12:00 PM and 6:00 PM due to vest not available. Further review of the TAR revealed there was no documented evidence the treatment was completed on [DATE] at 12:00 AM; however, interview with LPN #7 revealed he did not administer the CPT treatment, but he was unable to provide an explanation as to why. Continued review revealed there was no documented evidence in the Departmental Notes dated [DATE] and [DATE], that the physician was made aware the treatments were not completed. Interview with LPN #2 on [DATE] at 10:50 AM revealed she administered Resident #4's CPT treatments as ordered on [DATE] at 12:00 PM and 6:00 PM even though she documented the treatments were not done due to vest not being available. She stated she did not know why it was documented that way as she must have put the information in the record; however, she denies treatments were missed. She revealed if she were to miss a treatment, she would call the doctor to inform him. Interview with LPN #7 on [DATE] at 10:32 PM, revealed he did not give the midnight treatment on [DATE], but he was unable to give a reason why it was not administered. He stated if a treatment or medication was unable to be done, the Physician should be notified. Review of a Departmental Note, dated [DATE] at 2:09 AM by LPN #7, revealed at approximately 1:00 AM, LPN #7 was notified by the Certified Nurse Aide (CNA) that Resident #4 was not breathing. A code was called and staff initiated Cardiopulmonary Resuscitation (CPR). 911 was called and EMS arrived and took over the CPR. Further review revealed the resident'[MEDICAL CONDITION] pulled and the resident was intubated by EMS. The resident was transported to the local Emergency Department. Review of the Emergency Department Records dated [DATE], revealed Resident #4 was placed on mechanical ventilation. The resident expired three (3) days later after his/her Medical Power of Attorneys (the resident's sisters) removed him/her from the mechanical ventilation due to his/her grave prognosis. The resident expired on [DATE] in a local hospice house. Interviews on [DATE] with LPN #1 at 9:50 AM, LPN #8 at 10:00 AM and LPN #9 at 10:04 AM revealed if a medication or treatment was missed, the physician should be notified. Interview with Registered Nurse (RN) #3 on [DATE] at 10:00 AM revealed if a missed treatment was significant, the physician should be notified. Interview with Resident #4's Physician on [DATE] at 2:45 PM revealed he was not aware that Resident #4 had missed at least three (3) Chest Percussion Treatments with the automated CPT vest and he had not received any calls for any changes. Physician #1 stated missing the CPT vest treatments would definitely keep the resident from clearing his/her airway and would contribute to his/her respiratory arrest. Interview with the Director of Nursing (DON) on [DATE] at 10:13 AM revealed she expected staff to follow the facility's [MEDICAL CONDITION] care policy and to contact the physician and advise him/her of any changes of mucous from white to green. Interview with the Director of Nursing on [DATE] at 10:00 AM revealed the facility had computer problems and she was unaware why the information was documented in the Administrative Notes as not done. She stated it must have generated when LPN #2 documented N on the TAR which meant' the treatment was not administered. The DON stated, Even though she put N on the TAR as not administered, she believed LPN #2 did the treatment. She stated she expected staff to call the physician if something was not available for treatments. **The facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 was discharged to the hospital on [DATE] and has not returned to the facility. Resident #4 was discharged to the hospital on [DATE], and expired on [DATE] at a local Hospice House. 2. Audits were completed by the Nurse Management Team including the DON, ADONs, MDS Nurses, and SDC Nurse. An assessment of current in house resident(s) with a [MEDICAL CONDITION] was completed for changes in condition with sputum, and if medications and/or treatments were available for respiratory care. Audits were completed by [DATE] by nursing administration and no issues were identified. Audits included reviewing 24 hour reports, nurse's notes, care plans, medication and treatment administration records. 3. Education was provided to current employed licensed nurses by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, and MDS Nurses related to notification to physician regarding change of condition regarding respiratory treatment and care for oxygen administration and [MEDICAL CONDITION] care to include changes in sputum secretions amount and color, and signs of possible distress. Also, education was provided related to following physician orders [REDACTED]. The education also included following acceptable standards of practice regarding the above. This education was started on [DATE] and completed on [DATE]. No agency staff used at this time. 4. Administrator re-educated all department heads (DON, ADONs, MDS Nurses, Medical Records, Activities Director, Central Supply Director, Business Office Manager, Business Office Assistant, Social Services Director, Social Services Assistant, Admissions Coordinator and Payroll Clerk) on checking portable oxygen tanks to ensure that they have oxygen, including alerting the nurse if tank needs to be filled on [DATE]. 5. Audits will be conducted weekly on in house [MEDICAL CONDITION] residents for physician notification of changes regarding respiratory care 5 x a week x 4 weeks, then 3 x week x 8 weeks to check that physician notification was completed by the Nurse Management Team consisting of DON, ADON, SDC and MDS Nurses. These audits will begin on [DATE]. Results of audits will be reported to QA committee by the DON and Administrator and will assign follow-up as needed. Facility will hold weekly QA Meetings with at least one Regional Team Member (RQM and RDO) attending for 4 weeks and then facility will continue monthly thereafter. 6. Audits will be conducted weekly on residents with [MEDICAL CONDITION] care and services to ensure respiratory treatment and physician orders [REDACTED]. These audits will begin on [DATE]. Results of audits will be reported to the Quality Assurance committee by the DON and Administrator and will assign follow-up as needed. QAA meeting was held on [DATE] to discuss alleged deficient practices. Facility will hold weekly Quality Assurance Meetings with at least one Regional team Member. The Regional team consists of Regional Director of Operations, Regional Quality Manager, Regional Marketing Manager, Regional Reimbursement manager and regulator liaison. Members of the facility quality assurance committee consist of the Administrator, DON, ADONs Dietary Manager, Business office Manager, Activities Director, Director of Rehab and Social Services Manager with Medical Director participating at least quarterly as needed. 7. Audits will be conducted daily, once in the morning and once in the afternoon, x 8 weeks to ensure that residents with portable oxygen tanks are not empty, alerting the nurse if they need to be filled. Audits began [DATE]. 8. The Regional Quality Manager (RQM) provided education on [DATE] to the Nursing Administration Team which included the DON, ADON's, and SDC regarding oxygen and/or Respiratory treatment in accordance with standards of practice and the individuals care plan for tracheostomies (color, consistency, amount, vital sign changes, etc.), physician notification regarding signs and symptoms of respiratory changes with secretions and/or treatments and or medications not available, following physician orders, and ensuring residents receiving oxygen services receive them in accordance with their plan of care. Efforts to obtain the necessary treatment and services includenthe nurse will notify physician, administrator and/or DON. 9. The Administrator and Director of Nursing were fully educated regarding the cited deficiencies, ongoing plan of correction and the expectations involved by the Regional Quality Manager on [DATE]. 10. The Interdisciplinary team, including the Administrator, DON, RDO, and the Medical Director have been educated regarding the QA Process and role of the IDT team by the QA Compliance Consultant on [DATE]. 11 . A weekly QA meeting was held starting [DATE] related to reporting to the Governing Body regarding achieving and maintaining ongoing substantial compliance. The meetings will be held weekly with at least one Regional Team Member attending for 4 weeks and the facility will continue monthly thereafter. The Governing Body will receive updates from the facility's weekly QA meetings on a weekly basis directly from the Administrator. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility's medical record and local hospital records revealed Resident #1 was discharged to the hospital on [DATE] and has not returned to the facility; and, Resident #4 was discharged to the hospital on [DATE] and expired on [DATE] at a local Hospice House. 2. Review of audits completed by the Management Team which included DON, ADON's, SDC Nurse and MDS Nurse revealed an audit was completed [DATE] by nursing administration and no issues were identified. Audits included reviewing 24 hour reports, nurse's notes, care plans, medication and treatment administration records. 3. Review of the education provided to current employed licensed nurses by the DON, ADON's, SDC, and MDS nurses related to notification to physician regarding change of condition regarding respiratory treatment and care for oxygen administration and [MEDICAL CONDITION] care to include changes in sputum secretions amount and color, signs of possible distress. Also, education following physician orders [REDACTED]. This education was started on [DATE] and completed on [DATE]. No agency staff use at this time. Sign in sheets were reviewed to confirm licensed staff education. Interviews on [DATE] with LPN #2 at 2:11 PM, LPN #14 at 2:18 PM, RN #6 at 2:30 PM, RN #2 at 2:37 PM, RN #7 at 2:42 PM, and RN #8 at 3:00 PM; and on [DATE] with LPN #11 at 4:40 PM revealed they had received oxygen administration training to include reading portable canisters, filling canisters, following physician orders [REDACTED]. The education was provided by the SDC, started on [DATE], and completed on [DATE]. 4. Review of re-education sign in sheet dated [DATE] and information related to checking portable oxygen tanks to ensure that they have oxygen, including alerting the nurse if tank needs to be filled revealed the education was provided to all Department Heads. Interviews on [DATE] with MDS Nurse #1 at 4:13 PM, and MDS Nurse #2 at 4:24 PM; and, interviews on [DATE] with the Maintenance Director at 4:31 PM, Housekeeping Supervisor at 4:39 PM and Dietary Manager at 4:42 PM, revealed they were educated by the SDC Nurse regarding O2 canister checking to assess the tanks' fullness. They revealed they should pick up canister with strap on side where the dial was and then read the dial. They also revealed, they were educated to go and inform the license nurse that the tank needs to be filled. 5. Review of facility audits revealed the one [MEDICAL CONDITION] patient's care to include care plans, physician orders, MAR, TAR, revealed they were reviewed to ensure the resident was receiving proper care. This was completed on [DATE] and [DATE]. 6. Review of audits conducted beginning [DATE] which are ongoing revealed the one resident with [MEDICAL CONDITION] care was reviewed o ensure respiratory treatment and physician orders [REDACTED]. and MDS Nurses. Review of QAA meeting minutes revealed a meeting was held on [DATE] and [DATE] with topics discussed included deficient practices. Weekly meetings were held once weekly as evidenced by sign in sheets. Interviews on [DATE] with LPN #2 at 2:11 PM, LPN #14 at 2:18 PM, RN #6 at 2:30 PM, RN #2 at 2:37 PM, RN #7 at 2:42 PM, and RN #8 at 3:00 PM; and on [DATE] with LPN #11 at 4:40 PM revealed they had received oxygen administration training to include reading portable canisters, filling canisters, following physician orders [REDACTED]. The education was provided by the SDC, started on [DATE], and completed on [DATE]. 7. Review of daily audits of residents with portable O2 tanks revealed the audits were completed to include O2/nebulizers/bi-pap/c-pap checks as alleged in the AoC. The daily checks included O2 running prescribed rate. If using liquid O2, check tank to make sure not empty and on patient. Refill at ,[DATE] tank. If using concentrator, if its on resident, prescribed equipment is used (i.e., [MEDICAL CONDITION] or [MEDICAL CONDITION]), tubing bagged, dated placed appropriately to prevent infection, equipment clean including filters and bags. Audits started [DATE] and noted ongoing. 8. Review of education provided on [DATE] by the RQM to the Nursing Administration Team which included DON, ADON's, and SDC revealed they were educated on oxygen/respiratory treatment in accordance with standards of practice and the care plan for [MEDICAL CONDITION] resident's change of secretions, following physician orders [REDACTED]. Reviewed sign in sheet and the Administrative Nursing Team was in attendance. 9. Review of the sign in sheet dated [DATE] and the education provided by the RQM to the Administrator and DON revealed they were educated on the cited deficiencies, ongoing plan of correction and the expectations involved. Interview with the DON on ,[DATE] at 3:50 PM revealed the RQM educated her and the Administrator regarding the deficiencies that were cited during the revisit. She stated the RQM went over the ongoing plan of corrections and expectations involved as alleged in the AoC. 10. Review of education revealed the IDT Team was educated on the QA process and role of the IDT team by the QA Compliance Consultant on [DATE]. Interview (Post Survey) Regional Director of Operations on [DATE] at 9:55 AM revealed education was provided by the QA compliance consultant. The QA process was reviewed. 11. Review of QA minutes revealed a weekly meeting was held on [DATE] and [DATE]. Review of the attendance record revealed one regional team member attended the meeting.

Based on interview, record review, and facility policy review it was determined the facility failed to implement the care plan for one (1) of twenty-one (21) sampled residents (Resident #4). Resident #4 was care planned to receive Chest Percussion Therapy (CPT) Vest treatment every six (6) hours for twenty (20) minutes. However, there was no documented evidence the facility provided the treatment on [DATE] at 6:00 PM, on [DATE] at 6:00 AM and 12:00 PM; on [DATE] at 6:00 AM and 6:00 PM, on [DATE] at 12:00 PM and 6:00 PM; and on [DATE] at 12:00 AM (seven {7} of fourteen {14} treatments from [DATE] at 6:00 AM through [DATE] at 12:00 AM). On [DATE] at approximately 1:00 AM, the Resident #4 was found in cardiopulmonary arrest with Cardiopulmonary Resuscitation (CPR) initiated. Resident #4 was was hospitalized and placed on mechanical life support. Resident #4's medical power of attorney's (the resident's sisters) removed the resident from life support and the resident expired on [DATE] at a local Hospice House. The facility's failure to implement the care plan has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. 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 (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Comprehensive Care Plans Standard of Practice from the Clinical Standards of Practice Manual, last revised (MONTH) (YEAR) revealed it is the practice of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Person-centered care means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. The facility supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). Review of the facility's policy of Specialized Medical Services for Percussion Vest used by Resident #4 revealed a percussion vest system consists of an inflatable vest which is worn over the torso, and an air pulse generator that delivers air pulses to the vest. These air pulses produce a high frequency chest wall oscillation that creates air flow throughout the lungs. The pulsed air acts much like a cough to shear secretions away from the airway wall and move them upward where they can be coughed or suctioned out. Record review revealed the facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed a Brief Interview of Mental Status was not attempted due to the facility assessing the resident as severely cognitively impaired and he/she was not interviewable. Review of Resident #4's Comprehensive Care Plan for potential ineffective airway clearance/tissue perfusion related to unsafe swallowing ability, which requires NPO (nothing by mouth) status and the presence of a [MEDICAL CONDITION] to maintain airway, [MEDICAL CONDITION] with [MEDICAL CONDITION], and Hypertension, dated [DATE], revealed goals for the resident to maintain a patent airway and patent [MEDICAL CONDITION]; and, to have no acute respiratory distress noted. Further review revealed an intervention to apply the CPT vest every six hours for 20 minutes as ordered. However, review of the Resident #4's (MONTH) (YEAR) Treatment Administration Record (TAR) revealed there was no documentation the CPT Vest was applied or not applied on [DATE] at 6:00 PM, on [DATE] at 6:00 AM and 12:00 PM; and on [DATE] at 6:00 AM and 6:00 PM per the care plan. Further review of the (MONTH) (YEAR) TAR and review of Departmental Notes dated [DATE] at 6:45 PM, revealed Licensed Practical Nurse (LPN) #2 documented the vest was not administered on [DATE] at 12:00 PM and 6:00 PM due to vest not available. In addition, review of the TAR revealed there was no documented evidence the treatment was completed on [DATE] at 12:00 AM. Interview with LPN #7 revealed he did not follow the resident's care plan, as he did not administer the treatment, per the care plan. Review of a Departmental Note, dated [DATE] at 2:09 AM by LPN #7, revealed at approximately 1:00 AM, Resident #4 was found not breathing. A code was called and staff initiated Cardiopulmonary Resuscitation (CPR). 911 was called, and EMS arrived and took over the CPR. The resident'[MEDICAL CONDITION] pulled and the resident was intubated by EMS. The resident was transported to the local Emergency Department. Review of the Emergency Department Records dated [DATE], revealed Resident #4 was placed on mechanical ventilation. The resident expired three (3) days later after the medical power of attorneys (the resident's sisters) removed him/her from mechanical ventilation due to his/her grave prognosis. The resident expired on [DATE] in a local Hospice House. Interview with LPN #3 on [DATE] at 2:08 PM and LPN #6 on [DATE] at 6:00 PM, revealed when LPN #3 came to work on [DATE] at approximately 7:00 AM, Resident #4's vest was in the laundry room due to being soiled with tube feeding during the [DATE], 6:00 AM treatment, LPN #3 stated she obtained the vest from the laundry room, attempted to clean the best, then hung it in the shower room to dry due to the vest being very wet. Both of the LPN's stated they must have missed documenting the treatments (LPN #3 on [DATE] at 6:00 PM and LPN #6 on [DATE] and [DATE], both at 6:00 AM) and they followed Resident #4's Comprehensive Care Plan, related to the CPT treatments every 6 hours for 20 minutes. Interview with LPN #2 on [DATE] at 10:50 AM, revealed she did Resident #4's treatments on [DATE] at 12:00 PM and 6:00 PM as ordered; however, she documented on the TAR and in the Departmental Notes, the treatments were not completed due to the vest not being available. She was unable to provide an explanation as to why she recorded the treatments were not done due to the vest not being available. She stated she should follow the Comprehensive Care Plan as written Interview with LPN #7 on [DATE] at 10:32 PM, revealed he did not give the midnight treatment on [DATE] according to the care plan, but he was unable to give a reason why it was not administered. He stated he was to follow all the resident's care plans as written. Interview with Resident #4's Physician on [DATE] at 2:45 PM revealed he was not aware that Resident #4 had missed at least three (3) treatments with the automated CPT vest. He stated he had not received any calls for any changes. He also stated missing the CPT vest treatments would definitely keep the resident from clearing his/her airway and would contribute to his/her respiratory arrest. Interview with the Director of Nursing (DON) on [DATE] at 2:25 PM revealed she expected staff to perform nursing procedures as care plans are written. She stated if there was a problem with the vest not being available her staff would have informed her and the physician would have been called for orders. She also revealed the facility had a respiratory therapist on call to help with any concerns. She stated a new vest would have been ordered if the resident's vest were not available. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility's medical record and local hospital records revealed Resident #1 was discharged to the hospital on [DATE] and has not returned to the facility; and, Resident #4 was discharged to the hospital on [DATE] and expired on [DATE] at a local Hospice House. 2. Review of audits completed by the Management Team which included DON, ADON's, SDC Nurse and MDS Nurse revealed an audit was completed [DATE] by nursing administration and no issues were identified. Audits included reviewing 24 hour reports, nurse's notes, care plans, medication and treatment administration records. 3. Review of the education provided to current employed licensed nurses by the DON, ADON's, SDC, and MDS nurses related to notification to physician regarding change of condition regarding respiratory treatment and care for oxygen administration and [MEDICAL CONDITION] care to include changes in sputum secretions amount and color, signs of possible distress. Also, education following physician orders [REDACTED]. This education was started on [DATE] and completed on [DATE]. No agency staff use at this time. Sign in sheets were reviewed to confirm licensed staff education. Interviews on [DATE] with LPN #2 at 2:11 PM, LPN #14 at 2:18 PM, RN #6 at 2:30 PM, RN #2 at 2:37 PM, RN #7 at 2:42 PM, and RN #8 at 3:00 PM; and on [DATE] with LPN #11 at 4:40 PM revealed they had received oxygen administration training to include reading portable canisters, filling canisters, following physician orders [REDACTED]. The education was provided by the SDC, started on [DATE], and completed on [DATE]. 4. Review of re-education sign in sheet dated [DATE] and information related to checking portable oxygen tanks to ensure that they have oxygen, including alerting the nurse if tank needs to be filled revealed the education was provided to all Department Heads. Interviews on [DATE] with MDS Nurse #1 at 4:13 PM, and MDS Nurse #2 at 4:24 PM; and, interviews on [DATE] with the Maintenance Director at 4:31 PM, Housekeeping Supervisor at 4:39 PM and Dietary Manager at 4:42 PM, revealed they were educated by the SDC Nurse regarding O2 canister checking to assess the tanks' fullness. They revealed they should pick up canister with strap on side where the dial was and then read the dial. They also revealed, they were educated to go and inform the license nurse that the tank needs to be filled. 5. Review of facility audits revealed the one [MEDICAL CONDITION] patient's care to include care plans, physician orders, MAR, TAR, revealed they were reviewed to ensure the resident was receiving proper care. This was completed on [DATE] and [DATE]. 6. Review of audits conducted beginning [DATE] which are ongoing revealed the one resident with [MEDICAL CONDITION] care was reviewed o ensure respiratory treatment and physician orders [REDACTED]. and MDS Nurses. Review of QAA meeting minutes revealed a meeting was held on [DATE] and [DATE] with topics discussed included deficient practices. Weekly meetings were held once weekly as evidenced by sign in sheets. Interviews on [DATE] with LPN #2 at 2:11 PM, LPN #14 at 2:18 PM, RN #6 at 2:30 PM, RN #2 at 2:37 PM, RN #7 at 2:42 PM, and RN #8 at 3:00 PM; and on [DATE] with LPN #11 at 4:40 PM revealed they had received oxygen administration training to include reading portable canisters, filling canisters, following physician orders [REDACTED]. The education was provided by the SDC, started on [DATE], and completed on [DATE]. 7. Review of daily audits of residents with portable O2 tanks revealed the audits were completed to include O2/nebulizers/bi-pap/c-pap checks as alleged in the AoC. The daily checks included O2 running prescribed rate. If using liquid O2, check tank to make sure not empty and on patient. Refill at ,[DATE] tank. If using concentrator, if its on resident, prescribed equipment is used (i.e., [MEDICAL CONDITION] or [MEDICAL CONDITION]), tubing bagged, dated placed appropriately to prevent infection, equipment clean including filters and bags. Audits started [DATE] and noted ongoing. 8. Review of education provided on [DATE] by the RQM to the Nursing Administration Team which included DON, ADON's, and SDC revealed they were educated on oxygen/respiratory treatment in accordance with standards of practice and the care plan for [MEDICAL CONDITION] resident's change of secretions, following physician orders [REDACTED]. Reviewed sign in sheet and the Administrative Nursing Team was in attendance. 9. Review of the sign in sheet dated [DATE] and the education provided by the RQM to the Administrator and DON revealed they were educated on the cited deficiencies, ongoing plan of correction and the expectations involved. Interview with the DON on ,[DATE] at 3:50 PM revealed the RQM educated her and the Administrator regarding the deficiencies that were cited during the revisit. She stated the RQM went over the ongoing plan of corrections and expectations involved as alleged in the AoC. 10. Review of education revealed the IDT Team was educated on the QA process and role of the IDT team by the QA Compliance Consultant on [DATE]. Interview (Post Survey) Regional Director of Operations on [DATE] at 9:55 AM revealed education was provided by the QA compliance consultant. The QA process was reviewed. 11. Review of QA minutes revealed a weekly meeting was held on [DATE] and [DATE]. Review of the attendance record revealed one regional team member attended the meeting.

Based on interview, record review, and the facility's Lippincott Manual of Nursing Practice 10th Edition, it was determined the facility failed to provide services in accordance with professional standards of quality for one (1) of twenty-one (21) sampled residents (Resident #1). On [DATE] to [DATE], Resident #1 had a significant change in amount, color and consistency of tracheal suctioning; however, the licensed staff failed to notify the physician of the change per the facility's professional standards of quality. On [DATE], the resident was found with his/her [MEDICAL CONDITION]/oxygen pulled out and in respiratory distress. The resident was sent to the hospital with an admission for Bilateral Lower Lobe Pneumonia and a hospital stay of fourteen (14) days. The facility's failure to provide care according to professional standards of quality has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. 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 (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Lippincott Manual of Nursing Practice 10th Edition dated 2014, revealed for [MEDICAL CONDITION] care: Preparatory phase, Nursing Actions included: 1. Assess the condition of the stoma before [MEDICAL CONDITION] care (redness, swelling, character of secretions, presence of purulence of bleeding). 2. Examine the neck for subcutaneous crepitus. 3. Suction the trachea and pharynx thoroughly before [MEDICAL CONDITION] care. 4. Explain the procedure to the patient. 5. Wash hands thoroughly. Performance phase: 1. Assemble equipment: a. Place sterile towel on patient's chest under [MEDICAL CONDITION] site. b. Open four gauze pads and pour hydrogen peroxide on them. c. Open two gauze pads and pour antiseptic solution on them. d. Open two gauze pads; keep dry. e. Open two gauze pads and pour sterile water on them. f. Place [MEDICAL CONDITION] tapes on field. g. Put on face shield and sterile gloves. Follow-up Phase: 1. Document procedure performance, observations of stoma (irritation, redness, [MEDICAL CONDITION], subcutaneous air), and character of secretions (color, purulence). Report changes in stoma appearance or secretions. 2. Clean the fresh stoma every 8 hours or more frequently if indicated by accumulation of secretions. Ties should be changed every 24 hours, or more frequently if soiled or wet. The area must be kept clean and dry to prevent infection or irritation of tissues. 1. Record review revealed the facility admitted Resident #1 on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Minimum Data Set (MDS) assessment, dated [DATE] revealed the Brief Interview of Mental Status (BIMS) was not attempted due to the resident being severely cognitively impaired and not interviewable. Review of Departmental Notes (Nursing Progress Notes), dated [DATE] at 4:44 AM, [DATE] at 1:35 AM, [DATE] at 10:17 AM, [DATE] at 11:35 PM, [DATE] at 6:59 PM; and, on [DATE] at 4:13 AM and 12:27 PM revealed Resident #1'[MEDICAL CONDITION] suctioned with large amounts of secretions obtained ranging from white, yellow, and green in color; thick in consistency and required frequent suctioning and drain sponge changes, However, further review of the Departmental Notes revealed there was no documented evidence the licensed nurses notified the Physician of the change in the amount, consistency, and color of Resident #4's tracheal secretions per professional standards of quality. Review of the Departmental Note dated [DATE] at 12:59 PM, and interview (Post Survey) with Licensed Practical Nurse (LPN) #4 on [DATE] at 9:17 PM revealed on [DATE] at 12:38 AM, the resident was found in respiratory distress and cyanotic in color with his/her [MEDICAL CONDITION] and oxygen pulled out and bloody drainage coming out of the [MEDICAL CONDITION] site. The resident'[MEDICAL CONDITION] replaced, O2 was reapplied, and the resident's O2 Sat was 84%(normal: 96% average) . The resident was sent to the local Emergency Department. Review of the Emergency Department Record from the local hospital dated [DATE], revealed the resident was admitted to the Intensive Care Unit and diagnosed with [REDACTED]. The resident was discharged back to the facility on [DATE]. Interview (Post Survey) with LPN #11, on [DATE] at 9:27 PM revealed she had taken care of Resident #1 on [DATE] and suctioned the resident several times obtaining thick green sputum. She stated she should have filled out an incident report and contacted the physician about the green sputum, but she did not. Interview with Resident #1's Physician revealed he was not aware of the changes in the color and consistency of the resident's secretions. Physician #1 stated he expected nursing staff to call him and advise him of these changes. He stated an increase of thickness of secretions would cause the resident to want to pull his/her [MEDICAL CONDITION] out and if the resident could not clear his/her airway, it would cause him/her to fight it and want to pull it out. Interview with the Director of Nursing (DON) on [DATE] at 10:13 AM she expected staff to follow the facility's [MEDICAL CONDITION] care policy and to contact the physician to inform him of the changes in the mucous, when it went from white to green. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility's medical record and local hospital records revealed Resident #1 was discharged to the hospital on [DATE] and has not returned to the facility; and, Resident #4 was discharged to the hospital on [DATE] and expired on [DATE] at a local Hospice House. 2. Review of audits completed by the Management Team which included DON, ADON's, SDC Nurse and MDS Nurse revealed an audit was completed [DATE] by nursing administration and no issues were identified. Audits included reviewing 24 hour reports, nurse's notes, care plans, medication and treatment administration records. 3. Review of the education provided to current employed licensed nurses by the DON, ADON's, SDC, and MDS nurses related to notification to physician regarding change of condition regarding respiratory treatment and care for oxygen administration and [MEDICAL CONDITION] care to include changes in sputum secretions amount and color, signs of possible distress. Also, education following physician orders [REDACTED]. This education was started on [DATE] and completed on [DATE]. No agency staff use at this time. Sign in sheets were reviewed to confirm licensed staff education. Interviews on [DATE] with LPN #2 at 2:11 PM, LPN #14 at 2:18 PM, RN #6 at 2:30 PM, RN #2 at 2:37 PM, RN #7 at 2:42 PM, and RN #8 at 3:00 PM; and on [DATE] with LPN #11 at 4:40 PM revealed they had received oxygen administration training to include reading portable canisters, filling canisters, following physician orders [REDACTED]. The education was provided by the SDC, started on [DATE], and completed on [DATE]. 4. Review of re-education sign in sheet dated [DATE] and information related to checking portable oxygen tanks to ensure that they have oxygen, including alerting the nurse if tank needs to be filled revealed the education was provided to all Department Heads. Interviews on [DATE] with MDS Nurse #1 at 4:13 PM, and MDS Nurse #2 at 4:24 PM; and, interviews on [DATE] with the Maintenance Director at 4:31 PM, Housekeeping Supervisor at 4:39 PM and Dietary Manager at 4:42 PM, revealed they were educated by the SDC Nurse regarding O2 canister checking to assess the tanks' fullness. They revealed they should pick up canister with strap on side where the dial was and then read the dial. They also revealed, they were educated to go and inform the license nurse that the tank needs to be filled. 5. Review of facility audits revealed the one [MEDICAL CONDITION] patient's care to include care plans, physician orders, MAR, TAR, revealed they were reviewed to ensure the resident was receiving proper care. This was completed on [DATE] and [DATE]. 6. Review of audits conducted beginning [DATE] which are ongoing revealed the one resident with [MEDICAL CONDITION] care was reviewed o ensure respiratory treatment and physician orders [REDACTED]. and MDS Nurses. Review of QAA meeting minutes revealed a meeting was held on [DATE] and [DATE] with topics discussed included deficient practices. Weekly meetings were held once weekly as evidenced by sign in sheets. Interviews on [DATE] with LPN #2 at 2:11 PM, LPN #14 at 2:18 PM, RN #6 at 2:30 PM, RN #2 at 2:37 PM, RN #7 at 2:42 PM, and RN #8 at 3:00 PM; and on [DATE] with LPN #11 at 4:40 PM revealed they had received oxygen administration training to include reading portable canisters, filling canisters, following physician orders [REDACTED]. The education was provided by the SDC, started on [DATE], and completed on [DATE]. 7. Review of daily audits of residents with portable O2 tanks revealed the audits were completed to include O2/nebulizers/bi-pap/c-pap checks as alleged in the AoC. The daily checks included O2 running prescribed rate. If using liquid O2, check tank to make sure not empty and on patient. Refill at ,[DATE] tank. If using concentrator, if its on resident, prescribed equipment is used (i.e., [MEDICAL CONDITION] or [MEDICAL CONDITION]), tubing bagged, dated placed appropriately to prevent infection, equipment clean including filters and bags. Audits started [DATE] and noted ongoing. 8. Review of education provided on [DATE] by the RQM to the Nursing Administration Team which included DON, ADON's, and SDC revealed they were educated on oxygen/respiratory treatment in accordance with standards of practice and the care plan for [MEDICAL CONDITION] resident's change of secretions, following physician orders [REDACTED]. Reviewed sign in sheet and the Administrative Nursing Team was in attendance. 9. Review of the sign in sheet dated [DATE] and the education provided by the RQM to the Administrator and DON revealed they were educated on the cited deficiencies, ongoing plan of correction and the expectations involved. Interview with the DON on ,[DATE] at 3:50 PM revealed the RQM educated her and the Administrator regarding the deficiencies that were cited during the revisit. She stated the RQM went over the ongoing plan of corrections and expectations involved as alleged in the AoC. 10. Review of education revealed the IDT Team was educated on the QA process and role of the IDT team by the QA Compliance Consultant on [DATE]. Interview (Post Survey) Regional Director of Operations on [DATE] at 9:55 AM revealed education was provided by the QA compliance consultant. The QA process was reviewed. 11. Review of QA minutes revealed a weekly meeting was held on [DATE] and [DATE]. Review of the attendance record revealed one regional team member attended the meeting.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure three (3) of twenty-one (21) sampled residents (Residents #1, #4, and #55), who needed respiratory care including [MEDICAL CONDITION] care and tracheal suctioning, were provided the care in accordance with Professional Standards of Practice and the Comprehensive Care Plans. On [DATE] to [DATE], Resident #1 had a significant change in color and consistency of tracheal suctioning from white to green. The facility failed to notify the physician of the changes in the tracheal secretions regarding color and consistency. On [DATE], the resident was found with his/her [MEDICAL CONDITION]/oxygen pulled out and in respiratory distress. The resident was sent to the hospital with an admission [DIAGNOSES REDACTED]. Resident #4 was admitted to the facility on [DATE] with a [MEDICAL CONDITION]. On [DATE], an order was received for a Chest Percussion Vest (CPV) every six (6) hours for twenty (20) minutes with settings as tolerated. On [DATE] to [DATE], there were seven (7) treatments that were not documented as given or not given. Two (2) of the treatments ([DATE] at 12:00 PM and 6:00 PM) were documented as Not Administered due to vest not available. The [DATE] at 12:00 AM treatment was not given per interview, with no reason given. One hour later, on [DATE] at 1:00 AM, the resident was found in respiratory arrest. Cardiopulmonary Resuscitation (CPR) was provided and the resident was rushed to the local Emergency Department where he/she was placed on mechanical ventilation. The resident's Medical Power of Attorney chose to remove the resident from the mechanical ventilation. Resident expired in a local Hospice House on [DATE]. The facility failed to ensure the treatments were given to prevent an obstructed airway and to notify the physician when the treatments were not given. The facility's failure to ensure acceptable standards of care has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. 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 (QA) monitors the effectiveness of the systemic changes. In addition, observations on [DATE] at 1:00 PM revealed staff failed to provide adequate [MEDICAL CONDITION] care for Resident #55 related to to poor handwashing and sterile techniques. The findings include: Interview with the Director of Nursing (DON) on [DATE] at 2:00 PM, revealed the facility did not have a policy related to caring for a resident with a [MEDICAL CONDITION] except for the specific [MEDICAL CONDITION] Care Plan. The DON stated the facility uses the Lippincott Manual of Nursing Practice. Review of the Lippincott Manual of Nursing Practice 10th Edition dated 2014, revealed in the: Preparatory phase, Nursing Actions included: 1. Assess the condition of the stoma before [MEDICAL CONDITION] care (redness, swelling, character of secretions, presence of purulence of bleeding). 2. Examine the neck for subcutaneous crepitus. 3. Suction the trachea and pharynx thoroughly before [MEDICAL CONDITION] care. 4. Explain the procedure to the patient. 5. Wash hands thoroughly. Performance phase: 1. Assemble equipment: a. Place sterile towel on patient's chest under [MEDICAL CONDITION] site. b. Open four gauze pads and pour hydrogen peroxide on them. c. Open two gauze pads and pour antiseptic solution on them. d. Open two gauze pads; keep dry. e. Open two gauze pads and pour sterile water on them. f. Place [MEDICAL CONDITION] tapes on field. g. Put on face shield and sterile gloves. Follow-up Phase: 1. Document procedure performance, observations of stoma (irritation, redness, [MEDICAL CONDITION], subcutaneous air), and character of secretions (color, purulence). Report changes in stoma appearance or secretions. 2. Clean the fresh stoma every eight (8) hours or more frequently if indicated by accumulation of secretions. ties should be changed every 24 hours, or more frequently if soiled or wet. The area must be kept clean and dry to prevent infection or irritation of tissues. 1. Record review revealed the facility admitted Resident #1 on [DATE], and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Minimum Data Set ((MDS) dated [DATE], revealed that a Brief Interview of Mental Status (BIMS) score was not attempted because the resident was severely cognitively impaired and not interviewable. Review of the Admission Minimum Data Set (MDS) for Resident #1, dated [DATE], revealed there was no documentation related to the resident's respiratory status which according to the form included breathing (regular, irregular, labored, unlabored); nonproductive cough or productive cough; if cough is productive, describe sputum; oxygen use (liters and oxygen by nasal cannula, mask, continuous, as need), and lung sounds (clear, diminished, crackles, wheezes, absent, if abnormal, describe location). Review of the Departmental Note (Progress Note), dated [DATE] at 6:34 PM, revealed a late entry for 1:50 PM documenting the arrival of Resident #1 to the facility and the resident's oxygen saturation was 86% before tracheal cleaning and suctioning and 92% (normal:92%) after. There was no documented evidence the facility assessed the resident's breathing, cough, sputum, and lung sounds. Further review of the Admission Data Set and Departmental Note revealed they were signed by Registered Nurse (RN) #2. Review of the Interim Care Plan, dated [DATE], revealed Resident #1 had Special Treatments/Procedures, a [MEDICAL CONDITION] with a #5 extra large cannula; suction PRN (as needed); and, to provide oxygen 28% with a [MEDICAL CONDITION] mask. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. Review of Departmental Notes revealed on [DATE] at 4:44 AM, tracheal suctioning was completed numerous times with white thick mucous in large amounts. The resident's oxygen (O2) saturation was 94%. On [DATE] at 1:35 AM, Resident #1's tracheal suctioned sputum was thick and white with O2 sat of 93%; and the resident was agitated and grabbed [MEDICAL CONDITION] and [DEVICE] (gastrointestinal) tubing at times. On [DATE] at 10:17 AM, the resident had copious amounts of thick yellow sputum and the resident was flinging his/he right arm around when care was being provided. The resident required suctioning frequently and drain sponge changes. On [DATE] at 11:35 PM, the resident'[MEDICAL CONDITION] was provided and he/she was suctioned many times with thick white sputum noted. Further review revealed there was no documentation of tracheal suctioning to include the consistency and color on the day and night shifts of [DATE], per facility policy. Continued review of the Departmental Notes, revealed on [DATE], Licensed Practical Nurse (LPN) #5 documented the resident's physician saw Resident #1 in the AM (this was a late note written at 1:30 PM). However, interview with LPN #5 revealed she was not aware the resident was having copious amounts of thick secretions, and of the change in color of the tracheal secretions, so the physician was not made aware. On [DATE] at 6:59 PM, the resident was suctioned multiple times with copious amounts of thick yellow sputum; the resident's O2 sat. was 90% on O2 as ordered. On [DATE] at 4:13 AM, after several times of tracheal suctioning, the resident sputum was noted to be thick and green; and at 12:27 PM, the resident was suctioned often due to thick yellowish white secretions. Further review revealed on [DATE] at 5:50 PM, it was noted Resident #1 pulled his/her O2 off several times and the nurse asked the resident if he/she was in pain, and the resident shook his/her head no. Review of the notes revealed there was no documented evidence the Physician was made aware of the change in Resident #4's tracheal secretions. Interview (Post Survey) with Registered Nurse (RN) #5 (the night nurse) on [DATE] at 12:40 PM, revealed she was extremely busy on nights and [DATE] was no exception. She stated the hall she worked was full of residents with multiple behaviors. RN #5 stated if she did not chart the description of Resident #1's tracheal secretions, it was because she was too busy to do so. She stated she did not recall anything out of the ordinary, but that was why she no longer worked at the facility since there was not enough help. Interview (Post Survey) with Licensed Practical Nurse (LPN) #5/Wound Care Nurse, on [DATE] at 12:38 PM, revealed the Departmental Note dated [DATE] at 1:30 PM, was related to the physician seeing the resident. LPN #5 stated she was not aware the resident had a change in tracheal secretions so she did not know to to make the resident's physician aware. Interview (Post Survey) with Licensed Practical Nurse (LPN) #11, on [DATE] at 9:27 PM revealed she had taken care of Resident #1 on [DATE], and had suctioned Resident #1 several times and obtained thick green sputum with no shortness of air noted. She stated she would have taken the resident's O2 sat at the time, but she must not have documented it. LPN #11 further stated she should have filled out an incident report and contacted the physician about the green sputum, per policy, but she did not. She stated if the resident had signs and symptoms of shortness of breath, like agitation, she would check the oxygen saturation rate. Review of the Departmental Note dated [DATE] at 12:59 PM, revealed at 12:38 AM, the resident was heard calling out, and was found with his/her [MEDICAL CONDITION] and oxygen pulled out, with bloody drainage noted coming out of the [MEDICAL CONDITION] site. Further review revealed the resident was in respiratory distress and cyanotic (blue) in color. The resident'[MEDICAL CONDITION] replaced and O2 reapplied; the resident's oxygen saturation rate was noted to be 84%. 911 (Emergency Medical Services) was called due to respiratory distress and the resident was sent to the local Emergency Department. Interview (Post Survey) with LPN #4, on [DATE] at 9:17 PM, revealed she was working A Hall and the orientee nurse working B Hall hollered for her to help her with Resident #1 as he/she had pulled out his/her [MEDICAL CONDITION]. She stated there was a lot of blood, and the resident was cyanotic in color. She stated she was unable to obtain a good O2 saturation reading on the resident. LPN #4 stated the Emergency Medical Service (EMS) was called as the resident was not looking good. She stated she could not tell what color the resident's secretions were due to the large amount of blood. LPN #4 stated that green secretions usually meant that the resident had some sort of infection. Review of the Emergency Department Record from the local hospital dated [DATE], revealed the resident was in respiratory distress on arrival. The Emergency Department Physician caring for the resident documented what the Emergency Medical Services (EMS) reported to him. They found the resident gray in color with Oxygen Saturation (SAO2-O2 Sats) in the 60's. EMS also noted that the resident's O2 sats were in the mid 80's after intubation and the resident was placed on eight (8) liters of O2 via [MEDICAL CONDITION] mask and his/her O2 Sats improved to 98% during transport. Further review revealed the resident was in mild respiratory distress and had rhonchi in the bilateral bases and was mildly tachypneic (rapid respirations). No wheezing was heard. The resident's chest x-ray report showed Cardiomegaly (enlarged heart), Pneumonia, and Atelectasis (collapse or closure of a lung). The resident also had an elevated White Blood Cell Count of 19.8 (normal: 4.8 to 10.8). Further review of the Emergency Department Record revealed Resident #1 was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. Treatment included intravenous fluids (IV), [MEDICATION NAME] (medications to open up lung airways), breathing treatments with 3% saline inhalations due to the thick tracheal secretions, blood cultures drawn (blood cultures results were positive for bacteria in the blood) and Sputum Cultures were obtained (Sputum Culture results were also positive). Resident was placed on a IV antibiotics for treatment of [REDACTED]. Interview with RN #2 on [DATE] at 2:15 PM revealed Resident #1 was difficult to care for, as he/she always appeared fearful, anxious, even terrified by the look on his/her face. She stated the resident's tracheal secretions were frothy and white when she cared for him/her on [DATE] at the resident's admission at 1:50 PM, and on [DATE] at 11:03 AM. RN #2 stated O2 saturations were obtained prior to suctioning and after. She stated that she did not always chart the oxygen saturation or lung sounds. However, she stated it would be good to chart. Interview with Resident #1's Physician revealed he knew that the resident had been pulling at his/her [MEDICAL CONDITION]. However, he was not aware of the changes in the color and consistency of secretions. Physician #1 stated he expected nursing staff to call him and advise him of these changes. He also stated an increase of thickness of secretions would cause the resident to want to pull his/her [MEDICAL CONDITION] out. Physician #1 stated if the resident could not clear his/her airway, it would cause him/her to fight it and want to pull it out. Interview with the Director of Nursing (DON) on [DATE] at 10:13 AM regarding [MEDICAL CONDITION] care revealed she expected staff to follow [MEDICAL CONDITION] care policy and hand hygiene. She stated she also expected the nursing staff to contact the physician to advise of any changes to mucous from white to green. 2. Review of the policy of Specialized Medical Services for Percussion Vest used by Resident #4 revealed: Purpose: A percussion vest system consists of an inflatable vest which is worn over the torso, and an air pulse generator that delivers air pulses to the vest. These air pulses produce a high frequency chest wall oscillation that creates air flow throughout the lungs. The pulsed air acts much like a cough to shear secretions away from the airway wall and move them upward where they can be coughed or suctioned out. Indications for Use: [DIAGNOSES REDACTED], [MEDICAL CONDITIONS], Asthma, Bronchiectasis, [DIAGNOSES REDACTED], [MEDICAL CONDITION], and [MEDICAL CONDITION]. Equipment Needed: Air Pulse Generator, Vest, and Connecting Hose. Procedure: 1. Obtain a physician order [REDACTED].>Interview (Post Survey) with the DON on [DATE] at 4:30 PM, revealed the facility used Lippincott Manual of Nursing Practice 10th Edition for their Professional Standards of Practice related to concerns for medications or treatments not being available or missed. However, review of Lippincott Manual of Nursing Practice ,[DATE]th Edition revealed the Linppincott manual did not address what the licensed nurse should do when a medication or treatment was not available. Interview (Post Survey) on [DATE] at 9:00 AM, revealed calling a physician was basic nursing knowledge of what should be done. Record review revealed the facility admitted Resident #4 on [DATE]. with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed a Brief Interview of Mental Status was not attempted due to the resident being assessed as severely cognitively impaired and he/she was not interviewable. Review of Resident #4's Comprehensive Care Plan for potential ineffective airway clearance/tissue perfusion dated [DATE], revealed Resident #4's goals were to maintain patent airway and [MEDICAL CONDITION]; and to have no acute respiratory distress. Further review of the Care Plan revealed interventions to [MEDICAL CONDITION] per sterile technique as ordered, suction as indicated [MEDICAL CONDITION] ensure secretions are cleared and airway patent, monitor for any signs and symptoms of respiratory distress and low oxygen saturations (cyanosis, restlessness, agitation, gasping for breath, abdominal breathing, wet lung sounds, diaphoresis etc), auscultate lung sounds as indicated, and CPT vest applied every six (6) hours for 20 minutes as ordered. Review of Resident #4's (MONTH) (YEAR) Physician order [REDACTED]. Settings as tolerated. Mitt to right hand to prevent pulling [MEDICAL CONDITION] feeding tube. Check every thirty (30) minutes and release every two (2) hours.[MEDICAL CONDITION] every shift and as needed. O2 Sats with and without oxygen every Wednesday. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) [MEDICAL CONDITION] was provided every shift and O2 sats were obtained on Wednesdays ([DATE] and [DATE]). However, there was no documentation of the results of the O2 Sats. Review of Resident #4's Medicare Notes revealed on [DATE], the resident received [MEDICAL CONDITION] care and was suctioned two (2) times. On [DATE], the resident was expectorating moderate amounts of thick yellow/green secretions, and was suctioned three (3) times. Oxygen saturation was 97% with 100% humidified oxygen. On [DATE], the resident was suctioned frequently per nursing. Further review revealed on [DATE], the resident was suctioned for small amounts of thick whitish yellow secretions and oxygen saturation at 96%. However, there was no documented evidence staff noted the character of the secretions (color, purulence) when the resident was suctioned every shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], per facility policy. In addition, review of the Departmental Notes revealed there was no documentation of suctioning or the color or consistency of the resident's tracheal secretions on these dates. Review of the Resident #4's (MONTH) (YEAR) Treatment Administration Record (TAR) revealed to apply the CPT Vest every six (6) hours for 20 minutes at 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. However, there was no documentation the CPT Vest Treatment was provided or not provided on [DATE] at 6:00 PM, on [DATE] at 6:00 AM and 12:00 PM; and on [DATE] at 6:00 AM and 6:00 PM. Further review of the Departmental Notes for [DATE] through [DATE] revealed no documented evidence staff made the Physician aware the treatments were not provided. Interview with LPN #6 on [DATE] at 6:00 PM revealed she thought she neglected to chart on the TAR that she had completed the CPT treatment for [REDACTED]. She stated the resident's [DEVICE] (feeding tube) leaked [MEDICATION NAME] (nutritional supplement) on the vest on [DATE] during the 6:00 AM treatment. She stated she did not remember who took the vest to the laundry. Interview with LPN #3 on [DATE] at 2:08 PM, revealed she came in to work on [DATE] at 7:00 AM and went to Resident #4's room and began to assess the resident. She stated when she checked the CPT machine and vest, she found the vest missing. LPN #3 stated the night nurse told her she thought the CNA's had taken the vest to the laundry due to the vest being soiled with gastrostomy feeding which was very oily and sticky. She stated she immediately went to the laundry and found the vest in a plastic bag on the floor. Further interview revealed she immediately returned to the unit with the vest, and took it to the shower room and attempted to clean the vest. LPN #3 stated the vest was very wet after cleaning it so she hung the vest up to dry in the shower room. She stated she thought she must have missed documenting the treatment on [DATE] at 6:00 PM. The LPN stated when Resident #4 had the CPT vest treatment, there was usually copious amounts of secretions suctioned. Review of Departmental Note dated [DATE] at 1:37 AM (late entry for 1:00 AM), revealed Resident #4'[MEDICAL CONDITION] laying on his/her chest and staff were unable to re-insert it. The Physician was called with an order received to send the resident to the emergency room (ER). Further review of the Departmental Notes, dated [DATE] at 1:37 AM, revealed there was no documentation of the resident's respiratory status related to the resident'[MEDICAL CONDITION] on his/her chest to include O2 saturation, breathing, lung sounds, or description of resident's color. Review of the Emergency Medical Services Report dated [DATE], revealed the Paramedic found the resident fighting care when he arrived at the facility. However, after he intubated the resident's [MEDICAL CONDITION] stoma, the resident immediately improved with his/her O2 Sat. The resident was suctioned with a copious amount of secretions obtained, and then the resident coughed up a bloody sputum mucous plug and went into [MEDICAL CONDITION]. The Paramedic immediately ventilated the resident and he/she improved. Further review of the Emergency Department Records dated [DATE], revealed the emergency room Doctor replaced the resident's [MEDICAL CONDITION]. The resident was discharged from the Emergency Department on [DATE] at 7:23 AM and was transferred back to the facility according to the Hospital Emergency Department Record. Further review of the (MONTH) (YEAR) TAR revealed there was an N documented on [DATE] at 12:00 PM and 6:00 PM by LPN #2 which indicated the CPT treatment was not administered. Review of the Departmental Notes dated [DATE] at 6:45 PM, revealed vest not available on [DATE] at 12:00 PM and 6:00 PM which was keyed in by LPN #2. Further review of the TAR revealed there was no documented evidence the treatment was completed on [DATE] at 12:00 AM. Interview with LPN #2 on [DATE] at 10:50 AM revealed she did Resident #4's treatments as ordered and the vest was available. However, according to her documentation on [DATE] at 12:00 PM and 6:00 PM on the TAR and Departmental Notes, the treatments were not completed due to the vest not being available. She stated she did not know how the N populated onto the TAR on [DATE]. LPN #2 stated she must have typed it in but she didn't know why. She further stated, I would have had to put it in there but I cannot remember ever not having the vest on the resident. She also stated she would have had to type, vest not available in the record and she did not know why she did that. LPN #2 stated she was aware the vest had been washed and was wet but she did not know when. Interview with LPN #7 on [DATE] at 10:32 PM, revealed he did not give the midnight treatment on [DATE], but he was unable to give a reason why it was not administered. Review of a Departmental Note, dated [DATE] at 2:09 AM by LPN #7, revealed at approximately 1:00 AM, LPN #7 was notified by the Certified Nurse Aide (CNA) that Resident #4 was not breathing. A code was called and staff initiated Cardiopulmonary Resuscitation (CPR) and 911 was called. Further review revealed EMS arrived and took over CPR. The resident'[MEDICAL CONDITION] pulled and the resident was intubated by EMS. Resident #4 was transported to the local Emergency Department. Review of the Emergency Department Records dated [DATE], revealed the resident was placed on mechanical ventilation. The resident expired three (3) days later after the Medical Power of Attorneys (the resident's sisters) removed him/her from the mechanical ventilation due to his/her grave prognosis. The resident expired on [DATE] in a local Hospice House. Interview with the Medical Director/Resident #4's Physician on [DATE] at 2:45 PM revealed he was not aware Resident #4 had missed at least three (3) Chest Percussion Treatments with the automated CPT vest. He stated he had not received any calls for any changes. He stated missing the CPT vest treatments would definitely keep the resident from clearing his/her airway and would contribute to his/her respiratory arrest. Interview (Post Survey) with the Medical Director/Resident #4/s Physician on [DATE] at 3:00 PM (Post Survey) revealed he expected the nursing staff to document the results of the oxygen saturations and call him with any abnormal readings especially if they were below 88%. Interview with the Paramedic, who cared for/transported Resident #4 to the Emergency Department on [DATE] and [DATE] revealed every time he came to the facility and treated Resident #1 and Resident #4, it was due to a mucous plug causing airway compromise. He stated the mucous plugs were certainly a good reason for the residents to be pulling at the [MEDICAL CONDITION]. Further interview revealed most of the calls they received were concerning the residents pulling out the [MEDICAL CONDITION]. Interview with Director of Nursing (DON) on [DATE] at 10:00 AM revealed the facility had computer problems and she was unaware why the information was documented in the Administrative Notes as not done. She stated they, must have generated when LPN #2 documented N on the TAR which meant the treatment was not administered. She also stated, even though she put N on the TAR as not administered, she believed LPN #2 did the treatment. The DON stated the nursing staff would have told her if the vest was not available. She stated nursing staff were to call her if there was a medication or treatment not available so that the physician could be called for alternative treatment. The DON stated she never received a call that the vest was not available. 3. Review of the facility's polity titled, Hand Washing revealed washing hands with soap and water was the best way to reduce the number of germs on them. If soap and water were not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol. Alcohol-based hand sanitizers can quickly reduce the number of germs on hands in some situations, but sanitizers do not eliminate all types of germs. The specific indications for hand washing before patient contact were before donning gloves before inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don't require surgery. The specific indications for hand washing after patient contact were after contact with a patient's skin; contact with body fluids or excretions, non-intact skin, wound dressing; and after removing gloves. Review of the facility's [MEDICAL CONDITION] Care Policy, not dated revealed [MEDICAL CONDITION] Care will be provided by Licensed Nursing staff or Licensed Respiratory staff in accordance with facility guidelines for [MEDICAL CONDITION] care. Procedure: [MEDICAL CONDITION] Care with Disposable Inner Cannula: 1. Place resident in Semi-Fowler position 2. Wash Hands and apply exam gloves 3. Set up trach-care kit 4. Remove old dressings and ties; placing in the appropriate waste receptacle; remove gloves 5. Wash hands/use hand sanitizer and apply a new set of exam gloves 6. Clean tube and site with normal saline or per Physician orders 7. Apply new dressings and ties 8. Change disposable [MEDICAL CONDITION] inner cannula monthly or whenever there is excessive build-up of secretion 9. When inserting new inner cannula; use sterile gloves and technique 10. After completion of [MEDICAL CONDITION] care; remove soiled gloves and wash hands 11. Change dressings and ties when soiled or wet. Record review revealed the facility admitted Resident #55 on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated [DATE], revealed the facility assessed that Resident #55's was rarely/never understood, which indicated the resident was not interviewable. Review of Resident #55's Comprehensive Care Plan for Potential/Actual alteration in oxygen exchange related to [MEDICAL CONDITION] as evidenced by need for oxygen therapy dated [DATE], with a goal that the resident will be free from increased shortness of breath, Dyspnea, cyanosis or other signs and symptoms of respiratory distress. Further review revealed approaches to [MEDICAL CONDITION] and suction per Physician Order. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. (MONTH) [MEDICAL CONDITION] two (2) hours. Monitor O2 with and without oxygen Observation of [MEDICAL CONDITION] Care for Resident #55 on [DATE] at 2:00 PM, by LPN #5 and the Staff Development Coordinator (SDC)/Registered Nurse revealed LPN #5 donned non-sterile gloves and removed the inner cannula of the [MEDICAL CONDITION]. She then removed the gloves, dropped them in the trash and immediately donned sterile gloves without washing her hands between glove changes, per the facility's Handwashing and [MEDICAL CONDITION] policies. The SDC Nurse placed non-sterile gloves on her hands and did not wash her hands in the room. The SDC Nurse then opened sterile 4 x 4's and normal saltine for LPN #5. Further observation revealed LPN #5 cross contaminated her sterile hand when she placed a soiled 4 x 4 into her sterile hand after cleaning the [MEDICAL CONDITION] site causing both hands to be contaminated. She continued [MEDICAL CONDITION], placing a new inner cannula which was now contaminated. Interview with LPN #5 and the SDC on [DATE] at 2:15 PM revealed LPN #5 stated she contaminated her sterile hand and should have washed her hands prior to donning sterile gloves. She stated the procedure was contaminated due to cross contamination. The SDC stated she used hand sanitizer prior to coming into the resident's room; however, she should have washed her hands upon entering the room. Interview with the DON on [DATE] at 2:25 PM revealed she expected staff to perform [MEDICAL CONDITION] Care and handwashing per facility policy. She revealed the SDC assesses competency of staff by watching care and if she sees a problem, then that will prompt an inservice. She revealed if there is a problem it sometimes is reported through the morning meetings. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the facility's medical record and local hospital records revealed Resident #1 was discharged to the hospital on [DATE] and has not returned to the facility; and, Resident #4 was discharged to the hospital on [DATE] and expired on [DATE] at a local Hospice House. 2. Review of audits completed by the Management Team which included DON, ADON's, SDC Nurse and MDS Nurse revealed an audit was completed [DATE] by nursing administration and no issues were identified. Audits included reviewing 24 hour reports, nurse's notes, care plans, medication and treatment administration records. 3. Review of the education provided to current employed licensed nurses by the DON, ADON's, SDC, and MDS nurses related to notification to physician regarding change of condition regarding respiratory treatment and care for oxygen administration and [MEDICAL CONDITION] care to include changes in sputum secretions amount and color, signs of possible distress. Also, education following physician orders [REDACTED].

Based on observation, interview, record review, facility policy review and review of the facility's investigation, it was determined the facility failed to ensure one (1) of three (3) sampled residents received adequate supervision to prevent accidents (Resident #1). The facility assessed and care planned Resident #1 to be at risk for elopement. The resident had a wanderguard in place. However, on 04/27/18, a visitor of another resident let Resident #1 out through the front doors of the facility; the door alarm sounded. State Registered Nurse Aide (SRNA) #1 responded to the alarm, disarmed the alarm, then returned to her work area to continue her tasks. SRNA #1 failed to look outside for a wandering resident. At approximately 4:16 PM, the Activities Director, who was leaving for the day through the front door, saw Resident #1 sitting in a chair outside of the facility. The facility's failure to have an effective system in place to provide the necessary care and supervision to prevent an elopement, has caused or is likely to cause serious injury, harm, impairment, or death to residents. The facility was made aware of the Immediate Jeopardy on 05/07/18 and the Immediate Jeopardy was determined to exist on 04/27/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 05/08/18, alleging removal of the Immediate Jeopardy and substantial compliance on 04/30/18. The SSA identified the Immediate Jeopardy was not removed on 04/30/18 as alleged in the A[NAME]. Per interview, it was identified the notification letter to families regarding residents leaving the facility was not issued until 04/30/18; therefore, it was determined the IJ was removed on 05/01/18. The State Survey Agency validated the facility had corrected the deficient practice prior to the State Survey Agency entering the building on 05/04/18. Therefore, the State Survey Agency determined the facility had past non-compliance. The findings include: Review of the facility's policy titled, Elopement Protocol, dated (MONTH) (YEAR), revealed elopement is the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the building unsupervised and unnoticed and who may enter into harm's way. The facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk and elopement, implement prevention strategies for those identified as an elopement risk, institute measures for resident identification, and conduct a missing resident procedure. Further review of the protocol revealed it did not address what staff were to do when a door alarm sounded. Record review revealed the facility admitted Resident #1 on 10/14/16, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 03/09/18, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was interviewable. Further review of the MDS revealed there were behaviors of wandering. Review of the record revealed Resident #1 was out of the building and had recently been admitted to an inpatient psychiatric facility. Resident #1 was not in the facility during the survey. Review of Resident #1's physician's orders [REDACTED]. Review of the Elopement/Wandering Risk (MDS) data set [DATE], revealed Resident #1 was at risk for wandering and elopement. Review of the facility's investigation dated 04/27/18, revealed a visitor (another resident's family member) held the door open for Resident #1 allowing him/her to exit the facility. A SRNA responded to the alarm, turned off the alarm, and then returned to work without looking outside the door to see if a resident had exited the facility. Review of Resident #1's Nursing Notes written on 04/27/18 at 7:06 PM, revealed, the resident stated he/she was just going outside to enjoy the nice weather. Further review revealed the nurse educated the resident on the need to talk with staff before going out, and the resident voiced understanding. A full body skin check was done with no new issues noted. The Physician and State Guardian were notified. Observation of the facility video on 05/04/18 at 3:00 PM, with the Administrator revealed on 04/27/18 at 4:08 PM. Resident #1 was let out of the facility by a visitor. The resident was wearing a pair of pants and a shirt. Further review of the video revealed SRNA #1 came to the door that was sounding on 04/27/18 at 4:09 PM and did not look outside. According to website history, the daily temperature outside at the facility was 70 degrees Fahrenheit and sunny on 04/27/18. Interview with SRNA #1, on 05/04/18 at 12:04 PM, revealed she was in a resident's room providing care and when she left the room to obtain additional supplies, she heard the door alarm. She stated she went directly to the front door and disarmed the alarm, but she did not look outside for the resident. SRNA#1 stated she returned to complete her task at hand with another coworker. She stated she should have looked outside to see if there was a resident outside before disarming the alarm. Interview with the Activities Director, on 05/04/18 at 10:56 AM, revealed she was the person who found Resident #1 outside of the building. She stated the resident was sitting in a chair on the front porch and the resident told her that he/she . just wanted to enjoy the weather. Further interview revealed the resident was escorted back into the building and the Director of Nursing (DON) was notified, as well as Licensed Practical Nurse (LPN) #2, who escorted the resident back to his/her hall. She stated the Administrator was notified at approximately 4:20 PM and returned to the facility. Interview with SRNA #4, on 05/06/18 at 12:54 PM, revealed she was assigned the hall where Resident #1 resided on the afternoon the resident eloped. She stated she walked up and down the halls every five (5) minutes. The SRNA stated that at the time of the elopement, she was in another resident's room providing care. She stated when she finished care for the resident she was working with, she learned from other staff that Resident #1 went out the front door. SRNA #4 stated it was usual for Resident #1 to spend most of his/her time either in his/her room or sitting by the nurses' station. The SRNA could not recall the specific last time she had seen the resident prior to the elopement. An attempt was made, on 05/06/18 at 12:41 PM, to reach the other assigned SRNA. There was no answer at the phone number provided by staff but the Surveyor was able to leave a message requesting a return call from the SRNA. A return call was not received. Interview with LPN #2, on 05/06/18 at 12:44 PM, revealed she could not provide a specific time that she last saw Resident #1. The LPN stated she learned the resident had gone out the front door when she returned from her meal break. Interview with the Director of Nursing (DON), on 04/18/18 at 4:17 PM, revealed the Elopement policy did not contain information on what staff were to do when the door alarm sounds. She stated staff were educated on the not to silence any door alarm without first checking to see if a resident had gotten out the door. She stated staff should always check the immediate surrounding area to be sure all residents were inside the building. The DON stated if staff needed assistance with the alarm and were concerned for the residents' safety, they should call for someone to help them. She stated staff should document exit seeking as a behavior and report any occurrence to the charge nurse for addition to the Twenty-four (24) Hour Report Sheet. The DON stated a Code(NAME)is called to alert staff to initiate a search for a resident. She stated the facility conducts monthly Code(NAME)drills and have increased those numbers of drills since the elopement. Interview with the Administrator, on 05/04/18 at 1:05 PM, revealed he was called around 4:25 PM on 04/27/18 and informed that someone had let Resident #1 out of the front doors. He stated he immediately returned to the facility and began an investigation. The Administrator stated he interviewed Resident #1, who stated he/she was sitting outside. Further interview revealed he called SRNA #1 in to interview her regarding the incident. He stated SRNA #1 told him she did not look outside to see if there was a resident outside the building. He stated staff should go to the door where the alarm is sounding and look outside for residents before disarming the alarm. ** The facility implemented the following actions to correct the deficient practice: 1. The Administrator and the DON initiated an investigation on 04/27/18. The Administrator notified the physician, guardian, Department of Community Based Services (DCBS) and Office of Inspector General (OIG) by fax (facsimile) on 04/27/18. 2. SRNA #1 was re-educated on 04/27/18 by the Administrator and DON on the Elopement/Alarm Protocol and was suspended pending the outcome of the investigation. 3. The Administrator called the family member that had let Resident #1 out of the front door and educated them on the facility's policy about letting residents out the door. 4. The Administrator audited all residents in the facility on 04/27/18 to ensure that they had a current elopement assessment. 5. On 04/27/18, the DON and ADON's audited the last thirty (30) days of Nurses Notes to identify if there were any elopement or exit seeking behaviors that nurse management had not been notified. There were none identified. Care Plans were reviewed for all residents that were at risk for elopement on 04/27/18 and updated as necessary. Wanderguard books were reviewed on 04/27/18 and found to be accurate. 6. An undated letter was composed by the Administrator to send to resident families reminding them to not assist residents out the door without seeing the nurse first. 7. Education was provided by the Administrator to Department Heads (Dietary, Therapy, Housekeeping, Maintenance, Business office, Clinical Staff) in the building regarding the Elopement Protocol as well as responding to a door alarm from 04/27/18. The Department Heads further educated one-hundred percent (100%) of facility staff ending on 04/30/18. 8. Random elopement drills will be conducted by DON, Administrator, ADON once weekly on each shift for four (4) weeks, one (1) time a week on any shift for eight (8) weeks. 9. The DON will audit twenty-four (24) report daily. The DON is to review Nurses Notes for documentation of exit seeking behaviors, ** The State Survey Agency validated the following actions to correct the deficiency: 1. Review of the Long Term Care Self Reported Incident Form, dated 04/27/18, revealed it was sent to the physician, guardian, DCBS and OIG and contained a description of the incident. 2. A signed statement, dated 04/27/18, by the Administrator revealed he interviewed SRNA #1 after reviewing the video and observing her going to the alarm and silencing it without looking outside. Further review revealed the SRNA told the Administrator that she went to silence the alarm and forgot to look outside. She further stated that she knew she was supposed to check outside when a door alarm was sounding. The SRNA was immediately re-educated to check outside when door alarm was sounding. She was suspended pending investigation. This information was also reiterated during interview of the Administrator. Interview with SRNA #1, on 05/04/18 at 12:04 PM, revealed she has been re-educated on the Elopement Protocol and checking alarms as well as the importance of looking outside for residents before disarming an alarm on 04/27/18. The SRNA confirmed that she was suspended on 04/27/18 pending the outcome of the investigation. 3. Review of a note dated 04/27/18 by the Administrator revealed, per phone the family member of another resident stated that when he opened the door, Resident #1 stood up and came outside. He stated that he thought he/she was going out to sit on the front porch and that he didn't know he/she couldn't do that. This was also verified by interview of the Administrator. 4. Interview with the Administrator on 05/04/18 at 1:05 PM revealed he audited all residents' records to ensure they had an elopement assessment in the resident's charts on 04/27/18. 5. A written statement by the DON, dated 04/27/18, stated DON and ADON's audited the last thirty (30) days of Nurses Notes to identify any elopements or exit seeking behavior that nurse management had not been notified of. There were none identified. The DON and ADON's reviewed the Care Plans for all residents that were at risk for elopement and updated as necessary Wanderguard books were reviewed and found to be accurate. Interview with the DON, on 05/04/18 at 1:15 PM, revealed she and ADON's audited Nurses' Notes for the past thirty (30) days to look for signs of elopement or exit seeking behaviors and none were found. She stated the Care Plans were also reviewed for all residents at risk for elopement and were updated as necessary. The DON stated the Wanderguard books were also reviewed and found to be accurate. 6. Review of the letter penned by the Administrator to the families/visitors was reviewed. The content of the letter stated, Dear Visitors. Please help us keep our residents safe by not assisting any resident out the door without seeing their nurse first. Please alert nursing staff immediately if a resident attempts to leave while you are exiting our facility. If you are family and are taking your loved one out of the facility, please be sure to see their nurse to sign them out. Door codes must be entered by staff members and cannot be shared. Interview with the Social Worker, on 05/04/18 at 2:08 PM, revealed the letters were mailed by him on 04/30/18. 7. Review of the staff signature sheets dated 04/27-30/18 and interview with the Administrator, on 05/04/18 at 1:05 PM, revealed 100% of staff had been re-educated between 04/27/18 and 04/30/18 on the elopement protocol and what to do when a door alarm sounds. Interviews with the Registered Nurse (RN) Staff Development Coordinator (SDC) on 05/08/18 at 8:06 AM, Maintenance Director on 05/04/18 at 11:51 AM, LPN #1 on 05/05/18 at 8:34 AM, SRNA #2 on 05/05/18 at 8:40 AM, SRNA #3 on 05/05/18 at 8:45 AM, SRNA #4 on 05/06/18 at 12:54 PM, Central Supply Staff on 05/07/18 at 2:56 PM, LPN #3 on 05/07/18 AT 3:18 PM, Activities Director on 05/07/18 at 3:27 PM, SRNA #5 on 05/07/18 at 3:30 PM, SRNA #6 on 05/07/18 at 3:36 PM, SRNA #7 on 05/07/18 at 3:41 PM, SRNA #8 on 05/07/18 at 3:44 PM, Dietary Director Director on 05/07/18 at PM, Physical Therapy Aide on 05/07/18 at 3:55 PM, MDS Coordinator on 05/07/18 at 3:57 PM, Human Resources/Payroll Staff on 05/07/18 at 4:01 PM, Medical Records staff on 05/07/18 at 4:04 PM, Business Office Manager on 05/07/18 at 4:06 PM, LPN #4 on 05/07/18 at 4:19 PM, RN #1 on 05/08/18 at 8:06 AM, RN #2 on 05/08/18 at 8:43 AM, RN #6 on 05/08/18 at 9:03 AM, RN #3 on 05/08/18 at 9:12 AM and RN #4 on 05/08/18 at 9:20 AM revealed they had been educated on the Elopement Protocol and that they should respond to all alarms, and look outside for residents before disarming the alarm. 8. Review of Elopement Drill revealed a weekly drill was completed on 05/07/18 at 12:20 AM and 05/07/18 at 7:30 PM. 9. Interview (Post Survey) with the Director of Nursing on 04/18/18 at 4:00 PM revealed she continued to review 24 hour shift reports daily for any documentation of elopement risk behavior or elopements.

Based on interview, record review, and review of Kentucky Board of Nursing (KBN) AOS #14 Patient Care Orders, it was determined the facility failed to ensure services being provided meet professional standards of quality, in regard to following the physician's orders [REDACTED].#16). Resident #16's (MONTH) (YEAR) physician's orders [REDACTED]. The findings include: Review of KBN AOS #14 Patient Care Orders, last revised October, (YEAR), revealed a Registered Nurse (RN) will administer medications and treatments as subscribed by a Physician, Physician's Assistant, Dentist, or ARNP. Record review revealed the facility admitted Resident #16 on 01/02/18 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 01/20/18, revealed the facility assessed Resident #16's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was interviewable. Review of the Comprehensive Care Plan, dated 01/12/18, revealed the resident was at risk for alteration in nutrition with a history of weight loss. Review of the goal revealed he/she would remain free of dehydration for ninety (90) days. Review of the listed approaches included weekly weights for four (4) weeks, then monthly if stable. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. However, review of the Weight Change Comparison revealed the resident was weighed on 12/13/17 with a weight of 173.4 pounds, and not again until 03/07/18 when his/her weight was 167.0 pounds. Review of the facility's Dietary Data Set and Progress Notes, dated 12/05/17, revealed the resident's most recent weight was obtained on 11/15/17. Review of the Progress Notes, dated 01/12/18, revealed the resident's most recent weight was obtained on 01/05/18. Review of the Progress Notes, dated 02/10/18, revealed the resident's most recent weight was obtained on 12/13/17; and review of the Progress notes, dated 04/13/18, revealed the resident's most recent weight was obtained on 03/17/18. Interview with the Director of Nursing (DON), on 04/26/18 at 12:44 PM, revealed Restorative Nursing was responsible for obtaining weights as ordered. However, the facility did not currently have anyone in the Restorative Department, as one (1) aide was terminated and the other had recently resigned. She stated no one else had been made responsible for getting the weights, and his/her weekly weights had not been completed as ordered. The DON further stated it was her expectations for the resident to be weighed as ordered.

Based on observation, interview, record review, and review of Lippincott, Manual of Nursing Practice, it was determined the facility failed to provide Oxygen (O2) therapy, per the physician's orders [REDACTED].#16). Observation, on 04/24/18 at 11:47 AM, revealed Resident #16 was in the dining room wearing O2 tubing connected to a portable O2 tank. The nasal cannula was observed to the right side of the resident's face, not in his/her nares. Further observation revealed the O2 tank was empty. The resident's O2 saturation level (SaO2) was checked and revealed it was 86 percent (%). The findings include: Interview with the Director of Nursing (DON), on 04/26/18 at 12:47 PM, revealed the facility goes by physician's orders [REDACTED]. Review of the facility's procedure manual, Lippincott, Manual of Nursing Practice, Ninth Edition, revealed oxygen is used to treat or prevent symptoms and manifestation of [MEDICAL CONDITION] with symptoms including Tachypnea (fast respirations) and SaO2 less than 88%. Oxygen should be set to the flow rate at the prescribed liters per minute. Tips of the cannula should be placed in the resident's nose. Assess SaO2 and the functioning of the equipment at regular intervals. Record review revealed the facility admitted Resident #16 on 01/02/14 with a [DIAGNOSES REDACTED]. Further review revealed the resident was hospitalized with Bilateral Pneumonia on 01/02/18. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 01/20/18, revealed the facility assessed Resident #16's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was interviewable. In addition, further review revealed the resident required extensive to total assistance of two (2) persons for activities of daily living and used O2. Review of the Comprehensive Care Plan, dated 12/02/17, revealed the resident had a potential for alteration in O2 exchange related to [MEDICAL CONDITION]. The goal was for the resident to have no shortness of breath or cyanosis for ninety (90) days. Approaches included O2 as ordered, change tubing/devices per protocol; observe for cyanosis, shortness of breath or change in level of consciousness; and O2 saturation as ordered. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR), dated April, (YEAR), revealed a treatment to monitor O2 saturation with and without O2 and record weekly was added to the TAR on 04/24/18. Additional treatments included to check O2 saturation daily; and O2 at two (2) liters to maintain O2 at 88%. Observation, on 04/24/18 at 11:47 AM, revealed Resident #16 was up in a wheelchair in the dining room with O2 tubing around each ear, a nasal cannula to the right side of his/her face not in the nares, and tubing connected to a portable O2 tank on back of the resident's chair. Further observation revealed the O2 gauge needle was in the red, indicating the tank was empty. A spot check of SaO2 per LPN #2 revealed the resident's SaO2 was at 86%. Interview with Resident #16, on 04/24/18 at 11:50 AM, revealed he/she felt a little bit short of breath. Resident #16 stated he/she was not aware the nasal cannula was not in his/her nares nor that the O2 tank was empty. Interview with Licensed Practical Nurse (LPN) #2, on 04/24/18 at 11:50 AM, revealed O2 canisters were filled every two (2) hours by the Nurse or Certified Nurse Assistant (CNA) who recognized the canister was low. LPN #2 stated the cannisters were used when residents were out of bed and the resident had been out of bed since 9:30 AM that morning. LPN #2 further stated O2 checks were supposed to be completed periodically by Nursing, but did not know when it was checked last. LPN #2 stated she was assigned to care for Resident #16, and she checked the resident's SaO2 when the nebulizer treatment was given at approximately 6:00 AM. The LPN stated staff know how long the portable O2 tanks last and they just check them periodically. Interview with the Assistant Director of Nursing (ADON) #4, on 04/26/18 at 8:27 AM, revealed she expected the Nurses and/or CNAs to check O2 tanks, before taking residents to the dining room. The ADON stated if there was not enough O2 in the portable tank for the entire meal, she expected the Nurse and/or CNA to change the tank for a full one. Further interview with the DON, on 04/26/18 at 12:47 PM, revealed the portable tanks should be monitored frequently, by the Nurse or the CNA placing the resident on the portable O2 canister, every three to four (3-4) hours to make sure they were full. The DON stated the O2 tank should have been checked before taking the resident to the dining room, and if the gauge was in the red, the tank should have been filled.

Based on observation, interview, record review, hospital discharge orders and facility policy review, it was determined the facility failed to notify the physician for five (5) of twenty (20) sampled residents (Residents #4, #8, #13, #18, and #19) and two (2) unsampled residents (Residents A and B) when medications were not available to be administered; were administered late; or, a resident experienced a significant change in condition. The facility admitted Resident #18 on [DATE] post-surgical Left [MEDICAL CONDITION] (BKA), and [DIAGNOSES REDACTED]. He/She did not receive pain medication related to the BKA until [DATE] at 12:01 PM due to the facility's failure to notify the physician and obtain orders for the medication timely. The Physician was not made aware of the resident's admission and need for orders on [DATE] which resulted in the resident not receiving insulin for approximately nineteen (19) hours (first dose was due on [DATE] at 4:00 PM) after admission and pain medication for approximately thirty-two (32) hours after admission. On [DATE] at 1:54 PM, the resident's blood sugar was 435 milligrams/Deciliter (mg/Dl) (normal range ,[DATE] mg/Dl). On [DATE] at 2:50 PM, Resident #19 presented with cold like symptoms, and the physician was notified and orders for breathing treatments were received. On [DATE] at 8:30 AM, the resident's symptoms worsened, the On call physician was notified, and orders were received for antibiotic, oxygen and suctioning. However, the family was not made aware of the resident's change in condition and treatment until [DATE]. Resident #19 continued to decline on [DATE] through [DATE]. The facility failed to notify the physician of the resident's continued decline. The resident expired at the facility on [DATE] at 9:40 PM. In addition, Residents #4, #8, #13 and Unsampled Residents A's and B's Physicians were not notified when there was a possible need to alter treatment related to the residents' medications not being administered per physician's orders [REDACTED]. The facility's failure to notify the family/physician when there was a significant change in condition or the need to alter treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated, on [DATE], that the Immediate Jeopardy was removed on [DATE]. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Quality Assurance Policy revised ,[DATE] revealed all residents should be assessed at least on admission, quarterly, and with a change of condition per the Interact 111 system (system to determine when and if physician notification needed) for any additional or new needs noted. All changes should be communicated with the Interdisciplinary Team (IDT), the resident's responsible party, physician, and in the medical record of that resident according to the systems adopted. A follow-up on all levels of the assessment, to ensure a complete evaluation of the resident's condition, should be obtained and recorded in the medical record as needed, using the Situation Background Assessment Recommendation (SBAR) form when appropriate. Review of the facility's policy titled, Interact Version 4.0 Tool, last revised [DATE], revealed the guidance was adapted from the Clinical Practice Guidelines Acute Changes in Condition in the Long Term Care (LTC) Setting 2003 and was used by the facility as a tool to determine immediate and non-immediate notification of the physician. Further review revealed the symptoms requiring immediate physician notification were symptoms of a common cold: marked respiratory distress, severe cough, or temperature greater than 100.5 degrees Fahrenheit. Review of the facility's policy titled, Resident Assessment Policy and Procedure, dated [DATE], revealed it was the policy of the facility that all residents should be assessed to determine their needs. If the resident's condition was declining vs. maintaining or improving due to the progression of their medical condition, and if it was apparent the resident was approaching end of life, the physician and family/legal representative should be contacted. 1. Record review revealed the facility readmitted Resident #19 on [DATE] with diagnoses, which included [MEDICAL CONDITIONS] Fibrillation, Dysphasia, Arthritis, and [MEDICAL CONDITION]. Review of an SBAR, dated [DATE] at 2:50 PM; a Departmental Note dated [DATE] at 1:45 PM; and, a physician's orders [REDACTED].#19 had presented with cold like symptoms of wheezing, non-productive cough and a temperature of 99.6 degrees Fahrenheit (F) (normal of 98.6 degrees F) with orders received for [MEDICATION NAME] Nebulizer treatments 0.083% unit dose three (3) times a day (TID) times five (5) days, to administer oxygen (O2) at three (3) Liters per minute (LPM) per nasal cannula every shift to maintain O2 saturation greater than 88%. Further review of the SBAR revealed on [DATE] at 8:30 AM, Resident #19 had gurgly respirations, could not cough phlegm up, respirations were labored, lungs with bilateral rub and some wheezing noted, and face flushed. The resident's temperature was 99.9 degrees F and he/she was suctioned with a moderate amount of light brownish phlegm obtained. The On-call Physician was notified with orders received for [MEDICATION NAME] (antibiotic) 250 milligrams two (2) tablets now, then [MEDICATION NAME] 250 milligrams one-(1) tablet times four (4) days; and, Yonkers suction as needed (PRN). However, further review revealed there was no documented evidence the family was notified of the resident's change in condition and new orders on [DATE] or [DATE]. Review of the Departmental Notes, dated [DATE] at 1:47 AM, 7:03 AM, and 6:36 PM; and, on [DATE] at 3:05 AM, 11:06 AM, 1:48 PM and 11:42 PM, revealed the resident continued to decline throughout the day on [DATE] and [DATE]. Further review revealed Resident #19's temperature increased to 100.6 degrees F; O2 saturation decreased to 51% (normal ,[DATE]%); and, the resident's oxygen was increased to four (4) LPM per n/c. Resident #19 was unable to clear his/her throat and was being suctioned with a moderate amount of phlegm removed and had audible gurgling, with the head of bed raised to eighty (80) degrees to assist with breathing. The resident was exhibiting sporadic episodes of five (5) to seven (7) seconds periods of apnea (absence of breathing); his/her bilateral hands and part of his/her wrists were cyanotic and had started to mottle (discolored). Further review revealed at 9:42 PM, the resident's respirations were labored with blowing exhalations, and his/her respirations were thirty-two (32) breaths per minute (normal: 16 to 20). However, further review of the Departmental Notes and review of the resident's record revealed there was no documented evidence of a SBAR report that the resident's physician was made aware of the resident's continued decline from [DATE] up until the time of his/her death at 9:42 PM Review of Departmental Notes, dated [DATE] at 11:42 PM, late entry for 9:42 PM, revealed Resident #19 had no vital signs detected per two (2) nurses (Licensed Practical Nurse {LPN} #13 and Registered Nurse {RN}. Resident #19 had passed away. Review of the clinical record revealed Resident #19 was Do Not Resuscitate. Interviews were attempted with RN #2 on [DATE] at approximately 2:30 PM, and with LPN #13 at approximately 2:32 PM, with messages left, but no return calls were received. In addition, the Director of Nursing (DON) stated on [DATE] at 11:30 AM, she had calls out to these two (2) nurses requesting their return call. Interview with Resident #19's Durable Power of Attorney (DPOA), on [DATE] at 11:50 AM, revealed they were not aware of the resident's illness until they came for a visit on [DATE] at approximately 10:59 AM. The DPOA stated she discovered the resident was on oxygen, but as far as she knew, the physician had been notified of the resident's decline. Further interview with the DPOA, on [DATE] at 12:15 PM, revealed the family had attempted to call the facility on [DATE] to check on Resident #19's status but was unable to get anyone to answer the telephone even after multiple attempts. She stated on [DATE], the facility called the family with an update on the resident's condition. The DPOA stated, We just assumed the physician was involved and knowledgeable concerning (his/her) care and decline of condition. Interview with LPN #4, on [DATE] at 2:05 PM, revealed she remembered Resident #19 becoming lethargic and coughing so she notified the physician and received an order for [REDACTED]. LPN #4 was unable to provide an explanation as to why the family was not notified. Interview with LPN #11, on [DATE] at 5:40 PM, revealed she remembered Resident #19 being placed on antibiotics but she could not remember if she or any of her co-workers had notified the physician of the resident's continued decline. LPN #11 stated, I just remember (he/she) was sick and (he/she) wasn't doing very well, so it wasn't surprising that (he/she) passed away. LPN #11 further stated the facility's policy was to notify the physician of a change of status and she would have notified the physician if she had been working. Interview with LPN #9, on [DATE] at 8:55 AM, revealed it was the facility's policy to notify the physician of a change in status. She stated the physician should be made aware of a resident's condition, whether or not the resident was on comfort measures. Review of the clinical record revealed there was no documented evidence Resident #19 had been made comfort measures only. Interview, on [DATE] at 4:50 PM, with Resident #19's Primary Physician, who was also the facility's Medical Director, revealed he did not remember the resident being that bad. He stated he would have expected to be notified of the resident's continued decline and he was surprised the facility did not call him. The physician stated the resident's code status was Do Not Resuscitate (DNR), but the resident had not been changed to comfort measures only. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 10:00 AM, revealed the resident's code status was DNR. She stated the resident ended up with a respiratory illness and the family wanted to keep him/her comfortable. She stated it was the facility's policy to notify the physician and family of a change in condition. Interview with the prior Director of Nursing (DON), on [DATE] at 11:30 AM, revealed, I feel in my heart the doctor was notified but I can't find anything in the chart, I will keep looking but if I can't find anything then it is what it is. Further interview with the prior DON, on [DATE] at 4:00 PM, revealed the physician and family should always be notified when there was a decline in the resident's condition, no matter if their status was DNR or comfort measures only. Interview with the Administrator, on [DATE] at 3:00 PM, revealed he/she stated, The physician and family should have been notified and there is no other answer for that. 2. Record review revealed the facility admitted Resident #18 on [DATE] at 3:30 PM, with diagnoses, which included Type II Diabetes Mellitus, Left Leg [MEDICAL CONDITION] (BKA), [MEDICAL CONDITIONS], Hypertension, and [MEDICAL CONDITION]. Review of the Hospital Discharge Orders, dated [DATE], revealed to administer: 1. [MEDICATION NAME] (insulin), inject seventeen (17) Units (U) into skin nightly; inject fifty (50) U into skin twice a day. Start date [DATE] with next dose due at 9:00 PM. 2. Humalog Insulin one-hundred (100) U; inject twelve (12) U twice a day before meals. Start date [DATE] with next dose due at 4:00 PM. 3. [MEDICATION NAME] (diuretic) forty (40) milligrams (mgs) one (1) tablet every morning. Start date [DATE] with next dose due on [DATE] (received ,[DATE] dose in hospital prior to admission). 4. [MEDICATION NAME] ([MEDICATION NAME], Oral diabetic medication) eight-hundred fifty (850) mgs one (1) tablet twice a day with meals. Start date [DATE] with next dose due on [DATE]. ([DATE] doses given at the hospital prior to admission). However, review of the Departmental Notes and physician's orders [REDACTED]. In addition, review of the February 2016 Medication Administration Records (MAR), revealed Resident #18 did not receive any insulin as well as all other ordered medications that were due on [DATE] (after admission to the facility) and, on [DATE] prior to approximately 11:00 AM when he/she received now doses of insulin. In addition, the resident's pain medication was not administered until [DATE] at 12:01 PM. Review of Nursing Notes, dated [DATE] at 10:48 AM, (the resident was admitted on [DATE] at 3:30 PM and should have received insulin at 4:00 PM and 9:00 PM) documented by RN #4, revealed a finger stick blood sugar was obtained and the results were 435 mg/dL (normal range ,[DATE] mg/dL). Further review of the Nursing Notes, revealed at 11:02 AM, RN #4 spoke with the Primary Care Physician's (PCP) Nurse regarding Resident #18's increased blood sugar level and an order was received for a stat dose of [MEDICATION NAME] Insulin 17 U now and a stat dose of Humalog Insulin 12 U now. In addition, staff was to fax Resident #18's medication list to the PCP to review (approximately nineteen (19) hours after admission). Further review of the Nursing Notes on [DATE] revealed at 1:54 PM, the resident's blood sugar was obtained again after the STAT dose of Insulin was given and the results were three-hundred sixty-two (362) mg/dL. In addition, the Note stated the medication orders had been reviewed by the physician; the medications had been ordered through the pharmacy; and, the physician was to come to the facility on this date ([DATE]) to see the resident. Interview (Post Survey) with LPN #3, on [DATE] at 10:40 AM, revealed Resident #18 was moved to another unit ten (10) minutes after arriving. Therefore, she did not enter the resident's medications into the computer system. She stated the resident was moved to the West Unit and report was given to RN #4. She further stated RN #4 would have been responsible for completing the admission, notifying the physician, and ensuring medications were ordered. Interview with the DON, on [DATE] at 4:04 PM, revealed LPN #11 and RN #4 (nurses who worked on [DATE] and [DATE]) were no longer working at the facility and quit without giving the facility notice. Interviews were attempted with LPN #11, on [DATE] at 1:25 PM and at 2:30 PM; and, with RN #4, on [DATE] at 1:30 PM and 3:00 PM. Voice mail messages were left, with no return phone calls. Interview with Resident #18, on [DATE] at 12:40 PM, revealed he/she was admitted to the facility on a Wednesday ([DATE]). The resident stated the facility did not have any medications to administer to him/her and he/she was told by nursing staff the medications had to come from another city (one-hundred and seven {107} miles away), where their primary pharmacy was located. He/She stated on the second (2nd) day ([DATE]), he/she reported to nursing staff he/she still had not received any medications and was in pain. Also on this day, his/her blood sugar was high at four-hundred thirty-five (435) mg/dL due to the facility not having insulin to administer. Further interview revealed the resident stated, on a pain scale of one (1) to ten (10) his/her pain level was a seven (7). Resident #18 stated that on the first night ([DATE]) he/she was at the nursing facility he/she did not receive any pain medication and was unsure when he/she did receive pain medication on the 2nd day, [DATE]. He/She stated he/she called the physician himself and went to a care center on [DATE] because the facility was not providing him/her any pain medication and they had not contacted the physician regarding his/her medications. Interview with Resident #18's Primary Care Physician (PCP), on [DATE] at 4:48 PM, revealed he was not aware of the resident's admission to the facility until [DATE] when the resident contacted him regarding his/her pain medications and Insulin. The PCP stated he expected the resident's pain medication and Insulin to be available for administration. He stated the facility could have called a backup pharmacy to retrieve immediate medications, especially the Insulin as it was more critical to have than the pain medication. Further interview with the physician revealed Resident #18 had his Assistant's phone number through a mutual friend and contacted him through his assistant. The PCP stated the resident asked him, What am I supposed to do?, because he/she did not have Insulin at the nursing facility. Further interview revealed, when RN #4 on [DATE] contacted him, he asked for the resident's medication list from the hospital discharge to be sent to him for review so he could compare the medications he/she was ordered in the hospital to the ones he/she had taken at home. The Physician stated he did not know why the resident did not have his/her medications on [DATE] when he/she was admitted because a Nurse Practitioner could have been called to get Insulin at a local pharmacy. The PCP stated in his opinion, there was no excuse for the resident to have gone without any medications. Interview with the Administrator, on [DATE] at 3:00 PM, revealed residents were admitted with orders for medications and he expected medications to be obtained timely and if not available, the nurse should contact the Director of Nursing and the Medical Director as well as himself. He was not aware medications had not been administered or had been administered late. He stated he should have been made aware. 3. Record review revealed the facility admitted Resident #4 on [DATE] with diagnoses, which included Chronic Pancreatitis, Restless Leg Syndrome, Guillain-Barr Syndrome, Low Back Pain, Neck Pain, Major [MEDICAL CONDITIONS], and Cerebellar Ataxia. Review of the April and [DATE] Electronic Medication Sheet revealed the resident's 9:00 PM medications ([MEDICATION NAME] Sodium {anti-convulsion}, [MEDICATION NAME] {nerve pain}, [MEDICATION NAME] {anti-anxiety}, [MEDICATION NAME] {narcotic pain medication}, Dantrolene Sodium {muscle relaxant}and [MEDICATION NAME] {anti-hypertensive} were administered approximately two to three (,[DATE]) hours late on [DATE], [DATE], [DATE] and [DATE]. In addition,[MEDICATION NAME](for treatment of [REDACTED]. However, review of the medical record including Nurse's Notes and SBARs revealed no documented evidence the physician was made aware of the medications not being administered timely even though the medications were to prevent [MEDICAL CONDITION]; and to control pain and blood pressure. Interview with Resident #4, on [DATE] at 4:26 PM, revealed that he/she had more pain when the medications were late. The resident stated the medication were late especially at night. He/She stated this had happened in the past and was now happening again. 4. Record review revealed the facility admitted Resident #8 on [DATE] with diagnoses, which included Chronic Ischemic [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), Heart Failure, Cerebral Infarct, and [MEDICAL CONDITION]. Review of the April and [DATE] EMARs (electronic MAR) revealed the resident's [MEDICATION NAME] (anti-hypertensive), [MEDICATION NAME] (antihypertensive), and [MEDICATION NAME] (to prevent [MEDICAL CONDITION] attacks) were due at 9:00 AM and were administered as late as 11:15 AM (one {1} hour and fifteen {15} minutes late).[MEDICATION NAME](to treat [MEDICAL CONDITION]) was due at 9:00 PM and was administered at 11:39 PM (one {1} hour and thirty-nine {39} minutes late; and, [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) was administered as late as 12:25 AM, due at 9:00 PM (two {2} hours and twenty-five {25} minutes late). However, review of the medical record to including the Nurse's Notes and SBARs revealed no documented evidence the physician was made aware of the resident's medications not being given timely even though they were to help control blood pressure, to prevent [MEDICAL CONDITION] and to help with breathing. In addition, [MEDICATION NAME] to help with sleep but was not given until after midnight. 5. Record review revealed the facility admitted Resident #13 on [DATE] with diagnoses, which included End Stage [MEDICAL CONDITION], Dependence on [MEDICAL TREATMENT], Pain, [MEDICAL CONDITION], and Personal History of Malignant Neoplasm of [MEDICAL CONDITION]. Review of the April and [DATE] EMARs revealed [MEDICATION NAME] (to treat nerve pain) due to be administered at 9:00 PM was not administered until 12:01 AM (approximately two {2} hours late; and, on [DATE] (the resident's [MEDICAL TREATMENT] day) the [MEDICATION NAME] 300 mg scheduled for 1:00 PM was administered at 2:44 PM and the 5:00 PM dose was administered at 4:08 PM (only two {2} hours apart). Further review revealed [MEDICATION NAME] ([MEDICATION NAME] binder for [MEDICAL TREATMENT]) was not given on one (1) occasion, and [MEDICATION NAME] (to treat low [MEDICAL CONDITION] activity) was not administered for four (4) days ([DATE], [DATE], [DATE], and [DATE]) and was late on two (2) occasions. Additionally, Brintellix (antidepressant) was not available to be administered on [DATE] at 8:00 AM. However, review of the medical record including Nurse's Notes and SBARs revealed there was no documented evidence the physician was made aware of the medications not given timely even though the nerve pain medication was two (2) hours late and administered only two (2) hours apart on one (1) occasion; the [MEDICAL CONDITION] medication was not administered for three (3) consecutive days; and, a medication was not available to be administered. 6. Record review revealed the facility admitted Unsampled Resident A on [DATE] at 2:29 PM with [DIAGNOSES REDACTED]. Review of Unsampled Resident A's EMAR for [DATE] revealed [MEDICATION NAME] 3 mg and [MEDICATION NAME] 10 mg were not available for administration on the day of admission on [DATE] at 9:00 PM; however, they were documented as being administered on [DATE] at 6:23 AM. Further review revealed less than two (2) hours later, the medication was administered again at 8:21 AM. Continued review revealed on [DATE], Unsampled Resident A's [MEDICATION NAME] 3 mg, [MEDICATION NAME] 15 mg, and Trazadone 100 mg due at 9:00 PM were not administered until 10:56 PM (one {1} hour later). However, review of the medical record including Nurse's Notes revealed there was no documented evidence the physician was made aware of the medication being given only two (2) hours apart and one (1) hour late. 7. Record review revealed the facility admitted Unsampled Resident B on [DATE] with diagnoses, which included Chronic Pain, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux Disease, Polyarthritis, Convulsions, Hypertension, Major [MEDICAL CONDITIONS], and Gastrostomy ([DEVICE]). Review of the Annual MDS dated [DATE], revealed the facility assessed the resident to have a BIMS' score of twelve (12) which indicated Unsampled Resident B was interviewable. Review of the April and [DATE] EMAR revealed [MEDICATION NAME] (antihypertensive), [MEDICATION NAME] (antihypertensive), and [MEDICATION NAME] (antihypertensive) were ordered to be administered at 8:00 AM; however, they were administered late on several occasions. On [DATE], they were not given until 1:44 PM (approximately four {4} hours and forty-four {44} minutes late). Additionally, Levetiracetam (anticonvulsant) was administered seven (7) hours and fifty-one (51) minutes late, and the next dose was administered three and a half (3.5) hours later. The medication was ordered to be administered two (2) times daily at 8:00 AM and 8:00 PM. However, review of the medical record to include Nurse's Notes and SBARs revealed there was no documented evidence the physician was made aware the medications to control blood pressure were given late, an anti-convulsive (which requires a certain level in blood) was given approximately eight (8) hours late, and the next dose was given only three and a half (3.5) hours later. Interview with LPN #8, on [DATE] at 9:20 AM, revealed if a medication was available or had to be administered past the one (1) hour timeframe, the nurse should call the physician. She stated the nurse should document the physician's notification in the Nurse's Notes along with what the physician stated to do. She further stated if the medication was not available then the physician should be contacted for further orders. Interview with RN #3 on [DATE] at 8:22 AM revealed administering medications late occurred when the nurses were covering multiple halls. She stated the physician should be made aware when medications were administered late. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:10 PM, revealed there was no Nurse's Notes indicating the physician was notified so the nurses either failed to document or failed to notify the physician. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 1:55 PM, revealed the facility followed the standards of practice to administer medications within the period of one (1) hour before and one (1) hour after the administration time ordered. She stated if the medication could not be given in that timeframe then the physician and family should be notified. Interview with the DON, on [DATE] at 3:55 PM; and. on [DATE] at 8:45 AM and 1:55 PM, revealed if the physician notification was not in the chart then one must assume it was not done. She stated she expected medications to be passed one (1) hour before or one (1) hour after the time ordered and if not to contact the physician. She stated the process of notifying the physician should have been followed for late and unavailable medications. The DON stated there was not a policy for medications that were administered late and following physician's orders [REDACTED]. Interview with the Medical Director on [DATE] at 5:25 PM revealed he expected medications to be administered within the one (1) hour before and one (1) hour after window. He stated if medications were administered outside the two (2) hour window then he would expect a phone call to the physician on how to proceed next for the resident's safety. The Medical Director stated if the resident did not have the medication available then he would also expect a phone call to the physician. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #18 was discharged to the hospital on [DATE] and did not return to the facility. Resident #19 expired on [DATE]. The Physician was notified on [DATE] by the Director of Nursing that Residents #4, #8, #13 and A and B, medications given at late times. Vital signs and pain evaluations to assess for change of condition were completed by the Charge Nurses, DON and/or ADON, Nurse Unit Managers, Nurse Educator and MDS Nurses by [DATE]. The DON notified the Physician on [DATE] that Residents #8, A, B, #4, and #13's medications were administered late. The Medication Administration Record [REDACTED]. This was completed by [DATE]. 2. Vital signs and pain evaluations were conducted on residents who resided on the South, Skilled B and West Units by the Charge Nurses and/or Nurse Management Team. The Nurse Management Team audited the MARs of these residents to identify issues. These audits were completed by [DATE]. Residents receiving medications on the South, Skilled B and West Units care plans were updated related to risk potential related to medication administered untimely on [DATE] by two (2) MDS Nurses. 3. Admission charts within the last thirty (30) days beginning [DATE] were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed [DATE]. 4. Time Studies were conducted on all shifts (three times) by Charge Nurses to determine the time needed to deliver medications. The studies were conducted from [DATE] through [DATE]. From these studies, the facility determined the optimum medication pass times in accordance with physician's orders [REDACTED]. Times will be adjusted in accordance to resident needs and Physician order [REDACTED]. 5. Train the trainer education (related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulins or [MEDICAL CONDITION] medications and/or refusal of three consecutive doses of medication. The Regional Quality Manager provided this education to the DON and ADON on [DATE] prior to Licensed Nurse/KMA education. 6. In-servicing to current employed Licensed Nurses/Kentucky Medication Aides (KMA) by the Regional Quality Manager (RQM), Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulin or [MEDICAL CONDITION] medications and/or refusal of three consecutive doses of medication. This education was started on [DATE] and completed on [DATE]. This education was started on [DATE] and completed on [DATE]. Licensed Nurses/KMAs on Family Medical Leave (FMLA) and vacation will be trained prior to return to work. New hires and any future use of agency nursing staff will be trained prior to taking position. (No agency staff use at this time) <

Based on interview, record review and review of facility policy and the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual 3.0 ([DATE]), it was determined the facility failed to implement the care plan for four (4) of twenty sampled residents (Residents #4, #8, #13, and #19) and one (1) unsampled resident (Resident B). On [DATE] at 2:50 PM, Resident #19 presented with cold like symptoms, and the physician was notified and orders for breathing treatments were received. The facility care planned the resident for Potential for Infection on [DATE], with an intervention to update the medical doctor and family as needed. On [DATE] at 8:30 AM, the resident's symptoms worsened and the On-call Physician was notified and orders were received for an antibiotic, oxygen and suctioning. However, Resident #19 continued to decline from [DATE]-[DATE] and the facility failed to notify the physician of the resident's continued decline and possible need to alter treatment per the care plan. The resident expired at the facility on [DATE] at 9:40 PM. In addition, the facility failed to administer Residents #4, #8, #13, and Unsampled Resident B's medication according to the care plan. The facility consistently failed to administer medication in the appropriate time frame and failed to ensure medications were available to administer. Medications were as late as nine (9) hours and some of the medications included insulin, blood pressure medications, pain medications, mood stabilizer medications, antipsychotic medication, hypnotics, anti-convulsive medications, and a [MEDICATION NAME] binder medication for [MEDICAL TREATMENT]. The facility's failure to implement the care plan related to administering medications has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated, on [DATE], the Immediate Jeopardy was removed on [DATE]. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC), and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy Pain Management Process dated ,[DATE], revealed the resident's goals for pain control will be met by the use of medications and alternative methods to reduce pain as outlined in the Federal Regulatory Requirements for Long Term Care (LTC). This system will suggest necessary evaluation, intervention, and re-evaluation as standard care practice for licensed nurses. Documentation of pain intensity will be recorded along with intervention for pain reduction using appropriate facility forms and no less than the Pain Assessment, Pain Flow Sheet, and Situation Background Assessment Request (SBAR) form for notification and the twenty-four (24) hour report for any pending interventions. Post intensity evaluation will be assessed and documented in a timely manner. Upon follow-up if the intervention is ineffective, the process should be repeated until the resident indicates adequate relieve and/or functional goals are met. Pain scale assessments/evaluations should be documented as available in this AccuNurse (computer system) utilizations system. Review of the CMS RAI Manual 3.0 in Section 1.1 revealed the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving or maintaining his or her highest practical level of well-being. Section 1.4 Problem Identification using the RAI revealed implementation is putting the course of action which are specific interventions derived through interdisciplinary individualized care planning into motion by staff knowledge about the resident's care goals and approaches; carrying out the how and when of resident care. 1. Record review revealed the facility readmitted Resident #19 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident's cognition was severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. In addition, the resident was dependent on staff for all activities of daily living. Review of a facility form titled,Situation Background Assessment Recommendation (SBAR) dated [DATE]; and, a Departmental Note dated [DATE] at 8:30 AM (late entry [DATE]) revealed on [DATE] the physician was notified by facsimile (fax) that Resident #19 presented with cold like symptoms such as wheezing, non-productive cough and a temperature of 99.6 degrees Fahrenheit (F) (normal 98.6 F). Orders were received for [MEDICATION NAME] Nebulizer treatments and oxygen. On [DATE], the facility assessed Resident #19 to have a decline. The resident presented with gurgly labored respirations, lungs with bilaterally rub and some wheezing. The physician was notified with orders received for an antibiotic and suction as needed (PRN). Review of the Comprehensive Plan of Care for Potential for Infection, dated [DATE], revealed the resident had increased congestion, elevated temperature, cough, and decreased oxygen saturation. The interventions included to update the medical doctor and family as needed. Review of Departmental Notes, dated [DATE] at 1:47 AM, 7:03 AM, and 6:36 PM, (late entry for 5:00 PM); notes dated [DATE] at 3:05 AM, 11:06 AM (late entry for 9:30 AM), and 11:00 AM; and, on [DATE] at 1:48 PM and 6:46 PM, revealed Resident #19's condition continued to decline over the three (3) days with the resident's oxygen saturation dropping to 51% (normal (,[DATE] %). The resident's nasal cannula oxygen was increased to 4 LPM; it was noted the resident was taking in very little liquids. In addition, the resident's bilateral hands and part of his/her wrists were cyanotic, had started to mottle, and the resident would make eye contact slowly with pupils pinpoint. Further review revealed the resident's respirations were labored with blowing exhalations, and were thirty-two (32) breaths per minute (normal ,[DATE]). However, there was no documented evidence the resident's physician was notified of the resident's continued decline per the resident's care plan. Review of a Departmental Note, dated [DATE] at 11:42 PM, late entry for 9:42 PM, revealed Resident #19 had no vital signs detected per two (2) nurses. Resident #19 had passed away. Interview with Licensed Practical Nurse (LPN) #4, on [DATE] at 2:05 PM, RN #2 on [DATE] at 4:40 PM and LPN #11 on [DATE] at 5:40 PM, revealed they remember the resident being on antibiotics and having a change in condition. However, they did not recall if they had followed the care plan and notified the physician. 2. Record review revealed the facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident 4's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Pain and Self Care Deficit, last updated [DATE], revealed to administer pain medications as ordered and other medications as ordered by the physician and/or nurse practitioner ([MEDICATION NAME] {anti-spastic agent} 10 milligrams {mg} three times a day {TID}, Trazadone {anti-depressant} 50 mg at hours of sleep {hs}, [MEDICATION NAME] {opioid pain medication} ,[DATE] mg every six {6} hours, Dantrolene Sodium {muscle relaxant} 25 mg TID, [MEDICATION NAME] {anti-hypertensive} 80 mg every night, and [MEDICATION NAME] Sodium DR {manic disorders/anti-convulsant} 500 mg at bedtime, [MEDICATION NAME] {anti-anxiety} 10 mg two {2} tablets twice a day, [MEDICATION NAME] {nerve pain} 300 mg TID, [MEDICATION NAME] 24,000 units (a pancreatic enzyme), two (2) capsules by mouth before meals, and [MEDICATION NAME] extended release (ER) 500 mg, give one (1) tablet by mouth at bedtime). However, review of the [DATE] EMAR (electronic MAR) revealed the resident's 9:00 PM medications ([MEDICATION NAME], Trazadone, [MEDICATION NAME], Dantrolene Sodium, [MEDICATION NAME], and [MEDICATION NAME] Sodium DR) were not administered until 11:17 PM on [DATE] (one {1} hour and seventeen {17} minutes late); on [DATE], the 9:00 PM medications ([MEDICATION NAME], and Dantrolene Sodium) were not administered until 12:40 AM on [DATE] (two {2} hours and forty {40} minutes late); and the [DATE], 9:00 PM medications ([MEDICATION NAME] Sodium DR, [MEDICATION NAME], and Dantrolene Sodium) were not administered until [DATE] at 1:08 AM (three {3} hours and eight {8} minutes late). Review of the [DATE] EMAR [MEDICATION NAME] 24,000 units was to be administered before meals at 8:00 AM, 12:00 PM, and 5:00 PM; however, on [DATE] it was administered at 10:10 AM (after the breakfast meal); on [DATE] it was administered at 1:05 PM (after lunch meal); and on [DATE] it was administered at 1:16 PM (after the lunch meal). In addition, review of the [DATE] EMAR revealed on [DATE], the 9:00 PM medications ([MEDICATION NAME], Trazadone, [MEDICATION NAME] Sodium DR, Dantrolene Sodium) were not administered until [DATE] at 12:43 AM (approximately two(2) hours and forty-three {43} minutes late). Further review revealed the [MEDICATION NAME] extended release (ER) was unavailable for administration on [DATE] because the facility was waiting for the pharmacy to deliver. Interview with Resident #4, on [DATE] at 4:26 PM, revealed there were problems with receiving medications on time, at night especially. He/She stated he/she has more pain when medications were late. Further interview revealed this has happened in the past and was now happening again. 3. Record review revealed the facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated [DATE], revealed the facility assessed Resident #8's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Tissue Perfusion, Potential for Mood Disturbance, alteration in sleep disturbance and risk for complication related to Psychoptopic medication, last updated [DATE], revealed to administer medications as ordered ([MEDICATION NAME] {anti-[MEDICAL CONDITION]} 20 mg tablet, give one {1} tablet orally once daily; [MEDICATION NAME] {anti-hypertensive} 10 mg tablet, give one {1} tablet orally once daily; [MEDICATION NAME] {blood thinner} 75 mg tablet, give one {1} tablet orally once daily, [MEDICATION NAME] Diskus {[MEDICATION NAME][MEDICATION NAME]} ,[DATE], inhale one {1} puff by mouth every twelve {12} hours; and [MEDICATION NAME] Diskus ,[DATE], inhale one {1} puff by mouth every twelve {12} hours. However, review of the April and [DATE] E-MAR revealed on [DATE], the resident's 9:00 AM medications ([MEDICATION NAME], and Adair Diskus) were not administered until 11:15 AM (one {1} hour and fifteen {15} minutes late); on [DATE], the 9:00 PM medication ([MEDICATION NAME] Diskus) was not administered until [DATE] at 12:25 AM (two {2} hours and twenty {20} minutes late); the [DATE], 9:00 PM medication ([MEDICATION NAME] Diskus) was not administered until [DATE] at 12:22 AM (two {2} hours and twenty-two {22} minutes late); and, on [DATE], the 9:00 PM medication ([MEDICATION NAME] Diskus) was not administered until 11:54 PM (one {1} hour and fifty-four {54} minutes late). Interview with Resident #8, on [DATE] at 4:32 PM, revealed he/she was hurting when he/she finally received his/her pain medication. The resident stated he/she gets nervous when waiting for as needed pain medication because of the pain. 4. Record review revealed the facility admitted Resident #13 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated [DATE], revealed the facility assessed Resident #13's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for generalized pain, leg and back pain, weakness, unsteady with balance, Chronic [MEDICAL CONDITION], Cardiac and Respiratory Disease, [MEDICAL CONDITION], Arthritis, [MEDICAL CONDITIONS], easily fatigues, Obesity, History of Diabetes Mellitus, History of [MEDICAL CONDITION] and [MEDICAL CONDITION], last revised [DATE], revealed to administer medication as ordered ([MEDICATION NAME] 600 mg capsule, give one {1} 300 mg twice daily at 8:00 AM and 4:00 PM on non-[MEDICAL TREATMENT] days and [MEDICATION NAME] 300 mg capsule, give one {1} capsule by mouth twice daily; [MEDICATION NAME] 800 mg tablet take six {6} tablets {4800 mg} by mouth every day before meals three {3} times a day; [MEDICATION NAME] {[MEDICAL CONDITION]} 150 micrograms {mcg} tablet, give one {1} tablet by mouth on Tuesday, Thursday and Saturday at 12:00 noon when returns from [MEDICAL TREATMENT]. Give one (1) tablet by mouth every morning before food and drink at 6:00 AM on non-[MEDICAL TREATMENT] days and Brintellix {anti-depressant} 20 mg tablet, give one {1} tablet by mouth daily. However, review of the April and [DATE] MAR indicated [REDACTED]{1} hour and twenty-eight {28} minutes late). Further review revealed the [DATE], 9:00 PM dose of [MEDICATION NAME] was not administered until [DATE] at 12:01 (two {2} hours late) and the [DATE], 1:00 PM dose of [MEDICATION NAME] was not administered until 2:44 PM (forty-four {44} minutes late); and on [DATE], the 12:00 PM dose of Brintellix was not available. 5. Record review revealed the facility admitted Unsampled Resident B on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated [DATE], revealed the facility assessed Unsampled Resident B's cognition as moderately impaired with a BIMS score of twelve (12) which indicated the resident was interviewable. Review of the Comprehensive Care Plan, dated [DATE], and April and [DATE] physician's orders [REDACTED].{beta-blocker} 20 mg tablet, give one {1} tablet by mouth or per [DEVICE] daily; [MEDICATION NAME]-[MEDICATION NAME] (HCTZ) {anti-hypertensive} 37XXX,[DATE] mg tablet, give one {1} tablet by [DEVICE] everyday; [MEDICATION NAME] {pain reliever} ,[DATE] tablet, give one {1} tablet via [DEVICE] four {4} times a day for pain; Carvedilol {beta-Blocker} 25 mg tablet, give one {1} tablet by mouth or per [DEVICE] two {2} times daily with meals, Levetiracetam {anti-convulsant} 100 mg/milliliters {ml} solution, give five {5} ml {500} mg by mouth or per [DEVICE] two {2} times daily; and [MEDICATION NAME] {anti-depressant} 15 mg tablet, give ,[DATE] {one-half} tablet by mouth every day at bedtime). However, review of the April and [DATE] EMAR revealed the 8:00 AM dose of Carvedililol was not administered until 9:44 AM (forty-four {44} minutes late), and the 4:00 PM dose of [MEDICATION NAME] and Carvedililol was not administered until 6:26 PM (one {1} hour and twenty-six {26} minutes late) on [DATE]; the 8:00 AM dose of [MEDICATION NAME], HCTZ, [MEDICATION NAME] and Carvedililol was not administered until 10:21 AM (one {1} hour and twenty-one {21} minutes late) on [DATE]; the 8:00 AM dose of [MEDICATION NAME] was not administered until 10:20 AM (one {1} hour and twenty{20} minutes late) on [DATE]; the 8:00 AM dose of [MEDICATION NAME], HCTZ, Lisinipril, and Carvedililol was not administered until 10:20 AM (one {1} hour and twenty {20} minutes late), and the 4:00 PM dose of [MEDICATION NAME] was administered at 5:00 PM on [DATE] (less than two {2} hours from previous dose when it is supposed to be administered every six {6} hours) on [DATE]; the 12:00 PM dose of [MEDICATION NAME] was not administered until 3:09 PM (two {2} hours and nine (9) minutes late); the 4:00 PM dose of [MEDICATION NAME] and Carvedililol was not administered until 7:55 PM on [DATE] (approximately two {2} hours and fifty-five {55} minutes late); the 8:00 AM dose of Lisinipril was not administered until 11:38 AM (two {2} hours and thirty-eight {38} minutes late) on [DATE]; the [DATE], 8:00 PM dose of [MEDICATION NAME] was not administered until [DATE] at 1:09 AM (approximately four {4} hours late), the [DATE], 8:00 PM dose of [MEDICATION NAME] was not administered until [DATE] at 2:22 AM (five {5} hours and twenty-two {22} minutes late); the 8:00 AM dose of [MEDICATION NAME] and Carvedilol was not administered until 10:55 AM (one {1} hour and fifty-five {55} minutes late, and the 12:00 PM dose was not administered until 2:45 PM (one {1} hour and forty-five {45} minutes late) on [DATE]; the 4:00 PM dose of [MEDICATION NAME] and Carvedilol was not administered until 6:51 PM (one {1} hour and fifty-one {51} minutes late), and the 8:00 PM dose was not administered until 11:26 PM (two {2} hours and twenty-six {26} minutes late) on [DATE], the 8:00 AM dose of [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and HCTZ was not administered until 1:44 PM (four {4} hours and forty-four {44} minutes late) on [DATE]; the [DATE], 8:00 PM dose of Levetiracetam, [MEDICATION NAME] and [MEDICATION NAME] was not administered until 4:51 AM on [DATE] (seven {7} hours and fifty-one {51 minutes late) and the [DATE], 8:00 AM doses of HCTZ, Lisinipril, Carvedilol, and Levetiracetam were administered at 10:58 AM (one {1} hour and fifty-eight (58) minutes late). Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 8:00 AM, revealed she starts at one (1) end of that hallway one (1) night and the other end of the hallway the next night, because she didn't want to give the residents' medications late two (2) nights in a row. She stated nurses have to pass medications, help the CNAs answer lights, check in medications and get all the treatments done and they were not able to get everything done that was assigned due to short staffing. Interview with Staffing Coordinator on [DATE] at 10:30 AM, and [DATE] at 11:00 AM, revealed the facility had enough staff to administer medication timely unless there was a call in and so far this month, We have had thirty-four (34) call in's so far. Interview with the Director of Nursing (DON), on [DATE] at 8:45 AM, revealed the facility utilizes the Resident Assessment Instrument (RAI) manual for care plan implementation and she expected the staff to follow the care plans. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #18 was discharged to the hospital on [DATE] and did not return to the facility. Resident #19 expired on [DATE]. The Physician was notified on [DATE] by the Director of Nursing that Residents #4, #8, #13 and A's and B's, medications were given at late times. Vital signs and pain evaluations to assess for change of condition were completed by the Charge Nurses, DON and/or ADON, Nurse Unit Managers, Nurse Educator and MDS Nurses by [DATE]. The DON notified the Physician on [DATE] that Residents #8, A, B, #4, and #13's medications were administered late. The Medication Administration Record [REDACTED]. This was completed by [DATE]. 2. Vital signs and pain evaluations were conducted on residents who resided on the South, Skilled B and West Units by the Charge Nurses and/or Nurse Management Team. The Nurse Management Team audited the MARs of these residents to identify issues. These audits were completed by [DATE]. Residents receiving medications on the South, Skilled B and West Units care plans were updated related to risk potential related to medication administered untimely on [DATE] by two (2) MDS Nurses. 3. Admission charts within the last thirty (30) days beginning [DATE] were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed [DATE]. 4. Time Studies were conducted on all shifts (three times) by Charge Nurses to determine the time needed to deliver medications. The studies were conducted from [DATE] through [DATE]. From these studies, the facility determined the optimum medication pass times in accordance with physician's orders [REDACTED]. Times will be adjusted in accordance to resident needs and Physician order [REDACTED]. 5. Train the trainer education (related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulins or [MEDICAL CONDITION] medications and/or refusal of three (3) consecutive doses of medication. The Regional Quality Manager provided this education to the DON and ADON on [DATE] prior to Licensed Nurse/KMA education. 6. In-servicing to current employed Licensed Nurses/Kentucky Medication Aides (KMA) by the Regional Quality Manager (RQM), Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulin or [MEDICAL CONDITION] medications and/or refusal of three (3) consecutive doses of medication. This education was started on [DATE] and completed on [DATE]. This education was started on [DATE] and completed on [DATE]. Licensed Nurses/KMAs on Family Medical Leave (FMLA) and vacation will be trained prior to return to work. New hires and any future use of agency nursing staff will be trained prior to taking position. (No agency staff use at this time) 7. Audits will be conducted weekly on five (5) residents with change of condition times four (4) weeks, then three (3) residents a week for eight (8) weeks to check that Physician notification was completed by the Nurse Management Team consisting of DON, ADON, Nurse Unit Managers, or MDS Nurses. These Audits began [DATE]. Starting [DATE], a member of the Nurse Management Team, which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses will observe three (3) residents three (3) times weekly for four (4) weeks then three (3) residents one (1) time weekly for eight (8) weeks for delivery of care including medication pass to check that the care plan is being followed. Monitoring will be rotated on different shifts. 8. Beginning [DATE], three (3) residents a week for four (4) weeks then one (1) resident weekly for eight (8) weeks will be interviewed by a member of the IDT to check that medication is timely and pain policy is being followed. 9. A Licensed Nurse and/or KMA will be observed for medication pass by a member of the Nurse Management Team which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses. Three (3) residents will be observed during medication administration pass three (3) times a week for four (4) weeks, then three (3) residents one (1) time a week for eight (8) weeks validating the medication pass is completed within the time required, documentation of medication, following physician's orders [REDACTED]. 10. Admission charts will be audited within seventy-two (72) hours of admission to check that care plans are in place by the Interdisciplinary Team, which consists of DON, ADON, Nurse Unit Managers, Nurse Educator, Social Service Director, Dietary Manager, and MDS Nurses. The Weekend Manager will review new admission care plans on weekends for completion. These audits will be done ongoing for twelve (12) weeks beginning [DATE]. 11. A QA meeting was held [DATE], upon notification of Immediate Jeopardy. In attendance were the Administrator, DON, ADON, MDS Nurse, Nurse Educator, and Medical Director. The purpose of this meeting was to review the deficient practice and begin the process of preparing the abatement plan. The meeting minutes were reviewed and approved by the Regional Quality Manager (RQM). A second QA meeting was held [DATE] with the Administrator, DON, ADON, Nurse Educator, MDS Nurse, Dietary Manager, Social Services, Maintenance and RQM in attendance. The status of the plan of correction development and action items was reviewed. This meeting was attended by and minutes approved by the RQM. 12. The facility will hold weekly QA meetings with at least one (1) Regional team member attending for four (4) weeks and then the facility will continue monthly thereafter. The QA committee will be reviewing the status of the Plan of Correction and audit results. The Regional team consists of the RQM, Regional Marketing Manager and Regional Reimbursement Manager and Regulatory Liaison. Members of the facility's QA committee consist of the minimum of the Administrator, DON, ADON, Dietary Manager, Business Office Manager and Social Services Manager with Medical Director participating at least quarterly and as needed. 13. The Governing Body Meeting will be held annually and with any change in the assigned management appointments or responsibilities. Oversight will be provided by the RDO. 14. In-servicing to the Administrator and DON on regulations governing QA meetings, how to properly conduct a meeting, and when to have a QA meeting was completed by the RQM on [DATE]. The Administrator covered this information with QA committee on [DATE]. 15. A Regional Team member will make a minimum of twice-weekly calls or visits to the facility for four (4) weeks to validate effective administrative actions are being taken in regards to facility operations and execution of plans of correction. These began on [DATE] and will continue until IJ is validated as removed and substantial compliance obtained. These calls will review the status of the actions outlined in the Plan of Corrections and ensure any potential follow-up from QA is addressed. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Residents #8, A, B, #4, and #13's record on [DATE] revealed the Physician had been notified on [DATE] of medications not administered timely. The DON completed review of resident MARs, ADON, Unit Nurse Managers, and MDS nurses to validate current orders related to medications not administered timely. Review of the AOC binder revealed the DON, ADON, Nurse Unit Manager, Nurse Educator and MDS Nurses completed the pain evaluations on residents #8, A, B, #4, and #13 on [DATE]. Current orders were validated. 2. Review of the AOC binder and resident records on [DATE], revealed all the residents residing on units South, Skilled B and West MARs were reviewed by the DON, ADON, Unit Nurse Managers and MDS nurses to validate current orders related to medications not administered timely. This was completed on [DATE]. Review of the AOC binder and resident records on [DATE], revealed the residents on South, Skilled B and West hall were evaluated for pain and vital signs completed by a member of the Nurse Management Team. This was completed on [DATE]. 3. Review of the AOC Binder revealed Admission charts within the last thirty days beginning [DATE] were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed [DATE]. 4. Review of the AOC Binder revealed time studies on all shifts was completed on [DATE] through [DATE]. The results of the studies were taken to the weekly QA meetings ([DATE] and [DATE]). 5. On [DATE], the State Survey Agency validated in-servicing was conducted for the DON and ADON related to notification of significant change and medications not administered according to physician's orders [REDACTED]. Review of the in-service records on [DATE] and interview with the RQM, DON, and ADON verified this in-servicing was completed [DATE]. Train the trainer education was verified as completed on [DATE] by the RQM by reviewing the in-service records of the DON/ADON related to the care plans as well as interview with the DON and ADON on [DATE] at 2:20 PM. 6. Review of the in-service records dated [DATE] and [DATE] revealed all facility Licensed Nurses and KMAs had received in-servicing except one that was on FMLA. That Licensed Nurse will receive the in-servicing on return to work. Forty-four (44) total staff received the training with only one that will receive the training on return to work. The DON will be responsible to ensure that training is provided to any new hires and the Licensed Nurse that will return to work from FMLA. Interviews on [DATE] with LPN #1 at 10:20 AM, CMA #17 at 9:50 AM, RN #1 at 12:58 PM, LPN #12 at 1:15 PM, CMA #18 at 1:30 PM, CMA #19 at 1:41 PM, RN #2 at 10:50 AM, LPN #9 at 12:05 PM, CMA #20 at 1:20 PM, CMA #21 at 1:30 PM, RN #5 at 2:10 PM, LPN #6 at 2:30 PM, and LPN #11 and RN #4 at 2:04 PM revealed they were in serviced on [DATE] - [DATE]. The inservice consisted of physician notification of medications not available, resident refusal of medications of the first dose for [MEDICAL CONDITION] and insulin medications and notification of third dose refusal on all other medications, medications not administered timely with a time frame of medication administration which changed to a four (4) hour time span for every day and twice a day medications except for insulin and [MEDICAL CONDITION] medications, and physician notification for resident change in condition. Interviews also revealed in-service consisted of documentation of physician notification. Further interview revealed two (2) care plans were to be developed within a twenty four (24) hour period after an admission according to the resident's needs. Interview revealed when the nurse obtains a new order for an as needed pain medication the nurse is to put the special requirement into the computer to remind the nurses to perform a pre-assessment and post assessment. The nurses are to perform the pre and post assessments for pain, not CMAs. Further interview revealed the in-service was conducted by the Regional

Based on interview, record review, facility policy review, and hospital records review, it was determined the facility's system to ensure it was free from significant medication errors was ineffective for four (4) of twenty (20) sampled residents (Residents #4, #8, #13, #18) and two (2) unsampled residents (Residents A and B). Resident #18 was admitted to the facility on [DATE], and the facility failed to notify the physician of the hospital Discharge Orders on 02/10/16 to obtain orders for insulin. On 02/11/16 at 7:30 AM, physician orders [REDACTED]. On 02/11/16 at 10:48 AM, Resident #18's finger stick blood sugar was obtained and the results were 435 milligrams/deciliter (mg/dl) (normal range 70-100} and stat doses of insulin were administered. On 02/12/16, Resident #18's accu-check was 76 mg/dL and the 4:30 PM dose of Humalog 12 U was withheld. However, insulin was administered at 5:25 PM and 9:58 PM; and, again on 02/13/16 at 6:00 AM without any documented evidence the resident's blood sugar had been monitored since the accu-check at 02/11/16 at 4:30 PM. On 02/13/16 at 7:35 AM, Resident #18 was identified as having a blood sugar level of twenty-eight (28) mg/dL (critical) and the resident was sent to the hospital and placed in the intensive care unit. The resident was diagnosed with [REDACTED]. In addition, the facility failed to ensure its system to prevent significant medication errors was effective for Residents #4, #8, #13, and Unsampled Residents A and B. The facility failed to identify the medications were being administered consistently late with some administered almost nine (9) hours late. The medications included insulin, blood pressure medications, pain medications, mood stabilizer medications, antipsychotic medication, hypnotics, anti-convulsive medications, and a [MEDICATION NAME] binder medication for [MEDICAL TREATMENT]. The facility's failure to ensure the facility was free of a significant medication error has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/09/16 and determined to exist on 02/10/16. The facility was notified of the Immediate Jeopardy on 05/09/16. An acceptable Allegation of Compliance (AoC) was received on 05/19/16 alleging the removal of the Immediate Jeopardy on 05/17/16. The State Survey Agency validated, on 05/20/16, the Immediate Jeopardy was removed on 05/20/16. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC), and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Clinical QAPI Daily Review Process, dated 07/02/14 revealed participants included the Director of Nursing Services (DON)/designee, Nurse Assessment Coordinator, and other nurse managers as directed. This policy stated the purpose was to review the admission charts and physician orders [REDACTED]. The nursing management team should review and identify what additional follow-up or documentation was required. The meeting should be held where a computer was available so electronic documentation was available for review. The nursing management team should attach orders and/or list the areas that need follow-up on the Clinical QAPI Daily Review Form and follow up the following day to review for completion. Additional follow-up reviews are completed during the weekly Quality Assurance meeting to ensure appropriate interventions are in place and documented in the medical record. Review of the facility's policy titled, Emergency Pharmacy Service and Emergency Kits (E-Kits), dated September 2010; revealed emergency pharmaceutical services were available on a twenty-four (24) hour basis. Contact information for emergency pharmacy services was posted at each nursing station including the telephone and fax numbers of the provider pharmacy and after-hours (on-call) telephone numbers. Review of the facility's policy titled, Administering Medications, dated December 2012 revealed the DON should supervise and direct all nursing personnel who administer medications and/or have related functions. Further review revealed, medications should be administered in accordance with the orders, including any required periods. Medications should be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). In addition, the individual administering the medication should initial the resident's Medication Administration Record [REDACTED]. 1. Record review revealed the facility admitted Resident #18 on 02/10/16 at 3:30 PM with diagnoses, which included Type II Diabetes Mellitus, Right Leg [MEDICAL CONDITION] (BKA), [MEDICAL CONDITIONS], Hypertension, and [MEDICAL CONDITION]. Review of the Hospital Discharge Orders, dated 02/10/16, revealed to administer: [MEDICATION NAME] (insulin), inject 17U into skin nightly, and inject 50 U into skin twice a day. Start date 02/10/16 with next dose due at 9:00 PM; Humalog (insulin) 100U, inject 12U twice a day before meals. Start date 02/10/16 with next dose due at 4:00 PM; [MEDICATION NAME] (oral diabetic medication) 850 mg one (1) tablet twice a day with meals. Start date 02/10/16 with next dose due on 02/11/16 (02/10/16 doses given at the hospital prior to admission). However, review of the physician's orders [REDACTED]. In addition, there was no evidence the resident received the medication on 02/11/16 prior to stat doses of insulin being administered. Further review revealed there were no facility physician's orders [REDACTED]. Review of Nursing Notes, dated 02/11/16 at 10:48 AM, documented by Registered Nurse (RN) #4, revealed a finger stick blood sugar was obtained and the results were 435 mg/dL. At 11:02 AM, Registered Nurse (RN) #4 spoke with the Primary Care Physician's (PCP) nurse regarding Resident #18's increased blood sugar level and an order was received for a stat dose of [MEDICATION NAME] Insulin 17U now and a stat dose of Humalog Insulin 12 U now (approximately nineteen (19) hours after admission). In addition, the nurse was to fax Resident #18's medication list for to the PCP to review. Review of the Nursing Notes, dated 02/11/16 at 1:54 PM, revealed the resident's blood sugar was obtained after the STAT dose of Insulin was given and the results were 362 mg/dL. At 3:02 PM, LPN #6 documented a finger stick blood sugar was obtained with results of 244 mg/dL. Attempts to contact RN #4 by phone on 05/10/16 at 1:30 PM and 3:00 PM and again on 05/26/16 at 11:06 AM (Post Survey) were unsuccessful. Review of Nursing Note, dated 02/11/16 at 7:21 PM, revealed Licensed Practical Nurse (LPN) #6 documented that at 3:45 PM, the PCP's office had been contacted again regarding Resident #18's complaint of pain and request for [MEDICATION NAME] due to phantom pain related to the right BKA. She documented she spoke with the PCP's Nurse and was told the PCP would be in the facility later in the day to write prescriptions for pain medication if needed. She wrote she offered to reposition the resident and attempted to reassure him/her; however, the resident declined the offer. Review of a Visit Summary, dated 02/11/16 at 8:00 PM, revealed Resident #18 was sent to a Primary Care Facility related to a complaint of Phantom limb syndrome with pain as the primary diagnosis. The resident was ordered [MEDICATION NAME] (narcotic pain medication) 10/325 mgs four (4) tablets only, one (1) tablet four (4) times a day and an order for [REDACTED].{16} hours after going to Primary Care Center). Review of Nursing Notes, dated 02/12/16 at 7:33 AM, revealed Resident #18 had been restless most of the night, and had several bowel movements with incontinence noted. The Physician had visited the resident that morning and wrote prescriptions for [MEDICATION NAME] (narcotic pain medications) and [MEDICATION NAME] (anti-anxiety). The prescriptions were faxed to the pharmacy at that time; however, review of the February 2016 MAR indicated [REDACTED]{4} hours and thirty {30} minutes after physician order [REDACTED]. Further review of the Nursing Note, dated 02/12/16 at 12:48 PM, revealed LPN #6 documented that at 11:45 AM that morning she spoke with the Pharmacist regarding the new [MEDICATION NAME] orders, and obtained a Drug Enforcement Agency (DEA) number to be able to administer [MEDICATION NAME] 10/325 mgs from the Emergency Dispensing Kit (EDK) for Resident #18's pain. She documented she administered it at 12:01 PM and at 12:51 PM; the resident's pain level was coming down. At 2:31 PM, she spoke with the pharmacy again related to the pain medications not having been delivered to the facility yet and was told the medications were in route after having left the pharmacy two (2) hours prior. Interview with LPN #6 (who worked with Resident #18 on 02/11/16 and 02/12/16 from 7 AM to 7 PM each day), on 05/10/16 at 9:13 AM, revealed she did not have a prescription on 02/11/16 to be able to call the pharmacy for an order to give medication out of the EDK. She stated she called the Physician's office on 02/11/16 at 3:45 PM, and was told by the Nurse the Physician would be in that afternoon to visit the resident and to write prescriptions for pain medications. She revealed the Physician did not come in until the following morning on 02/12/16 at 7:33 AM and he wrote prescriptions for narcotic pain medications. She stated the pharmacy was notified at 11:45 AM for a DEA number, which was required to give narcotic medications from the EDK. She further stated she was not sure why the pharmacy was not contacted until 11:45 AM after the prescriptions were written at 7:33 AM. LPN #6 stated she might have been in orientation and performing a medication pass leaving the responsibility to the other Charge Nurse (no longer employed) on duty who did not call the pharmacy. Further interview revealed the facility only had back up medications for narcotics and routine pills and there was no insulin in the EDK. Further review of the February 2016 MAR indicated [REDACTED]{2} hours and thirty (30) minutes late), Humalog Insulin 12 U at 6:42 AM, [MEDICATION NAME] Insulin 50 U at 7:45 AM. The facility withheld the resident's Humalog Insulin twelve (12) U due at 4:30 PM dose due to Resident #18's accu-check of 76 mg/dL. Further review of the February 2016 E-MAR revealed on 02/12/16, [MEDICATION NAME] 50 U was given at 5:25 PM, [MEDICATION NAME] 17 U was given at 9:58 PM, and [MEDICATION NAME] 50 U was given on 02/13/16 at 6:00 AM. However, there was no documented evidence an accu-check had been obtained since 02/12/16 at 5:25 PM (when the resident blood sugar was 76 mg/dL). Review of Nursing Notes, dated 02/13/16 at 8:05 AM, revealed the Charge Nurse entered Resident #18's room and he/she was only opening his/her eyes when responding to communication. A finger stick blood sugar was obtained with a reading of 28 mg/dL. Orange juice and Ensure were given with several packs of sugar. The resident's finger stick blood sugar was rechecked with a reading of twenty-seven (27). The Physician was notified and an order was obtained to administer [MEDICATION NAME], (fast acting sugar), one (1) mg Intramuscularly (IM) and to repeat in fifteen (15) minutes related to decreased blood sugar levels. The Physician was notified at 7:25 AM, and an order was obtained to send the resident to the Emergency Department for evaluation related to decreased blood sugar levels. Review of the Emergency Report, dated 02/13/16, revealed Resident #18 was assessed at 8:16 AM and was noted to present with altered mental status. Emergency Medical Services was unable to initiate an Intravenous (IV) line and the Chem Strip (check for blood glucose) was critically low with associated symptom of Hypothermia (decreased core body temperature). The resident's blood sugar, upon arrival to the Emergency Department was 44 mg/dL and his/her vital signs revealed a body temperature of 88 degrees Fahrenheit (normal: 98.7 F). Further review revealed Resident #18 was admitted to the Intensive Care Unit for blood sugar monitoring and for body temperature increase. Review of Hospital History & Physical, dated 02/13/16, revealed the hospital's impression was Resident #18 had Transient Alteration of Awareness, [DIAGNOSES REDACTED] due to insulin, Hypothermia probably could be side effect from [DIAGNOSES REDACTED], Type 1 Diabetes Mellitus with [DIAGNOSES REDACTED] and coma, Prolonged Q-T interval on electrocardiogram (ECG), [MEDICAL CONDITION] and Chronic combined systolic and diastolic [MEDICAL CONDITION]. The plan was for the resident to be placed on diabetes subcutaneous protocol and hold beta-blocker at that time due to severe [MEDICAL CONDITION]. Interview with Resident #18, on 05/09/16 at 12:40 PM, revealed he/she was admitted to the nursing facility on a Wednesday (02/10/16), and the facility did not have any medications to administer to him/her. The resident stated the nursing staff told him/her the medications had to come from another town, where their primary pharmacy was located. Resident #18 stated on the second day (02/11/16), he/she reported to nursing staff he/she still had not received any medications and was in pain. Also on this day, his/her blood sugar was high at 435 mg/dL due to the facility not having insulin to administer. Further interview revealed the resident stated, on a pain scale of one (1) to ten (10), his/her pain level was a seven (7) and the first night (02/10/16) he/she was at the nursing facility, he/she did not receive any pain medication. The resident stated he/she was not sure, when he/she received any pain medication on the second day (02/11/16). Resident #18 stated he/she called the physician himself/herself and went to a Care Center on 02/11/16 because the facility was not providing him/her any pain medication. Additionally, Resident #18 stated on the third (3rd) day (02/13/16), the facility gave him/her too much insulin which resulted in his/her blood sugar dropping to 24 mg/dL and he/she was hypothermic (low body core temperature) when he/she arrived at the Emergency Department. Interview (Post Survey) with Resident #18's Primary Care Physician (PCP), on 05/27/16 at 4:48 PM, revealed he was not aware of the resident's admission to the facility until 02/11/16 when the resident contacted him about his/her pain medications and Insulin. The Physician revealed he expected the resident to have his/her pain medication and especially his/her Insulin because the facility could have called a backup pharmacy to retrieve immediate medications, especially the Insulin. He stated he did not know why the resident did not have his/her medications on 02/10/16 when he/she was admitted because a Nurse Practitioner could have been called to get Insulin at a local pharmacy. He revealed in his opinion, there was no excuse for the resident to have gone without any medications. Interview with the DON, on 05/10/16 at 4:04 PM, revealed LPN #11 and RN #4 were no longer working at the facility and quit without giving notice. Further interview revealed the facility only had back up medications for narcotics and routine pills and no insulin in the EDK. 2. Record review revealed Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the April and May 2016 Physician order [REDACTED]. disorders/anticonvulsant) 500 mg at bedtime, [MEDICATION NAME] (anti-anxiety) 10 mg two (2) tablets twice a day, [MEDICATION NAME] (nerve pain) 300 mg three (3) times a day (tid), [MEDICATION NAME] 24,000 units (a pancreatic enzyme), two (2) capsules by mouth before meals. In addition the May 2016 Physician order [REDACTED]. Review of the April 2016 EMAR revealed the resident's 9:00 PM medications ([MEDICATION NAME], Trazadone, [MEDICATION NAME], Dantrolene Sodium, [MEDICATION NAME], and [MEDICATION NAME] Sodium DR) were not administered until 11:17 PM on 04/09/16 (one {1} hour and seventeen {17} minutes late); on 04/19/16, the 9:00 PM medications ([MEDICATION NAME], and Dantrolene Sodium) were not administered until 12:40 AM on 04/20/16 (two {2} hours and forty {40} minutes late); and the 04/20/16, 9:00 PM medications ([MEDICATION NAME] Sodium DR, [MEDICATION NAME], and Dantrolene Sodium) were not administered until 04/21/16 at 1:08 AM (three {3} hours and eight {8} minutes late. Further review of the April 2016 EMAR [MEDICATION NAME] 24,000 units was to be administered before meals at 8:00 AM, 12:00 PM, and 5:00 PM; however, on 04/08/16 it was administered at 10:10 AM (after the breakfast meal), on 04/02/16 it was administered at 1:05 PM (after the lunch meal); and on 04/05/16 it was administered at 1:16 PM (after the lunch meal). Review of the May 2016 EMAR revealed on 05/03/16, the 9:00 PM medications ([MEDICATION NAME], Trazadone, [MEDICATION NAME] Sodium DR, Dantrolene Sodium) were not administered until 05/04/16 at 12:43 AM (approximately two {2} hours and forty-three {43} minutes late). Further review revealed the [MEDICATION NAME] extended release (ER) was unavailable for administration on 05/04/16 because the facility was waiting for the pharmacy to deliver. Interview with the Staff Development Coordinator, on 05/11/16 at 1:54 PM, revealed Resident #4 usually eats meals in the dining room which is around 11:30 AM or 11:40 AM for lunch. 3. Record review revealed the facility admitted Resident #8 on 07/01/12 with diagnoses, which included Chronic Ischemic [MEDICAL CONDITIONS], Heart Failure, Cerebral Infarct, and [MEDICAL CONDITION]. Review of the April 2016 physician's orders [REDACTED]. Review of the April 2016 E-MAR revealed on 04/22/16, the resident's 9:00 AM medications ([MEDICATION NAME], and Adair Diskus) were not administered until 11:15 AM (one {1}hour and fifteen {15} minutes late); on 04/20/16, the 9:00 PM medication ([MEDICATION NAME] Diskus) was not administered until 04/21/16 at 12:25 AM (two {2} hours and twenty {20} minutes late); and the 04/25/16, 9:00 PM medication ([MEDICATION NAME] Diskus) was not administered until 04/26/16 at 12:22 AM (two {2} hours and twenty-two {22} minutes late). In addition, review of the May 2016 physician's orders [REDACTED].{1} hour and fifty-four {54} minutes late). 4. Record review revealed the facility admitted Resident #13 on 03/19/15 with diagnoses, which included End Stage [MEDICAL CONDITION], Dependence on [MEDICAL TREATMENT], Pain, [MEDICAL CONDITION], and Personal History of Malignant Neoplasm of [MEDICAL CONDITION]. Review of the April 2016 physician's orders [REDACTED].) tablet, give one (1) tablet by mouth on Tuesday, Thursday and Saturday at 12:00 when returns from [MEDICAL TREATMENT]. Give one (1) tablet by mouth every morning before food and drink at 6:00 AM on non-[MEDICAL TREATMENT] days. However, review of the April 2016 EMAR revealed the 8:00 AM dose of [MEDICATION NAME] was not administered on 04/14/16 and the 6:00 AM dose of [MEDICATION NAME] was not administered on 04/09/16, 04/12/16, and, on 04/14/16 it was not administered until 8:28 AM (one {1} hour and twenty-eight {28} minutes late). Further review revealed the 04/20/16, 9:00 PM dose of [MEDICATION NAME] was not administered until 04/21/16 at 12:01 (two {2} hours late) and the 04/28/16, 1:00 PM dose of [MEDICATION NAME] was not administered until 2:44 PM (forty-four {44} minutes late). Interview with Certified Medication Aide (CMA) #13, on 05/06/16 at 11:00 AM, revealed the medication was probably not administered before [MEDICAL TREATMENT] as he/she usually takes this medication before he/she leaves for [MEDICAL TREATMENT]. In addition, review of the May 2016 physician's orders [REDACTED]. Review of Departmental Notes, dated 05/04/16 at 2:07 PM, revealed Brintellix 20 mg scheduled for 05/04/16 at 12:00 PM requested STAT from pharmacy at 0800 and again at 11:30 AM. 5. Record review revealed the facility admitted Unsampled Resident A on 04/21/16 at 2:29 PM with [DIAGNOSES REDACTED]. Review of the April 2016 physician's orders [REDACTED].) times daily. Review of the April 2016 EMAR revealed [MEDICATION NAME] 3 mg scheduled for 9:00 PM and [MEDICATION NAME] 10 mg scheduled for 9:00 AM and 9:00 PM were not available for administration on 04/21/16 at 9:00 PM (day of admission). However, further review revealed the [MEDICATION NAME] was administered on 04/22/16 at 6:23 AM and again at 8:21 AM (only two {2} hours apart). Further review of the EMAR revealed on 04/26/16 the 9:00 PM medications ([MEDICATION NAME] and [MEDICATION NAME]) were not administered until 10:56 PM (fifty-six {56} minutes late). Interview with CMA #13, on 05/10/16 at 10:40 AM, revealed a note could be made in the computer or on the shift report sheet if a medication was late. However, she stated the next nurse coming on shift to pass medications could not see in the computer system that a medication had been given late. She further stated the paper report system was better but there was always room for error. 6. Record review revealed the facility admitted Unsampled Resident B on 09/09/15 with diagnoses, which included Chronic Pain, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux Disease, Polyarthritis, Convulsions, Hypertension, Major [MEDICAL CONDITIONS], and Gastrostomy ([DEVICE]). Review of the April and May 2016 physician's orders [REDACTED]. mg tablet, give one (1) tablet by mouth or per [DEVICE] two (2) times daily with meals. Further review of the May 2016 physician's orders [REDACTED]. Review of the April and May 2016 EMAR revealed the 8:00 AM dose of Carvedilol was not administered until 9:44 AM (forty-four {44} minutes late), and the 4:00 PM dose of [MEDICATION NAME] and Carvedilol was not administered until 6:26 PM (one {1}hour and twenty-six {26} minutes late) on 04/05/16; the 8:00 AM dose of [MEDICATION NAME], HCTZ, [MEDICATION NAME] and Carvedilol was not administered until 10:21 AM (one {1} hour and twenty-one {21} minutes late) on 04/06/16; the 8:00 AM dose of [MEDICATION NAME] was not administered until 10:20 AM (one {1} hour and twenty {20} minutes late) on 04/08/16; the 8:00 AM dose of [MEDICATION NAME], HCTZ, [MEDICATION NAME], and Carvedilol was not administered until 10:20 AM (one {1} hour and twenty {20} minutes late), and the 4:00 PM dose of [MEDICATION NAME] was administered at 5:00 PM on 4/09/16 (less than two {2} hours from previous dose when it is supposed to be administered every {6} hours) on 04/09/16; the 12:00 PM dose of [MEDICATION NAME] was not administered until 3:09 PM (two {2} hours and nine {9} minutes late; the 4:00 PM dose of [MEDICATION NAME] and Carvedilol was not administered until 7:55 PM on 04/14/16 (two {2} hours and fifty-five {55} minutes late); the 8:00 AM dose of [MEDICATION NAME] was not administered until 11:38 AM (two {2} hours and thirty-eight {38} minutes late) on 04/15/16; the 04/18/16, 8:00 PM dose of [MEDICATION NAME] was not administered until 04/19/16 at 1:09 AM (approximately four {4} hours late), the 04/19/16, 8:00 PM dose of [MEDICATION NAME] was not administered until 04/20/16 at 2:22 AM (five {5} hours and twenty-two {22} minutes late); the 8:00 AM dose of [MEDICATION NAME] and Carvedilol was not administered until 10:55 AM (one {1} hour and fifty-five {55} minutes late, and the 12:00 PM dose was not administered until 2:45 PM (one {1} hours and forty-five {45} minutes late) on 04/23/16; the 4:00 PM dose of [MEDICATION NAME] and Carvedililol was not administered until 6:51 PM (one {1} hour and fifty-one {51} minutes late), and the 8:00 PM dose was not administered until 11:26 PM (two {2} hours and twenty-six {26} minutes late) on 04/26/16, the 8:00 AM dose of [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and HCTZ was not administered until 1:44 PM (four {4} hours and forty-four {44} minutes late) on 04/30/16; the 05/03/16, 8:00 PM dose of Levetiracetam, [MEDICATION NAME] and [MEDICATION NAME] was not administered until 4:51 AM on 05/04/16 (seven {7} hours and fifty-one {51} minutes late) and the 05/04/16, 8:00 AM dose was administered at 11:25 AM (two and a half {2 1/2} hours later). Further review revealed the 8:00 AM doses of HCTZ, [MEDICATION NAME], Carvedilol, and Levetiracetam were administered at 10:58 AM ( one {1} hour and fifty-eight {58} minutes late). Interview with Certified Medication Aide (CMA) #6 on 05/06/16 revealed if a medication was not available she would call the pharmacy. She stated sometimes, she had to call the pharmacy a couple times to receive the medication. Interview with CMA #13 on 05/10/16 at 10:40 AM revealed Pharmacy can deliver as late as six (6) hours after notification. She stated that she could make a note in the computer regarding late medication but the next nurse would not see this information. Interview with LPN #10, on 05/16/16 at 4:21 PM, revealed it was difficult to pass medications on two (2) halls and be the nurse because there were quite a few residents. LPN #1 stated there have been occasions where You are the CNA and the Nurse. Interview with LPN #8 on 05/10/16 at 9:20 AM revealed that when she administers medications she would sign out the medications with her thumbprint to verify the medications had been given. She stated if medications were administered past the one (1) hour time, the physician should be notified and documented in the chart. If a medication was not available, the physician should also be notified. She stated Skilled Halls A and B have up to forty-four (44) residents and she had to pass medications to those residents herself as well. LPN #8 stated the Pharmacy has discussed with staff regarding protocol for ordering medications, but no policy book was available in the facility for new staff. Interview with LPN #2, on 05/05/16 at 8:00 AM, revealed there were a lot of call ins at the facility. She stated when there was only one (1) nurse working both skilled halls it was difficult to pass medications timely and therefore the nurse must prioritize. LPN #2 stated when someone calls in it is usually one half (1/2) hour to forty-five (45) minutes before their scheduled shift and the nurses get thrown in. She stated she might start at one end of the hall one night and the other end of the hall the next night so that the same resident does not receive late medications two (2) nights in a row. LPN #2 stated it was consistent that there was only one (1) nurse for Skilled Halls one (1) and two (2). She stated she could provide better care if she has ample help. LPN #2 stated that she was not aware of who to call to help fill in for the call ins. She revealed that orientation included one (1) day in the office with the Staff Development Coordinator (SDC); and, one (1) medication pass following someone, then you were handed the keys to the medication cart. She stated there were numerous times that residents were woken up at night for medications. Interview with LPN #3 on 05/05/16 at 1:10 PM revealed staffing has been an issue here since December 2015. She stated it was difficult to have to complete both Certified Nurse Aide (CNA) and Nurse Duties when there were call-ins. She revealed the facility wants us to get out on time but to make sure all our work is done with no overtime. Interview with RN #3 on 05/10/16 at 8:22 AM revealed administering late medications occurs when the nurse has to cover multiple halls. She stated some nights; a nurse was has to pass the medications and help the one (1) CNA. RN #3 stated she would have to prioritize depending on what medication it was, for example heart medication, insulin, and antibiotic, and she knew which resident require those medications. She stated she had spoken with the DON, ADON, and Administrator regarding late medications and was told more staff has been hired. She further revealed overtime has been available to nurses and CNAs to try to cover staffing but at times there were no staff available. Interview with the Staff Development Coordinator (SDC), on 05/04/16 at 1:25 PM, revealed she did not think anyone reviewed late medications and she was unaware of a computer report regarding late medications. She further stated she did not feel staff had enough time in orientation on the Electronic Medication Administration Record [REDACTED] Interview with the ADON on 05/04/16 at 1:55 PM revealed she was not aware of reports that would show medications that were administered late. She stated that the Director of Nursing (DON) (who is out of town) did not bring anything to the morning meeting regarding late medications. The ADON stated that she

Based on interview and record review, it was determined the facility failed to provide sufficient staff to provide nursing and related services to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident as determined by the residents' needs, physician's orders [REDACTED].#4, #8, and #13) and seven (7) unsampled residents (Residents A, B, C, E, F, G and H). The facility failed to ensure that sufficient qualified nursing staff was available to meet the residents' needs as evidenced by interviews with facility staff, and alert and oriented residents, revealing the facility staff administered medication late consistently, and residents having to wait extended periods of time for call lights to be answered, for assistance with toileting and assistance with being transferred to bed. The facility's failure to provide sufficient staff to provide nursing and related services to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated, on [DATE], the Immediate Jeopardy was removed on [DATE]. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC), and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's, Attendance and Tardiness Policy, (undated) revealed employee absenteeism negatively affects the ability of the nursing center to provide high quality care to residents on a consistent basis. While absenteeism has many causes, it creates additional burdens for employees who do report to work and increases the potential for hazardous situations in the Center. Interview with the Administrator, [DATE] at 8:45 AM, revealed they do not have a staffing policy. 1. Record review revealed the facility admitted Resident #4 with [DIAGNOSES REDACTED]. The resident's 9:00 PM medications were administered the next morning. [MEDICATION NAME] and [MEDICATION NAME] (for pain) were administered at 1:07 AM, and Trazadone and [MEDICATION NAME] were administered at 1:08 AM.[MEDICATION NAME](for treatment of [REDACTED]. The resident stated he/she had increased pain when medications were not administered timely. 2. Record review revealed the facility admitted Resident #8 on [DATE], with [DIAGNOSES REDACTED]. The resident's [MEDICATION NAME] and [MEDICATION NAME] (antihypertensive) and [MEDICATION NAME] (to prevent [MEDICAL CONDITION] attacks) were due at 9:00 PM and were administered at 11:39 PM, and [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) was administered as late as 12:15 AM (due at 9:00 PM). In addition, review of the Plan of Care, dated [DATE], revealed the resident had a risk for injury related to impaired balance, impaired range of motion and Guillian Barre. Further review revealed he/she required assistance of two (2) for transfers and to utilize the sit to stand lift. Interview with Resident #8 on [DATE] at 4:45 PM, revealed he/she was concerned there was not enough staff because there were times when only one (1) Certified Nursing Assistant (CNA) was available to put him/her to bed. The resident stated medications were administered very late on occasion for example one (1) night last week, it was 12:30 AM before we got our bedtime medication. The resident further stated it made him/her anxious when the medications were late. 3. Record review revealed the facility admitted Resident #13 with [DIAGNOSES REDACTED]. Resident #13 received medications late on multiple days. [MEDICATION NAME] (for pain), due to be administered at 9:00 PM, was documented as late as 12:00 AM; [MEDICATION NAME] ([MEDICATION NAME] binder for [MEDICAL TREATMENT]) was not given on one (1) occasion and [MEDICATION NAME] (for [MEDICAL CONDITION]) was administered late on two (2) occasions. Additionally, Brintellix (anti-depressant) was not available to be administered on one (1) occasion. 4. Record review revealed the facility admitted Unsampled Resident A with diagnoses, which included [MEDICAL CONDITION], Hypertension, Anxiety, and [MEDICAL CONDITION]. Three (3) of the resident's medications were not available for administration until [DATE], one (1) day after the resident's admission to the facility on [DATE]. The medications included [MEDICATION NAME] (antihypertensive), [MEDICATION NAME] (hormone regulating sleep and wake cycles) and [MEDICATION NAME] (for treating mental disorders). 5. Record review revealed the facility admitted Unsampled Resident B with [DIAGNOSES REDACTED]. He/she did not receive [MEDICATION NAME] (antihypertensive and heart failure), [MEDICATION NAME] (antihypertensive), and [MEDICATION NAME] (antihypertensive) until 1:44 PM; however, these medications were due at 8:00 AM. Additionally, Levetiracetam (anticonvulsant) was administered eight (8) hours and fifty-one (51) minutes late and the next dose was administered three (3) hours and thirty (30) minutes later. The medication was ordered to be administered two (2) times daily at 8:00 AM and 8:00 PM. 6. Record review revealed the facility admitted Unsampled Resident C on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated [DATE], revealed the facility assessed Unsampled Resident C's cognition as intact with a BIMS score of fifteen (15) indicating the resident was interviewable. Further review of the MDS assessment revealed the resident required set up help for Activities of Daily Living (ADLs). Interview with Unsampled Resident C, on [DATE] at 10:00 AM, revealed there have been times at night when residents were not given their medications on time. The resident stated he/she had been up late at night to receive his/her bedtime medications. The resident further stated he/she was not sure why his/her medications were late. 7. Record review revealed the facility admitted Unsampled Resident E on [DATE] with [DIAGNOSES REDACTED]. Review of an Admission MDS assessment, dated [DATE], revealed the facility assessed Unsampled Resident E's cognition as intact with a BIMS score of fifteen (15), indicating the resident was interviewable. Further review revealed the resident required extensive assistance with bed mobility and transfer and had limitations and impairment in lower extremities on both sides. Review of physician's orders [REDACTED]. Interview with Unsampled Resident E, on [DATE] at 8:45 AM, revealed the resident was concerned the facility had a staffing problem and some nights it takes over forty-five (45) minutes to find enough staff to put him/her to bed or get him/her out of bed. The resident further stated a lift was required to transfer him/her in and out of bed and it required two (2) staff members to use it. He/She stated it was frustrating to have to wait so long to get in or out of bed. 8. Record review revealed the facility admitted Unsampled Resident F on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS Assessment completed [DATE] revealed a BIMS' assessment of fifteen (15) indicating the resident was interviewable. Further review of the Quarterly MDS assessment revealed the resident was coded as always being incontinent of bowel and bladder. Interview with Unsampled Resident F, on [DATE] at 10:20 AM, revealed once in a while he/she receives his/her medications late when the nurse works two (2) halls. He/She stated, It takes a while to get to me and my roommate. He/She further revealed it depends on how many staff was working at night on how quickly the call lights were answered. The resident further stated there have been times when he/she had been incontinent and had to lay in it for a long time, and had gotten rashes and a sore bottom from it. 9. Record review revealed the facility admitted Unsampled Resident G on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment completed on [DATE] revealed a BIMS' assessment of fifteen (15) indicating the resident was interviewable. Review of physician's orders [REDACTED]. Further review of the MDS assessment revealed the resident required extensive assistance of two (2) staff for bed mobility, toilet use, and personal hygiene and was always incontinent of bowel. Interview with Unsampled Resident G on [DATE] at 10:15 AM revealed he/she had problems getting people to change his/her linens after a bowel movement. He/she further revealed the staff on nights was having problems. The resident stated they always make him/her feel like it is his/her fault when they have work to do. He/She stated that a few times they did not change his/her bed until the next morning when the bed was soiled. The resident further stated it made him/her feel bad and, I'm afraid it will make me have sores on my bottom from laying in the bowel movement. The resident stated, sometimes it is late when medication was given. He/she further revealed one (1) night the nurse did not bring his/her pain pill ([MEDICATION NAME] {narcotic pain medication}) at all, and he/she had to wait until the next morning to get it. 10. Record review revealed the facility admitted Unsampled Resident H on [DATE] with diagnoses, which included Diabetes, Heart Failure, Cerebral Infarction, and Difficulty in Walking. Review of the Annual MDS assessment dated [DATE], revealed a BIMS assessment score of thirteen (13) indicating the resident was interviewable. Further review of the assessment revealed the resident required extensive assistance with bed mobility, extensive assistance of one (1) for transfer and extensive assistance of two (2) for toilet use and personal hygiene. Interview with Unsampled Resident H on [DATE] at 9:50 AM revealed the staff had to wake him/her up to give him/her bedtime medications. The resident further revealed if he/she needed help, sometimes it took a long time because they were shorthanded. He/She stated that he/she had incontinent episodes in bed because they were shorthanded. The resident stated that it made him/her feel uncomfortable and embarrassed to be changed in the bed. Interview with Unsampled Resident D, on [DATE] at 8:50 AM, whom the facility assessed to have a BIMS' score of fifteen (15) which indicated he/she was interviewable, revealed the facility had staffing problems. The resident stated, Some nights we don't get the 9:00 PM medications until 1:00 AM or 2:00 AM. The resident further stated he/she, takes a pain pill and could cry because the pain is so bad. He/She revealed there was only one (1) nurse on the floor and stated, We never have a nurse aide scheduled to help. The resident revealed he/she kept towels and washcloths on the sink counter because he/she could not reach them if they put them in closet, and, There is not enough help here at night to get them for me. Interview with CNA #8, on [DATE] at 9:21 PM, revealed she thought the facility had been short staffed since [DATE]. She stated, It gets hard at night when we are understaffed. We get our work done but it's very hard. She further stated the facility recently had a no call no show and she had to work two (2) halls by herself. CNA #8 stated, They send out alerts to try to find help but that night they did not send the alert, and people in the office don't know what they are doing. She further stated a nurse called the on-call nurse and was told that was not her night to work even though she was the assigned on-call person. CNA #8 stated the residents complained staff was not fast enough getting their water and the nurses were not fast enough getting their Tylenol. Interview with CNA #9, on [DATE] at 8:25 AM, revealed We are always short, there should be three (3) of us on this hall today but there is only two (2). She stated there was a call in and there was staff working sixteen (16) hour shifts. When asked if this interfered with resident care, she stated, Yes, we rush as fast as we can go but there is so much we can do, we have to prioritize. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 8:00 AM, revealed when someone calls in it is usually one half (,[DATE]) hour to forty-five (45) minutes before their scheduled shift and the nurses get thrown in. She stated there was consistently only one (1) nurse working for both skilled halls and it was difficult to pass medications timely so the nurse must prioritize. She revealed she would rotate starting at different ends of the halls passing medication so the same resident would not receive late medications two (2) nights in a row. LPN #2 stated when there were call ins she did not know who to call to help fill in for the call ins. She stated residents are being woke up at night to administer their medications. She stated she could provide better care if she has ample help. Further interview revealed when hired nurses receive one day of orientation in the office with the Staff Development Coordinator (SDC) and follow one (1) nurse one (1) day while giving medications. She stated after that the nurses are handed the keys to the medication cart and begin working on their own. Interview with LPN #10, on [DATE] at 4:21 PM, revealed there were times when You are the CNA and the Nurse. She also stated it difficult to pass medications on two (2) halls and be the nurse because there were quite a few residents. Interview with LPN #3, on [DATE] at 1:10 PM revealed when there were call ins it was difficult to provide care as a nurse and try to perform the CNA duties also. She stated there has been a staffing issue since [DATE] but the facility wants us to make sure all of the work gets completed without any overtime. Interview with Registered Nurse (RN) #3 on [DATE] at 8:22 AM revealed there were nights when a nurse was passing the medications and having to help the one (1) CNA who was working. RN #3 stated she would prioritize the resident depending on what medication had to be administered, for example heart medication, insulin, and antibiotic and she knew which resident require those medications. She stated she had spoken with the DON, ADON, and Administrator regarding late medications and was told more staff had been hired. Interview with Staffing Coordinator on [DATE] at 10:30 AM and 1:25 PM, and on [DATE] at 11:00 AM, revealed she was responsible for fixing the schedule and placing it in the break room. She stated the Charge Nurses were to call the on call nurse if they had a call in to help find coverage. She stated if they could not fill the position with staff nurses the department heads were required to come in to fill the spot. The Staffing Coordinator stated if the Skilled A Hall did not have a scheduled nurse the Skilled B Hall Nurse was required to take half of the hallway and the North Hall Nurse was required to take the other half of the residents. She stated the facility has adequate coverage unless there was a call in and so far this month, We have had thirty-four (34) call in's. The Staffing Coordinator stated the facility had set goals to limit admissions due to staffing and their current resident census limit was not to admit over 110 residents. She stated they currently had seven (7) openings for licensed staff for the 7:00 AM -7:00 PM positions. She further stated she did not feel staff had enough time in orientation on the Electronic Medication Administration Record [REDACTED] Interview with the Administrator on [DATE] at 3:00 PM, revealed he was aware of the staffing issues, but he was not aware they were that low. The Administrator stated the staffing was based on a ratio of one (1) to seven (7) residents. He stated he expected the staff to call him when staffing was down to know what to do. He revealed he was not aware that there was only one (1) nurse at night for the Skilled Halls A and B; and that they did not have a CMA working with them. He stated he looked at the schedule every day but did not realize there were no CMAs and only one (1) nurse on the North Hall and no CNAs. He stated call ins have been his biggest challenge and he was aware that staffing was not sufficient in some instances. Interview with the Regional Director of Operations, on [DATE] at 2:50 PM, revealed he was not aware of staffing issues and concerns, that according to the People per Day (PPD) Report they were over staffed. He also stated the facility had a mock survey recently and no staffing issues were brought to his attention, but if there were issues with staffing he depended on the Administrator and Director of Nursing (DON) to notify him of the concerns. He stated there have been times in the past when the facility called him and asked to limit admissions until they could get staffing up. He stated they fix a staffing model based on the whole building and they take in consideration the acuity of the residents and he depends on the Administrator and DON to tell him the needs of the facility. He stated the facility has not had to utilize agency staffing but if they had requested it he would have provided it for them. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #18 was discharged to the hospital on [DATE] and did not return to the facility. Resident #19 expired on [DATE]. The Physician was notified on [DATE] by the Director of Nursing that Residents #4, #8, #13 and A and B, medications given at late times. Vital signs and pain evaluations to assess for change of condition were completed by the Charge Nurses, DON and/or ADON, Nurse Unit Managers, Nurse Educator and MDS Nurses by [DATE]. The DON notified the Physician on [DATE] that Residents #8, A, B, #4, and #13's medications were administered late. The Medication Administration Record [REDACTED]. This was completed by [DATE]. 2. Vital signs and pain evaluations were conducted on residents who resided on the South, Skilled B and West Units by the Charge Nurses and/or Nurse Management Team. The Nurse Management Team audited the MARs of these residents to identify issues. These audits were completed by [DATE]. Residents receiving medications on the South, Skilled B and West Units care plans were updated related to risk potential related to medication administered untimely on [DATE] by two (2) MDS Nurses. 3. Admission charts within the last thirty (30) days beginning [DATE] were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed [DATE]. 4. Time Studies were conducted on all shifts (three times) by Charge Nurses to determine the time needed to deliver medications. The studies were conducted from [DATE] through [DATE]. From these studies, the facility determined the optimum medication pass times in accordance with physician's orders [REDACTED]. Times will be adjusted in accordance to resident needs and Physician order [REDACTED]. 5. Train the trainer education (related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulins or [MEDICAL CONDITION] medications and/or refusal of three (3) consecutive doses of medication. The Regional Quality Manager provided this education to the DON and ADON on [DATE] prior to Licensed Nurse/KMA education. 6. In-servicing to current employed Licensed Nurses/Kentucky Medication Aides (KMA) by the Regional Quality Manager (RQM), Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulin or [MEDICAL CONDITION] medications and/or refusal of three (3) consecutive doses of medication. This education was started on [DATE] and completed on [DATE]. This education was started on [DATE] and completed on [DATE]. Licensed Nurses/KMAs on Family Medical Leave (FMLA) and vacation will be trained prior to return to work. New hires and any future use of agency nursing staff will be trained prior to taking position. (No agency staff use at this time) 7. Audits will be conducted weekly on five (5) residents with change of condition times four (4) weeks, then three (3) residents a week for eight (8) weeks to check that Physician notification was completed by the Nurse Management Team consisting of DON, ADON, Nurse Unit Managers, or MDS Nurses. These Audits began [DATE]. Starting [DATE], a member of the Nurse Management Team, which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses will observe three (3) residents three (3) times weekly for four (4) weeks then three (3) residents one (1) time weekly for eight (8) weeks for delivery of care including medication pass to check that the care plan is being followed. Monitoring will be rotated on different shifts. 8. Beginning [DATE], three (3) residents a week for four (4) weeks then one (1) resident weekly for eight (8) weeks will be interviewed by a member of the IDT to check that medication is timely and pain policy is being followed. 9. A Licensed Nurse and/or KMA will be observed for medication pass by a member of the Nurse Management Team which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses. Three (3) residents will be observed during medication administration pass three (3) times a week for four (4) weeks, then three (3) residents one (1) time a week for eight (8) weeks validating the medication pass is completed within the time required, documentation of medication, following physician's orders [REDACTED]. 10. Admission charts will be audited within seventy-two (72) hours of admission to check that care plans are in place by the Interdisciplinary Team, which consists of DON, ADON, Nurse Unit Managers, Nurse Educator, Social Service Director, Dietary Manager, and MDS Nurses. The Weekend Manager will review new admission care plans on weekends for completion. These audits will be done ongoing for twelve (12) weeks beginning [DATE]. 11. A QA meeting was held [DATE], upon notification of Immediate Jeopardy. In attendance were the Administrator, DON, ADON, MDS Nurse, Nurse Educator, and Medical Director. The purpose of this meeting was to review the deficient practice and begin the process of preparing the abatement plan. The meeting minutes were reviewed and approved by the Regional Quality Manager (RQM). A second QA meeting was held [DATE] with the Administrator, DON, ADON, Nurse Educator, MDS Nurse, Dietary Manager, Social Services, Maintenance and RQM in attendance. The status of the plan of correction development and action items was reviewed. This meeting was attended by and minutes approved by the RQM. 12. The facility will hold weekly QA meetings with at least one (1) Regional team member attending for four (4) weeks and then the facility will continue monthly thereafter. The QA committee will be reviewing the status of the Plan of Correction and audit results. The Regional team consists of the RQM, Regional Marketing Manager and Regional Reimbursement Manager and Regulatory Liaison. Members of the facility's QA committee consist of the minimum of the Administrator, DON, ADON, Dietary Manager, Business Office Manager and Social Services Manager with Medical Director participating at least quarterly and as needed. 13. The Governing Body Meeting will be held annually and with any change in the assigned management appointments or responsibilities. Oversight will be provided by the RDO. 14. In-servicing to the Administrator and DON on regulations governing QA meetings, how to properly conduct a meeting, and when to have a QA meeting was completed by the RQM on [DATE]. The Administrator covered this information with QA committee on [DATE]. 15. A Regional Team member will make a minimum of twice-weekly calls or visits to the facility for four (4) weeks to validate effective administrative actions are being taken in regards to facility operations and execution of plans of correction. These began on [DATE] and will continue until IJ is validated as removed and substantial compliance obtained. These calls will review the status of the actions outlined in the Plan of Corrections and ensure any potential follow-up from QA is addressed. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Residents #8, A, B, #4, and #13's record on [DATE] revealed the Physician had been notified on [DATE] of medications not administered timely. The DON completed review of resident MARs, ADON, Unit Nurse Managers, and MDS nurses to validate current orders related to medications not administered timely. Review of the AOC binder revealed the DON, ADON, Nurse Unit Manager, Nurse Educator and MDS Nurses completed the pain evaluations on residents #8, A, B, #4, and #13 on [DATE]. Current orders were validated. 2. Review of the AOC binder and resident records on [DATE], revealed all the residents residing on units South, Skilled B and West MARs were reviewed by the DON, ADON, Unit Nurse Managers and MDS nurses to validate current orders related to medications not administered timely. This was completed on [DATE]. Review of the AOC binder and resident records on [DATE], revealed the residents on South, Skilled B and West hall were evaluated for pain and vital signs completed by a member of the Nurse Management Team. This was completed on [DATE]. 3. Review of the AOC Binder revealed Admission charts within the last thirty (30) days beginning [DATE] were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed [DATE]. 4. Review of the AOC Binder revealed time studies on all shifts was completed on [DATE] through [DATE]. The results of the studies were taken to the weekly QA meetings ([DATE] and [DATE]). 5. On [DATE], the State Survey Agency validated in-servicing was conducted for the DON and ADON related to notification of significant change and medications not administered according to physician's orders [REDACTED]. Review of the in-service records on [DATE] and interview with the RQM, DON, and ADON verified this in-servicing was completed [DATE]. Train the trainer education was verified as completed on [DATE] by the RQM by reviewing the in-service records of the DON/ADON related to the care plans as well as interview with the DON and ADON on [DATE] at 2:20 PM. 6. Review of the in-service records dated [DATE] and [DATE] revealed all facility Licensed Nurses and KMAs had received in-servicing except one (1) that was on FMLA. That Licensed Nurse will receive the in-servicing on return to work. Forty-four (44) total staff received the training with only one (1) that will receive the training on return to work. The DON will be responsible to ensure that training is provided to any new hires and the Licensed Nurse that will return to work from FMLA. Interviews on [DATE] with LPN #1 at 10:20 AM, CMA #17 at 9:50 AM, RN #1 at 12:58 PM, LPN #12 at 1:15 PM, CMA #18 at 1:30 PM, CMA #19 at 1:41 PM, RN #2 at 10:50 AM, LPN #9 at 12:05 PM, CMA #20 at 1:20 PM, CMA #21 at 1:30 PM, RN #5 at 2:10 PM, LPN #6 at 2:30 PM, and LPN #11 and RN #4 at 2:04 PM revealed they were in serviced on [DATE] - [DATE]. The inservice consisted of physician notification of medications not available, resident refusal of medications of the first dose for [MEDICAL CONDITION] and insulin medications and notification of third dose refusal on all other medications, medications not administered timely with a time frame of medication administration which changed to a four (4) hour time span for every day and twice a day medications except for insulin and [MEDICAL CONDITION] medications, and physician notification for resident change in condition. Interviews also revealed in-service consisted of documentation of physician notification. Further interview revealed two (2) care plans were to be developed within a twenty four (24) hour period after an admission according to the resident's needs. Interview revealed when the nurse obtains a new order for an as needed pain medication the nurse is to put the special requirement into the computer to remind the nurses to perform a pre-assessment and post assessment. The nurses are to perform the pre and post assessments for pain, not CMAs. Further interview revealed the in-service was conducted by the Regional Quality Manager, DON, ADON, or SDC. 7. Review of audits was conducted on [DATE] to verify five (5) residents were audited. The audit dat

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents received routine and emergency drugs for two (2) of twenty (20) sampled residents (Residents #4 and #13); and, one (1) unsampled resident (Resident A). The facility failed to ensure its system to receive routine and emergency drugs was effective for Residents #4 and #13, and Unsampled Resident A. The medications unavailable for administration included Niaspan (used to prevent a lack of niacin in the body and decrease cholesterol), Brintellix (anti-depressant), Melatonin (sleep hormone), and Propranolol (beta blocker). The facility's failure to ensure the facility received routine and emergency drugs has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 05/09/16 and determined to exist on 02/10/16. The facility was notified of the Immediate Jeopardy on 05/09/16. An acceptable Allegation of Compliance (AoC) was received on 05/19/16 alleging the removal of the Immediate Jeopardy on 05/17/16. The State Survey Agency validated, on 05/20/16, the Immediate Jeopardy was removed on 05/20/16. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC), and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Emergency Pharmacy Service and Emergency Kits (E-Kits), dated September 2010; revealed emergency pharmaceutical services were available on a twenty-four (24) hour basis. Emergency needs for medication are met by using the nursing care center's approved emergency medication supply or by special order from the provider pharmacy. Emergency medications and supplies are provided by the pharmacy in compliance with applicable state and federal regulations. Procedures include: Contact information for emergency pharmacy services was posted at each nursing station including the telephone and fax numbers of the provider pharmacy and after-hours (on-call) telephone numbers. The provider pharmacy is contacted if an emergency arises requiring immediate pharmacist consultation regarding medications ordered and needed prior to the next scheduled pharmacy delivery. The ordered medication is obtained either from the emergency kit or from the provider pharmacy. 1. Record review revealed the facility admitted Resident #4 on 09/14/13 with [DIAGNOSES REDACTED]. Review of May 2016 physician's orders [REDACTED]. However, further review revealed the Niaspan extended release (ER) was unavailable for administration on 05/04/16 at 9:00 PM because the facility was waiting for the pharmacy to deliver the medication. Interview (Post Survey) with the Pharmacy Director, on 06/29/16 at 1:30 PM, revealed the facility was on demand refill which means the facility must submit electronically or call when a refill is required. She stated Resident #4's Niaspan was reordered by the facility electronically on 05/05/16 at 9:00 PM (forty-eight {48} hours after the last dose was administered). This medication was sent to the facility with the night delivery on 05/05/16; and, the facility received the medication on 05/06/16 at 3:23 AM. The resident did not receive the 9:00 PM dose of this medication on 05/04/16. 2. Record review revealed the facility admitted Resident #13 on 03/19/15 with [DIAGNOSES REDACTED]. Review of the May 2016 physician's orders [REDACTED]. However, review of the May 2016 EMAR revealed the 12:00 PM dose of Brintellix was not available on 05/03/16. Further review of the May 2016 EMAR revealed the resident did not receive the 12:00 PM dose on 05/03/16. This medication was not administered until 05/04/16 at 12:00 PM. Interview (Post Survey) with the Pharmacy Director, on 06/29/16 at 1:30 PM, revealed Resident #13's Brintellix was requested by the facility on 05/04/16 at 1:38 PM (over forty-eight ({48) hours after last dose administered). This medication was sent by the back up pharmacy on 05/04/16. The Pharmacy Director stated she did not see where the facility had notified pharmacy requesting a refill of the medication prior to that date. 3. Record review revealed the facility admitted Unsampled Resident A on 04/21/16 at 2:29 PM with [DIAGNOSES REDACTED]. Review of the April 2016 physician's orders [REDACTED]. However, review of the April 2016 EMAR revealed Melatonin 3 mg scheduled for 9:00 PM and Propranolol 10 mg scheduled for 9:00 AM and 9:00 PM were not available for administration on 04/21/16 at 9:00 PM (day of admission). The resident did not receive these medications on 04/21/16. Further review of the April 2016 EMAR revealed the Propranolol was not initialed as administered until 04/22/16 at 9:00 AM. The Melatonin was initialed as administered on 04/22/16 at 9:00 PM. Interview (Post Survey) with the Pharmacy Director, on 06/29/16 at 1:30 PM, revealed Unsampled Resident A's Propanolol and Melatonin were delivered on 04/22/16 at 1:44 AM. This was almost twelve {12} hours after the resident was admitted to the facility. The pharmacy called the facility at 5:50 PM on 04/21/16 and spoke to the ADON and she stated it was okay to send the medications with the night delivery. Interview (Post Survey) with the Pharmacy Director, on 06/23/16 at 12:47 PM, revealed the facility was responsible for obtaining the resident's narcotic scripts to send to the pharmacy. She stated the facility's system was to request refills electronically with their Electronic Medication Administration System. The Pharmacy Director stated the medications that were due for refill come over automatically into the computer system and then were available for the pharmacist to check in the computer with their query system. She further stated the pharmacy calls back up for a medication at the request of the facility. She stated the facility did not need to call the pharmacy if refills were electronically sent or faxed unless they were requesting the medication STAT. If the medications were faxed after the cut-off time, then the facility would need to request for the back-up pharmacy to send the medication, if needed and then there would be a four (4) hour turn around time from start to finish. Interview with the Staff Development Coordinator (SDC), on 05/06/16 at 2:45 PM, revealed all nurses and CMAs were educated in orientation related to ordering medications from the pharmacy. This included admissions, routine medications, and as needed (PRN) medications. Interview with Certified Medication Aide (CMA) #6, on 05/06/16 at 10:47 AM, revealed if a medication was not available she would call the pharmacy. She stated sometimes, she had to call the pharmacy a couple times to receive the medication. She further stated if the medication was available in the emergency box she would use the medication from there and order the rest of the medications stat from the pharmacy. Interview with CMA #13, on 05/10/16 at 10:40 AM and 11:00 AM, revealed the Pharmacy could deliver as late as six (6) hours after notification; but if the medication was not delivered then she would call the pharmacy again. She stated that she could make a note in the computer regarding late medication but the next nurse would not see this information as it does not appear on the MAR. She stated she would make a list of medications not available and send to the pharmacy. CMA #13 further stated she would call the pharmacy to find out when medications would be delivered and if not until the night delivery she would speak with the DON to receive approval for the charge nurse to obtain after hours from the local pharmacy as this happens often. She stated if a prescription was required for the back up pharmacy, the back up pharmacy may not receive the prescription until hours later after they had faxed and called the pharmacy requesting the medication being delivered stat. Interview with Licensed Practical Nurse (LPN) #4, on 05/06/16 at 10:50 AM, revealed it was the nurse's responsibility to put the orders in the computer and fax the physician's orders [REDACTED]. Interview with LPN #8, on 05/10/16 at 9:20 AM, revealed the Pharmacy had discussed with staff regarding protocol for ordering medications, but no policy book was available in the facility for new staff. She further revealed she faxed the pharmacy when she received a new physician's orders [REDACTED]. Interview with Registered Nurse (RN) #3, on 05/10/16 at 8:22 AM, revealed she did not know what pharmacy was their back-up pharmacy. Interview with the Assistant Director of Nursing (ADON), on 05/10/16 at 11:08 AM, revealed if there was a situation with the pharmacy she would call and ask as there was not a pharmacy manual to reference for staff. Further interview with the ADON, on 05/26/16 (post survey) at 10:50 AM revealed, when orders were put into the computer system, it automatically connected (linked) to the pharmacy so the pharmacy had the order immediately. The facility has a contract with the pharmacy for twenty-four (24) hours/seven (7) days a week medication delivery. If the medication does not make the delivery time of 5:00 PM, and 1:00 AM or 2:00 AM through the week (weekend delivery at random times), then the pharmacy was to deliver stat (immediately) to the facility; however, there was a six (6) hour turn around time from the time the order was received for stat medications because the pharmacy was out of town. Interview with the DON, on 05/11/16 at 8:45 AM, revealed she had discussed the pharmacy not delivering medications timely in morning meeting and then she would follow up with pharmacy after the meeting. She stated there was a form on each nursing unit to be filled out when a medication did not arrive from the pharmacy and this form was a reminder for staff to keep calling the pharmacy until the medication arrived. Further interview with the DON revealed she expected the staff to follow the policies regarding medication administration and obtaining medications. Interview with the Administrator, on 05/10/16 at 2:55 PM, revealed the morning meeting should have addressed the medication availability and he was aware there was a problem with pharmacy and medications. Interview with the Regional Director of Operations (RDO), on 05/10/16 at 1:12 PM revealed, the DON was responsible to ensure medications were taken care of in regards to resident needs. He stated he expected the staff to follow the policy for receiving medications from the pharmacy as well as the on-call pharmacy. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #18 was discharged to the hospital on [DATE] and did not return to the facility. Resident #19 expired on 02/21/16. The Physician was notified on 04/12/16 by the Director of Nursing that Residents #4, #8, #13 and A and B, medications given at late times. Vital signs and pain evaluations to assess for change of condition were completed by the Charge Nurses, DON and/or ADON, Nurse Unit Managers, Nurse Educator and MDS Nurses by 05/12/16. The DON notified the Physician on 05/12/16 that Residents #8, A, B, #4, and #13's medications were administered late. The Medication Administration Record [REDACTED]. This was completed by 05/12/16. 2. Vital signs and pain evaluations were conducted on residents who resided on the South, Skilled B and West Units by the Charge Nurses and/or Nurse Management Team. The Nurse Management Team audited the MARs of these residents to identify issues. These audits were completed by 05/15/16. Residents receiving medications on the South, Skilled B and West Units care plans were updated related to risk potential related to medication administered untimely on 05/11/16 by two (2) MDS Nurses. 3. Admission charts within the last thirty (30) days beginning 05/09/16 were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed 05/12/16. 4. Time Studies were conducted on all shifts (three times) by Charge Nurses to determine the time needed to deliver medications. The studies were conducted from 05/10/16 through 05/12/16. From these studies, the facility determined the optimum medication pass times in accordance with physician's orders [REDACTED]. Times will be adjusted in accordance to resident needs and Physician order [REDACTED]. 5. Train the trainer education (related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulins or seizure medications and/or refusal of three consecutive doses of medication. The Regional Quality Manager provided this education to the DON and ADON on 05/12/16 prior to Licensed Nurse/KMA education. 6. In-servicing to current employed Licensed Nurses/Kentucky Medication Aides (KMA) by the Regional Quality Manager (RQM), Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulin or seizure medications and/or refusal of three (3) consecutive doses of medication. This education was started on 05/12/16 and completed on 05/13/16. This education was started on 05/12/16 and completed on 05/13/16. Licensed Nurses/KMAs on Family Medical Leave (FMLA) and vacation will be trained prior to return to work. New hires and any future use of agency nursing staff will be trained prior to taking position. (No agency staff use at this time) 7. Audits will be conducted weekly on five (5) residents with change of condition times four (4) weeks, then three (3) residents a week for eight (8) weeks to check that Physician notification was completed by the Nurse Management Team consisting of DON, ADON, Nurse Unit Managers, or MDS Nurses. These Audits began 05/12/16. Starting 05/12/16, a member of the Nurse Management Team, which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses will observe three (3) residents three (3) times weekly for four (4) weeks then three (3) residents one (1) time weekly for eight (8) weeks for delivery of care including medication pass to check that the care plan is being followed. Monitoring will be rotated on different shifts. 8. Beginning 05/12/16, three (3) residents a week for four (4) weeks then one (1) resident weekly for eight (8) weeks will be interviewed by a member of the IDT to check that medication is timely and pain policy is being followed. 9. A Licensed Nurse and/or KMA will be observed for medication pass by a member of the Nurse Management Team which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses. Three (3) residents will be observed during medication administration pass three (3) times a week for four (4) weeks, then three (3) residents one (1) time a week for eight (8) weeks validating the medication pass is completed within the time required, documentation of medication, following physician's orders [REDACTED]. 10. Admission charts will be audited within seventy-two (72) hours of admission to check that care plans are in place by the Interdisciplinary Team, which consists of DON, ADON, Nurse Unit Managers, Nurse Educator, Social Service Director, Dietary Manager, and MDS Nurses. The Weekend Manager will review new admission care plans on weekends for completion. These audits will be done ongoing for twelve (12) weeks beginning 05/13/16. 11. A QA meeting was held 05/09/16, upon notification of Immediate Jeopardy. In attendance were the Administrator, DON, ADON, MDS Nurse, Nurse Educator, and Medical Director. The purpose of this meeting was to review the deficient practice and begin the process of preparing the abatement plan. The meeting minutes were reviewed and approved by the Regional Quality Manager (RQM). A second QA meeting was held 05/11/16 with the Administrator, DON, ADON, Nurse Educator, MDS Nurse, Dietary Manager, Social Services, Maintenance and RQM in attendance. The status of the plan of correction development and action items was reviewed. This meeting was attended by and minutes approved by the RQM. 12. The facility will hold weekly QA meetings with at least one (1) Regional team member attending for four (4) weeks and then the facility will continue monthly thereafter. The QA committee will be reviewing the status of the Plan of Correction and audit results. The Regional team consists of the RQM, Regional Marketing Manager and Regional Reimbursement Manager and Regulatory Liaison. Members of the facility ' s QA committee consist of the minimum of the Administrator, DON, ADON, Dietary Manager, Business Office Manager and Social Services Manager with Medical Director participating at least quarterly and as needed. 13. The Governing Body Meeting will be held annually and with any change in the assigned management appointments or responsibilities. Oversight will be provided by the RDO. 14. In-servicing to the Administrator and DON on regulations governing QA meetings, how to properly conduct a meeting, and when to have a QA meeting was completed by the RQM on 05/12/16. The Administrator covered this information with QA committee on 05/13/16. 15. A Regional Team member will make a minimum of twice-weekly calls or visits to the facility for four (4) weeks to validate effective administrative actions are being taken in regards to facility operations and execution of plans of correction. These began on 05/09/16 and will continue until IJ is validated as removed and substantial compliance obtained. These calls will review the status of the actions outlined in the Plan of Corrections and ensure any potential follow-up from QA is addressed. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Residents #8, A, B, #4, and #13's record on 05/20/16 revealed the Physician had been notified on 05/12/16 of medications not administered timely. The DON completed review of resident MARs, ADON, Unit Nurse Managers, and MDS nurses to validate current orders related to medications not administered timely. Review of the AOC binder revealed the DON, ADON, Nurse Unit Manager, Nurse Educator and MDS Nurses completed the pain evaluations on residents #8, A, B, #4, and #13 on 05/13/16. Current orders were validated. 2. Review of the AOC binder and resident records on 05/20/16, revealed all the residents residing on units South, Skilled B and West MARs were reviewed by the DON, ADON, Unit Nurse Managers and MDS nurses to validate current orders related to medications not administered timely. This was completed on 05/15/16. Review of the AOC binder and resident records on 05/20/16, revealed the residents on South, Skilled B and West hall were evaluated for pain and vital signs completed by a member of the Nurse Management Team. This was completed on 05/15/16. 3. Review of the AOC Binder revealed Admission charts within the last thirty (30) days beginning 05/09/16 were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed 05/12/16. 4. Review of the AOC Binder revealed time studies on all shifts was completed on 05/10/16 through 05/12/16. The results of the studies were taken to the weekly QA meetings (05/13/16 and 05/19/16). 5. On 05/20/16, the State Survey Agency validated in-servicing was conducted for the DON and ADON related to notification of significant change and medications not administered according to physician's orders [REDACTED]. Review of the in-service records on 05/20/16 and interview with the RQM, DON, and ADON verified this in-servicing was completed 05/12/16. Train the trainer education was verified as completed on 05/12/16 by the RQM by reviewing the in-service records of the DON/ADON related to the care plans as well as interview with the DON and ADON on 05/20/16 at 2:20 PM. 6. Review of the in-service records dated 05/12/16 and 05/13/16 revealed all facility Licensed Nurses and KMAs had received in-servicing except one that was on FMLA. That Licensed Nurse will receive the in-servicing on return to work. Forty-four (44) total staff received the training with only one (1) that will receive the training on return to work. The DON will be responsible to ensure that training is provided to any new hires and the Licensed Nurse that will return to work from FMLA. Interviews on 05/20/16 with LPN #1 at 10:20 AM, CMA #17 at 9:50 AM, RN #1 at 12:58 PM, LPN #12 at 1:15 PM, CMA #18 at 1:30 PM, CMA #19 at 1:41 PM, RN #2 at 10:50 AM, LPN #9 at 12:05 PM, CMA #20 at 1:20 PM, CMA #21 at 1:30 PM, RN #5 at 2:10 PM, LPN #6 at 2:30 PM, and LPN #11 and RN #4 at 2:04 PM revealed they were in serviced on 05/12/16 - 05/13/16. The inservice consisted of physician notification of medications not available, resident refusal of medications of the first dose for seizure and insulin medications and notification of third dose refusal on all other medications, medications not administered timely with a time frame of medication administration which changed to a four (4) hour time span for every day and twice a day medications except for insulin and seizure medications, and physician notification for resident change in condition. Interviews also revealed in-service consisted of documentation of physician notification. Further interview revealed two (2) care plans were to be developed within a twenty four (24) hour period after an admission according to the resident's needs. Interview revealed when the nurse obtains a new order for an as needed pain medication the nurse is to put the special requirement into the computer to remind the nurses to perform a pre-assessment and post assessment. The nurses are to perform the pre and post assessments for pain, not CMAs. Further interview revealed the in-service was conducted by the Regional Quality Manager, DON, ADON, or SDC. 7. Review of audits was conducted on 05/20/16 to verify five (5) residents were audited. The audit dates were 05/13/16 and 05/16/16. Interviews on 05/20/16 with the DON at 2:20 PM and the ADON on 05/20/16 at 2:42 PM revealed the week of completion of the audits would be the week of July 29, 2016 with the DON, ADON, Unit Managers, and MDS Nurses conducting the Audits. 8. Interviews with residents on 05/12/16 by Unit Charge Nurses related to timeliness of medication and pain protocol was being followed. 9. Review by the State Survey Agency on 05/20/16 verified medication pass was audited on three Licensed Nurses and KMAs. Those medication pass observations were verified completed on 05/12/16, 05/14/16, 05/15/16, 05/16/16, and 05/17/16. 10. Review of the AOC binder on 05/20/16 verified new admission charts within the last thirty (30) days, had been audited by MDS Nurses to ensure a care plan was in place. The weekend manager (Department Head) to review for any new admission charts for care plans on weekends and these audits will be completed by week of 06/29/16. The weekly QA related to these audits to be completed by 06/03/16. This was verified completed 05/12/16. 11. Review of the AOC binder revealed a QA meeting held on 05/09/16 with attendees listed including the RQM. The second meeting on 05/11/16 held to verify status of the plan of correction development and action items reviewed. 12. Interview with the Administrator and DON, on 05/20/16 at 2:20 PM and review of the AOC binder on 05/20/16, revealed a QA meeting was held on 05/13/16 and 05/19/16. The meetings will continue weekly being completed by 06/03/16 and then will be monthly thereafter. 13. A Governing Body meeting was conducted 05/12/16, attended by the Administrator, DON, RQM, RDO, and Medical Director. The roles and understanding of the roles of these positions was reviewed. The Governing Body to meet annually and with any change in assigned management appointments or responsibilities. 14. Review of the AOC Binder revealed In-servicing to the Administrator and DON on how to conduct a QA meeting, and when to have a meeting was conducted by the RQM on 05/12/16 and was covered with the QA committee on 05/13/16 by the Administrator. 15. A Regional team member, RDO, RQM will make a minimum of two (2) times a week calls to the facility or visit the facility for four (4) weeks. The RQM has been at the facility weekly starting on 05/09/16. These visits and/or calls to continue until IJ removed. These visits and/or calls to validate effective administrative actions related to facility operations and execution of plan of correction. Interview with the RQM on 05/20/16 at 2:35 PM validated these visits and/or calls.

Based on interview, record review, and facility policy it was determined the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were accurately documented for three (3) of twenty (20) sampled residents (Residents #4, #8, and #13); and, two (2) unsampled residents (Residents A and B). The facility's system for documenting medication administration times showed medications were administered at the physician ordered times on the Electronic Medication Record (E-MAR). However, the medications were actually administered up to nine (9) hours late and Administration was unaware that there was a report that showed the actual times the medications were administered. This failure caused the facility staff to not be aware medications were administered late. The facility's failure to ensure the clinical record was accurate has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated, on [DATE], the Immediate Jeopardy was removed on [DATE]. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC), and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Administering Medications dated [DATE] revealed, the individual administering the medication will record in the medical record the date and time the medication was administered. 1. Record review revealed Resident #4 was admitted on [DATE] with diagnoses, which included Chronic Pancreatitis, Restless Leg Syndrome, Guillain-Barr Syndrome, Low Back Pain, Neck Pain, Major [MEDICAL CONDITIONS], and Cerebellar Ataxia. Review of the [DATE] EMAR (electronic MAR) revealed on [DATE], [DATE], and [DATE], staff documented [MEDICATION NAME], Trazadone, [MEDICATION NAME], Dantrolene Sodium, [MEDICATION NAME], and [MEDICATION NAME] Sodium DR were administered at 9:00 PM per physician's orders [REDACTED]. Review of the [DATE] EMAR revealed on [DATE], [DATE], [DATE], staff documented [MEDICATION NAME] 24,000 units was administered before meals at 8:00 AM and 12:00 PM per physician's orders [REDACTED]. Review of the [DATE] EMAR revealed on [DATE], staff documented they administered [MEDICATION NAME], Trazadone, [MEDICATION NAME] Sodium DR, and Dantrolene Sodium at 9:00 PM. However, review of the computer generated individual resident administration times revealed the medication was administered on [DATE] at 12:43 AM. 2. Record review revealed the facility admitted Resident #8 on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] and [DATE] E-MAR revealed on [DATE], staff initialed [MEDICATION NAME], and Adair Diskus was administered at 9:00 AM per physician's orders [REDACTED]. On [DATE], [DATE], [DATE], and [DATE] staff documented [MEDICATION NAME] Diskus was administered at 9:00 PM per physician's orders [REDACTED]. 3. Record review revealed the facility admitted Resident #13 on [DATE] with diagnoses, which included End Stage [MEDICAL CONDITION], Dependence on [MEDICAL TREATMENT], Pain, [MEDICAL CONDITION], and Personal History of Malignant Neoplasm of [MEDICAL CONDITION]. Review of the [DATE] EMAR revealed on [DATE], staff documented [MEDICATION NAME] was administered at 6:00 AM per physician orders. However, review of the computer generated individual resident administration time, revealed the medication was administered at 8:28 AM. On [DATE], staff documented [MEDICATION NAME] was administered at 9:00 PM. However, review of the computer generated individual resident administration time, revealed it was administered on [DATE] at 12:01 AM. On [DATE], staff documented [MEDICATION NAME] was administered at 1:00 PM; however, review of computer generated individual resident administration time revealed it was administered at 2:44 PM. 4. Record review revealed the facility admitted Unsampled Resident A on [DATE] at 2:29 PM with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated [DATE], revealed the facility assessed Unsampled Resident A's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. Review of the [DATE] EMAR revealed on [DATE], staff documented [MEDICATION NAME] was administered at 9:00 PM per physician's orders [REDACTED]. Further review revealed on [DATE], staff documented [MEDICATION NAME] and Trazadone were administered at 9:00 PM; however, review of computer generated individual resident administration time, revealed the medication was administered at 10:56 PM. 5. Record review revealed the facility admitted Unsampled Resident B on [DATE] with diagnoses, which included Chronic Pain, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux Disease, Polyarthritis, Convulsions, Hypertension, Major [MEDICAL CONDITIONS], and Gastrostomy ([DEVICE]). Review of the April and [DATE] EMAR and computer generated medication administration times revealed on [DATE] staff documented Carvedilol was administered at 8:00 AM; however, it was administered at 9:44 AM; and, [MEDICATION NAME] and Carvedilol were documented as given at 4:00 PM; however, the medication was administered at 6:26 PM. On [DATE], staff documented [MEDICATION NAME], HCTZ (Mazide), [MEDICATION NAME] and Carvedililol were administered at 8:00 AM; however, the medication was administered at 10:21 AM. On [DATE], [MEDICATION NAME] was documented as given at 8:00 AM but was given at 10:20 AM. On [DATE], staff documented [MEDICATION NAME], HCTZ, [MEDICATION NAME], and Carvedilol were administered at 8:00 AM but was given at 10:20 AM. On [DATE], [MEDICATION NAME] was documented as given at 12:00 PM but was administered at 3:09 PM, and [MEDICATION NAME] and Carvedilol were documented as given at 4:00 PM but were not administered until 7:55 PM. On [DATE], [MEDICATION NAME] was documented as given at 8:00 AM but was administered at 11:38 AM. On [DATE], [MEDICATION NAME] was documented as given at 8:00 PM but was given on [DATE] at 1:09 AM. On [DATE], [MEDICATION NAME] was documented as given at 8:00 PM but was given at [DATE] at 2:22 AM. On [DATE], [MEDICATION NAME] and Carvedilol was documented as given at 8:00 AM but was given at 10:55 AM, and the 12:00 PM dose was documented as given at 12:00 PM but was given at 2:45 PM. On [DATE], [MEDICATION NAME] and Carvedililol were documented as given at 4:00 PM but were given at 6:51 PM. On [DATE], the [MEDICATION NAME] and Carvedililol were documented as given at 8:00 PM but were given at 11:26 PM. On [DATE], [MEDICATION NAME], Carvedilol, [MEDICATION NAME], and HCTZ were documented as given at 8:00 AM but were given at 1:44 PM. On [DATE], Levetiracetam, [MEDICATION NAME] and [MEDICATION NAME] were documented as given at 8:00 PM, but were given at 4:51 AM on [DATE]. On [DATE], staff documented the medication was given at 8:00 AM but was actually given at 11:25 AM. Interview with the Staff Development Coordinatior (SDC), on [DATE] at 10:15 AM, revealed she was not aware of anyone reviewing late medications, nor how to pull a computer generated report showing when medications were administered. Further interview with the SDC, on [DATE] at 9:55 AM, revealed when a nurse clicked a medication and signed it out, that was the time the medication was administered which appeared on the computer generated screen. Interview with Registered Nurse (RN) #3, on [DATE] at 8:22 AM, revealed times could be looked up in the computer when medications were actually administered. She further revealed when she clicked administered and signed electronically, that was the time it was recorded in the computer; however, was not visible on the MAR or TAR. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 1:55 PM, revealed she was not aware there were nursing reports that would show the actual time that medications were administered, which indicated they were late. She further stated she was not very familiar with the computer system. Interview with the Director of Nursing (DON), on [DATE] at 8:45 AM, revealed she did not pull a report regarding late medications and she was not aware of such a report. She stated the EMARs showed the medication was administered at the appropriate times. The DON stated she, the ADON, and Unit Manager were expected to monitor late medications. Interview with the Administrator, on [DATE] at 3:00 PM, revealed he expected all staff to follow physician's orders [REDACTED]. He stated he thought when a staff member clicked administration of a medication that was the time the medication was administered and it would be recorded on the MAR/TAR and was not aware of a separate area and report for exact administration time of medications. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #18 was discharged to the hospital on [DATE] and did not return to the facility. Resident #19 expired on [DATE]. The Physician was notified on [DATE] by the Director of Nursing that Residents #4, #8, #13 and A and B, medications given at late times. Vital signs and pain evaluations to assess for change of condition were completed by the Charge Nurses, DON and/or ADON, Nurse Unit Managers, Nurse Educator and MDS Nurses by [DATE]. The DON notified the Physician on [DATE] that Residents #8, A, B, #4, and #13's medications were administered late. The Medication Administration Record (MAR) for Residents #8, #4, #13, A, and B were reviewed by the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses to validate current orders. This was completed by [DATE]. 2. Vital signs and pain evaluations were conducted on residents who resided on the South, Skilled B and West Units by the Charge Nurses and/or Nurse Management Team. The Nurse Management Team audited the MARs of these residents to identify issues. These audits were completed by [DATE]. Residents receiving medications on the South, Skilled B and West Units care plans were updated related to risk potential related to medication administered untimely on [DATE] by two (2) MDS Nurses. 3. Admission charts within the last thirty (30) days beginning [DATE] were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed [DATE]. 4. Time Studies were conducted on all shifts (three times) by Charge Nurses to determine the time needed to deliver medications. The studies were conducted from [DATE] through [DATE]. From these studies, the facility determined the optimum medication pass times in accordance with physician's orders [REDACTED]. Times will be adjusted in accordance to resident needs and Physician order [REDACTED]. 5. Train the trainer education (related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulin or [MEDICAL CONDITION] medications and/or refusal of three consecutive doses of medication. The Regional Quality Manager provided this education to the DON and ADON on [DATE] prior to Licensed Nurse/KMA education. 6. In-servicing to current employed Licensed Nurses/Kentucky Medication Aides (KMA) by the Regional Quality Manager (RQM), Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulin or [MEDICAL CONDITION] medications and/or refusal of three (3) consecutive doses of medication. This education was started on [DATE] and completed on [DATE]. This education was started on [DATE] and completed on [DATE]. Licensed Nurses/KMAs on Family Medical Leave (FMLA) and vacation will be trained prior to return to work. New hires and any future use of agency nursing staff will be trained prior to taking position. (No agency staff use at this time) 7. Audits will be conducted weekly on five (5) residents with change of condition times four (4) weeks, then three (3) residents a week for eight (8) weeks to check that Physician notification was completed by the Nurse Management Team consisting of DON, ADON, Nurse Unit Managers, or MDS Nurses. These Audits began [DATE]. Starting [DATE], a member of the Nurse Management Team, which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses will observe three (3) residents three (3) times weekly for four (4) weeks then three (3) residents one (1) time weekly for eight (8) weeks for delivery of care including medication pass to check that the care plan is being followed. Monitoring will be rotated on different shifts. 8. Beginning [DATE], three (3) residents a week for four (4) weeks then one (1) resident weekly for eight (8) weeks will be interviewed by a member of the IDT to check that medication is timely and pain policy is being followed. 9. A Licensed Nurse and/or KMA will be observed for medication pass by a member of the Nurse Management Team which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses. Three (3) residents will be observed during medication administration pass three (3) times a week for four (4) weeks, then three (3) residents one (1) time a week for eight (8) weeks validating the medication pass is completed within the time required, documentation of medication, following physician's orders [REDACTED]. 10. Admission charts will be audited within seventy-two (72) hours of admission to check that care plans are in place by the Interdisciplinary Team, which consists of DON, ADON, Nurse Unit Managers, Nurse Educator, Social Service Director, Dietary Manager, and MDS Nurses. The Weekend Manager will review new admission care plans on weekends for completion. These audits will be done ongoing for twelve (12) weeks beginning [DATE]. 11. A QA meeting was held [DATE], upon notification of Immediate Jeopardy. In attendance were the Administrator, DON, ADON, MDS Nurse, Nurse Educator, and Medical Director. The purpose of this meeting was to review the deficient practice and begin the process of preparing the abatement plan. The meeting minutes were reviewed and approved by the Regional Quality Manager (RQM). A second QA meeting was held [DATE] with the Administrator, DON, ADON, Nurse Educator, MDS Nurse, Dietary Manager, Social Services, Maintenance and RQM in attendance. The status of the plan of correction development and action items was reviewed. This meeting was attended by and minutes approved by the RQM. 12. The facility will hold weekly QA meetings with at least one (1) Regional team member attending for four (4) weeks and then the facility will continue monthly thereafter. The QA committee will be reviewing the status of the Plan of Correction and audit results. The Regional team consists of the RQM, Regional Marketing Manager and Regional Reimbursement Manager and Regulatory Liaison. Members of the facility's QA committee consist of the minimum of the Administrator, DON, ADON, Dietary Manager, Business Office Manager and Social Services Manager with Medical Director participating at least quarterly and as needed. 13. The Governing Body Meeting will be held annually and with any change in the assigned management appointments or responsibilities. Oversight will be provided by the RDO. 14. In-servicing to the Administrator and DON on regulations governing QA meetings, how to properly conduct a meeting, and when to have a QA meeting was completed by the RQM on [DATE]. The Administrator covered this information with QA committee on [DATE]. 15. A Regional Team member will make a minimum of twice-weekly calls or visits to the facility for four (4) weeks to validate effective administrative actions are being taken in regards to facility operations and execution of plans of correction. These began on [DATE] and will continue until IJ is validated as removed and substantial compliance obtained. These calls will review the status of the actions outlined in the Plan of Corrections and ensure any potential follow-up from QA is addressed. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Residents #8, A, B, #4, and #13's record on [DATE] revealed the Physician had been notified on [DATE] of medications not administered timely. The DON completed review of resident MARs, ADON, Unit Nurse Managers, and MDS nurses to validate current orders related to medications not administered timely. Review of the AOC binder revealed the DON, ADON, Nurse Unit Manager, Nurse Educator and MDS Nurses completed the pain evaluations on residents #8, A, B, #4, and #13 on [DATE]. Current orders were validated. 2. Review of the AOC binder and resident records on [DATE], revealed all the residents residing on units South, Skilled B and West MARs were reviewed by the DON, ADON, Unit Nurse Managers and MDS nurses to validate current orders related to medications not administered timely. This was completed on [DATE]. Review of the AOC binder and resident records on [DATE], revealed the residents on South, Skilled B and West hall were evaluated for pain and vital signs completed by a member of the Nurse Management Team. This was completed on [DATE]. 3. Review of the AOC Binder revealed Admission charts within the last thirty (30) days beginning [DATE] were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed [DATE]. 4. Review of the AOC Binder revealed time studies on all shifts was completed on [DATE] through [DATE]. The results of the studies were taken to the weekly QA meetings ([DATE] and [DATE]). 5. On [DATE], the State Survey Agency validated in-servicing was conducted for the DON and ADON related to notification of significant change and medications not administered according to physician's orders [REDACTED]. Review of the in-service records on [DATE] and interview with the RQM, DON, and ADON verified this in-servicing was completed [DATE]. Train the trainer education was verified as completed on [DATE] by the RQM by reviewing the in-service records of the DON/ADON related to the care plans as well as interview with the DON and ADON on [DATE] at 2:20 PM. 6. Review of the in-service records dated [DATE] and [DATE] revealed all facility Licensed Nurses and KMAs had received in-servicing except one that was on FMLA. That Licensed Nurse will receive the in-servicing on return to work. Forty-four (44) total staff received the training with only one (1) that will receive the training on return to work. The DON will be responsible to ensure that training is provided to any new hires and the Licensed Nurse that will return to work from FMLA. Interviews on [DATE] with LPN #1 at 10:20 AM, CMA #17 at 9:50 AM, RN #1 at 12:58 PM, LPN #12 at 1:15 PM, CMA #18 at 1:30 PM, CMA #19 at 1:41 PM, RN #2 at 10:50 AM, LPN #9 at 12:05 PM, CMA #20 at 1:20 PM, CMA #21 at 1:30 PM, RN #5 at 2:10 PM, LPN #6 at 2:30 PM, and LPN #11 and RN #4 at 2:04 PM revealed they were in serviced on [DATE] - [DATE]. The inservice consisted of physician notification of medications not available, resident refusal of medications of the first dose for [MEDICAL CONDITION] and insulin medications and notification of third dose refusal on all other medications, medications not administered timely with a time frame of medication administration which changed to a four (4) hour time span for every day and twice a day medications except for insulin and [MEDICAL CONDITION] medications, and physician notification for resident change in condition. Interviews also revealed in-service consisted of documentation of physician notification. Further interview revealed two (2) care plans were to be developed within a twenty four (24) hour period after an admission according to the resident's needs. Interview revealed when the nurse obtains a new order for an as needed pain medication the nurse is to put the special requirement into the computer to remind the nurses to perform a pre-assessment and post assessment. The nurses are to perform the pre and post assessments for pain, not CMAs. Further interview revealed the in-service was conducted by the Regional Quality Manager, DON, ADON, or SDC. 7. Review of audits was conducted on [DATE] to verify five (5) residents were audited. The audit dates were [DATE] and [DATE]. Interviews on [DATE] with the DON at 2:20 PM and the ADON on [DATE] at 2:42 PM revealed the week of completion of the audits would be the week of [DATE] with the DON, ADON, Unit Managers, and MDS Nurses conducting the Audits. 8. Interviews with residents on [DATE] by Unit Charge Nurses related to timeliness of medication and pain protocol was being followed. 9. Review by the State Survey Agency on [DATE] verified medication pass was audited on three Licensed Nurses and KMAs. Those medication pass observations were verified completed on [DATE], [DATE], [DATE], [DATE], and [DATE]. 10. Review of the AOC binder on [DATE] verified new admission charts within the last thirty days, had been audited by MDS Nurses to ensure a care plan was in place. The weekend manager (Department Head) to review for any new admission charts for care plans on weekends and these audits will be completed by week of [DATE]. The weekly QA related to these audits to be completed by [DATE]. This was verified completed [DATE]. 11. Review of the AOC binder revealed a QA meeting held on [DATE] with attendees listed including the RQM. The second meeting on [DATE] held to verify status of the plan of correction development and action items reviewed. 12. Interview with the Administrator and DON, on [DATE] at 2:20 PM and review of the AOC binder on [DATE], revealed a QA meeting was held on [DATE] and [DATE]. The meetings will continue weekly being completed by [DATE] and then will be monthly thereafter. 13. A Governing Body meeting was conducted [DATE], attended by the Administrator, DON, RQM, RDO, and Medical Director. The roles and understanding of the roles of these positions was reviewed. The Governing Body to meet annually and with any change in assigned management appointments or responsibilities. 14. Review of the AOC Binder revealed In-servicing to the Administrator and DON on how to conduct a QA meeting, and when to have a meeting was conducted by the RQM on [DATE] and was covered with the QA committee on [DATE] by the Administrator. 15. A Regional team member, RDO, RQM will make a minimum of two (2) times a week calls to the facility or visit the facility for four (4) weeks. The RQM has been at the facility weekly starting on [DATE]. These visits and/or calls to continue until IJ removed. These visits and/or calls to validate effective administrative actions related to facility operations and execution of plan of correction. Interview with the RQM on [DATE] at 2:35 PM validated these visits and/or calls.

Based on interview, record review and review of the facility's Quality Assurance (QA) Policy, it was determined the Quality Assessment and Assurance Committee failed to have an effective system in place to identify quality issues so an effective plan could be developed and implemented to correct the identified quality deficiencies. Resident #19, who required extensive assistance with all activities of daily living, experienced a change in condition and his/her health declined. The facility failed to ensure the resident's family was notified of the significant change in condition, and failed to notify the Physician of the resident's continued decline. The resident expired at the facility. Resident #18 was admitted to the facility on [DATE] at 3:30 PM with diagnoses, which included Diabetes Mellitus and status [REDACTED]. The facility failed to obtain the resident's prescribed insulin for administration until [DATE], more than twenty-four (24) hours after admission. Additionally, the facility failed to obtain and provide medication for pain (related to the amputation) until [DATE]. The facility failed to identify medications were not being obtained and administered timely to prevent significant medication errors for Residents #4, #8, #13, and Unsampled Residents A and B. The facility failed to identify the medications were being administered consistently late with some administered almost nine (9) hours late. Medications included insulin, pain relievers, mood stabilizers, antipsychotics, hypnotics, anticonvulsive, and a [MEDICATION NAME] binder medication for [MEDICAL TREATMENT] were not administered as prescribed. The facility failed to identify Resident #19's Physician was not notified of a continued decline in status, failed to identify Resident #18 was not provided the prescribed insulin and pain medication as needed and failed to identify medications of multiple residents in the facility were not available and/or not being administered timely. (Refer to F157, F282, F309, F333, F425 and F514) The facility's failure to have an effective Quality Assurance program in place to assure the facility identified and implemented corrective actions that promoted, protected and enhanced the health and safety of each resident and provided quality assessed needs has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated, on [DATE], the Immediate Jeopardy was removed on [DATE]. The scope and severity was lowered to an E while the facility develops and implements the Plan of Correction (PoC), and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Quality Assurance Policy, last revised [DATE], revealed the purpose of the policy was to ensure there was an Interdisciplinary Team approach to all residents' needs and to provide the highest level of care possible all the while keeping the Interdisciplinary Team (IDT), Physician and Responsible Party informed of their condition changes and interventions implemented as they occur and when necessary. All residents should be assessed at least on admission, quarterly and with change of condition per Interact 111 system for any additional or new needs noted. All changes will be communicated with the IDT, Responsible Party, Physician, and the medical record of that resident according to the systems adopted. A follow-up on all levels of the assessment, to ensure a complete evaluation of the resident's condition will be obtained and recorded in the medical record as needed using the Situation Background Assessment Recommendation (SBAR) form when appropriate. Residents #19, who required extensive assistance with all activities of daily living, experienced a change in condition and his/her health declined. The facility failed to notify the resident's family of the initial significant change in condition on [DATE] when the resident presented with cold like symptoms. He/she was started on oxygen (O2) at three (3) liters per minute (LPM), and breathing treatments were initiated. On [DATE], the On-call Physician was notified and antibiotics were initiated. However, on [DATE] at 7:03 AM, the resident ' s O2 saturation dropped to 87% (normal range 95- 100% according to Lippincott Manual of Nursing Practice) and the resident was unable to clear secretions on his/her own. The resident had audible gurgling and bilateral lung sounds were diminished in all fields with sporadic periods of apnea (not breathing) and required suctioning twice. At 10:23 AM, the resident was yelling out and had audible congestion. At 6:36 PM, O2 saturation was down to 81% and the resident was coughing to clear his/her airway. The facility failed to notify the Physician of the resident's decline after the initial decline. The resident expired at the facility on [DATE]. Resident #18 was admitted to the facility on [DATE] at 3:30 PM, with a [DIAGNOSES REDACTED]. The discharge Physician prescribed Humalog (antidiabetic medication) 12 Units (U) two (2) times daily before meals and Levimier (anti-diabetic medication) 17 U at night and 50 U twice per day; however, the facility failed to obtain the medication from the pharmacy on the [DATE] (day of admission). On [DATE] at 11:15 AM, an order was obtained for a now dose of Humalog insulin 12 U and Levimier 17 U. Six and a half (6 ,[DATE]) hours later, on [DATE] at 12:18 AM, the facility administered another 17 U of insulin. On [DATE] at 6:42 AM, the resident received Humalog 12 U; at 7:45 AM received Levimier 50 U; and received 50 U, again, at 5:25 PM. On [DATE], the resident was sent to the emergency room (ER) with a blood glucose level of 28 mg/dl (normal 80 - 100 mg/dl). The resident was admitted to the hospital's Intensive Care Unit (ICU). In addition, six (6) residents (Residents #4, #8, #13, and #18 and Unsampled Residents A and B) were not provided prescribed medications as ordered and/or timely (some up to nine hours after the prescribed time). Insulin was not available for administration and medications such as pain relievers, mood stabilizers, antipsychotics, hypnotics, anticonvulsives, and a [MEDICATION NAME] binder for [MEDICAL TREATMENT] were not administered as prescribed. Resident #4's [DIAGNOSES REDACTED]. The resident's 9:00 PM medications were not administered until the next morning. [MEDICATION NAME] and [MEDICATION NAME] (for pain) were administered at 1:07 AM, and Trazadone and [MEDICATION NAME] were administered at 1:08 AM.[MEDICATION NAME](for treatment of [REDACTED]. The resident stated he/she had increased pain when medications were not administered timely. Resident #8's [DIAGNOSES REDACTED]. [MEDICATION NAME] (anti-hypertensive), [MEDICATION NAME] (antihypertensive), and [MEDICATION NAME] (to prevent [MEDICAL CONDITION] attacks) were due at 9:00 AM and were administered as late as 11:15 AM.[MEDICATION NAME](to treat [MEDICAL CONDITION]) was due at 9:00 PM and was administered at 11:39 PM [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) was administered as late as 12:15 AM (due at 9:00 PM). Interview with the resident revealed medications were administered very late on occasion and it made him/her anxious. Residents #13's [DIAGNOSES REDACTED]. This resident received medications late on multiple days. [MEDICATION NAME] (to treat nerve pain) due to be administered at 9:00 PM as not administered until 12:00 AM; [MEDICATION NAME] ([MEDICATION NAME] binder for [MEDICAL TREATMENT]) was not given on one occasion and [MEDICATION NAME] (to treat low [MEDICAL CONDITION] activity) was administered late on two (2) occasions. Additionally Brintellix (antidepressant) was not available to be administered on one (1) occasion. Unsampled Resident A had [DIAGNOSES REDACTED]. Three (3) of the resident's medications were not available for administration until [DATE], one (1) day after admission to the facility on [DATE]. The medications included [MEDICATION NAME] (antihypertensive), [MEDICATION NAME] (hormone regulating sleep and wake cycles), and [MEDICATION NAME] (for treating mental disorders). Unsampled Resident B's [DIAGNOSES REDACTED]. He/she did not receive [MEDICATION NAME] (antihypertensive and heart failure), [MEDICATION NAME] (antihypertensive), and [MEDICATION NAME] (antihypertensive) until 1:44 PM; these medications were due at 8:00 AM. Additionally, Levetiracetam (anticonvulsant) was administered eight (8) hours and fifty-one (51) minutes late and the next dose was administered three and a half (3 ,[DATE]) hours later. The medication was ordered to be administered two (2) times daily at 8:00 AM and 8:00 PM. Interview with the Director of Nursing (DON), on [DATE] at 8:45 AM, 11:40 AM and 3:55 PM, revealed she had not been aware of the above-mentioned situations and did not think any of the situations had been brought to QA and absolutely should have been. She stated she was not aware some medications had been hours late. She stated, We all know the potential problems that could occur. The DON stated she did not pull a report regarding late medications and she was not aware of such a report. She stated no one brought a report to Quality Assurance or the morning meeting regarding late medications. The DON stated that she, the ADON, and Unit Manager were expected to monitor late medications. She revealed she had discussed the pharmacy not delivering medications timely in morning meeting and she would follow up after the meeting. The DON stated that the ADON was responsible to monitor staffing when she was out of the office. She stated late medications should have been brought up in Quality Assurance and morning meeting. She further revealed that she was not made aware of late medications or medications administered too close together and she should have been made aware. The DON stated there was a form on each nursing unit to be filled out when a medication did not arrive from pharmacy. She stated this form was a reminder to keep calling the pharmacy until the medication arrived. Interview with the Medical Director, on [DATE] at 12:10 PM, revealed he participated in the facility's Quality Assurance process and he was available twenty-four (24) hours a day and attended all the meetings. The Medical Director stated he was surprised to learn about medications not being available and/or administered late and as he had been called many times about issues and was surprised he had not been notified of these issues. Interview with the Administrator, on [DATE] at 3:00 PM, revealed residents were admitted with orders for medications and he expected medications to be obtained timely and if not available the nurse should contact the Director of Nursing (DON) and the Medical Director as well as himself. He stated physician's orders [REDACTED]. He revealed he was not aware medications had not been administered or was administered late and he should have been made aware. The Administrator stated he was not aware that late reports could be obtained from the electronic Medication Administration Record [REDACTED]. Additionally, he stated QA should have addressed those things and No one was monitoring that system. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #18 was discharged to the hospital on [DATE] and did not return to the facility. Resident #19 expired on [DATE]. The Physician was notified on [DATE] by the Director of Nursing that Residents #4, #8, #13 and A and B, medications given at late times. Vital signs and pain evaluations to assess for change of condition were completed by the Charge Nurses, DON and/or ADON, Nurse Unit Managers, Nurse Educator and MDS Nurses by [DATE]. The DON notified the Physician on [DATE] that Residents #8, A, B, #4, and #13's medications were administered late. The Medication Administration Record [REDACTED]. This was completed by [DATE]. 2. Vital signs and pain evaluations were conducted on residents who resided on the South, Skilled B and West Units by the Charge Nurses and/or Nurse Management Team. The Nurse Management Team audited the MARs of these residents to identify issues. These audits were completed by [DATE]. Residents receiving medications on the South, Skilled B and West Units care plans were updated related to risk potential related to medication administered untimely on [DATE] by two (2) MDS Nurses. 3. Admission charts within the last thirty (30) days beginning [DATE] were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed [DATE]. 4. Time Studies were conducted on all shifts (three times) by Charge Nurses to determine the time needed to deliver medications. The studies were conducted from [DATE] through [DATE]. From these studies, the facility determined the optimum medication pass times in accordance with physician's orders [REDACTED]. Times will be adjusted in accordance to resident needs and Physician order [REDACTED]. 5. Train the trainer education (related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulins or [MEDICAL CONDITION] medications and/or refusal of three (3) consecutive doses of medication. The Regional Quality Manager provided this education to the DON and ADON on [DATE] prior to Licensed Nurse/KMA education. 6. In-servicing to current employed Licensed Nurses/Kentucky Medication Aides (KMA) by the Regional Quality Manager (RQM), Director of Nursing (DON) and/or Assistant Director of Nursing (ADON) related to notification to the Physician regarding change of condition and medications not administered according to the physician's orders [REDACTED]. [REDACTED]. This also included how to document medication not given and notification of the Physician if not administered, as well as notifying the Physician with any refusals of long acting insulin or [MEDICAL CONDITION] medications and/or refusal of three (3) consecutive doses of medication. This education was started on [DATE] and completed on [DATE]. This education was started on [DATE] and completed on [DATE]. Licensed Nurses/KMAs on Family Medical Leave (FMLA) and vacation will be trained prior to return to work. New hires and any future use of agency nursing staff will be trained prior to taking position. (No agency staff use at this time) 7. Audits will be conducted weekly on five (5) residents with change of condition times four (4) weeks, then three (3) residents a week for eight (8) weeks to check that Physician notification was completed by the Nurse Management Team consisting of DON, ADON, Nurse Unit Managers, or MDS Nurses. These Audits began [DATE]. Starting [DATE], a member of the Nurse Management Team, which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses will observe three (3) residents three (3) times weekly for four (4) weeks then three (3) residents one (1) time weekly for eight (8) weeks for delivery of care including medication pass to check that the care plan is being followed. Monitoring will be rotated on different shifts. 8. Beginning [DATE], three (3) residents a week for four (4) weeks then one (1) resident weekly for eight (8) weeks will be interviewed by a member of the IDT to check that medication is timely and pain policy is being followed. 9. A Licensed Nurse and/or KMA will be observed for medication pass by a member of the Nurse Management Team which consists of the DON, ADON, Nurse Unit Managers, Nurse Educator and/or MDS Nurses. Three (3) residents will be observed during medication administration pass three (3) times a week for four (4) weeks, then three (3) residents one (1) time a week for eight (8) weeks validating the medication pass is completed within the time required, documentation of medication, following physician's orders [REDACTED]. 10. Admission charts will be audited within seventy-two (72) hours of admission to check that care plans are in place by the Interdisciplinary Team, which consists of DON, ADON, Nurse Unit Managers, Nurse Educator, Social Service Director, Dietary Manager, and MDS Nurses. The Weekend Manager will review new admission care plans on weekends for completion. These audits will be done ongoing for twelve (12) weeks beginning [DATE]. 11. A QA meeting was held [DATE], upon notification of Immediate Jeopardy. In attendance were the Administrator, DON, ADON, MDS Nurse, Nurse Educator, and Medical Director. The purpose of this meeting was to review the deficient practice and begin the process of preparing the abatement plan. The meeting minutes were reviewed and approved by the Regional Quality Manager (RQM). A second QA meeting was held [DATE] with the Administrator, DON, ADON, Nurse Educator, MDS Nurse, Dietary Manager, Social Services, Maintenance and RQM in attendance. The status of the plan of correction development and action items was reviewed. This meeting was attended by and minutes approved by the RQM. 12. The facility will hold weekly QA meetings with at least one (1) Regional team member attending for four (4) weeks and then the facility will continue monthly thereafter. The QA committee will be reviewing the status of the Plan of Correction and audit results. The Regional team consists of the RQM, Regional Marketing Manager and Regional Reimbursement Manager and Regulatory Liaison. Members of the facility's QA committee consist of the minimum of the Administrator, DON, ADON, Dietary Manager, Business Office Manager and Social Services Manager with Medical Director participating at least quarterly and as needed. 13. The Governing Body Meeting will be held annually and with any change in the assigned management appointments or responsibilities. Oversight will be provided by the RDO. 14. In-servicing to the Administrator and DON on regulations governing QA meetings, how to properly conduct a meeting, and when to have a QA meeting was completed by the RQM on [DATE]. The Administrator covered this information with QA committee on [DATE]. 15. A Regional Team member will make a minimum of twice-weekly calls or visits to the facility for four (4) weeks to validate effective administrative actions are being taken in regards to facility operations and execution of plans of correction. These began on [DATE] and will continue until IJ is validated as removed and substantial compliance obtained. These calls will review the status of the actions outlined in the Plan of Corrections and ensure any potential follow-up from QA is addressed. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of Residents #8, A, B, #4, and #13's record on [DATE] revealed the Physician had been notified on [DATE] of medications not administered timely. The DON completed review of resident MARs, ADON, Unit Nurse Managers, and MDS nurses to validate current orders related to medications not administered timely. Review of the AOC binder revealed the DON, ADON, Nurse Unit Manager, Nurse Educator and MDS Nurses completed the pain evaluations on residents #8, A, B, #4, and #13 on [DATE]. Current orders were validated. 2. Review of the AOC binder and resident records on [DATE], revealed all the residents residing on units South, Skilled B and West MARs were reviewed by the DON, ADON, Unit Nurse Managers and MDS nurses to validate current orders related to medications not administered timely. This was completed on [DATE]. Review of the AOC binder and resident records on [DATE], revealed the residents on South, Skilled B and West hall were evaluated for pain and vital signs completed by a member of the Nurse Management Team. This was completed on [DATE]. 3. Review of the AOC Binder revealed Admission charts within the last thirty (30) days beginning [DATE] were audited by two (2) MDS Nurses to check that a care plan was in place. This was completed [DATE]. 4. Review of the AOC Binder revealed time studies on all shifts was completed on [DATE] through [DATE]. The results of the studies were taken to the weekly QA meetings ([DATE] and [DATE]). 5. On [DATE], the State Survey Agency validated in-servicing was conducted for the DON and ADON related to notification of significant change and medications not administered according to physician's orders [REDACTED]. Review of the in-service records on [DATE] and interview with the RQM, DON, and ADON verified this in-servicing was completed [DATE]. Train the trainer education was verified as completed on [DATE] by the RQM by reviewing the in-service records of the DON/ADON related to the care plans as well as interview with the DON and ADON on [DATE] at 2:20 PM. 6. Review of the in-service records dated [DATE] and [DATE] revealed all facility Licensed Nurses and KMAs had received in-servicing except one that was on FMLA. That Licensed Nurse will receive the in-servicing on return to work. Forty-four (44) total staff received the training with only one (1) that will receive the training on return to work. The DON will be responsible to ensure that training is provided to any new hires and the Licensed Nurse that will return to work from FMLA. Interviews on [DATE] with LPN #1 at 10:20 AM, CMA #17 at 9:50 AM, RN #1 at 12:58 PM, LPN #12 at 1:15 PM, CMA #18 at 1:30 PM, CMA #19 at 1:41 PM, RN #2 at 10:50 AM, LPN #9 at 12:05 PM, CMA #20 at 1:20 PM, CMA #21 at 1:30 PM, RN #5 at 2:10 PM, LPN #6 at 2:30 PM, and LPN #11 and RN #4 at 2:04 PM revealed they were in serviced on [DATE] - [DATE]. The inservice consisted of physician notification of medications not available, resident refusal of medications of the first dose for [MEDICAL CONDITION] and insulin medications and notification of third dose refusal on all other medications, medications not administered timely with a time frame of medication administration which changed to a four (4) hour time span for every day and twice a day medications except for insulin and [MEDICAL CONDITION] medications, and physician notification for resident change in condition. Interviews also revealed in-service consisted of documentation of physician notification. Further interview revealed two (2) care plans were to be developed within a twenty four (24) hour period after an admission according to the resident's needs. Interview revealed when the nurse obtains a new order for an as needed pain medication the nurse is to put the special requirement into the computer to remind the nurses to perform a pre-assessment and post assessment. The nurses are to perform the pre and post assessments for pain, not CMAs. Further interview revealed the in-service was conducted by the Regional Quality Manager, DON, ADON, or SDC. 7. Review of audits was conducted on [DATE] to verify five (5) residents were audited. The audit dates were [DATE] and [DATE]. Interviews on [DATE] with the DON at 2:20 PM and the ADON on [DATE] at 2:42 PM revealed the week of completion of the audits would be the week of [DATE] with the DON, ADON, Unit Managers, and MDS Nurses conducting the Audits. 8. Interviews with residents on [DATE] by Unit Charge Nurses related to timeliness of medication and pain protocol was being followed. 9. Review by the State Survey Agency on [DATE] verified medication pass was audited on three Licensed Nurses and KMAs. Those medication pass observations were verified completed on [DATE], [DATE], [DATE], [DATE], and [DATE]. 10. Review of the AOC binder on [DATE] verified new admission charts within the last thirty days, had been audited by MDS Nurses to ensure a care plan was in place. The weekend manager (Department Head) to review for any new admission charts for care plans on weekends and these audits will be completed by week of [DATE]. The weekly QA related to these audits to be completed by [DATE]. This was verified completed [DATE]. 11. Review of the AOC binder revealed a QA meeting held on [DATE] with attendees listed including the RQM. The second meeting on [DATE] held to verify status of the plan of correction development and action items reviewed. 12. Interview with the Administrator and DON, on [DATE] at 2:20 PM and review of the AOC binder on [DATE], revealed a QA meeting was held on [DATE] and [DATE]. The meetings will continue weekly being completed by [DATE] and then will be monthly thereafter. 13. A Governing Body meeting was conducted [DATE], attended by the Administrator, DON, RQM, RDO, and Medical Director. The roles and understanding of the roles of these positions was reviewed. The Governing Body to meet annually and with any change in assigned management appointments or responsibilities. 14. Review of the AOC Binder revealed In-servicing to the Administrator and DON on how to conduct a QA meeting, and when to have a meeting was conducted by the RQM on [DATE] and was covered with the QA committee on [DATE] by the Administrator. 15. A Regional team member, RDO, RQM will make a minimum of two (2) times a week calls to the facility or visit the facility for four (4) weeks. The RQM has been at the facility weekly starting on [DATE]. These visits and/or calls to continue until IJ removed. These visits and/or calls to validate effective administrative actions related to facility operations and execution of plan of correction. Interview with the RQM on [DATE] at 2:35 PM validated these visits and/or calls.

Based on observation, interview, record review, review of the hospital emergency room Report and History and Physical, and review of the facility's policy and procedure, it was determined the facility failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two (2) of twenty (20) sampled residents (Resident #18 and #19). On [DATE] at 2:50 PM, Resident #19 presented with cold like symptoms, and the physician was notified and orders for breathing treatments were received. The facility care planned the resident for Potential for Infection on [DATE], with an intervention to update the medical doctor and family as needed. On [DATE] at 8:30 AM, the resident's symptoms worsened, the On-call Physician was notified, and orders were received for antibiotic, oxygen and suctioning. However, Resident #19 continued to decline from [DATE]-[DATE]. The facility failed to notify the physician of the resident's continued decline and possible need to alter treatment. The resident expired at the facility on [DATE] at 9:40 PM. Resident #18 was admitted to the facility, on [DATE] at 3:30 PM after having a leg amputated and a [DIAGNOSES REDACTED]. The facility failed to obtain physician's orders for medications which included Insulin (diabetic medication) when the resident was admitted . On [DATE] at 7:45 AM, the facility obtained orders for insulin and pain medication; however, the facility failed to obtain the medication. On [DATE] at 10:48 AM, a finger stick blood sugar test revealed the resident's blood sugar level was at 435 milligrams per deciliter (mg/dL) (normal ,[DATE] mg/dl) with stat doses of insulin administered. On [DATE], Humalog Insulin 12 U due at 4:30 PM was withheld due to Resident #18's accu-check of 76 mg/dL; the insulin was administered at 5:25 PM and 9:58 PM; and, again on on [DATE] at 6:00 AM without any documented evidence the resident's blood sugar had been monitored since [DATE] at 4:30 PM. On [DATE] at 7:35 AM, Resident #18 was found unresponsive and had a blood sugar level of twenty-eight (28) mg/dL (critical). The resident was sent to the hospital and placed in the intensive care unit with [DIAGNOSES REDACTED]. In addition, Resident #18 had complaints of pain due to his/her recent right leg [MEDICAL CONDITION] (BKA) on [DATE]. The facility obtained orders from the physician on [DATE] at 7:30 AM and sent Resident #18 to the Primary Care Center on [DATE] at 8:00 PM with orders received for pain medication; however, the facility failed to provide the resident with pain medication until [DATE] at 12:01 PM (approximately twenty-eight {28} hours after the physician orders were received). The facility's failure to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] alleging the removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated, on [DATE], the Immediate Jeopardy was removed on [DATE]. The scope and severity was lowered to an D while the facility develops and implements the Plan of Correction (PoC), and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled Pain Management Process, last revised [DATE], revealed the facility recognizes that each resident has the right to treatment and services to maintain their quality of life. The facility also recognizes that each resident reacts to pain in different ways, and that narcotics carry significant risk with use including side effects and abuse. The facility will react to the resident's pain control needs based on the resident's goals for pain relief and the resident's goals for functional ability. The facility's goal is to ensure all residents receive appropriate pain relief measures to assure that the resident's pain does not affect their ability to function within their designated goals for functional ability. The resident's goals for pain control will be met by the use of medications and alternative methods to reduce pain as outlined in the Federal Regulatory Requirements for Long Term Care (LTC) (Altering the environment for comfort, ice packs or cold compresses, mild heat {to decrease joint stiffness and increase blood flow to an area}, neutral body alignment and repositioning, baths, transcutaneous electrical nerve stimulation {TENS}, massage, acupuncture/acupressure, chiropractic, or rehabilitation therapy; exercises to address stiffness and prevent contractures; and cognitive/behavioral interventions {e.g., relaxation techniques, reminiscing, diversions, activities, music therapy, coping techniques and education about pain}). This system will suggest necessary evaluation, intervention, and re-evaluation as standard care practice for licensed nurses. Review of the facility's policy and procedure titled Administering Medications, last revised [DATE], revealed medications shall be administered in a safe and timely manner, and as prescribed. 1. Record review revealed the facility admitted Resident #18 on [DATE] at 3:30 PM with [DIAGNOSES REDACTED]. Review of the Admission Data Set, dated [DATE] at 4:00 PM, completed by Licensed Practical Nurse (LPN) #3, revealed Resident #18 was alert and oriented to person, time, place and purpose, with no memory deficits noted. The resident's pain status revealed the resident had received an as needed (PRN) pain medication in the past five (5) days prior to admission. In addition, review of the Hospital Discharge Orders, dated [DATE], revealed routine orders for two (2) types of insulin ([MEDICATION NAME] and Humalog), and an oral diabetic medication ([MEDICATION NAME]). However, further review of the record revealed there was no documented evidence an Interim Care Plan was developed to address the resident's [DIAGNOSES REDACTED]. Review of the Hospital Discharge Orders, dated [DATE], revealed to administer: 1. [MEDICATION NAME] (insulin), inject seventeen (17) U into skin nightly; Inject fifty (50) U into skin twice a day. Start date [DATE] with next dose due at 9:00 PM. 2. Humalog Insulin one-hundred (100)U; Inject twelve (12) U twice a day before meals. Start date [DATE] with next dose due at 4:00 PM. 3. [MEDICATION NAME] (diuretic) forty (40) mgs one (1) tablet every morning. Start date [DATE] with next dose due on [DATE]. (rec'd ,[DATE] dose in hospital prior to admission) 4. [MEDICATION NAME] ([MEDICATION NAME]) Oral diabetic medication) eight-hundred fifty (850) mgs one (1) tablet twice a day with meals. Start date [DATE] with next dose due on [DATE]. ([DATE] doses given at the hospital prior to admission). However, review of the Departmental Notes and Physician's Orders revealed there was no documented evidence the physician was notified of the Hospital Discharge Orders and no evidence the orders were written. Review of the February 2016 Medication Administration Records (MAR), revealed Resident #18 did not receive any insulin on [DATE] at 4:30 PM and 9:00 PM. Interview (Post Survey) with Licensed Practical Nurse (LPN) #3, on [DATE] at 10:40 AM, revealed Resident #18 was to be admitted to her unit (Skilled B) on [DATE]. However, the other resident in the room kept the heat on high and Resident #18 requested to be moved after ten (10) minutes of being in the room. Therefore, she did not enter the resident's medications into the computer system. She stated the resident was moved to the West Unit, report was given to Registered Nurse (RN) #4, who would have been responsible for completing the admission, and to ensure medications were ordered. Further review of the February 2016 Medication Administration Records (MAR), revealed Resident #18 did not receive any medication on the morning of [DATE]. Review of Nursing Notes, dated [DATE] at 10:48 AM, documented by Registered Nurse (RN) #4, revealed a fingerstick blood sugar was obtained and the results were 435 mg/dL (normal range ,[DATE] mg/dL). However, there was no documented evidence of why the blood sugar was obtained as the resident had no orders for accu-checks. Further review of the Nursing Notes, revealed at 11:02 AM, RN #4 spoke with the Primary Care Physician's (PCP) Nurse regarding Resident #18's increased blood sugar level and an order was received for a stat dose of [MEDICATION NAME] Insulin 17 U (units) now and a stat dose of Humalog Insulin 12 U now and to fax Resident #18's medication list for the PCP to review. Further review of the Nursing Notes, dated [DATE] revealed at 1:54 PM, the resident's blood sugar was obtained again after the STAT doses of Insulin were given and the result was three-hundred sixty-two (362) mg/dL. In addition, the Note stated the medications orders had been reviewed by the Physician; the medications had been ordered through the pharmacy; and, the Physician was to come to the facility on this date to see the resident. Review of the facility's Admission Physician's Orders written by the Primary Care Physician for Resident #18, dated [DATE], revealed to administer: 1. [MEDICATION NAME] (insulin) one-hundred (100) U/ml vial; inject fifty (50) U SubQ twice daily (bid). Order dated [DATE]. 2. Humalog (insulin) one-hundred (100) U/ml cartridge; inject twelve (12) U SubQ bid before meals (ac). Order dated [DATE]. 2. [MEDICATION NAME] ,[DATE] (narcotic pain medication) milligrams (mgs) tablet one (1) by mouth (po) every six (6) hours for four (4) pills. Order dated [DATE]. 3. [MEDICATION NAME] ,[DATE] mg tablet one (1) po every four (4) hours for pain. Order dated [DATE]. 4. [MEDICATION NAME] (insulin) one-hundred (100) U/ml vial; inject seventeen (17) U every night (HS). Order dated [DATE]. 6. Humalog (insulin) one-hundred (100) U/ml vial; inject twelve (12) U SubQ bid with meals. Order dated [DATE]. Attempts to contact RN #4 by telephone on [DATE] at 1:30 PM and 3:00 PM and again on [DATE] at 11:06 AM (Post Survey) were unsuccessful. Review of the Nursing Notes, dated [DATE] at 7:21 PM, revealed LPN #6 documented that at 3:45 PM, the PCP's office had been contacted again regarding Resident #18's complaint of pain and request for [MEDICATION NAME]. She documented she spoke with the PCP's Nurse and was told the PCP would be in the facility later in the day to write prescriptions for pain medication if needed. At 7:21 PM, LPN #6 also documented she contacted the physician again regarding Resident #18's complaints of pain and requested [MEDICATION NAME]. LPN #6 documented that she was informed by the nurse at the Physician's office that the physician would be in that evening to see the resident and would write a prescription for pain medication, if needed. Further review revealed she offered to reposition the resident and attempted to reassure him/her; however, the resident declined the offer. Review of a Visit Summary, dated [DATE] at 8:00 PM, revealed Resident #18 was sent to the Primary Care Center related to a complaint of Phantom limb syndrome with pain as the primary diagnosis. The resident was ordered [MEDICATION NAME] (narcotic pain medication) ,[DATE] mgs four (4) tablets only, one (1) tablet four (4) times a day and an order for [REDACTED]. Review of Nursing Notes, dated [DATE] at 7:33 AM, revealed Resident #18 had been restless most of the night, and had several bowel movements with incontinence noted. The Physician had visited the resident that morning and wrote prescriptions for [MEDICATION NAME] (narcotic pain medications) and [MEDICATION NAME] (anti-anxiety). The prescriptions were faxed to the pharmacy at that time. Further review of the Nursing Note, dated [DATE] at 12:48 PM, revealed LPN #6 documented that at 11:45 AM that morning she spoke with the Pharmacist regarding the new [MEDICATION NAME] orders and obtained a Drug Enforcement Agency (DEA) number to be able to administer [MEDICATION NAME] ,[DATE] mgs from the Emergency Dispensing Kit (EDK) for Resident #18's pain and it was administered at 12:01 PM (approximately twenty-eight {28} hours after the original order for pain medication was received). At 12:51 PM, LPN # 6 documented the resident's pain level was coming down and at 2:31 PM, she spoke with the pharmacy again related to the pain medications not been delivered to the facility yet and was told the medications were in route after having left the pharmacy two (2) hours prior. Further review of the February 2016 EMAR revealed Resident #18 had received [MEDICATION NAME] 17 U, on [DATE] at 12:18 AM (due [DATE] at 8:30 PM); Humalog Insulin 12 U at 6:42 AM; and, [MEDICATION NAME] Insulin 50 U at 7:45 AM (due at 6:00 AM). Further review revealed Humalog Insulin 12 U dose due at 4:30 PM was withheld due to Resident #18's blood sugar level was seventy-six (76) mg/dL; however, [MEDICATION NAME] Insulin 50 U was given at 5:25 PM (due at 4:30 PM) and [MEDICATION NAME] 17 U was given at 9:58 PM. In addition, LPN #11 documented she administered [MEDICATION NAME] fifty (50) U on [DATE] at 6:00 AM. However, there was no documented evidence the resident's blood sugar had been monitored since [DATE] at 4:30 PM. Review of Nursing Notes, dated [DATE] at 8:05 AM, revealed the Charge Nurse entered Resident #18's room and he/she was only opening his/her eyes when responding to communication. A finger stick blood sugar was obtained with a reading of twenty-eight (28) mg/dL. Orange juice and Ensure were given with several packs of sugar and the finger stick blood sugar was rechecked with a reading of twenty-seven (27). The Physician was notified and an order was obtained to administer [MEDICATION NAME], (fast acting sugar), one (1) mg Intramuscularly (IM) and to repeat in fifteen (15) minutes related to decreased blood sugar levels. The Physician was notified at 7:25 AM, and an order was obtained to send the resident to the Emergency Department for evaluation related to decreased blood sugar levels. Interviews were attempted with Licensed Practical Nurse (LPN) #11, on [DATE] at 1:25 PM and at 2:30 PM, with no success. Messages were left to return calls on both occasions with no return calls received. Interview, on [DATE] at 9:13 AM, with LPN #6 (who worked with Resident #18 on [DATE] and [DATE] from 7 AM to 7 PM each day) revealed she did not have a prescription on [DATE] to be able to call the pharmacy for an order to give medication out of the EDK. She stated she called the Physician's office on [DATE] at 3:45 PM, and was told by the Nurse the Physician would be in that afternoon to visit the resident and to write prescriptions for pain medications. LPN #6 stated the Physician did not come in until the following morning on [DATE] at 7:33 AM and wrote prescriptions for narcotic pain medications. She stated the pharmacy was notified at 11:45 AM for a DEA number, which was required to give narcotic medications from the EDK. During further interview, she stated she was not sure why the pharmacy was not contacted until 11:45 AM after the prescriptions were written at 7:33 AM. She stated she may have been in orientation and performing a medication pass leaving the responsibility to the other Charge Nurse (no longer employed) on duty who did not call the pharmacy. Further interview revealed the facility only had back up medications for narcotics and routine pills and no insulin in the EDK. Review of the Emergency Report, dated [DATE], revealed Resident #18 was assessed at 8:16 AM and presented with altered mental status. Emergency Medical Services was unable to initiate an Intravenous (IV) line and the Chem Strip (check for blood glucose) was critically low with associated symptom of Hypothermia (decreased core body temperature). The resident's blood sugar, upon arrival to the Emergency Department was forty-four (44) mg/dL and his/her vital signs revealed a body temperature of eighty-eight (88.8) degrees Fahrenheit (normal: 98.7). Further review revealed Resident #18 was admitted to the Intensive Care Unit for blood sugar monitoring and for body temperature increase. Review of the Hospital History & Physical, dated [DATE], revealed the hospital's impression was Resident #18 had Transient Alteration of Awareness, [DIAGNOSES REDACTED] due to insulin, Hypothermia probably could be side effect from [DIAGNOSES REDACTED], Type 1 Diabetes Mellitus with [DIAGNOSES REDACTED] and coma, Prolonged Q-T interval on electrocardiogram (ECG), [MEDICAL CONDITION] and Chronic combined systolic and diastolic [MEDICAL CONDITION]. The plan was for the resident to be placed on diabetes subcutaneous protocol and hold beta-blocker at that time due to severe [MEDICAL CONDITION]. Interview with Resident #18, on [DATE] at 12:40 PM, revealed he/she was admitted to the nursing facility on a Wednesday ([DATE]), and the facility did not have any medications to administer to him/her and he/she was told by nursing staff the medications had to come from another town, over a hundred miles away, where their primary pharmacy was located. He/She stated on the second (2nd) day ([DATE]), he/she reported to nursing staff he/she still had not received any medications and was in pain. Also on this day, his/her blood sugar was high at four-hundred thirty-five (435) mg/dL due to the facility not having insulin to administer. Further interview revealed the resident stated, on a pain scale of one (1) to ten (10), his/her pain level was a seven (7) and the first night, [DATE], he/she was at the nursing facility he/she did not receive any pain medication and he/she was unsure when he/she did receive any pain medication on the 2nd day, [DATE]. He/She stated he/she called the physician himself/herself and went to a care center on [DATE] because the facility was not providing him/her any pain medication. Additionally, Resident #18 revealed on the third (3rd) day, [DATE], the facility gave him/her too much insulin which resulted in his/her blood sugar dropping to twenty-four (24) mg/dL (normal range seventy {70} to one-hundred {100} mg/d. He/She stated he/she was hypothermic (low body core temperature) when he/she arrived at the Emergency Department. Interview (Post Survey) with Resident #18's Primary Care Physician (PCP) , on [DATE] at 4:48 PM, revealed he was not aware of the resident's admission to the facility until [DATE] when he was contacted by the resident himself/herself regarding his/her pain medications and Insulin. The Physician stated he expected the resident to not have to go without his/her pain medication and especially not his/her Insulin because the facility could have called a backup pharmacy to retrieve immediate medications, especially the Insulin as it was more critical to have than the pain medication. He stated Resident #18 had his assistant's phone number through a mutual friend and contacted him through his assistant. The PCP stated the resident asked him, What am I supposed to do?, because he/she did not have Insulin at the Nursing facility. Further interview revealed, when he was contacted by RN #4 on [DATE], he asked for the resident's medication list from the hospital discharge to be sent to him for review so he could compare the medications he was ordered in the hospital to the ones he/she had taken at home. He stated he did not know why the resident did not have his medications on [DATE] when he was admitted because a Nurse Practitioner could have been called to get insulin at a local pharmacy. The PCP stated in his opinion, there was no excuse for the resident to have gone without any medications. Interview with the Medical Director, on [DATE] at 12:10 PM, revealed he was surprised to learn about medications not being available. He stated he thought either way the order for the pain medication for Resident # 18 should have been obtained from the EDK with either a verbal order or a written script and not have the resident go without pain medication. Further interview revealed he felt the nursing staff should have been more proactive in obtaining the insulin and he was available twenty-four (24) hours a day if the nursing facility staff needed to reach him. Interview with the Administrator, on [DATE] at 3:00 PM, revealed residents were admitted with orders for medications, he expected medications to be obtained timely, and if not available, the nurse should contact the Director of Nursing and the Medical Director, as well as himself. 2. Review of the facility policy titled, Residents Assessment Policy and Procedure, dated [DATE], revealed all residents should be assessed to determine their needs. The facility should provide care and treatment to promote the resident's highest practicable physical, psychological, and social needs. It further revealed when the resident's condition is declining vs. maintaining or improving due to the progression of their medical condition, and it is apparent the resident is approaching end of life, the physician/legal representative should be contracted. Review of the facility's policy titled, Quality Assurance Policy, last revised [DATE], revealed all residents should be assessed at least on admission, quarterly, and with change of condition per system (Interact 111) for any additional or new needs noted. All changes should be communicated with the Interdisciplinary Team (IDT), Responsibility party, physician, and in the medical record of that resident according to the systems adopted. A follow-up on all levels of the assessment, to ensure a complete evaluation of the resident's condition, will be obtained and recorded in the medical record as needed using the Situation Background Assessment Recommendation (SBAR) form when appropriate. Review of the facility's policy titled, Interact Version 4.0 Tool, last revised [DATE], revealed this guidance was adapted from the Clinical Practice Guidelines Acute Changes in Condition in the Long Term Care (LTC) Setting 2003, and is used by the facility as a tool to determine immediate and non-immediate notification of the physician. Further review revealed listed under symptoms that required immediate physician notification were symptoms of a common cold, which included marked respiratory distress, severe cough, or temperature greater than 100.5 degrees Fahrenheit (F). Record review revealed the facility readmitted Resident #19 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident's cognition was severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. In addition, the resident was dependent on staff for all activities of daily living. Review of the Comprehensive Plan of Care for Potential for Infection, dated [DATE], revealed the resident had increased congestion, elevated temperature, cough, and decreased (O2) saturation with an intervention to update the medical doctor and family as needed. Review of a facility form titled, Situation Background Assessment Recommendation (SBAR) revealed on [DATE] the physician was notified by fax (facsimile) that Resident #19 presented with cold like symptoms such as wheezing, non-productive cough and a temperature of 99.6 degrees F. A chest x-ray was requested and orders were received for [MEDICATION NAME] Nebulizer treatments 0.083% unit dose three (3) times a day (TID) times five (5) days. In addition, review of a Physician Telephone Order, dated [DATE], revealed to administer oxygen (O2) at three (3) Liters per nasal cannula (n/c) every shift to maintain O2 saturation greater than eighty-eight percent (88%). Review of a Departmental Note, dated [DATE] at 1:45 PM, revealed a late entry was made for [DATE] at 8:30 AM. The nurse documented Resident #19 had gurgly respirations, could not cough phlegm up, respirations were labored, lungs with bilaterally rub and some wheezing noted, and face flushed. The resident's temperature was 99.9 F and the resident was suctioned with a moderate amount of light brownish phlegm obtained. The On-call Physician was notified with orders received for [MEDICATION NAME] (antibiotic) 250 milligrams two (2) tablets now, then [MEDICATION NAME] 250 milligrams one (1) tablet times four (4) days; and, Yonkers suction as needed (PRN). Review of a Departmental Note, dated [DATE] at 1:45 PM written by RN #2, revealed the resident's temperature was 98.5 degrees F and O2 saturation was 96% on oxygen 3L per n/c. Further review revealed the family was visiting from out of town and they were updated on the resident's condition with all questions answered to the best of the nurse's knowledge. In addition, it was noted the resident continued on antibiotic for upper respiratory infection with no adverse reaction noted. No suctioning was required so far that shift and the resident ate breakfast and he/she felt better. Review of a Departmental Note, dated [DATE] at 1:47 AM, revealed Resident #19's temperature was 100.6 degrees F, O2 saturation was 87 to 93% on O2 at three (3) liters of O2 via N/C, and the resident was unable to clear his/her throat and was being suctioned for comfort. Further review revealed the resident had audible gurgling, the head of the bed (HOB) was elevated approximately eighty (80) degrees to assist the resident with breathing, and the resident's lung sounds were diminished bilaterally. At 7:03 AM, the resident's O2 saturation was 85% with O2 on at three (3) LPM per N/Cl, the resident was exhibiting sporadic episodes of five (5) to seven (7) second periods of apnea (absence of breathing), and the resident had refused fluids this shift and remained dry. The (HOB) was elevated approximately forty-(40) to fifty (50) degrees to assist with breathing. Audible congestion was noted and the resident was unable to clear congestion on his/her own. The nurse suctioned the resident two (2) times with a moderate amount of phlegm removed and auscultation of bilateral lungs remained diminished in all fields. Additional review revealed, at 6:36 PM, (late entry for 5:00 PM), O2 saturation was ,[DATE]% and the O2 had been increased from three (3) LPM to four (4) LPM with O2 saturations remaining at ,[DATE]%. Fluids were encouraged and the resident consumed some this shift. However, there was no documented evidence the resident's physician was notified of the resident's decline and no evidence an SBAR was completed per the facility policy. Review of Departmental Notes, dated [DATE] revealed at 3:05 AM, the residents O2 saturation was 81% and the resident had hollered out all shift and was unable to voice needs. The head of bed (HOB) was elevated to facilitate breathing, but the resident was noted to have head leaned back and was unable to hold his/her head in an upright position. Very little liquids were taken in and the resident's bilateral lungs sounds remained diminished in the lower fields and congested in the upper. Further review revealed at 11:06 AM, late entry for 9:30 AM, the resident's O2 saturation was 51%, and the resident had O2 off laying on abdomen. The oxygen was reapplied at 4 LPM per N/C, a breathing treatment was given, and suctioning was attempted without success. The resident's O2 saturation came up to 62% and his/her nailbeds and fingertips were cyanotic. At 11:00 AM, his/her O2 saturation remained in the 60's with O2 at four (4) LPM per nasal cannula and the resident was noted holding hands up in the air, staring into space. The resident's bilateral hands and part of wrists were cyanotic, had started to mottle, and the resident would make eye contact slowly with pupils pinpoint. Review of Departmental Notes, revealed on [DATE] at 1:48 PM (late entry for 1:00 PM), the resident's O2 saturation had dropped to 62% and the resident's oxygen was increased to 4 LPM per N/C. Respirations were labored with puffing exhalations. Hands and fingers remained cyanotic, and the resident's face was ashen colored. The HOB was elevated for respiration relief. Further review revealed at 6:46 PM, the resident's O2 saturation was 63% at four (4) LPM of O2. Respirations were labored with blowing exhalation and respirations were thirty-two (32) breaths per minute. The resident had pinpoint pupils and fluids were encouraged but the resident would choke easily. However, there was still no documented evidence the resident's physician was notified of the resident's continued decline and no evidence an SBAR was completed per the facility policy. Review of a Departmental Note, dated [DATE] at 11:42 PM, late entry for 9:42 PM, revealed Resident #19 had no vital signs detected per two (2) nurses and Resident #19 had passed away. Interview with Certified Nurse Assistant (CNA) #2, on [DATE] at 2:25 PM, revealed Resident #19 had been put on oxygen and had quit eating. She stated Resident #19 did not get out of bed much and staff had to feed him/her and help with all his/her needs. Interview with Licensed Practical Nurse (LPN) #4, on [DATE] at 2:05 PM, revealed she remembered Resident #19 becoming lethargic and coughing so she notified the physician and received an order for [REDACTED]. LPN #4 stated she would have notified the physician if she had realized how bad the resident's condition had declined. She was unable to provide an explanation as to why the family was not notified. Interview with RN #2, on [DATE] at 4:40 PM, revealed she had discussed the resident's decline with the physician when he made rounds earlier in the week. She stated she forgot to document it in the record. Interview with LPN #11, on [DATE] at 5:40 PM, revealed she remembered Resident #19 being put on antibiotics but she could not remember if she or any of her co-workers had notified the physician about the resident's continued decline in condition. She stated, I just remember (he/she) was sick, the resident wasn't doing very well, and it was not surprising that (he/she) passed away. LPN #11 called back later on [DATE] at approximately 5:50 PM, and stated she thought the resident was on comfort measures only. However, further review of the Physician's Orders revealed there was no physician's order placing the resident on comfort measures. Interview with LPN #9, on [DATE] at 8:55 AM, revealed it was the facility's policy to notify the physician of a change in status and the physician should be made aware whether the resident was on comfort measures or not. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 10:00 AM, revealed the resident's code status was DNR. She stated the resident ended up with a respiratory illness and the family wanted to keep him/her comfortable. She stated it was the facility's policy to notify the physician and family of a change in condition. Interview with Resident #19's Primary Ph

Based on interview, record review, review of the emergency room (ER) record and hospital Discharge Summary, and facility policy review it was determined the facility failed to revise the care plan for one (1) of five (5) sampled residents (Resident #1). The facility admitted Resident #1 on [DATE] and care planned the resident for the assistance of one staff for ambulation and toileting on [DATE]. Interviews with staff revealed Resident #1 continuously got out of bed without asking for assistance, and would exit the bathroom into the wrong room and at times was found in the bed in that room. However, the facility failed to revise the care plan to address the resident's safety due to getting up without assistance and failed to address the resident's confusion when leaving the bathroom. On [DATE] at approximately 11:55 PM (per Nurse's Notes), Resident #1 was found in the adjacent room (room [ROOM NUMBER]) on the floor. Resident #1 was transferred to the hospital ER where he/she was admitted to the hospital with [REDACTED]. Resident #1 died in the hospital on [DATE]. The findings include: Review of the facility's policy titled, Clinical Quality Assurance and Performance Improvement (QAPI) Daily Review Process, dated [DATE], revealed the Nurse Assessment Coordinator and Assistant Director of Nursing (ADON)/ Director of Nursing (DON)/designee will ensure appropriate updates to the Comprehensive Care Plan and Accunurse Activities of Daily Living (ADL) care plan are carried out and communicated to the direct care staff and Interdisciplinary Team (IDT). Interview with the Director of Nursing (DON), on [DATE] at 10:10 AM, revealed there was no specific policy on Stop and Watch. However, interview with the Education and Training Director (ETD), on [DATE] at 2:05 PM, revealed the facility used Interact, (Interventions to Reduce Acute Care Transfers), a quality improvement program that focused on the management of acute change in resident condition. It included clinical and educational tools and strategies for use in every day practice in long-term care facilities. The ETD said one of the educational tools within the Interact system was Stop and Watch notepads used by direct care staff to report changes in residents' condition to licensed nurses. The ETD said she expected care plan interventions to be added for changes in condition, behavior changes, and if residents were not following directions. The ETD said the Stop and Watch process was covered during orientation. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as alert and oriented to person, place, time, and purpose with no memory problem. Review of Resident #1's Comprehensive Plan of Care, dated [DATE], revealed the resident was at risk for fall/injury related to generalized weakness and compression fracture, with an intervention to refer to a plan of care in the voice-assisted, hands free documentation and communication system (AccuNurse Activities of Daily Living Care Plan) Review of the Activities of Daily Living (ADL) Plan of Care, dated [DATE], revealed the resident required one (1) person physical assistance for ambulation, bathing and dressing. Toileting cautions listed on the plan of care included assistance needed for toileting transfer, do not leave unattended in bathroom and high risk for falls. Review of a Nursing Note, dated [DATE] at 1:44 AM, revealed Resident #1 was found on the floor in the adjoining room (room [ROOM NUMBER]). The resident told staff he/she went to the bathroom and exited the wrong door into the wrong room. The resident stated he/she fell on to his/her back and when trying to get up rolled onto his/her right side. The resident was assessed with [REDACTED]. The Primary Care Physician was notified and the resident was sent to the ER for evaluation. Review of Resident #1's ER record, dated [DATE], revealed, Clinical Impression 1. Fall from slipping, tripping or stumbling, 2. Closed left [MEDICAL CONDITION]. Review of the resident's Hospital Discharge Summary, dated [DATE], revealed the resident was admitted and surgery was planned; however, the resident's condition declined and it was determined the resident would not survive surgery. Palliative care was provided and the resident expired on [DATE]. Interview with Certified Nurse Aide (CNA) #5, on [DATE] at 8:10 AM, revealed she worked the North Unit and had witnessed Resident #1 out of bed unassisted and reminded the resident to use the call light. The CNA worked on [DATE] from 11:00 PM to 7:00 AM and was told in report that Resident #1 was weak and that he/she could go to the bathroom on his/her own. The CNA said she was passing ice and when she entered Resident #1's room (108) she realized Resident #1 was not in the bed or in the bathroom. The CNA stated she told Licensed Practical Nurse (LPN) #2 and the two (2) of them split-up to do room checks. CNA #5 stated she opened the door to room [ROOM NUMBER], flipped on the light switch and saw Resident #1 lying on his/her side on the floor near the sink. CNA #5 stated the resident said he/she was in the bathroom, went out of the wrong bathroom door, was weak and fell . The resident said he/she did not know the time of the fall; the resident was complaining of left hip and lower back pain. CNA #5 stated LPN #2 came in and said not to move the resident. LPN #2 called the ambulance and the ambulance arrived between 11:45 PM and 12:00 AM. The resident was transferred to the hospital. Interview with LPN #2, on [DATE] at 8:55 AM, revealed she worked at the facility for five (5) years and floated to all units and shifts as needed. LPN #2 stated she worked on [DATE] from 11:00 PM to 7:00 AM on the North Unit. She stated she completed a bed check at 10:50 PM and Resident #1 was in the bed. The LPN said she was at the nurse's station completing paper work when CNA #5 asked her to come to room [ROOM NUMBER] because Resident #1 was not in his/her bed or bathroom. LPN #2 stated she and the CNA divided all the rooms and began searching for Resident #1 and after approximately ten (10) minutes CNA #5 yelled she found Resident #1 in room [ROOM NUMBER], on the floor. The LPN stated Resident #1 was on the floor on his/her right side, holding his/her left leg. LPN #2 said the resident told her that he/she went to the bathroom alone, went out the wrong bathroom door, turned back toward the bathroom, realized he/she was going to fall and grabbed toward the sink and fell . The LPN said she did not move the resident due to the resident's history of fractures. CNA #5 remained with the resident while she (LPN #2) went to the nurse's station to call the doctor, family, on-call administration, and Emergency Medical Services (EMS). Interview with CNA #9, on [DATE] at 3:20 PM, revealed she previously worked full time on night shift until three (3) months ago and now worked an as needed schedule. The CNA said Resident #1 was care planned for assistance of one (1) and had a bad habit of getting out of bed at night and getting into an unoccupied bed in the adjacent room. CNA #9 said there was a resident in the bed near the door but the window bed was unoccupied and she had witnessed Resident #1 in the unoccupied bed. The CNA said she heard other staff say, keep an eye on the resident because he/she got turned around, and went into room [ROOM NUMBER]. CNA #9 said she told LPN #5 the night she found Resident #1 in the unoccupied bed in the adjacent room and LPN #5 said the resident just got turned around. In addition, CNA #9 said a couple nights prior to finding Resident #1 in the adjacent room in an unoccupied bed she saw Resident #1 walking down the hallway and she told LPN #5. CNA #9 said they usually began using bed alarms when a resident was getting out of bed without using the call light. Interview with LPN #5, on [DATE] at 9:20 AM, revealed she remembered someone telling her Resident #1 was in an unoccupied bed in an adjacent room but she did not remember if she was working and she was unsure if she would have documented the incident. LPN #5 said Resident #1 was confused at times and might have gone out the wrong bathroom door because he/she was in a new environment. LPN #5 stated she did not remember anyone telling her the resident was walking down the hallway unassisted. Interview with CNA #7, on [DATE] at 2:25 PM, revealed Resident #1 would not call for assistance prior to getting out of bed. CNA #7 said he told a nurse about Resident #1 getting out of bed alone but did not remember which nurse he told. The CNA said he did not remember who he told and he did not complete a Stop and Watch form. Interview with CNA #13, on [DATE] at 10:30 AM, revealed she usually worked day shift on the South Unit but worked on the North unit on [DATE] and [DATE]. The CNA said Resident #1 was an assist of one. The CNA stated she witnessed the resident in the bathroom unassisted and re-educated him/her on use of the call light. CNA #13 said she did not tell the Charge Nurse the resident was out of bed unassisted. Interview with LPN #7 on [DATE] at 12:00 PM, revealed she expected staff to notify the Charge Nurse when a resident was care planned for assistance with ambulation and repeatedly getting out of bed without assistance. Interview with LPN #8, on [DATE] at 11:15 AM, revealed the CNAs should notify the Charge Nurse when a resident, who was care planned for one assist, was out of bed unassisted to ensure appropriate interventions were care planned to prevent falls. In addition, the LPN said she expected staff to complete a Stop and Watch form and consider additional interventions when needed. Interview with LPN #4 on [DATE] at 5:30 PM, revealed she expected staff to notify her when a resident was care planned for assistance of one (1) person, and was observed out of bed without assistance. The LPN said additional interventions should be added to keep it from happening again. Interview with LPN #6, on [DATE] at 11:20 AM, revealed she expected staff to tell her when a resident was observed out of bed without assistance and care planned for one (1) person assist. In addition, the LPN said she would add a bed alarm or fall mat alarm if a resident was repeatedly observed out of bed without assistance. Interview with Registered Nurse (RN) #1, on [DATE] at 11:35 AM, revealed she was the Unit Manager on the North Unit until about three (3) months ago and currently worked as a Charge Nurse on the South Unit on twelve (12) hour day shifts. The RN said she expected staff to encourage use of the call light and consider a bed alarm when a resident was care planned for a one (1) person assist and witnessed out of bed without assistance. Interview with the Unit Manager (UM) of the North and South Units, on [DATE] at 12:25 PM, revealed she was hired on [DATE]. The UM said staff should notify the nurse if a resident was getting up unassisted and was care planned for one (1) person assist. She said other interventions would be considered to ensure the resident's safety. Further review of Resident #1's Comprehensive Plan of Care, dated [DATE], revealed there was no documented evidence the facility revised the care plan to address the resident's ambulating without assistance and the resident's confusion when leaving the bathroom. Interview with the Director of Nursing (DON), on [DATE] at 3:30 PM, revealed CNAs should complete a Stop and Watch form to alert other staff of a change in behavior. The DON said they had been using the Stop and Watch system for about a year and the CNAs were good about using the system. Interview with the Administrator, on [DATE] at 12:50 PM, revealed she expected the CNAs to complete a Stop and Watch form if they witnessed a change in the resident. In addition, the Administrator said she had total responsibility over the building.

Based on observation, interview, record review, review of a hospital radiology report, a facility Incident Report, facility Fall Investigation, facility policy and Manufacturer's instructions for the sit to stand lift, it was determined the facility failed to ensure services were provided by qualified persons for one (1) of five (5) sampled residents (Resident #4) related to the use of a Sit to Stand Lift. On 06/03/15, Resident #4 was assisted with a Sit to Stand lift in the shower room; however, the Certified Nurse Aide (CNA) failed to ensure the safety belt was applied snugly according to manufacturer directions. Resident #4 slipped from the sling onto his/her knees, was assisted to the floor with the resident's right leg bent at an approximate forty five (45) degree angle and his/her right foot was beneath the wheelchair. Three (3) CNAs then lifted the resident and placed him/her in a wheelchair without having a licensed staff assess the resident. Resident #4 was not assessed by licensed staff until the resident was returned to his/her bedroom. The facility failed to ensure staff was qualified to use the lift in a safe manner. Resident #4 was transferred to the hospital emergency room (ER) where he/she was admitted to the hospital with [REDACTED]. The findings include: Review of the facility's policy entitled, Safe Patient Handling and Movement Policy, last revised 10/31/13, revealed documentation to include the facility intended residents were cared for safely and mechanical lifting equipment should be used to prevent manual lifting and handling of residents. Staff should complete and document training initially and annually as needed; all transfers with mechanical lifts should be done with a minimum of two (2) persons or as specified in resident's Plan of Care and injuries resulting from resident handling and movement should be reported pursuant to the facility policy. Review of the facility document titled, Resident Handling Observation Instructions, undated, revealed the facility should complete a minimum of two (2) observations each month to comply with Occupational Safety and Health Administration (OSHA) and State Patient Handling laws. In addition, the document provided instructions of how to complete the Resident Handling Observation Form. Further review of the document revealed all new hires must be observed conducting a resident transfer with and without a lift and kept in the employee file.!!! Review of the facility's procedure titled, Procedure For Using Sit to Stand Lift, undated, revealed documentation to include fasten the safety belt around resident's waist and adjust to a snug but comfortable fit. Review of the Manufacturer User Manual for the Sit to Stand Lift, last revised 2010, revealed the belt should be snug, otherwise the resident could slide out of the sling during transfer, possibly causing injury and residents were not to be raised to a full standing position while using the transfer sling as injury may occur. In addition, the user manual revealed, individuals that use the standing resident sling must be able to support the majority of their own weight, otherwise injury may occur. Record review revealed the facility admitted Resident #4 on 07/01/12 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of Resident #4's Comprehensive Care Plan, dated 02/03/15, revealed the resident was a high risk for falls and injury and should be transferred with Sit to Stand lift. Review of the AccuNurse plan of care custom notes (CNA care plan) revealed Resident #4 required a Sit to Stand Lift to transfer from 09/08/12 through 06/08/15. Interview with CNA #21, on 06/10/15 at 3:50 PM, and review of his/her written statement dated 06/03/15, revealed Resident #4 was injured on 06/03/15 at approximately 5:00-5:30 PM. The CNA said she and CNA #20 used the Sit to Stand Lift to transfer the resident from his/her recliner to the wheelchair and from the wheelchair to the shower chair; however, after the shower the CNAs used the Sit and Stand Lift to stand the resident while they dried him/her in the shower room and the resident's legs buckled and his/her feet came off the platform. The CNA said she thought the sling belt was fastened but not tight enough because the sling slid upward under the resident's arms when his/her feet slid back. The CNA said she thought the belt was too loose because the sling was moving upward and the resident was moving downward. She said they were unable to place the wheelchair beneath him/her so they lowered the resident to the floor with the resident's right leg bent. CNA #21 said she, CNA #20 and CNA #22 lifted the resident from the floor to his/her wheelchair, pushed the resident in the wheelchair to his/her room and transferred the resident back to bed using the Sit to Stand Lift. The CNA said she told Licensed Practical Nurse (LPN) #1 the resident complained of knee pain and the LPN asked him/her where the pain was and the resident pointed to his/her knee. The CNA said by 6:45 PM the resident's upper right leg was swollen compared to his/her upper left leg. CNA #21 said she asked the oncoming nurse, LPN #9, to check on Resident #4. Review of CNA #21's personnel record revealed the Resident Handling Observation form, dated 02/11/15, was blank and signed by the CNA. There was a form with step by step instructions of the use of the sit to stand lift; however, further review revealed there was no documented evidence CNA 21 had been observed conducting a resident transfer with and without a lift per the facility Resident Handling Observation Instructions . Interview with CNA #20, on 06/11/15 at 3:15 PM, revealed CNA #20 had never used a Sit to Stand Lift at this facility or any other place where she had worked. The CNA said during classroom orientation she reviewed and signed a form with written systematic instructions for use of a Sit to Stand Lift. CNA #20 said she was not required to return demonstrate the proper use of the Sit to Stand lift for skills check-off and had no hands on experience in using the Sit to Stand Lift. CNA #20 said she was in training and observed and assisted CNA #21 on 06/03/15. CNA #20 said she assisted CNA #21 using the Sit to Stand Lift to transfer Resident #4 from his/her recliner to the wheelchair and from the wheelchair to the shower chair. CNA #20 said they finished the shower and put a gown on the resident and CNA #20 fastened the standing sling loops to the Sit to Stand arm pegs then fastened the safety belt around the resident's waist. The CNA indicated she should have fastened the safety belt around the resident's waist before she fastened the standing sling loops to the Sit to Stand arm pegs and she did not tighten the belt. The CNA said they lifted the resident to a full upright position and when the resident's knees buckled, they lowered the resident to his/her knees. The CNA said the sling slipped upward underneath the resident's arms. CNA #20 stated she, CNA #21 and CNA #22 then lifted the resident from the floor to the wheelchair, pushed the resident to his/her room and used the Sit to Stand Lift to transfer the resident from the wheelchair to the bed. The CNA said LPN #1 came into the resident's room and asked the resident if he/she was in pain. Review of CNA #20's personnel record, revealed no documented evidence of the CNA #20 receiving/attending Resident Handling Observation in her record. There was a form with step by step instructions of the use of the sit to stand lift; however, further review revealed there was no documented evidence CNA 20's had been observed conducting a resident transfer with and without a lift per the facility Resident Handling Observation Instructions. Interview with CNA #22, on 06/11/15 at 4:20 PM, revealed she was asked to assist CNA #20 and CNA #21. CNA #22 said Resident #4 said, They broke my leg, they broke my leg. She said her and the other two CNA's lifted the resident from the floor to the wheelchair, rolled the resident to his /her room, and used the Sit to Stand Lift to transfer the resident from the wheelchair to the bed. CNA #22 revealed Resident #4 was crying with pain. In addition, CNA #22 said prior to this the resident used to self propel short distances in his/her wheelchair, went to the dining room for meals and enjoyed looking out the window. The CNA said now the resident was a complete feed, was in bed all of the time, and seemed to be in pain or sleeping most of the time. Interview with LPN #1, on 06/12/15 at 9:25 AM, revealed on 06/03/15 at approximately 6:00-6:30 PM, a CNA told her Resident #4 fell . The LPN said she assumed the resident fell in his/her room because the Sit to Stand Lift was in the resident's room. LPN #1 said she assessed the resident's vital signs and range of motion and documented the information on an incident report. Further review of Resident #4's Departmental Notes, dated 06/04/15, revealed LPN #9 documented on 06/04/15 at 1:48 AM that CNA #21 asked her to evaluate Resident #4's right knee due to swelling and pain at approximately 7:30 PM on 06/03/15. The LPN documented CNA #21 informed her that Resident #4 had fallen to his/her knees during transfer from lift to shower chair. Further review revealed LPN #9 documented she found the resident's knee swollen and extremely tender to touch and movement, she notified the physician, the Assistant Director of Nursing (ADON), a family member and Emergency Medical Services. The resident was transferred to the emergency room (ER). Interview with LPN #9, on 06/12/15 at 11:30 AM, revealed she worked 06/03/15 from 7:00 PM until 7:00 AM. The LPN said CNA #21 approached her as soon as she entered the facility and requested she assess Resident #4 because the resident's knee was swollen and the resident was complaining of pain. LPN #9 said that during report LPN #1 had told her the resident had fallen. LPN #9 stated she finished report and then assessed Resident #4. LPN #9 stated the resident's upper right leg was swollen and he/she was complaining of pain. LPN #9 revealed she notified the physician, called EMS and the resident was transferred to the ER at approximately 8:00 PM. Review of a hospital radiology report, dated 06/03/15, revealed Resident #4 was diagnosed with [REDACTED]. Further record review revealed Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's Comprehensive Care Plan, dated 06/06/15, was reviewed. Also, the reports noted the resident was placed on End of Life care related to [DIAGNOSES REDACTED]. Review of Resident #4's physician's orders [REDACTED]. Observation on 06/12/15 at 8:50 AM, revealed Resident #4 lying on the bed with eyes closed. Interview with RN #2 on 06/12/15 at 8:50 AM, revealed Resident #4 was not eating well, was declining and that the Resident's condition had deteriorated since earlier in the week. Review of the facility's Fall Investigation Worksheet completed by the Assistant Director of Nursing (ADON), dated 06/04/15, revealed Resident #4 fell during a transfer from the shower chair to the wheelchair using a Sit to Stand Lift and based on the fall investigation, Resident #4 was deemed unsafe for a Sit to Stand Lift and progressed to a Sling Lift for further transfers. The family requested comfort care measures. Interview with CNA #8, on 06/10/15 at 3:10 PM, revealed staff should not use a Sit to Stand lift if a resident was unable to hold the handle. She said the sling should catch a resident if they let go of the handle or slip and a resident could slip if the sling was not snug. CNA #8 said she had used the Sit to Stand lift to transfer Resident #8 and never had any problems. The CNA said there has not been any additional inservices or training since Resident #8 returned from the hospital. In addition, CNA #8 said Resident #8 used to feed self in the dining room and self propel in the wheelchair and now he/she moaned often and would rarely eat. Interview with CNA #23, on 06/10/15 at 2:35 PM, revealed there were four (4) Sit to Stand lifts and were stored in the shower rooms. The CNA said they used the under arm sling with the Sit to Stand lift. In addition, CNA #23 said she only received verbal instruction in training on the use of lifts. Interview with the Unit Manager of Skilled Unit on 06/15/15 at 7:50 AM, revealed she began working at the facility the first of June, 2015. She said it was her understanding Resident #4 was being transferred using the Sit to Stand lift and the resident's knees buckled and he/she was lowered to the floor. The Unit Manager said the staff were trained to use the lift with verbal instruction in the classroom. She said staff should be trained using a visual and hands on inservice. In addition, the UM said a nurse should assess before a resident is moved following a fall. Interview with the Director of Nursing (DON), on 06/11/15 at 10:10 AM, revealed she had CNA # 20 and CNA #21 return demonstrate the use of the Sit to Stand Lift and re-educated the two CNA's on 06/10/15. The DON said the CNAs' were very competent and the return demonstration revealed the sling was not tight enough and both CNAs' agreed. The DON said she showed the CNAs' how snug the sling should be fastened. The DON said training prior to using a lift should include education, a demonstration and staff return demonstrate and the person providing the education should sign the skills checklist when the return demonstration was correct. The DON said it was the facility's policy for staff to view a demonstration of the use of the lift and then do a return demonstration. She said the ETD was responsible and ultimately the DON was responsible. On 06/11/15 at 11:00 AM, the DON stated CNAs #20, CNAs #21 and CNAs #22 should not have moved Resident #4 prior to a nursing assessment following the assisted fall. Interview with the Administrator, on 06/12/15 at 12:50 PM, revealed the facility provided lift demonstration during orientation and there was no return demonstration by the orientates at that time but at some point during their first thirty (30) days of employment they were asked to return demonstrate the use of the lift for the skills check off. She said the orientates received hands on training when they worked on the nursing units. The Administrator said they were planning to implement hands on training during orientation.

Based on observation; interview; record review; review of the facility policy, Fall Investigation, and Incident Report; and review of the hospital emergency room (ER) record, Discharge Summary and Radiology Report; it was determined the facility failed to ensure adequate supervision to prevent accidents for two (2) of five (5) sampled residents (Residents #1 and #4). On [DATE], Certified Nurse Aide (CNAs) #20 and CNAs #21 transferred Resident #4 with a Sit to Stand Lift (mechanical lift) in the shower room. The facility failed to ensure Resident #4 was assessed for the use of the lift; and, failed to ensure the CNAs were trained and able to use the Sit to Stand Lift safety by return demonstration. Resident #4 slipped from the sling onto his/her knees with his/her leg bent at an approximate forty five (45) degree angle and his/her right foot beneath the wheelchair. CNAs #20 failed to apply the safety belt appropriately. Three (3) Certified Nurse Aides (CNAs) then lifted Resident #4 and placed the resident in his/her wheelchair without having licensed staff assess the resident prior to the transfer and wheeled the resident to his/her room and transferred the resident with the Sit to Stand Lift again. Resident #4 was transferred to the hospital emergency room (ER) and admitted with a [DIAGNOSES REDACTED]. Resident #4 returned to the facility on [DATE] on comfort measures. During the facility's investigation, the facility failed to identify that the resident had not been assessed for the use of the lift and the CNAs did not apply the belt correctly. Refer to F282 The facility failed to have an effective system in place to ensure Resident #1 received adequate supervision while ambulating and toileting. The facility readmitted Resident #1 on [DATE]. Licensed Practical Nurse (LPN) #8 failed to conduct the fall assessment per facility instructions. Resident #1 was care planned for one (1) person physical assist while ambulating and toileting. Interviews with staff revealed Resident #1 had difficulty walking, continuously got out of bed without asking for assistance, and would exit the bathroom into the wrong room and at times was found in another room, on the bed. However, staff failed to use the facility's Stop and Watch form to make licensed staff aware of the resident's actions to ensure Resident #1 had adequate supervision when ambulating. On [DATE] at approximately 11:15 PM, Resident #1 was found in an adjacent room (Room #106) at approximately 11:38 PM, on the floor. Resident #1 was transferred to the hospital ER where he/she was admitted to the hospital with [REDACTED]. Resident #1 died in the hospital on [DATE]. Refer to F280 The findings include: 1. Review of the facility's policy titled, Safe Patient Handling and Movement Policy, last revised [DATE], revealed the facility intended for residents to be cared for safely and mechanical lifting equipment should be used to prevent manual lifting and handling of residents. Staff should complete and document training initially and annually as needed, all transfers with mechanical lifts should be done with a minimum of two (2) persons or as specified in the resident's plan of care. Injuries resulting from resident handling and movement should be reported pursuant to the facility policy. Review of the facility's document, Resident Handling Observation Instructions, undated, revealed the facility should complete a minimum of two (2) observations each month to comply with Occupational Safety and Health Administration (OSHA) and State Patient Handling laws. In addition, the document provided instructions to complete the Resident Handling Observation Form. Further review of the document revealed All new hires must be observed conducting a resident transfer with and without a lift and kept in the employee file. Review of the facility's procedure titled, Procedure For Using Sit to Stand Lift , undated, revealed to fasten the safety belt around resident's waist and adjust to a snug but comfortable fit. Review of the Manufacturer User Manual for the Sit to Stand Lift, last revised 2010, revealed the belt should be snug, otherwise the resident could slide out of the sling during transfer, possibly causing injury; and, residents were not to be raised to a full standing position while using the transfer sling as injury may occur. In addition, the user manual revealed, individuals that use the standing resident sling must be able to support the majority of their own weight, otherwise injury may occur. Record review revealed the facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Interviews on [DATE] with the Quality Assurance (QA) Nurse at 4:00 PM, and with the Regional Director of Clinical Operations at 4:30 PM and further record review revealed there was no documented evidence of a Safety Device Assessment for the use of the Sit to Stand Lift for Resident #4. Review of Resident #4's Comprehensive Care Plan, dated [DATE], revealed the resident was a high risk for falls and injury and should be transferred with a Sit to Stand lift. The AccuNurse Plan of Care custom notes revealed Resident #4 required a Sit to Stand Lift to transfer from [DATE] through [DATE]. Interviews with CNAs #21 on [DATE] at 3:50 PM and CNAs #20 on [DATE] at 3:15 PM, revealed on [DATE] at approximately 6:,[DATE]:30 PM Resident #4 was injured. The CNAs stated they used the Sit to Stand Lift to transfer the resident from his/her recliner to the wheelchair, from the wheelchair to the shower chair; and, after the shower the CNAs used the Sit and Stand Lift to stand the resident while they dried him/her in the shower room. The CNAs revealed CNAs #20 fastened the standing sling loops to the Sit to Stand arm pegs then fastened the safety belt around the resident's waist but she did not tighten the belt. The CNAs stated they lifted the resident to a full upright position and when the resident's knees buckled, his/her feet came off the platform so they lowered the resident to his/her knees. The CNAs stated the sling slipped upward underneath the resident's arms because the safety belt was not fastened snugly. However, the Manufacturer User Manual for the Sit to Stand Lift specifically states the belt should be snug, otherwise the resident could slide out of the sling during transfer causing injury; and residents were not to be raised to a full standing position while using the transfer sling as injury may occur. The CNAs stated they asked CNAs #22 for assistance and they lifted the resident from the floor to his/her wheelchair, pushed the resident in the wheelchair to his/her room and transferred the resident back to bed using the Sit to Stand Lift without having licensed staff assess the resident prior to transfer. The CNAs stated they told LPN #1 the resident complained of knee pain and the LPN asked the resident where the pain was and the resident pointed to his/her knee. The CNAs said by 6:45 PM the resident's upper right leg was swollen compared to his/her upper left leg and CNAs #21 asked the oncoming nurse, LPN #9, to check on Resident #4. Review of the Incident Report for Resident #4, dated [DATE] at 6:00 PM, revealed the resident's knees buckled during a sit to stand lift transfer to the resident's bed and the staff assisted the resident to the floor. Further review of the report revealed the resident sustained [REDACTED]. The immediate action taken was to assist the resident to bed. Further review revealed the report was prepared by LPN #1, and witnessed by CNAs #21. however, interview with CNAs #21, on [DATE] at 3:50 PM, revealed the incident report was not accurate as Resident #4 sustained the fall in the shower room and complained of pain to the left knee. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 9:25 AM, revealed a CNAs told her Resident #4 fell . The LPN said she assumed the resident fell in his/her room because the Sit to Stand Lift was in the room and had she known the resident fell in the shower room, she would have treated the situation differently. She stated at the time of the fall she should have asked the CNAs how his/her knees buckled and how his/her feet went out and where the resident fell because it did not make sense to her, she said at the end of the day, after eleven (11) hours of a twelve (12) hour shift she was exhausted. LPN #1 said she assessed the resident's vital signs and range of motion and documented the information on an incident report. The LPN said she normally would have documented in the Nursing Notes but the day was crazy busy and by the end of the twelve (12) hour shift she was exhausted. The LPN said she should have reprimanded the CNAs for moving the resident and not following protocol. Further review of Resident #4's Departmental Notes, dated [DATE], and interview with LPN #9, on [DATE] at 11:30 AM, revealed on [DATE] at approximately 7:30 PM, CNAs #21 approached LPN #9 as soon as she entered the facility and asked her to evaluate Resident #4's right knee due to swelling and pain. CNAs #21 informed LPN #9 that Resident #4 had fallen to his/her knees during a transfer from the lift to shower chair. LPN #9 assessed the resident and determined the resident's knee was swollen and extremely tender to touch or movement so she notified the physician, the Assistant Director of Nursing (ADON), a family member and Emergency Medical Services (EMS). The resident was transferred to the ER approximately 8:00 PM. Review of a hospital Radiology Report, dated [DATE], revealed Resident #4 was diagnosed with [REDACTED]. Interview with a hospital Radiologist, on [DATE] at 10:40 AM, revealed the resident had sustained a displaced fracture of the distal femur near the knee. The Radiologist said this type of fracture occurred due to trauma, osteoporosis, a bone lesion, or a twist. In addition, the Radiologist said it would not take much to result in a fracture if a resident had osteoporosis. Further record review revealed Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Comprehensive Care Plan, dated [DATE], revealed the resident was placed on End of Life care related to [DIAGNOSES REDACTED]. Review of Resident #4's Physician's Orders, dated [DATE], revealed the resident's pain was uncontrolled and his/her pain medication was changed to Roxanol (for pain) 20 mg/ml, give 0.5 ml (10 mg) sublingually every two (2) hour as needed for pain. Observation on [DATE] at 8:50 AM, revealed Resident #4 lying in bed with eyes closed. Interview with RN #2 on [DATE] at 8:50 AM, revealed Resident #4 was not eating well, was declining and Resident #4's condition had deteriorated since earlier in the week. Further interview with CNAs #20, on [DATE] at 3:15 PM, revealed she had never used a Sit to Stand Lift at this facility or any other place where she had worked. The CNAs said during classroom orientation she reviewed and signed a form with written systematic instructions for use of a Sit to Stand Lift but she was not required to do a return demonstration of the proper use of the Sit to Stand lift for skills check-off. Review of Resident #20's and Resident 21's personnel records, revealed there was no Resident Handling Observation in Resident #20's record and a blank form in Resident #21's record. There was a form with step by step instructions of the use of the sit to stand lift in both personnel records; however, further review revealed there was no documented evidence CNAs #20 and CNAs #21 had been observed conducting a resident transfer with and without a lift at the time of hire per the facility's Resident Handling Observation Instructions. Review of the facility's Fall Investigation Worksheet completed by the Assistant Director of Nursing (ADON), dated [DATE], revealed Resident #4 fell during a transfer from the shower chair to the wheelchair using a Sit to Stand Lift and based on the fall investigation, Resident #4 was deemed unsafe for a Sit to Stand Lift and progressed to a Sling Lift for further transfers. The family requested comfort care measures. Further review revealed there was no evidence the facility identified a device assessment had not been conducted and no evidence the facility had identified the aides had not received hands on training on the use of a lift or had to complete a demonstration of the use of the lift. Further interview with the QA Nurse, on [DATE] at 9:30 AM, revealed there were twenty-eight (28) residents out of one-hundred twenty (120) residents who were transferred using a lift and ten (10) out of the (28) residents were transferred using a Sit to Stand Lift. The QA Nurse stated, prior to [DATE], two (2) of the (28) residents had been assessed for the safe use of the lift. Interview with the Director of Nursing (DON), on [DATE] at 10:10 AM, revealed the facility had determined the root cause of Resident #4's fall/fracture was a status change and the resident could no longer bear weight. She stated the sling should hold a resident if their legs slipped and she believed Resident #4's sling was not tight enough. She said on [DATE], CNAs #20 and CNAs #21 demonstrated use of the Sit to Stand lift and the CNAs told the DON the sling was not snug when they attempted to transfer Resident #4 from the shower chair. The DON said this should have been investigated on Thursday [DATE]. She said the investigation was ongoing and the root cause was the resident's inability to stand up and bear weight and the improper application of the sling contributed to the assisted fall. She said according to the incident report the fall happened in the resident's room; however, the investigation revealed the fall happened in the shower room. Interview with the DON, on [DATE] at 10:55 AM, revealed the CNAs told her the reason they did not notify the nurse prior to moving the resident was because they did not realize it was considered a fall since they lowered the resident to the floor. She said staff should never move a resident after a fall, assisted-fall etc, they should get a nurse. The DON said she expected staff to be trained on lifts on hire and as needed and she assumed new hires did hands on training and that was her expectation because that was their policy and procedure. Interview with the Administrator, on [DATE] at 12:50 PM, revealed use of the lift was demonstrated during classroom orientation then sometime during the first thirty (30) days of training the employee should be observed using the lift and a skills check off completed by the trainer. In addition, the Administrator said the staff received hands on training when they worked on the floor. The Administrator said there was no hands on training during orientation and they were planning to implement hands on training during orientation. In addition, the Administrator said lift assessments were completed sporadically in the past and now they were going to be more consistent. 2. Review of the facility's policy titled, Fall Assessment/Intervention Process, dated ,[DATE], revealed residents were to be assessed on admission for fall risk and appropriate interventions initiated to reduce the risk of injuries with falls. Further review revealed the Admission Nurse should evaluate the resident for fall risks, complete the Get Up and Go Assessment and initiate appropriate interventions to the fall care plan to minimize the risk for falls. Interview with the DON, on [DATE] at 10:10 AM, revealed there was no specific policy on Stop and Watch. However, interview with the Education and Training Director (ETD), on [DATE] at 2:05 PM, revealed the facility used Interact, (Interventions to Reduce Acute Care Transfers), a quality improvement program that focused on the management of acute change in resident condition. It included clinical and educational tools and strategies for use in every day practice in long-term care facilities. The ETD said one of the educational tools within the Interact system were Stop and Watch notepads used by direct care staff to report changes in residents' condition to licensed nurses. The ETD said she expected care plan interventions to be added for changes in condition, behavior changes, and if residents were not following directions. The ETD said the Stop and Watch process was covered during orientation. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Assessment, dated [DATE], revealed the facility assessed Resident #1 as alert and oriented to person, place, time, and purpose, with no memory problem. Review of the facility's Electronic Documentation system revealed instructions for the Get Up and Go Assessment to include: 1. Have the person sit in the chair with their back to the chair and their arms resting on the arm rests. 2. Ask the person to stand up from a standard chair and walk a distance of ten (10) feet. 3. Have the person turn around, walk back to the chair, and sit down again. Timing begins when the person starts to rise from the chair and ends when he or she returns to the chair and sits down. Review of the Timed Get Up and Go Assessment, dated [DATE], revealed LPN #8 had marked Resident #1 as less than twenty (20) seconds, mostly independent. Interview with LPN #8, on [DATE] at 11:15 AM, revealed she completed Resident #1's Timed Get Up and Go Assessment. LPN #8 stated she has worked at the facility for six (6) or seven (7) years, and worked on all units as a Charge Nurse. She said the Charge Nurse was responsible for completing a four (4) page head to toe Admission Assessment in the electronic documentation system which included the Timed Get Up and Go Assessment. The LPN said the Timed Get Up and Go assessment was used as the fall risk assessment and the nurse should document if a resident was a one (1) or two (2) person assist. LPN #8 stated the Timed Get Up and Go Assessment was not timed. She stated you just look at how the resident's body is and how they move and check the appropriate box. However, review of the instructions for the Get up and Go Assessment revealed timing begins when the person starts to rise from the chair and ends when he or she returns to the chair and sits down. The LPN stated the box next to the comment, less than twenty (20) seconds mostly independent indicated a resident would require assist of one (1) person. Review of Resident #1's Comprehensive Plan of Care, dated [DATE], revealed the resident was at risk for fall/injury related to generalized weakness and compression fracture, with an intervention to refer to a plan of care in the voice-assisted, hands free documentation and communication system (AccuNurse Activities of Daily Living Care Plan). Review of the Activities of Daily Living (ADL) Plan of Care, dated [DATE], revealed the facility assessed the resident to require assistance of one (1) person physical assist for ambulation, bathing, dressing and toileting, and cautions to include assistance needed for toileting transfer, do not leave unattended in bathroom and high risk for falls. Review of a Nursing Note, dated [DATE] at 1:44 AM, revealed Resident #1 was found on the floor in the adjoining room and stated he/she went to the bathroom and when he/she finished he/she got turned around and went into the wrong room. The resident stated he/she fell on to his/her back and when trying to get up rolled onto his/her right side. The resident was assessed with [REDACTED]. The Primary Care Physician was notified and the resident was sent to the ER for evaluation. Ambulance here at 12:15 AM to transport the resident. Review of Resident #1's ER record, dated [DATE], revealed Clinical Impression 1. Fall from slipping, tripping or stumbling, 2. Closed left hip fracture. Review of the Resident's Hospital Discharge Summary, dated [DATE], revealed the resident was admitted and surgery was planned; however, the resident's condition declined and it was determined the resident would not survive surgery. Palliative care was provided and the resident expired on [DATE]. Interview with CNAs #1, on [DATE] at 3:35 PM, revealed Resident #1 was in the bed asleep during the final bed check on [DATE] around 10:00 or 10:30 PM. The CNAs said Resident #1's roommate was outside on smoke break when she made rounds. Interview with Resident #1's Roommate, on [DATE] at 11:00 AM, revealed Resident #1 was in pain and moaned at night. The Roommate said Resident #1 would get out of bed to go to the bathroom during the day and night and he/she did not remember hearing a staff member encouraging Resident #1 to call for assistance prior to getting out of bed. The Roommate said he/she and Resident #1 would have conversations and the resident seemed confused at times. Further interview revealed on the evening of [DATE], the Roommate saw Resident #1 out of bed and pacing back and forth from bed 1 to bed 2 and then went into the bathroom and shut the door behind him/her. The Roommate said he/she fell asleep after he/she heard the bathroom door shut and was told the next morning Resident #1 was transferred to the hospital. Interviews on [DATE] with CNAs #5 at 8:10 AM and LPN #2 at 8:55 AM, revealed on [DATE] around 11:00 PM, CNAs #5 began to pass ice water sometime after 11:00 PM; and, when she entered Resident #1's room (108) she observed Resident #1 was not in the bed or in the bathroom. CNAs #5 told LPN #2 and the two (2) of them split-up to do room checks. CNAs #5 opened the door to room 106, flipped on the light switch and found Resident #1 lying on his/her side on the floor near the sink. LPN #2 and CNAs #5 stated the resident said he/she was in the bathroom, got turned around and went out of the wrong bathroom door. The resident told them he/she was weak and fell . The resident complained of left hip and lower back pain. LPN #2 and CNAs #5 did not move the resident, LPN #5 called an ambulance and the ambulance arrived between 11:45 PM and 12:00 AM. Interviews with CNAs #9, on [DATE] at 3:20 PM, CNAs #13 on [DATE] at 10:30 AM, CNAs #7 on [DATE] at 2:25 PM, CNAs #8 on [DATE] at 3:10 PM, and CNAs #10 on [DATE] at 10:20 AM revealed Resident #1 was care planned for assistance of one (1) staff for ambulation but would get out of bed without calling for assistance; and, would get confused after using the bathroom, would exit the bathroom into the adjacent room, and get in the unoccupied bed in that room. The CNAs stated they did not complete a Stop and Watch notepad to notify the licensed staff of the resident's ambulation without assistance or going into the adjacent room. Interviews with LPN #7 on [DATE] at 12:00 PM, LPN #8 on [DATE] at 11:15 AM, LPN #4 on [DATE] at 5:30 PM, and LPN #6 on [DATE] at 11:20 AM, revealed they were not aware of Resident #1 getting up without assistance. The LPNs stated the CNAs should notify the Charge Nurse when a resident was care planned for assistance with ambulation and was repeatedly getting out of bed without assistance to ensure appropriate interventions were added to the care plan to prevent falls. LPN #7 said she expected staff to complete a Stop and Watch form. Interviews on [DATE] with Registered Nurse (RN) #1, South Unit Charge Nurse at 11:35 AM, and Unit Manager of North and South Units at 12:25 PM, revealed they expected staff to report the resident's getting up without assistance so other interventions such as a bed alarm could be considered. Interview with the Staff Education/Trainer (EDT) on [DATE] at 2:05 PM, revealed the Accunurse Care Plan was initiated by the Admission Nurse and the CNAs should access the Accunurse Care Plan via headset for the resident's ADL's and assistance needed. The EDT said staff should reinforce use of the call light when a resident was getting out of bed without assistance and the CNAs should report to the Charge Nurse. The EDT said the Charge Nurse should relay in report and document in the Nurse's Notes and the Shift to Shift report when a resident was found in the wrong bed. Interview with the Director of Nursing (DON), , revealed Resident #1 was care planned appropriately for his/her diagnoses. The DON stated she was not sure who initiated the ADL Plan of Care in the Accunurse and she said the one (1) person physical assist for toileting might have been changed after Resident #1 was transferred to the hospital, it might have been added in anticipation for his/her return to the facility. The DON said there was absolutely no way to determine when one (1) person physical assist was added in accunurse to Resident #1's plan of care. However, interview, on [DATE] at 4:15 PM, with the Senior Clinical Account Manager of the company that makes the Accunurse System, revealed the Accunurse was a system facilities used for CNAs to check resident's Activities of Daily Living care plan via headset. She stated that all updates to an Accunurse Plan of Care were dated and timed stamped in the system. Review of the Plan of Care updates for Resident #1 revealed all care plan updates were entered on [DATE] between 8:27 AM and 8:50 AM. Further interview with DON, on [DATE] at 3:30 PM, revealed Resident #1 had been in the facility for almost two (2) weeks and made progress with therapy, and had not stumbled or walked off balance. The DON said she was not sure why some of the CNAs thought Resident #1 was an assist of one (1). In addition, the DON said she assessed Resident #1 the morning after he/she was admitted and the resident was verystable, but she did not document her assessment. The DON stated there was no indication the resident was a fall risk because his/her previous fractures were pathologic in nature. The DON said Resident #1 was alert and oriented and not showing any signs of fall risk. Further interview with the DON, on [DATE] at 8:50 AM, revealed there was no assessment policy and all residents were care planned as an assist of one (1) on admission and then reviewed during the twenty four (24) hour meeting the next morning. The DON said the Accunurse assessment did not accurately reflect Resident #1's level of function as Resident #1 was able to ambulate without assistance. However, interview with the Physical Therapist, on [DATE] at 11:30 AM, revealed the initial assessment on [DATE] revealed Resident #1 exhibited a forward lean of the trunk, inadequate hip and trunk extension, pain and muscle weakness and was at risk for falls. The Therapist stated he would recommend assistance when out of bed until the resident's balance improved. Further interview with the DON, on [DATE] at 3:30 PM, revealed she was not aware of any occasion when Resident #1 was found in room 106 in an unoccupied bed. The DON stated the CNAs should complete a Stop and Watch form in addition to telling the Charge Nurse if a resident was found in an unoccupied bed and getting up without assistance. The DON said they had been using the Stop and Watch system for about a year and the CNAs were good about using the system. Interview with the Medical Director on [DATE] at 7:30 AM, revealed he was Resident #1's physician when the resident was in the facility. The Medical Director stated when a resident was care planned for one (1) person assist then that was what should be done. Interview with the Administrator, on [DATE] at 12:50 PM, revealed she expected the CNAs to complete a Stop and Watch form if they witnessed a change in the resident. In addition, the Administrator said she had total responsibility over the building.

Based on interview, record review, review of the emergency room (ER) record and hospital Discharge Summary, and facility policy review it was determined the facility failed to revise the care plan for one (1) of five (5) sampled residents (Resident #1). The facility admitted Resident #1 on [DATE] and care planned the resident for the assistance of one staff for ambulation and toileting on [DATE]. Interviews with staff revealed Resident #1 continuously got out of bed without asking for assistance, and would exit the bathroom into the wrong room and at times was found in the bed in that room. However, the facility failed to revise the care plan to address the resident's safety due to getting up without assistance and failed to address the resident's confusion when leaving the bathroom. On [DATE] at approximately 11:55 PM (per Nurse's Notes), Resident #1 was found in the adjacent room (room [ROOM NUMBER]) on the floor. Resident #1 was transferred to the hospital ER where he/she was admitted to the hospital with [REDACTED]. Resident #1 died in the hospital on [DATE]. The findings include: Review of the facility's policy titled, Clinical Quality Assurance and Performance Improvement (QAPI) Daily Review Process, dated [DATE], revealed the Nurse Assessment Coordinator and Assistant Director of Nursing (ADON)/ Director of Nursing (DON)/designee will ensure appropriate updates to the Comprehensive Care Plan and Accunurse Activities of Daily Living (ADL) care plan are carried out and communicated to the direct care staff and Interdisciplinary Team (IDT). Interview with the Director of Nursing (DON), on [DATE] at 10:10 AM, revealed there was no specific policy on Stop and Watch. However, interview with the Education and Training Director (ETD), on [DATE] at 2:05 PM, revealed the facility used Interact, (Interventions to Reduce Acute Care Transfers), a quality improvement program that focused on the management of acute change in resident condition. It included clinical and educational tools and strategies for use in every day practice in long-term care facilities. The ETD said one of the educational tools within the Interact system was Stop and Watch notepads used by direct care staff to report changes in residents' condition to licensed nurses. The ETD said she expected care plan interventions to be added for changes in condition, behavior changes, and if residents were not following directions. The ETD said the Stop and Watch process was covered during orientation. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as alert and oriented to person, place, time, and purpose with no memory problem. Review of Resident #1's Comprehensive Plan of Care, dated [DATE], revealed the resident was at risk for fall/injury related to generalized weakness and compression fracture, with an intervention to refer to a plan of care in the voice-assisted, hands free documentation and communication system (AccuNurse Activities of Daily Living Care Plan) Review of the Activities of Daily Living (ADL) Plan of Care, dated [DATE], revealed the resident required one (1) person physical assistance for ambulation, bathing and dressing. Toileting cautions listed on the plan of care included assistance needed for toileting transfer, do not leave unattended in bathroom and high risk for falls. Review of a Nursing Note, dated [DATE] at 1:44 AM, revealed Resident #1 was found on the floor in the adjoining room (room [ROOM NUMBER]). The resident told staff he/she went to the bathroom and exited the wrong door into the wrong room. The resident stated he/she fell on to his/her back and when trying to get up rolled onto his/her right side. The resident was assessed with [REDACTED]. The Primary Care Physician was notified and the resident was sent to the ER for evaluation. Review of Resident #1's ER record, dated [DATE], revealed, Clinical Impression 1. Fall from slipping, tripping or stumbling, 2. Closed left [MEDICAL CONDITION]. Review of the resident's Hospital Discharge Summary, dated [DATE], revealed the resident was admitted and surgery was planned; however, the resident's condition declined and it was determined the resident would not survive surgery. Palliative care was provided and the resident expired on [DATE]. Interview with Certified Nurse Aide (CNA) #5, on [DATE] at 8:10 AM, revealed she worked the North Unit and had witnessed Resident #1 out of bed unassisted and reminded the resident to use the call light. The CNA worked on [DATE] from 11:00 PM to 7:00 AM and was told in report that Resident #1 was weak and that he/she could go to the bathroom on his/her own. The CNA said she was passing ice and when she entered Resident #1's room (108) she realized Resident #1 was not in the bed or in the bathroom. The CNA stated she told Licensed Practical Nurse (LPN) #2 and the two (2) of them split-up to do room checks. CNA #5 stated she opened the door to room [ROOM NUMBER], flipped on the light switch and saw Resident #1 lying on his/her side on the floor near the sink. CNA #5 stated the resident said he/she was in the bathroom, went out of the wrong bathroom door, was weak and fell . The resident said he/she did not know the time of the fall; the resident was complaining of left hip and lower back pain. CNA #5 stated LPN #2 came in and said not to move the resident. LPN #2 called the ambulance and the ambulance arrived between 11:45 PM and 12:00 AM. The resident was transferred to the hospital. Interview with LPN #2, on [DATE] at 8:55 AM, revealed she worked at the facility for five (5) years and floated to all units and shifts as needed. LPN #2 stated she worked on [DATE] from 11:00 PM to 7:00 AM on the North Unit. She stated she completed a bed check at 10:50 PM and Resident #1 was in the bed. The LPN said she was at the nurse's station completing paper work when CNA #5 asked her to come to room [ROOM NUMBER] because Resident #1 was not in his/her bed or bathroom. LPN #2 stated she and the CNA divided all the rooms and began searching for Resident #1 and after approximately ten (10) minutes CNA #5 yelled she found Resident #1 in room [ROOM NUMBER], on the floor. The LPN stated Resident #1 was on the floor on his/her right side, holding his/her left leg. LPN #2 said the resident told her that he/she went to the bathroom alone, went out the wrong bathroom door, turned back toward the bathroom, realized he/she was going to fall and grabbed toward the sink and fell . The LPN said she did not move the resident due to the resident's history of fractures. CNA #5 remained with the resident while she (LPN #2) went to the nurse's station to call the doctor, family, on-call administration, and Emergency Medical Services (EMS). Interview with CNA #9, on [DATE] at 3:20 PM, revealed she previously worked full time on night shift until three (3) months ago and now worked an as needed schedule. The CNA said Resident #1 was care planned for assistance of one (1) and had a bad habit of getting out of bed at night and getting into an unoccupied bed in the adjacent room. CNA #9 said there was a resident in the bed near the door but the window bed was unoccupied and she had witnessed Resident #1 in the unoccupied bed. The CNA said she heard other staff say, keep an eye on the resident because he/she got turned around, and went into room [ROOM NUMBER]. CNA #9 said she told LPN #5 the night she found Resident #1 in the unoccupied bed in the adjacent room and LPN #5 said the resident just got turned around. In addition, CNA #9 said a couple nights prior to finding Resident #1 in the adjacent room in an unoccupied bed she saw Resident #1 walking down the hallway and she told LPN #5. CNA #9 said they usually began using bed alarms when a resident was getting out of bed without using the call light. Interview with LPN #5, on [DATE] at 9:20 AM, revealed she remembered someone telling her Resident #1 was in an unoccupied bed in an adjacent room but she did not remember if she was working and she was unsure if she would have documented the incident. LPN #5 said Resident #1 was confused at times and might have gone out the wrong bathroom door because he/she was in a new environment. LPN #5 stated she did not remember anyone telling her the resident was walking down the hallway unassisted. Interview with CNA #7, on [DATE] at 2:25 PM, revealed Resident #1 would not call for assistance prior to getting out of bed. CNA #7 said he told a nurse about Resident #1 getting out of bed alone but did not remember which nurse he told. The CNA said he did not remember who he told and he did not complete a Stop and Watch form. Interview with CNA #13, on [DATE] at 10:30 AM, revealed she usually worked day shift on the South Unit but worked on the North unit on [DATE] and [DATE]. The CNA said Resident #1 was an assist of one. The CNA stated she witnessed the resident in the bathroom unassisted and re-educated him/her on use of the call light. CNA #13 said she did not tell the Charge Nurse the resident was out of bed unassisted. Interview with LPN #7 on [DATE] at 12:00 PM, revealed she expected staff to notify the Charge Nurse when a resident was care planned for assistance with ambulation and repeatedly getting out of bed without assistance. Interview with LPN #8, on [DATE] at 11:15 AM, revealed the CNAs should notify the Charge Nurse when a resident, who was care planned for one assist, was out of bed unassisted to ensure appropriate interventions were care planned to prevent falls. In addition, the LPN said she expected staff to complete a Stop and Watch form and consider additional interventions when needed. Interview with LPN #4 on [DATE] at 5:30 PM, revealed she expected staff to notify her when a resident was care planned for assistance of one (1) person, and was observed out of bed without assistance. The LPN said additional interventions should be added to keep it from happening again. Interview with LPN #6, on [DATE] at 11:20 AM, revealed she expected staff to tell her when a resident was observed out of bed without assistance and care planned for one (1) person assist. In addition, the LPN said she would add a bed alarm or fall mat alarm if a resident was repeatedly observed out of bed without assistance. Interview with Registered Nurse (RN) #1, on [DATE] at 11:35 AM, revealed she was the Unit Manager on the North Unit until about three (3) months ago and currently worked as a Charge Nurse on the South Unit on twelve (12) hour day shifts. The RN said she expected staff to encourage use of the call light and consider a bed alarm when a resident was care planned for a one (1) person assist and witnessed out of bed without assistance. Interview with the Unit Manager (UM) of the North and South Units, on [DATE] at 12:25 PM, revealed she was hired on [DATE]. The UM said staff should notify the nurse if a resident was getting up unassisted and was care planned for one (1) person assist. She said other interventions would be considered to ensure the resident's safety. Further review of Resident #1's Comprehensive Plan of Care, dated [DATE], revealed there was no documented evidence the facility revised the care plan to address the resident's ambulating without assistance and the resident's confusion when leaving the bathroom. Interview with the Director of Nursing (DON), on [DATE] at 3:30 PM, revealed CNAs should complete a Stop and Watch form to alert other staff of a change in behavior. The DON said they had been using the Stop and Watch system for about a year and the CNAs were good about using the system. Interview with the Administrator, on [DATE] at 12:50 PM, revealed she expected the CNAs to complete a Stop and Watch form if they witnessed a change in the resident. In addition, the Administrator said she had total responsibility over the building.

Based on observation; interview; record review; review of the facility policy, Fall Investigation, and Incident Report; and review of the hospital emergency room (ER) record, Discharge Summary and Radiology Report; it was determined the facility failed to ensure adequate supervision to prevent accidents for two (2) of five (5) sampled residents (Residents #1 and #4). On [DATE], Certified Nurse Aide (CNA) #20 and CNA #21 transferred Resident #4 with a Sit to Stand Lift (mechanical lift) in the shower room. The facility failed to ensure Resident #4 was assessed for the use of the lift; and, failed to ensure the CNAs were trained and able to use the Sit to Stand Lift safety by return demonstration. Resident #4 slipped from the sling onto his/her knees with his/her leg bent at an approximate forty five (45) degree angle and his/her right foot beneath the wheelchair. CNA #20 failed to apply the safety belt appropriately. Three (3) Certified Nurse Aides (CNAs) then lifted Resident #4 and placed the resident in his/her wheelchair without having licensed staff assess the resident prior to the transfer and wheeled the resident to his/her room and transferred the resident with the Sit to Stand Lift again. Resident #4 was transferred to the hospital emergency room (ER) and admitted with a [DIAGNOSES REDACTED]. Resident #4 returned to the facility on [DATE] on comfort measures. During the facility's investigation, the facility failed to identify that the resident had not been assessed for the use of the lift and the CNA did not apply the belt correctly. Refer to F282 The facility failed to have an effective system in place to ensure Resident #1 received adequate supervision while ambulating and toileting. The facility readmitted Resident #1 on [DATE]. Licensed Practical Nurse (LPN) #8 failed to conduct the fall assessment per facility instructions. Resident #1 was care planned for one (1) person physical assist while ambulating and toileting. Interviews with staff revealed Resident #1 had difficulty walking, continuously got out of bed without asking for assistance, and would exit the bathroom into the wrong room and at times was found in another room, on the bed. However, staff failed to use the facility's Stop and Watch form to make licensed staff aware of the resident's actions to ensure Resident #1 had adequate supervision when ambulating. On [DATE] at approximately 11:15 PM, Resident #1 was found in an adjacent room (Room #106) at approximately 11:38 PM, on the floor. Resident #1 was transferred to the hospital ER where he/she was admitted to the hospital with [REDACTED]. Resident #1 died in the hospital on [DATE]. Refer to F280 The findings include: 1. Review of the facility's policy titled, Safe Patient Handling and Movement Policy, last revised [DATE], revealed the facility intended for residents to be cared for safely and mechanical lifting equipment should be used to prevent manual lifting and handling of residents. Staff should complete and document training initially and annually as needed, all transfers with mechanical lifts should be done with a minimum of two (2) persons or as specified in the resident's plan of care. Injuries resulting from resident handling and movement should be reported pursuant to the facility policy. Review of the facility's document, Resident Handling Observation Instructions, undated, revealed the facility should complete a minimum of two (2) observations each month to comply with Occupational Safety and Health Administration (OSHA) and State Patient Handling laws. In addition, the document provided instructions to complete the Resident Handling Observation Form. Further review of the document revealed All new hires must be observed conducting a resident transfer with and without a lift and kept in the employee file. Review of the facility's procedure titled, Procedure For Using Sit to Stand Lift , undated, revealed to fasten the safety belt around resident's waist and adjust to a snug but comfortable fit. Review of the Manufacturer User Manual for the Sit to Stand Lift, last revised 2010, revealed the belt should be snug, otherwise the resident could slide out of the sling during transfer, possibly causing injury; and, residents were not to be raised to a full standing position while using the transfer sling as injury may occur. In addition, the user manual revealed, individuals that use the standing resident sling must be able to support the majority of their own weight, otherwise injury may occur. Record review revealed the facility admitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Interviews on [DATE] with the Quality Assurance (QA) Nurse at 4:00 PM, and with the Regional Director of Clinical Operations at 4:30 PM and further record review revealed there was no documented evidence of a Safety Device Assessment for the use of the Sit to Stand Lift for Resident #4. Review of Resident #4's Comprehensive Care Plan, dated [DATE], revealed the resident was a high risk for falls and injury and should be transferred with a Sit to Stand lift. The AccuNurse Plan of Care custom notes revealed Resident #4 required a Sit to Stand Lift to transfer from [DATE] through [DATE]. Interviews with CNA #21 on [DATE] at 3:50 PM and CNA #20 on [DATE] at 3:15 PM, revealed on [DATE] at approximately 6:,[DATE]:30 PM Resident #4 was injured. The CNAs stated they used the Sit to Stand Lift to transfer the resident from his/her recliner to the wheelchair, from the wheelchair to the shower chair; and, after the shower the CNAs used the Sit and Stand Lift to stand the resident while they dried him/her in the shower room. The CNAs revealed CNA #20 fastened the standing sling loops to the Sit to Stand arm pegs then fastened the safety belt around the resident's waist but she did not tighten the belt. The CNAs stated they lifted the resident to a full upright position and when the resident's knees buckled, his/her feet came off the platform so they lowered the resident to his/her knees. The CNAs stated the sling slipped upward underneath the resident's arms because the safety belt was not fastened snugly. However, the Manufacturer User Manual for the Sit to Stand Lift specifically states the belt should be snug, otherwise the resident could slide out of the sling during transfer causing injury; and residents were not to be raised to a full standing position while using the transfer sling as injury may occur. The CNAs stated they asked CNA #22 for assistance and they lifted the resident from the floor to his/her wheelchair, pushed the resident in the wheelchair to his/her room and transferred the resident back to bed using the Sit to Stand Lift without having licensed staff assess the resident prior to transfer. The CNAs stated they told LPN #1 the resident complained of knee pain and the LPN asked the resident where the pain was and the resident pointed to his/her knee. The CNAs said by 6:45 PM the resident's upper right leg was swollen compared to his/her upper left leg and CNA #21 asked the oncoming nurse, LPN #9, to check on Resident #4. Review of the Incident Report for Resident #4, dated [DATE] at 6:00 PM, revealed the resident's knees buckled during a sit to stand lift transfer to the resident's bed and the staff assisted the resident to the floor. Further review of the report revealed the resident sustained [REDACTED]. The immediate action taken was to assist the resident to bed. Further review revealed the report was prepared by LPN #1, and witnessed by CNA #21. however, interview with CNA #21, on [DATE] at 3:50 PM, revealed the incident report was not accurate as Resident #4 sustained the fall in the shower room and complained of pain to the left knee. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 9:25 AM, revealed a CNA told her Resident #4 fell . The LPN said she assumed the resident fell in his/her room because the Sit to Stand Lift was in the room and had she known the resident fell in the shower room, she would have treated the situation differently. She stated at the time of the fall she should have asked the CNAs how his/her knees buckled and how his/her feet went out and where the resident fell because it did not make sense to her, she said at the end of the day, after eleven (11) hours of a twelve (12) hour shift she was exhausted. LPN #1 said she assessed the resident's vital signs and range of motion and documented the information on an incident report. The LPN said she normally would have documented in the Nursing Notes but the day was crazy busy and by the end of the twelve (12) hour shift she was exhausted. The LPN said she should have reprimanded the CNAs for moving the resident and not following protocol. Further review of Resident #4's Departmental Notes, dated [DATE], and interview with LPN #9, on [DATE] at 11:30 AM, revealed on [DATE] at approximately 7:30 PM, CNA #21 approached LPN #9 as soon as she entered the facility and asked her to evaluate Resident #4's right knee due to swelling and pain. CNA #21 informed LPN #9 that Resident #4 had fallen to his/her knees during a transfer from the lift to shower chair. LPN #9 assessed the resident and determined the resident's knee was swollen and extremely tender to touch or movement so she notified the physician, the Assistant Director of Nursing (ADON), a family member and Emergency Medical Services (EMS). The resident was transferred to the ER approximately 8:00 PM. Review of a hospital Radiology Report, dated [DATE], revealed Resident #4 was diagnosed with [REDACTED]. Interview with a hospital Radiologist, on [DATE] at 10:40 AM, revealed the resident had sustained a displaced fracture of the distal femur near the knee. The Radiologist said this type of fracture occurred due to trauma, osteoporosis, a bone lesion, or a twist. In addition, the Radiologist said it would not take much to result in a fracture if a resident had osteoporosis. Further record review revealed Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Comprehensive Care Plan, dated [DATE], revealed the resident was placed on End of Life care related to [DIAGNOSES REDACTED]. Review of Resident #4's Physician's Orders, dated [DATE], revealed the resident's pain was uncontrolled and his/her pain medication was changed to Roxanol (for pain) 20 mg/ml, give 0.5 ml (10 mg) sublingually every two (2) hour as needed for pain. Observation on [DATE] at 8:50 AM, revealed Resident #4 lying in bed with eyes closed. Interview with RN #2 on [DATE] at 8:50 AM, revealed Resident #4 was not eating well, was declining and Resident #4's condition had deteriorated since earlier in the week. Further interview with CNA #20, on [DATE] at 3:15 PM, revealed she had never used a Sit to Stand Lift at this facility or any other place where she had worked. The CNA said during classroom orientation she reviewed and signed a form with written systematic instructions for use of a Sit to Stand Lift but she was not required to do a return demonstration of the proper use of the Sit to Stand lift for skills check-off. Review of Resident #20's and Resident 21's personnel records, revealed there was no Resident Handling Observation in Resident #20's record and a blank form in Resident #21's record. There was a form with step by step instructions of the use of the sit to stand lift in both personnel records; however, further review revealed there was no documented evidence CNA #20 and CNA #21 had been observed conducting a resident transfer with and without a lift at the time of hire per the facility's Resident Handling Observation Instructions. Review of the facility's Fall Investigation Worksheet completed by the Assistant Director of Nursing (ADON), dated [DATE], revealed Resident #4 fell during a transfer from the shower chair to the wheelchair using a Sit to Stand Lift and based on the fall investigation, Resident #4 was deemed unsafe for a Sit to Stand Lift and progressed to a Sling Lift for further transfers. The family requested comfort care measures. Further review revealed there was no evidence the facility identified a device assessment had not been conducted and no evidence the facility had identified the aides had not received hands on training on the use of a lift or had to complete a demonstration of the use of the lift. Further interview with the QA Nurse, on [DATE] at 9:30 AM, revealed there were twenty-eight (28) residents out of one-hundred twenty (120) residents who were transferred using a lift and ten (10) out of the (28) residents were transferred using a Sit to Stand Lift. The QA Nurse stated, prior to [DATE], two (2) of the (28) residents had been assessed for the safe use of the lift. Interview with the Director of Nursing (DON), on [DATE] at 10:10 AM, revealed the facility had determined the root cause of Resident #4's fall/fracture was a status change and the resident could no longer bear weight. She stated the sling should hold a resident if their legs slipped and she believed Resident #4's sling was not tight enough. She said on [DATE], CNA #20 and CNA #21 demonstrated use of the Sit to Stand lift and the CNAs told the DON the sling was not snug when they attempted to transfer Resident #4 from the shower chair. The DON said this should have been investigated on Thursday [DATE]. She said the investigation was ongoing and the root cause was the resident's inability to stand up and bear weight and the improper application of the sling contributed to the assisted fall. She said according to the incident report the fall happened in the resident's room; however, the investigation revealed the fall happened in the shower room. Interview with the DON, on [DATE] at 10:55 AM, revealed the CNAs told her the reason they did not notify the nurse prior to moving the resident was because they did not realize it was considered a fall since they lowered the resident to the floor. She said staff should never move a resident after a fall, assisted-fall etc, they should get a nurse. The DON said she expected staff to be trained on lifts on hire and as needed and she assumed new hires did hands on training and that was her expectation because that was their policy and procedure. Interview with the Administrator, on [DATE] at 12:50 PM, revealed use of the lift was demonstrated during classroom orientation then sometime during the first thirty (30) days of training the employee should be observed using the lift and a skills check off completed by the trainer. In addition, the Administrator said the staff received hands on training when they worked on the floor. The Administrator said there was no hands on training during orientation and they were planning to implement hands on training during orientation. In addition, the Administrator said lift assessments were completed sporadically in the past and now they were going to be more consistent. 2. Review of the facility's policy titled, Fall Assessment/Intervention Process, dated ,[DATE], revealed residents were to be assessed on admission for fall risk and appropriate interventions initiated to reduce the risk of injuries with falls. Further review revealed the Admission Nurse should evaluate the resident for fall risks, complete the Get Up and Go Assessment and initiate appropriate interventions to the fall care plan to minimize the risk for falls. Interview with the DON, on [DATE] at 10:10 AM, revealed there was no specific policy on Stop and Watch. However, interview with the Education and Training Director (ETD), on [DATE] at 2:05 PM, revealed the facility used Interact, (Interventions to Reduce Acute Care Transfers), a quality improvement program that focused on the management of acute change in resident condition. It included clinical and educational tools and strategies for use in every day practice in long-term care facilities. The ETD said one of the educational tools within the Interact system were Stop and Watch notepads used by direct care staff to report changes in residents' condition to licensed nurses. The ETD said she expected care plan interventions to be added for changes in condition, behavior changes, and if residents were not following directions. The ETD said the Stop and Watch process was covered during orientation. Record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Review of an Admission Assessment, dated [DATE], revealed the facility assessed Resident #1 as alert and oriented to person, place, time, and purpose, with no memory problem. Review of the facility's Electronic Documentation system revealed instructions for the Get Up and Go Assessment to include: 1. Have the person sit in the chair with their back to the chair and their arms resting on the arm rests. 2. Ask the person to stand up from a standard chair and walk a distance of ten (10) feet. 3. Have the person turn around, walk back to the chair, and sit down again. Timing begins when the person starts to rise from the chair and ends when he or she returns to the chair and sits down. Review of the Timed Get Up and Go Assessment, dated [DATE], revealed LPN #8 had marked Resident #1 as less than twenty (20) seconds, mostly independent. Interview with LPN #8, on [DATE] at 11:15 AM, revealed she completed Resident #1's Timed Get Up and Go Assessment. LPN #8 stated she has worked at the facility for six (6) or seven (7) years, and worked on all units as a Charge Nurse. She said the Charge Nurse was responsible for completing a four (4) page head to toe Admission Assessment in the electronic documentation system which included the Timed Get Up and Go Assessment. The LPN said the Timed Get Up and Go assessment was used as the fall risk assessment and the nurse should document if a resident was a one (1) or two (2) person assist. LPN #8 stated the Timed Get Up and Go Assessment was not timed. She stated you just look at how the resident's body is and how they move and check the appropriate box. However, review of the instructions for the Get up and Go Assessment revealed timing begins when the person starts to rise from the chair and ends when he or she returns to the chair and sits down. The LPN stated the box next to the comment, less than twenty (20) seconds mostly independent indicated a resident would require assist of one (1) person. Review of Resident #1's Comprehensive Plan of Care, dated [DATE], revealed the resident was at risk for fall/injury related to generalized weakness and compression fracture, with an intervention to refer to a plan of care in the voice-assisted, hands free documentation and communication system (AccuNurse Activities of Daily Living Care Plan). Review of the Activities of Daily Living (ADL) Plan of Care, dated [DATE], revealed the facility assessed the resident to require assistance of one (1) person physical assist for ambulation, bathing, dressing and toileting, and cautions to include assistance needed for toileting transfer, do not leave unattended in bathroom and high risk for falls. Review of a Nursing Note, dated [DATE] at 1:44 AM, revealed Resident #1 was found on the floor in the adjoining room and stated he/she went to the bathroom and when he/she finished he/she got turned around and went into the wrong room. The resident stated he/she fell on to his/her back and when trying to get up rolled onto his/her right side. The resident was assessed with [REDACTED]. The Primary Care Physician was notified and the resident was sent to the ER for evaluation. Ambulance here at 12:15 AM to transport the resident. Review of Resident #1's ER record, dated [DATE], revealed Clinical Impression 1. Fall from slipping, tripping or stumbling, 2. Closed left hip fracture. Review of the Resident's Hospital Discharge Summary, dated [DATE], revealed the resident was admitted and surgery was planned; however, the resident's condition declined and it was determined the resident would not survive surgery. Palliative care was provided and the resident expired on [DATE]. Interview with CNA #1, on [DATE] at 3:35 PM, revealed Resident #1 was in the bed asleep during the final bed check on [DATE] around 10:00 or 10:30 PM. The CNA said Resident #1's roommate was outside on smoke break when she made rounds. Interview with Resident #1's Roommate, on [DATE] at 11:00 AM, revealed Resident #1 was in pain and moaned at night. The Roommate said Resident #1 would get out of bed to go to the bathroom during the day and night and he/she did not remember hearing a staff member encouraging Resident #1 to call for assistance prior to getting out of bed. The Roommate said he/she and Resident #1 would have conversations and the resident seemed confused at times. Further interview revealed on the evening of [DATE], the Roommate saw Resident #1 out of bed and pacing back and forth from bed 1 to bed 2 and then went into the bathroom and shut the door behind him/her. The Roommate said he/she fell asleep after he/she heard the bathroom door shut and was told the next morning Resident #1 was transferred to the hospital. Interviews on [DATE] with CNA #5 at 8:10 AM and LPN #2 at 8:55 AM, revealed on [DATE] around 11:00 PM, CNA #5 began to pass ice water sometime after 11:00 PM; and, when she entered Resident #1's room (108) she observed Resident #1 was not in the bed or in the bathroom. CNA #5 told LPN #2 and the two (2) of them split-up to do room checks. CNA #5 opened the door to room 106, flipped on the light switch and found Resident #1 lying on his/her side on the floor near the sink. LPN #2 and CNA #5 stated the resident said he/she was in the bathroom, got turned around and went out of the wrong bathroom door. The resident told them he/she was weak and fell . The resident complained of left hip and lower back pain. LPN #2 and CNA #5 did not move the resident, LPN #5 called an ambulance and the ambulance arrived between 11:45 PM and 12:00 AM. Interviews with CNA #9, on [DATE] at 3:20 PM, CNA #13 on [DATE] at 10:30 AM, CNA #7 on [DATE] at 2:25 PM, CNA #8 on [DATE] at 3:10 PM, and CNA #10 on [DATE] at 10:20 AM revealed Resident #1 was care planned for assistance of one (1) staff for ambulation but would get out of bed without calling for assistance; and, would get confused after using the bathroom, would exit the bathroom into the adjacent room, and get in the unoccupied bed in that room. The CNAs stated they did not complete a Stop and Watch notepad to notify the licensed staff of the resident's ambulation without assistance or going into the adjacent room. Interviews with LPN #7 on [DATE] at 12:00 PM, LPN #8 on [DATE] at 11:15 AM, LPN #4 on [DATE] at 5:30 PM, and LPN #6 on [DATE] at 11:20 AM, revealed they were not aware of Resident #1 getting up without assistance. The LPNs stated the CNAs should notify the Charge Nurse when a resident was care planned for assistance with ambulation and was repeatedly getting out of bed without assistance to ensure appropriate interventions were added to the care plan to prevent falls. LPN #7 said she expected staff to complete a Stop and Watch form. Interviews on [DATE] with Registered Nurse (RN) #1, South Unit Charge Nurse at 11:35 AM, and Unit Manager of North and South Units at 12:25 PM, revealed they expected staff to report the resident's getting up without assistance so other interventions such as a bed alarm could be considered. Interview with the Staff Education/Trainer (EDT) on [DATE] at 2:05 PM, revealed the Accunurse Care Plan was initiated by the Admission Nurse and the CNAs should access the Accunurse Care Plan via headset for the resident's ADL's and assistance needed. The EDT said staff should reinforce use of the call light when a resident was getting out of bed without assistance and the CNAs should report to the Charge Nurse. The EDT said the Charge Nurse should relay in report and document in the Nurse's Notes and the Shift to Shift report when a resident was found in the wrong bed. Interview with the Director of Nursing (DON), , revealed Resident #1 was care planned appropriately for his/her diagnoses. The DON stated she was not sure who initiated the ADL Plan of Care in the Accunurse and she said the one (1) person physical assist for toileting might have been changed after Resident #1 was transferred to the hospital, it might have been added in anticipation for his/her return to the facility. The DON said there was absolutely no way to determine when one (1) person physical assist was added in accunurse to Resident #1's plan of care. However, interview, on [DATE] at 4:15 PM, with the Senior Clinical Account Manager of the company that makes the Accunurse System, revealed the Accunurse was a system facilities used for CNAs to check resident's Activities of Daily Living care plan via headset. She stated that all updates to an Accunurse Plan of Care were dated and timed stamped in the system. Review of the Plan of Care updates for Resident #1 revealed all care plan updates were entered on [DATE] between 8:27 AM and 8:50 AM. Further interview with DON, on [DATE] at 3:30 PM, revealed Resident #1 had been in the facility for almost two (2) weeks and made progress with therapy, and had not stumbled or walked off balance. The DON said she was not sure why some of the CNAs thought Resident #1 was an assist of one (1). In addition, the DON said she assessed Resident #1 the morning after he/she was admitted and the resident was verystable, but she did not document her assessment. The DON stated there was no indication the resident was a fall risk because his/her previous fractures were pathologic in nature. The DON said Resident #1 was alert and oriented and not showing any signs of fall risk. Further interview with the DON, on [DATE] at 8:50 AM, revealed there was no assessment policy and all residents were care planned as an assist of one (1) on admission and then reviewed during the twenty four (24) hour meeting the next morning. The DON said the Accunurse assessment did not accurately reflect Resident #1's level of function as Resident #1 was able to ambulate without assistance. However, interview with the Physical Therapist, on [DATE] at 11:30 AM, revealed the initial assessment on [DATE] revealed Resident #1 exhibited a forward lean of the trunk, inadequate hip and trunk extension, pain and muscle weakness and was at risk for falls. The Therapist stated he would recommend assistance when out of bed until the resident's balance improved. Further interview with the DON, on [DATE] at 3:30 PM, revealed she was not aware of any occasion when Resident #1 was found in room 106 in an unoccupied bed. The DON stated the CNAs should complete a Stop and Watch form in addition to telling the Charge Nurse if a resident was found in an unoccupied bed and getting up without assistance. The DON said they had been using the Stop and Watch system for about a year and the CNAs were good about using the system. Interview with the Medical Director on [DATE] at 7:30 AM, revealed he was Resident #1's physician when the resident was in the facility. The Medical Director stated when a resident was care planned for one (1) person assist then that was what should be done. Interview with the Administrator, on [DATE] at 12:50 PM, revealed she expected the CNAs to complete a Stop and Watch form if they witnessed a change in the resident. In addition, the Administrator said she had total responsibility over the building.

Based on interview, record review and policy review it was determined the facility failed to ensure care was provided in accordance with the resident plan of care for one (1) of three sampled residents (Resident #1). The facility assessed and care planned Resident #1 as requiring the assistance of two (2) staff for bed mobility and incontinent care. On 06/01/13 at 2:30 AM, one Certified Nursing Assistant (CNA #1) initiated care by removing a foot bolster from the resident's feet and a positioning wedge from behind Resident #1's back. The CNA turned her back on Resident #1 to obtain a brief and the resident rolled off the bed onto the floor. Resident #1 was transported to the hospital for further evaluation and was diagnosed with [REDACTED]. The findings include: Review of the facility's policy entitled "Comprehensive Care Plans", last revised 10/2010, revealed each resident's comprehensive care plan was designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; build on resident's strengths; aid in preventing or reducing declines in the resident's functional status and/or functional level; and reflect currently recognized standards of practice for problem areas and conditions. The Care Plan interventions were designed after careful consideration of the relationship between the resident's problem area and their causes. Record review revealed the facility admitted Resident #1 on 10/05/06 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 05/09/13, revealed the facility assessed Resident #1's cognition as severely impaired and the resident required the extensive assistance of two (2) staff for bed mobility and toilet use. Review of the Comprehensive Care Plan, last revised 05/09/13, revealed two (2) staff should assist Resident #1 with bed mobility. Review of the Activities of Daily Living (ADL) Plan of Care Skilled Sheet, dated 06/18/13, revealed Resident #1 was totally dependent on two staff for positioning and for incontinent care. Interview with MDS Coordinator, on 06/20/13 at 2:30 PM, revealed Resident #1 was assessed and care planned for total assist of two (2) staff for all of his/her Activity's of Daily living. Review of the Nurse's Note, dated 06/01/13 at 2:30 AM, revealed the Certified Nurse Assistant (CNA#1) entered Resident #1's room to provide incontinent care. The CNA removed the foot bolster and positioning wedge from the resident. Continued review revealed the CNA went to the closet to get a brief for the resident, and the resident was shaking his/her arms and legs in bed. The CNA heard a thud, turned around and saw the resident lying on the right side of the bed on the floor. The CNA yelled for assistance to lift the resident from the floor to the bed. The resident was assessed by Licensed Practical Nurse (LPN) #1, who identified a two (2) centimeter (cm) abrasion to the resident's left thigh. The resident's right upper leg was swollen with deformity noted to the right femur. Further review revealed the physician was notified at 2:45 AM and an order was received to send the resident to the emergency room for evaluation. The resident was transferred to the emergency room per ambulance at 3:10 AM. At 7:30 AM, the facility called the emergency room and received information the resident was being admitted with a fracture to the right femur. An interview with CNA#1, on 06/19/13 at 10:15 AM and 3:30 PM, revealed she entered Resident #1's room to provide routine check and change care for Resident #1. She stated CNA #2 was answering a call light and was coming to assist her with Resident #1. CNA #1 revealed she removed the foot bolsters from the resident's feet and the positioning wedge from behind the resident's back to prepare the resident for incontinent care. When she removed the wedge, Resident #1 began shaking his/her hands as he/she always does when staff begin to provide care. CNA #1 revealed she turned her back to the resident to get a brief from the resident's closet and heard a thump and when she turned around the resident had fallen to the floor. CNA #1 stated when she removed the wedge from behind the resident's back, the resident may have been too close to the edge of the bed, so when the resident started shaking his/her hands it caused him/her to fall out of the bed. Further interview with CNA #1 revealed she really did not think the resident was near the edge of the bed, but she didn't really know what happened because her back was to the resident and she did not see the resident fall. The CNA revealed the resident was care planned for the assistance of two (2) and she would never change the resident by herself. The CNA stated she was waiting on CNA #2 to change the resident. Interview with CNA #2, on 06/19/13 and 06/20/13 at 10:10 AM and 11:10 AM respectively, revealed she was on the way to assist CNA #1 with the checking and changing of Resident #1 but had to answer a call light before getting there. CNA #2 revealed she heard CNA #1 yell for help and when she entered the room, CNA #1 was holding Resident #1's head up, the feeding tube was tucked under the resident very tightly, and they were afraid the tubing was going to pull out of the resident. CNA #2 revealed she observed CNA #1 pick Resident #1 up and place the resident back in bed. CNA #2 stated Resident #1 was care planned for two (2) person assist with all care except for feeding. Interview with Licensed Practical Nurse (LPN) #1, on 06/19/13 at 8:30 AM, revealed she was called to Resident #1's room by CNA #1. The CNA told her she was preparing Resident #1 for incontinent care by removing the wedge from behind the resident's back and the foot bolster. The CNA stated she turned around to get a brief out of the closet and heard a thud and when the CNA turned back around she saw Resident #1 had fallen out of the bed. CNA #1 further reported to the LPN the resident's feeding tube and oxygen tubing were still attached to the resident and were stretching. The CNAs were afraid the feeding tube would pull out, so CNA #1 and CNA #2 lifted the resident back to the bed. LPN #1 stated Resident #1 had a [DIAGNOSES REDACTED]. LPN #1 stated she notified the on call nursing supervisor (Registered Nurse #1), the physician and the State Guardian and then she called the ambulance. LPN #1 stated she conducted a head to toe assessment of Resident #1 and checked the resident's vital signs. Interview with Registered Nurse (RN) #1, on 06/19/13 at 1:05 PM, revealed she received a phone call from LPN #1 in the middle of the night that Resident #1 had fallen out of bed and LPN #1 thought the resident had a leg fracture. RN #1 stated Resident #1 was a two (2) person assist with incontinent care and turning, had tremors and would shake at times. The RN revealed the resident's tremors were worse in the evening and sometimes she would shake so hard it could have caused the resident to fall out of the bed. The RN stated the resident's tremors are mostly in the upper body, but sometimes it's in his/her legs too. Interviews with CNA #3, CNA #4, CNA #5, CNA #6 on 06/19/13 at 9:15 AM, 9:25 AM and 9:30 AM; and, on 06/20/13 at 8:20 AM revealed Resident #1 was care planned for two (2) assist with all care. The CNAs revealed they would not attempt to provide care for Resident #1 without the assistance of another staff because the resident was too heavy and the resident had tremors, mainly his/her hands, when they would start to provide care to the resident. Interview with the Assistant Director of Nursing (ADON), on 06/19/13 at 1:55 PM, revealed the root cause of the fall was Resident #1's shaking which caused the resident to fall out of the bed. The ADON stated this was typical behavior for Resident #1 when staff was getting the resident ready to be changed or bathed. Further interview revealed Resident #1 was a two (1) assist with all his/her care, except for feeding. Interview with the Administrator, on 06/21/13 at 9:58 AM, revealed Resident #1's fall took place on 06/01/13 and the DON informed the Administrator the resident had fallen out of bed with an injury, but the plan of care was followed and the resident did not have a history of falls. The Administrator stated she reviewed the resident's record and spoke to the DON asking her if care was being provided by one staff. The Administrator stated the DON said "no", the staff was waiting for the other staff member to get there and CNA #1 was doing her preparation for care when the resident fell from the bed.

Based on interview, record review, facility policy review and review of the facility's investigation it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision to prevent accidents. On 06/01/13 at 2:30 AM, Certified Nursing Assistant (CNA) #1 initiated care for Resident #1 by removing the foot bolsters from the resident's feet and a positioning wedge from behind the resident's back. The CNA then turned her back away from the resident to obtain a brief from the closet and the resident rolled off the bed onto the floor. Resident #1 was transported to the hospital for further evaluation and was diagnosed with [REDACTED]. The findings include: Review of the facility's policy titled, "Assessing Falls and Their Causes", revised 10/2010, revealed the staff will identify significant potential complications of falling for each resident at risk of falling. Record review revealed the facility admitted Resident #1 on 10/05/06 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 05/09/13, revealed the facility assessed Resident #1's cognition as severely impaired and the resident required extensive assistance of two (2) staff for bed mobility, dressing, toilet use and personal hygiene. Review of a Fall Risk Assessment, dated 02/19/13, revealed the facility assessed Resident #1 at high risk for falls. Review of the Comprehensive Care Plan, dated 01/23/12, revealed two (2) staff should assist Resident #1 with bed mobility. Review of the Activities of Daily Living (ADL) Plan of Care Skilled Sheet, dated 06/18/13, revealed Resident #1 was totally dependent on two (2) staff for positioning and incontinent care. Review of the Nurse's Note, dated 06/01/13 at 2:30 AM, revealed the Certified Nurse Assistant (CNA) #1 had entered Resident #1's room to provide incontinent care. The CNA removed the foot bolster and positioning wedge from the resident. The CNA went to the closet to get a brief for the resident, and the resident was shaking his/her arms and legs in bed. Further review revealed the CNA heard a thud, turned around and saw the resident lying on the right side of the bed on the floor. The CNA yelled for assistance to pick the resident up from the floor. The resident was assessed by Licensed Practical Nurse (LPN)#1, and was noted to have a two (2) centimeter (cm) abrasion to the left thigh. The resident's right upper leg was swollen with a deformity noted to the right femur. The physician was notified at 2:45 AM and an order was received to send the resident to the emergency room for evaluation. The resident was transferred to the emergency room per ambulance at 3:10 AM. At 7:30 AM, the facility called the emergency room and received information the resident was being admitted with a fracture to the right femur. Interview with CNA#1, on 06/19/13 at 10:15 AM and 3:30 PM, revealed she entered Resident #1's room to provide routine check and change care for Resident #1, but was waiting for CNA #2 to finish answering a call light. CNA #1 stated while waiting for CNA #2 she removed the wedge from behind the resident's back, and removed the foot bolsters from the resident's feet. The CNA stated she then turned and walked over to the closet and bent down to obtain a brief when she heard a thump. When she turned around the resident had fallen out of the bed. The CNA stated when she pulled the wedge from behind the resident, he/she began shaking his/her hands. CNA #1 stated Resident #1 always moved his/her upper body when people touched him/her. Further interview revealed the CNA stated she thought that maybe when she removed the wedge, the resident was to close to the edge of the bed, but she really didn't know because her back was to the resident and she did not see the resident fall. The CNA stated Resident #1 was a two (2) assist for bed mobility and incontinent care and she would never change him/her by herself. CNA #1 stated Resident #1 did not have side rails and never had as far as she could remember. Further interview revealed the wedge was used to support and position the resident off his/her back because the resident was large and was unable to turn and reposition without assistance. The CNA stated without the wedge, the resident would lie flat on his/her back all the time. Interview with CNA #2, on 06/19/13 at 11:10 AM, and on 06/20/13 at 10:10 AM, revealed she was going to assist CNA #1 with a check and change of Resident #1 but she had to answer a call light first. CNA #2 stated she heard CNA #1 yelling for help and when she got to the room she saw CNA #1 holding the resident's head up, and the resident's feeding tube was tucked under the resident very tightly. The CNA stated they were afraid the tubing was going to pull out, so CNA #2 picked up Resident #1 and placed the resident back in the bed. CNA #2 further stated Resident #1 was a two (2) person assist with all care except for feeding and the resident sometimes jiggled his/her arms and hands when staff started to provide care, but the resident stops soon after the care begins. The CNA stated staff used the wedge to turn and reposition the resident so the resident could lay on his/her side and not on his/her back all the time. Interview with Licensed Practical Nurse (LPN) #1, on 06/19/13 at 8:30 AM, revealed she was called to Resident #1's room by CNA #1. The LPN stated CNA #1 told her she prepared Resident #1 for incontinent care by first removing the wedge from behind the resident's back and removed the foot bolster. The CNA then turned and walked to the closet and bent down to obtain a brief out of the closet when she heard a thud and turned back around and saw Resident #1 had fallen out of the bed. CNA #1 picked the resident up and placed him/her back in the bed before the LPN arrived because the resident had fallen on top of his/her feeding tube and oxygen tubing and they were afraid the feeding tube would pull out. LPN #1 stated she assessed the resident and notified the on call supervisor (Registered Nurse #1), the physician, the state guardian and then she called the ambulance. Interview with Registered Nurse (RN) #1, on 06/19/13 at 1:05 PM, revealed she received a phone call from LPN #1 in the middle of the night that Resident #1 had fallen out of bed and LPN #1 thought the resident had a leg fracture. The RN stated Resident #1 required the assist of two (2) with incontinent care and turning, and had tremors and shakes at times. The RN stated the resident's tremors were mostly of the upper body, but they were worse in the evenings and the resident shakes pretty hard at times. The RN stated this possible could have caused the resident to fall from the bed. Interview with CNA #3, on 06/19/13 at 9:15 AM; and, on 06/20/13 at 2:18 PM, revealed Resident #1 was a two (2) person assist with all care and she would not attempt any care by herself because the resident was heavy and hard to handle. CNA #3 further stated the resident has little tremors, mainly his/her hands, but she just stops and waits till the resident calmed down. The CNA stated the staff used a wedge for turning and positioning for residents who couldn't keep themselves on one side or the other. The wedge kept them in a certain position. The CNA stated Resident #1 couldn't support himself/herself on his/her side, so they used the wedge. Interview with CNA #4, on 06/19/13 at 9:25 AM, revealed Resident #1 was total care of two (2) persons for assistance. The CNA stated the resident's hands and arms jiggled. The CNA revealed the wedge behind the resident's back was used for positioning to help keep the resident of of his/her back. Interview with CNA #5, on 06/19/13 at 9:30 AM, revealed Resident #1 was a two (2) person assist and was total care. CNA #5 stated she would never attempt to provide care for the resident by herself, because the resident was just to heavy. The CNA stated the resident was incontinent and required check and change every two (2) hours. Further interview revealed Resident #1 did shake his/her arms at times, but not very much. Interview with CNA #6 on 06/19/13 at 8:22 AM and 3:55 PM, revealed when staff turn Resident #1 on his/her side to provide incontinent care, he/she would sometimes start to jerk his/her upper arms and hands and there should always be two (2) staff to ensure the resident's safety. The CNA stated Resident #1 was care planned for the total assist of two (2) and the wedge was used to keep the resident off his/her back. The CNA stated Resident #1 never moved unless care was being provided. Interview with CNA #8 on 6/20/13 at 1:45 PM, revealed staff used wedges to keep residents off their backs and for positioning. The CNA stated it kept them from rolling over on their backs, when they have no back support. Further interview revealed some residents can't stay on their side without a wedge. Interview with the Physical Therapy Assistant, on 06/20/13 at 1:31 PM, revealed Resident #1 couldn't stay over on his/her side because he/she has no trunk control or body alignment. Interview with the Assistant Director of Nursing (ADON), on 06/19/13 at 1:55 PM and 06/20/13 at 3:30 PM, revealed they determined the root cause of the fall was Resident #1 was shaking and this caused Resident #1 to fall out of the bed. The ADON stated this was the resident's typical behavior when staff was starting to change or bathe the resident. The ADON revealed Resident #1 had always had these shaking episodes but only when someone gets ready to provide care. A wedge was used for positioning and foot bolsters to prevent foot drop. Further interview revealed Resident #1 was a two (2) person assist with all his/her care, except for feeding. Interview with the Administrator on 06/21/13 at 9:58 AM, revealed Resident #1's fall took place on 06/01/13 and the DON called and informed him of what had taken place. The Administrator stated the DON told him the resident had fallen out of bed with an injury, but the plan of care was followed and the resident did not have a history of falls. The Administrator further stated that on 06/02/13, he reviewed Resident #1's record, spoke to the DON and asked her if the care was being provided by one staff and the DON said, "no" that the CNA was waiting for another CNA to get there to provide incontinent care. The Administrator stated the DON told him the CNA was prepping for the incontinent care while the other CNA answered a call light. The Administrator stated that there was nothing that could have been foreseen or predicted that would have caused the resident to fall out of his/her bed. The Administrator stated the CNA did not leave the resident in an unsafe position, the resident was lying midline in the bed and the resident had no history of falls. Review of the facility's investigation of Resident #1's fall sustained on 06/01/13, dated 06/03/13, revealed "CNA #1 was preparing supplies to give incontinent care. While the CNA was at the closet getting supplies, she heard a noise and the resident was falling out of the bed onto the floor. CNA stated when she removed the wedge pillow from behind the resident's back, the resident began shaking (tremors) which is very usual for the resident to do when he/she knows he/she is getting ready to be changed or bathed. Resident also has a seizure disorder. Apparently, had rolled out of the bed onto the floor during this time. Cannot rule out that resident had a seizure to cause the fall." A review of the Fall Investigation worksheet, dated 06/01/13, revealed that based on the fall investigation the immediate intervention to prevent further falls was to ensure the resident was positioned properly in the middle of the bed.